Kevin Majeres MD | Only Focus on Compulsions
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Only Focus on Compulsions

17 Mar Only Focus on Compulsions

An interesting study has been recently published by Twohig et al. comparing standard Exposure and Response Prevention to “cognitive restructuring” to Acceptance and Commitment Therapy. If it sounds confusing, try reading all the tables and figures. At any rate, the idea behind the study (which is the most interesting part, since the sample size was quite small) was that it may not be necessary to focus so much on obsessions; it is enough to focus on compulsions, and curtailing them so that one can act instead in ways consistent with one’s ideals and goals. In the tiny sample, the effect of this approach was pretty amazing.

This makes sense to me. Compulsions are things that one does to stop feeling anxiety and to stop having obsessions. For instance, in contamination-themed OCD, a person will have the obsession that they got contaminated, and will have intense anxiety accompanying it. The obsession occurs automatically in response to a trigger, and the anxiety follows automatically as well. Both of these processes are generated and contained within the limbic system; the upper cortex has no chance to intervene, and has no means of directly stopping the automatic processes involved. This means that one cannot will away anxiety, or will the obsessions to stop.

Compulsions also tend to occur automatically  whenever obsessions are triggered — at least, one might say, they want to be automatic. Because they (usually) require the use of one’s arms and legs (control for those is located in the upper cortex), they have a glaring vulnerability that anxiety and obsessions do not have: they can be directly stopped, by voluntarily choosing to not do them, or at least to do something else that is incompatible with doing them. Compulsions are complex automatic behaviors, and though the urge to do them may be quite strong, with practice one can learn to stop them. Typically, the window one has to stop them before they feel overwhelmingly automatic begins very small (perhaps a second or two!) and then gradually increases as the effort to stop them continues.

If one is going to stop doing a compulsion, it is easiest and best to focus instead on one’s values. Because compulsions are a behavior, when one is doing them it is always at the expense of another behavior that is more in keeping with our aspirations and purpose in life. Compulsions steal time from other meaningful activities: spending time with family and friends, being able to be of service to others, being able to focus on one’s work, and so on.

Acceptance and Commitment Therapy (ACT) is a kind of cognitive-behavioral therapy that focuses on accepting the discomfort of not acting on one’s emotions (e.g., doing a compulsion) while instead choosing to act in accordance with one’s highest values. When applied to OCD, the treatment does not entail purposefully doing exposure exercises. Instead, it focuses on regaining the meaningful activities of life that the compulsions have crowded out. As one goes through life guided by ideals and not anxiety avoidance, anxiety will necessarily arise — i.e., obsessions and compulsions will be triggered. This is enough for ACT. As one goes through letting the OCD be triggered whenever it happens to get triggered, one is taught to accept the anxiety and obsessing (things one cannot change directly). The more one practices this acceptance, the more the foundation of OCD — the desperate struggle to avoid all anxiety and obsessions — is destroyed.

Another way of putting this: if one makes it one’s goal to not obsess and not have anxiety, one is unwittingly siding with compulsions, the whole purpose of which is to stop obsessing and having anxiety. When one focuses on accepting anxiety and accepting obsessions occuring, one is doing a work that a compulsion could never do: acts of acceptance are anti-compulsive, exact opposites of compulsions. At the same time as learning acceptance, one learns to not give in to compulsions that interfere with leading a meaningful, rich life. (It’s too bad that my favorite book on OCD is called “Stop Obsessing!” That’s exactly what a compulsion wants!)

This approach takes practice. Particularly, one must learn to stay in the present moment, and mindfully attend to the unwanted anxiety and obsessions when they occur without doing anything to remedy them. There is growing evidence in support of this approach. For more details, one can check out the Twohig study, which was published in the International Journal of Behavioral and Cognitive Therapies, Vol.6 (1), 2010.