This is the blog of India Haylor, writing on behalf of OCD First Aid.  OCD First Aid is a treatment centre based in London which offers highly effective treatment programmes for OCD. Uniquely, the treatment is designed by clinicians with OCD to provide tangible, lasting relief and is based upon cognitive behavioural and third generation techniques. OCD First Aid has 14 years of experience as specialists in treating OCD, supporting families and carers and raising awareness.

When my clients first arrive for therapy I’m under no illusion.  At that stage they don’t really want therapy, coping skills or even their life to be more functional. What they would really like from me is certainty.  So they say things like, ‘If only I could trust my mind………’, ‘I used to be certain and I don’t understand how that changed.’ And ‘I need to know this is OCD.’.  This initial therapy phase is very predictable and reliable, unlike certainty. To be honest, I don’t even like that word and it’s generally associated with things that aren’t always pleasant, like death, DNA tests and doomsayer predictions. I also don’t like it because the apparent lack of it drives OCD forward to much bigger and more ominous things. I say apparent, because there is no such thing as certainty and therein lies the illusion of OCD.
OCD relies very much on planting the idea that certainty is an option and it can be accessed via the right test, evidence, research, reassurance (from self/others) or very detailed thinking. This, like  ‘fake news’, is fake certainty and the quest for it is very, very addictive.
So, what do people with OCD think certainty looks like? Who cares! This is irrelevant, because for them, it’s all about how certainty feels. That feeling of certainty. That absence of the sense that something is wrong. The feeling of relief that they are, at last, feeling the right feelings. But they won’t be able to identify or articulate exactly what the feeling is and sadly it will last for minutes or hours. If they are lucky it might last for longer but it won’t be permanent.
Part of the process of effective therapy is being able to firstly, identify the difference between feelings and thoughts, e.g., ‘I feel as if the world is against me’ is a thought whereas ‘I feel guilty’ is a feeling. And secondly, helping clients place far less importance upon feelings since they bear little relation to fact or actuality in the case of OCD (and apparently for those who don’t have OCD). Feelings are a poor criteria or basis for decision making. It is hard for clients to embrace this idea since we have become increasingly cerebral, culturally and sociologically. Thousands of books, articles, movies, social media and diary entries are written every day about the importance of feelings. I’ve read OCD forum posts where desperate people seek answers to questions such as, ‘I don’t feel love when I look at my partner so how do I know they are the one?’ (Relationship OCD). When someone replies, ‘If it feels wrong, it is wrong!’, I just think, ‘Good grief, that will set them back weeks in getting help or recovery’. Again, the idea of choice and the quest for certainty is the culprit. However badly behaved a child is, most parents don’t wake up in the morning and question why they aren’t feeling the love and if their child is right for them? Especially if it’s horrid weather and they have the flu. They enjoy positive feelings when they are there, but if they are not, they realise they must do the school run anyway.
Fortunately, neuroscience is moving in a helpful direction. The work of neurologist Robert Burton points to the fact that certainty or the ‘feeling of knowing’ is a mental sensation and hence, chemical & biological. In the same way that the information processing around what we see isn’t based on what enters our eyes but is a highly processed signal that is partly determined by our expectations, the ‘feeling of knowing’ is independent of active, conscious reflection/reasoning and has little basis in fact or actuality. In his book, ‘On Being Certain’* he states that feelings of certainty stem from a primitive area of the brain and cannot be controlled by us. What this means for OCD is that those constant, frantic attempts to be certain are not only tortuous but a fruitless waste of time. This feeling cannot be controlled and it has nothing to do with what has happened, is happening or might happen – the big one. It also means that the search for certainty, reinforced by strong habitual behaviour, adds up to something very negative indeed. Moreover, as Burton also says, ‘Once firmly established, a neural network that links a thought and the feeling of correctness is not easily undone. An idea known to be wrong continues to feel correct”. Therefore a person with OCD isn’t easily dissuaded from the search for acceptance and that’s where we, as therapists, come in.

*On Being Certain by Robert A. Burton M.D, 2009 https://goo.gl/WBFQw4

CBT (or REBT) is key