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My name is Frank and a year ago I came to the end of a course of treatment for OCD at the Centre for Anxiety Disorders and Trauma, where I had 20 weekly sessions of cognitive behavioural therapy – CBT. I’ve been asked to write something about it, for people with OCD who may be considering a course of CBT. If that’s you, you may be wondering about the treatment – about what you’ve heard and read. You may have spent years living in fear, shifting from one object of anxiety to another, scrabbling around, making small adjustments that mean you can just about carry on functioning. And now someone talks to you about challenging those fears, rather than buying them off with rituals and avoidance. You may be thinking, that sounds hard. Too hard, maybe.
People who’ve been through medical conditions often say that the treatment was tough – they worked at it, they ‘beat’ the condition and so on. It’s the language of struggle, of fighting. I’d like to tell you that CBT isn’t so difficult – not when you’re guided and helped, as you will be.
Perhaps right now, you’re thinking about your worst OCD fear – the thing that makes your life most gruelling, that stops you in the street and makes you feel nauseous. Even if, like me, you’ve had OCD for a long time and your fears have turned into a rag-bag of nagging ideas, you probably have a number-one terror that seems beyond reach, beyond challenge. Maybe you’re thinking, how could I ever approach that? How can I think about it in a different way, how can I make it less massive?
If you’ve never had CBT, it’s bound to seem mysterious. Mental health conditions feel mysterious too, especially in their early stages – where on earth did that come from? So it may make the whole thing easier to imagine if I compare it to another condition – one that’s more up front and evident. Since 1980, I’ve been a type-1 diabetic, which means I need to inject myself with insulin several times a day. As a child, I used to read about diabetes or listen to diabetics being interviewed on TV and think, how on earth do you go about pushing a needle into your own body? The idea seemed impossible, and I was glad I’d never have to do it. Or so I thought.
Then after a long spell of ill-health, I was diagnosed with diabetes. I had to think again about the injections. The medical team took it slowly. They gave me a few days to get less sick, they showed me how injections are done, they gave me an orange to practise on – it takes a similar amount of pressure, apparently – in general, they encouraged me. And before long, the task didn’t seem quite so enormous. You know that to regain some control over your life, you need to do your jabs yourself. And you set yourself down to try it.
You put the needle to your skin and push… and it doesn’t hurt. Not usually, and never very much. It isn’t your skin that’s the barrier, it’s your fear – and you can get past both of them. Afterwards, I felt excited – elated, even. I felt healthier, stronger and in control – as much as you can be in this unpredictable life (which is another thing it’s important to think about when you have OCD!).
When I started my CBT treatment at CADAT, I felt the same fears. I’d had OCD for years, bent my life out of shape to appease it, been in thrall to it, in fact. Appeasing the fear had been the only relief I got, so all the rituals and avoiding seemed like magic spells of protection – they brought me scraps of comfort, at a huge, huge price. I didn’t want to think about the day when I’d abandon the most ‘powerful’ of them. I pushed it to the back of my mind, and thought if it gets too much, I can twist the treatment, do just enough to get by, make life easier for a year or so, maybe. Because anyone who’s had various therapies for OCD knows that we will stop short of a breakthrough if we can – we tweak the condition, do what we can to improve it without addressing it at its most basic, crucial level.
I’d done that before, but CBT has improved vastly since I first did it in the late 90s, when therapists were still telling us to take our minds off OCD by snapping rubber bands against our arms. At CADAT, the therapy and the therapists are brilliant. It’s very focused, totally shaped for and aimed at your condition. The therapists have enough time to take you to the crucial turning point and beyond – the point at which you start to act against your fears, with what they call anti-OCD behaviour. That is, you don’t find a route around the OCD, you confront it and do things that challenge it. I find myself wanting to say ‘transgress against it’, even though I accept it isn’t entirely helpful – it makes the fear seem masterful, like the boss of the situation, although as you’ll discover, it isn’t really like that.
The therapy starts slowly. No one will throw your worst nightmare into your lap and say ‘Deal with it.’ You’ll talk, you’ll learn new ways to think about OCD (and about life, which as it turns out is more important than OCD). First you’ll challenge some target behaviours that feel within reach. But sooner or later, yes – you will stand at that turning point, the worst of your fears, and you’ll have to take a step forward. You’ll confront something that feels out of reach and you will act against it, because if you don’t, you’ll slip backwards. It will be a troublesome moment, but it will not be impossible. Far from it.
Because you will be helped. You’ll have new ways of thinking, and it will feel like having tools for the job – you can reach into your toolbox and pick strategies that make the work easier. Your therapist will be there for you, and it won’t be as bad as you imagine right now. For me, it did feel like my first insulin injection – I was helped through the barriers and I was surprised how little it hurt. I even felt the same sense of elation afterwards. (Elation makes me suspicious, but I suppose it’s better than fear.)
The CBT wasn’t all about anti-OCD behaviour. I needed to think about the idea that, yes, life is fragile. There is no magic bullet for that, however much we wish there were. In fact, there is no magic, full stop. Bad things will happen to us, but those things will be unpredictable – they will happen whatever we do, whether we walk under ladders or not. No one enjoys thinking about the precarious nature of life, but surprisingly, taking on that notion makes living feel easier, not more grim – it won’t stop the bad stuff happening, but at least you won’t be to blame for it. If you’ve spent your life thinking about magical defences, it’s hard to ditch OCD talismans completely. But the treatment will help.
I still get the OCD fears. I’d be lying if I said I had no slip-ups. But during the last year, there have been several points where I’ve known I could go badly wrong, if I let myself, and fall into a behaviour that will end up seriously corrupting my life. Each time, I’ve been able to think it through and make a better choice. That’s thanks to the treatment I had at CADAT, and to my therapist and her assistant.
Maybe it’s best not to think too much about the most challenging moments in CBT – not before you start, anyhow. Coming face to face with fear and then living with it – perhaps that seems like an unreal ambition to you now. It did to me, back in 2016. But it isn’t unreal at all. The thought of confronting OCD is much, much worse than actually doing it. You will be smashing some of your personal idols, but that will turn out to be a good thing – not just in terms of managing your OCD, but also of living a bolder, more productive, less cowed life.