Something useful about psychiatric diagnosis is that it allows us to discern who certain treatment approaches are likely to help and which are likely to harm.
At the same time, it is important to remember that modern clinical research tends to rely on averages. Psychiatric diagnoses, their associated treatment recommendations, and their likely outcomes are only one factor in the larger clinical picture.
It can be challenging to hold both ideas at once: that a standardized diagnosis tells us something important about what makes a person different from the norm, and that there are elements of normal psychology that a diagnosis does not require us to write off.
Take OCD, for example. There can be a kind of exceptionalism in how we think about patients with OCD. This can come from an important place: clinicians have observed enormous misunderstanding of the disorder and of the people who experience it. There can be a strong protective urge to avoid treating someone with OCD exactly as we might treat someone without it. In some respects, this exceptionalism is warranted. But just because OCD is an exception in certain ways does not mean that it is in all ways.
Much of the work of therapy involves becoming interested in the psychological relevance of what we fear, what we want, what we avoid, what we deny, and what we defend against. With OCD, however, many clinicians are understandably wary of granting an obsessive thought this kind of psychological value. The concern is that interpreting the content of an obsession may feed the obsession itself, leading the person deeper into the rabbit hole of doubt and rumination.
For example, someone may have an obsessive fear that they are selfish. They may develop compulsive rituals around this fear, including elaborate mental gymnastics aimed at definitively answering the question of what kind of person they are.
I see the case for resisting a formulation that assumes an obsession has psychological significance. People can find great relief when they are able to externalize their pervasive doubts and worries onto a disorder; when they can see the obsession as irrelevant noise. Sometimes, this might be what’s needed.
But I don’t believe the presence of a disorder negates the possibility of psychological significance in the content of the fear. And to treat a person as though it does is to risk absolutism in the other direction. Moreover, it may itself become a form of reassurance (that is, of providing a false sense of certainty) which is counterproductive in the treatment of OCD.
The distinction, to me, is between saying that an obsessive thought is not necessarily true and saying that it is necessarily meaningless.
Moving past these binaries is extremely challenging and requires developing a greater tolerance for anxiety. And this is the task that OCD treatment is concerned with.
In this example, possible binaries include “I am either selfish or not,” and “this is the OCD talking or me,” and they weave through each other.
Moving beyond the first binary might involve accepting that there may, in fact, be some selfish motivation driving an action that the patient feels compelled to understand as purely altruistic.
Moving past the second binary might involve holding the possibility that the contents of one’s mind can be simultaneously shaped by OCD and have connections to the person’s psychic life.
This wouldn’t be a verdict on the patient’s character, as all humans have the capacity to act from mixed motives and exercise that capacity regularly. The person with OCD, if able to build a tolerance for such uncomfortable possibilities, may gain access to a fuller picture of their reality.
From there, they have greater freedom to make decisions.
Maybe they decide that it is perfectly acceptable to do something partly out of selfish motivation; maybe they decide it’s worth it. Or maybe they decide to stop doing the thing driven primarily by selfish motivation, realizing they feel better filling their days with actions that come from a different place.
Looking at the situation honestly isn’t meant to condemn, but to liberate. When a person accepts that they cannot always prove their fears false, they are freed from the paralysis that comes from trying to. With that acceptance, they are freer to live, letting themselves and expecting to learn from their actions rather than feeling the need to have everything sorted out before acting.
The paradox is that in our effort to prevent a person with OCD from treating every thought as meaningful, we may inadvertently teach them to always treat them as meaningless. And this can reproduce the very certainty-seeking that perpetuates the disorder.
How and when to guide a person toward building this capacity requires clinical judgment. Interpretation can fuel rumination, and perhaps not every obsession is worth investigating. The clinician must consider the person’s tolerance, the function the inquiry is serving, and whether exploration is expanding the person’s freedom or rather giving the compulsion new material.
But if we treat people with OCD as too fragile to ever tolerate the less flattering, fear-inducing aspects of themselves, we might rob them of one of therapy’s greatest benefits: the development of greater agency in their own lives.
