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Key points
- Although exposure-response prevention is the most popular and studied treatment, it has some limitations.
- ERP doesn't address a key trait of those with OCD: overdeveloped empathy.
- Many OCD sufferers decline ERP treatment.
Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them the best intervention for OCD, and you’ll likely get the same answer: exposure-response prevention.
ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their fears and learn not to blink. Trained to conjure their worst-case scenarios—the terror of harming their newborn child, the yuck factor of hands submerged in a trash can, or entertaining the possibility that they’re a psychopath, for example—ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.
Although it provides relief, ERP can miss the most astounding feature of the OCD set: their enormous hearts. Recent studies find that OCD subjects show higher empathy levels compared to healthy controls. They report more distress over their heightened empathy and are more emotionally responsive to others compared to controls.
A behavioral approach gives little room to map this heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39.5-foot pole. Between one-quarter and one-half of them decline exposure-response prevention, in some cases even before it begins.
Unfortunately, OCD has one gold standard treatment, a virtual monopoly that soothes with Jedi mind tricks. Shouldn’t we be treating the expansive hearts of the 2.2 million adults and 500,000 kids and teenagers with OCD, too?
Perhaps ERP is so popular that few have the audacity to question it, but maybe we should start. As Pascal said, “The heart has its own reasons of which reason knows nothing.” Such is what I learned through Kate.
A cinematographer, Kate was fast losing hope she’d never get past her OCD that only relented on set. “I always thought I was failing at treatment, but when I read your work, I felt treatment was failing me.”
Kate read my unconventional theory that OCD arises from an empathic sensitivity that goes unnoticed and turns in on itself. That enlarged heart capable of so much love is also keenly aware of loss. Is it any wonder that the majority of OCD sufferers worry that death might befall someone they love?
Kate suffered from paralyzing obsessions when out in public places, fearful that the gaze of others might cause her to implode. She never understood why her obsessions centered around this particular theme.
“It doesn’t really matter,” her former therapist would say. “That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep going down the rabbit hole. It’s not to be trusted as your friend.”
But Kate, ever so fascinated by the motivations of the characters she tracked in the movies, knew there was more. Obsessions have a funny way of distracting and focusing on what is most feared and desired for a reason.
We worked on a new kind of ERP that mined her feelings. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others. With her big heart, she was so tuned in to everyone’s unexpressed fears and desires that there was hardly room for herself.
We joked about how many artists and innovators have OCD. Greta Thundberg, reportedly herself an OCD sufferer, transforms her profound sensitivity into fierce advocacy to save us all from extinction. Young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis and peers into the thought spirals of obsessive-compulsive protagonist Aza Holmes.
Like Kate, Aza seeks her own center. Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself is she lost again, spiraling about a possible infection. Compelled to drain the pus and blood, Aza is a hostage in her own claustrophobic cell.
I knew Kate was making progress in our treatment one day when she said: “I bet you want to talk about what we half-completed last week, but I don’t want to. This is what I need today.”
My heart swelled. I loved the fire she needed in order to own herself, even if it risked losing me. “I’m not screwing up your plan?”
“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger, it was her middle finger. She needed to say a healthy ‘f*ck you’ to the people she loved—her mother, her best friend, even her own OCD—and trust that she was entitled to it. That’s what you’re doing now, and I love it.”
For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.
We found the heart of it, the mystery that hovers somewhere between life and death, love and hate, and all the false choices that even OCD treatments place before us. OCD wasn’t just a problem of Kate’s mind, nor was it something she needed to obliterate. When Kate could decode OCD’s hidden and strange wisdom, she tapped into a fuller understanding of herself and the world. One heart to another, she could find the reasons of which reason knew nothing.
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