Let's talk about OCD

In response to a friend's question about a recent Guardian article, I wrote a blog-post-length reply on WhatsApp, so now it's over here too.

This morning my friend sent me this article in the Guardian about OCD. It’s worth a read if you want the full back story, but briefly it goes: woman gets diagnosed with OCD. Writes a memoir about it. Films a TV show about it. Then discovers that maybe OCD doesn’t exist, takes some mushrooms about it, and cures herself.

Aaaand <scene>.

The friend who sent it to me has OCD. So do I. It’s one of the things we’ve bonded over in the past (as well as a mutual love of Kelly Clarkson and cheese).

Next to the link, her message read: “I found this incredibly frustrating. But I thought, let me run it past Scar who will know better from an actual therapist perspective.”

Look if you don’t want a literal essay-length response landing in your WhatsApp inbox then you shouldn’t ask a neurospicy philosopher a complicated question about mental health 😅

Here’s what I said.

This is really complicated and a huge topic of debate but I will give you an overview of the landscape and then tell you my own opinion as concisely as possible, but it would be easy to write an entire book about this one thing.

Obviously everyone who has An Opinion™️ believes theirs is The Right One but the truth is no one actually knows for sure.

So basically the history of our understanding of OCD goes something like:

Freud is obviously all like “PENIS” and then the psychoanalysts come in and they’re like “REPRESSION” and “REPETITION COMPULSION” and then the psychodynamic people develop from them and they’re like “nooo, transference, hence YO MAMA” and then the existential therapists are like “🚬 nah man, it’s just a way of ✨being in the world✨ dude 🍷”

The influence of psychology

Meanwhile psychology as a discipline is developing alongside psychotherapy but the psychologists are finding it hard to fund any of their studies because the world is into OBJECTIVITY because focusing on subjective experience is all about 💖feelings💖 and we should all be SCIENTISTS instead because that’s more MANLY and therefore CORRECT.

So the psychologists are like “no no no we’re scientists too we promise please love us and give us funding 🥺” and then neuropsychology starts growing as a discipline and people start realising things like:

• oh hey turns out not all brains are exactly the same and

• ooo they’re a lot more malleable than we thought and

• some people are born with the wiring a bit skewiff and

• some people are born with more traditional-looking wiring but then it goes skewiff later but

• therapy can actually help to un-skewiff it

• …oh and so can drugs. Cool. 😎

And then all these terms start springing up like ‘OCD’ and ‘schizophrenia’ and ‘autism’ and ‘ADHD’ and all sorts of words which, like all words, we use as signifiers for phenomena that would be better explained by actually describing what is going on but that would take too long.

So then at some point there’s a split and, like everything, it’s political and tied up with capitalism and patriarchy and the left and the right and all that great stuff which makes life so much fun 🤨

The debate about psychiatry and pathologies

One side of the split goes:

• the human body is like a machine

• physical illness is what happens when a machine breaks down

• ‘mental illness’ is what we call it when physical illness happens in the brain

• hence mental illness is purely because there’s something wrong with a person’s brain, for example a misfiring of neurons, or a miswiring of brainy bits, or a chemical imbalance

• if we (historically) do a lobotomy or (presently) give people pills, then that eases the symptoms, which means the problem is gone

• therefore the problem was (for example) a lack of serotonin, because giving serotonin made the problem go away.

(This is massively oversimplified but you get the gist.)

The other side of the split goes:

• but humans aren’t machines tho?

• saying it’s “a lack of serotonin” because serotonin fixes it is like saying pain in the body is due to “a lack of paracetamol”

• and some people get better without drugs

• and some people get better with therapy

• and some people never get better regardless of drugs OR therapy

• and some people who have the same chemical (im)balances or brain (mis)wirings etc. as other people don’t have the same symptoms, so WHAT’S GOING ON?

• it must be something in the 🍃environment🍃
  (Read: YO MAMA / I’ve decided you secretly want to have sex with your dad because I’m Freud and I’m high on cocaine / you must be repressing some kind of 🌟terrible trauma🌟)

(This is also massively oversimplified but I’m trying to keep it relatively short.)

So these groups are generally at loggerheads with each other and both have some good points and some wildly reckless bits.

The ‘body = machine’ people are right that drugs can help; that some people’s brains / chemicals don’t seem to be rewireable; etc.

The 🍃 environment 🍃 people are right that #NotAllPeopleWithMiswiredBrains, and that sometimes drugs don’t help, and that there’s evidence that a lot of the time people are just sent home from their GP with drugs because there isn’t enough funding to give them more in-depth care that might be better placed to help them.

There’s a growing anti-psychiatry movement particularly amongst the existentialists. The furthest people along this continuum don’t believe in mental illness at all, think of all things we label “madness” etc. as just ways of being in the world, and think we should listen to mad people and treat their views with the same level of seriousness and consideration we give to the views of non-mad people.

(They do tend to use the word ‘mad’ too. They describe society as ‘saneist’ in the same way that disabled people describe it as ‘ableist,’ i.e. we don’t listen to the experiences of the people we deem ‘mad’ or take into account the societal structures that might be behind them feeling this way. They cite the (very real!) increases in anxiety etc. in late capitalist societies and the (also very real) abundant evidence of racism and colonisation within psychology and psychotherapy.)

So, scar, what’s your view?

I sit sort of somewhere in between, and I’m a Kierkegaardian existential therapist so I tend to be most interested in how people themselves view their illnesses / ways of being in the world / etc. rather than what they’ve been told about them. I think we can give all sorts of things labels and sometimes they’re helpful and sometimes they aren’t.

I also think there are lots of things that could be given all different labels and ultimately the patient ends up deciding which label they feel fits them best or they are most comfortable with (for example, someone might be diagnosed with autism but later realise they have OCD and decide that autism was a misdiganosis, or vice versa, or decide they identify with both.)

Drugs can certainly help which means there is definitely at least a physiological component which makes sense because we are… y’know… physical entities. Therapy can also help (and yes, there’s evidence that therapy can “rewire the brain” to put it in very simple terms) which means there are ways in which being with other people in supportive environments can help us physiologically too, which makes sense because we’re social beings as well as physical entities.

I would be hugely skeptical of anyone saying they can fix OCD with CBT in six weeks. Although the data suggest that initial outcomes from CBT-based therapies are generally positive for OCD, meta analyses show that we don’t have enough data to tell whether that remains true over a longer period, and there is evidence to suggest that more deeply embedded traumata and symptoms won’t be helped by CBT in the long term. There’s also evidence to suggest that there might be a placebo effect at play in some cases.

So for example, if a person developed OCD as a reaction to a one-off trauma that happened in adulthood (for example, they survived a plane crash and they happened to have done things in a certain order that morning and now they always have to do things in that order) then maybe a six-week programme might help.

But OCD tends to be something that begins earlier on in life and there are signs of it way back even if the symptomatology doesn’t become problematic for the person until later. If the patient has a history of childhood trauma then long-term trauma-focused therapy can help with OCD (and other similar things), but whether that’s because the trauma caused the OCD or because the trauma caused all sorts of other things (excess of cortisol / flashbacks / whatever) that then make OCD symptoms more likely is impossible to tell.

The fascinating thing is that people can go through similar things and come out very differently. And one thing I find clients often forget is that children don’t have a fully-fledged understanding of the world yet, so something that might not be traumatic as an adult (your parent going away for a weekend) could genuinely be traumatic for e.g. a 4-year-old who has no idea what is happening other than Safe Person is Gone 😭

Another issue with the ‘it’s all physical’ viewpoint is that, for some people, it takes away a sense of agency and gives a feeling of “this can never change.” If you’re just “like that” and you feel helpless about it then it’s unlikely to change because the thought of changing the entire wiring of your brain sounds long and exhausting (which it is!) and/or impossible (which it often isn’t). However there are plenty of people who try drugs and therapy and all sorts of things and still have whatever disorder they were originally diagnosed with, so it’s more complicated than a binary answer.

So how does this work in practice?

The way I frame it for my clients is:

1. Does this thing bother you?

2. If so, why? (Because it actually bothers you, or because it bothers other people?)

3. If just other people, who are they and why does it bother them (i.e. are you just surrounded by judgemental wankers, or are you repeatedly screwing people over and they’re angry with you about it?)

4. ⁠If it bothers you, what about it bothers you? (The constant nature of it? The amount of time it takes up? The feeling in your body when you’re trying to suppress a tic? The way people around you react when they see you doing something “weird”? The scary nature of some of the intrusive images / thoughts? etc.)

5. ⁠How long has this been going on?

All of those can either be answered from a medicalist viewpoint or an existentialist one. I go with whatever my clients want. I strongly believe that pretty much anyone would be diagnosed with something if they happened to sit in front of a psychiatrist for a couple of hours, but that doesn’t mean I think all diagnoses are bullshit (I don’t. I grew up around schizophrenics. And I find ‘OCD’ a helpful label to describe some of my behaviours to other people.)

I guess actually my view can be summed up by this piece of art I made:

…which is the word ‘human’ spraypainted over a poster of the DSM-V list of mental illnesses.

i.e. I don’t believe in throwing out the DSM completely, but I do believe in “spraypainting over it” with the humanity of the person in front of you. OK, they have OCD: what’s their subjective experience of that? Why does it matter to them? etc. Both can be simultaneously true, it just depends on which one you want in the foreground, and that’s really up to each of us to decide for ourselves.

I wrote all of that and yet completely forgot to address the drugs theme which was also prominent in the article. I left a four-minute voice note for my friend about that, so if you’re interested in my views on it I’ll post and transcribe that for you. But for now, the above are my thoughts on pathologies more broadly.

What do you think?