Some therapists believe there is a core fear underlying OCD symptoms, and any effective treatment should break down that fear, not just treat the symptoms. A good example would be Lady Macbeth rubbing her hands in an attempt to wash imaginary blood away. She feels that the distressing recurring thoughts about the King’s murder will never leave her alone, and her hand washing is a desperate attempt to drive them away. In that case, ERP will not be just a matter of abstaining from excessive hand-washing and getting used to it, but to address her core fear of being doomed and show her a more adapted way to redeem herself and regain hope.
Those therapists see the determination of our core fears as an essential first step in treating OCD. For instance, for Michael Greenberg the basic core fear is the fear of emotional suffering. OCD sufferers are ready to go to great lengths to avoid that unpleasant feeling. Alex Pollard divides our core fears into three categories: fear of the “not just right” feeling, of a catastrophic event, and of making a potentially devastating mistake. Elna Yadin sees our fear of causing irreversible damage, of being ‘bad’ in some way, or of death at the root of OCD. The idea is that identifying our core fears will allow us to tailor ERP exercises to our specific needs and so make them more effective. It’s not just a matter of restraining from checking or washing excessively. It’s learning to break down one’s core fear so OCD wouldn’t reappear in another form.
The problem with that approach is that it assumes there is, at the beginning, an underlying core fear feeding OCD. But, what about if there is none, and OCD is mainly a self-fueling disorder, that is, once you start on that path it’s extremely difficult to stop, but if, from the start or after treatment, you use appropriate ways to deal with life difficulties, you’re okay.
It’s like the question of what comes first. The chicken or the egg? Let’s take a personal example. In the past I’ve done some volunteer accounting work. Logically, I knew that below a certain sum, it’s not worth looking for mistakes, but I couldn’t help doing it. So, the question is, was I greatly disturbed by a discrepancy not worth to worry about and compelled to find its source at any costs because there was an underlying fear of the “not just right” feeling or of causing some kind of irreversible damage? Or was it because, from a young age, I became used to rely on the elimination of all imperfections and uncertainties in certain domains as a source of peace of mind?
You see, if, for instance, the possibility of losing a loved one or having caused irreparable harm generates some anxiety in me, I may use the performing of a ritual or an excessive search in my memory to lower my anxiety. The anxiety is normal. What’s not normal is the way I choose to extinguish it. If I use maladaptive ways to reduce my discomfort instead of accepting that I can’t control everything in life and making the best possible choices given the circumstances then I lose my freedom of choice because I do it at the expense of more sustainable/healthy sources of comfort. Performing rituals, excessive checking or cleaning, ruminating, etc. becomes a compulsive need because I emotionally depend too much on it and not enough on more sensible behaviors. It’s kind of a vicious cycle from which it’s not always easy to escape.
In a nutshell, I agree with Michael Greenberg that at the root of OCD there is a core fear like the fear of emotional suffering. However, from my own experience, I tend to think that starting to use dysfunctional ways to suffer less and appease our mind amplifies a fear that’s initially normal and set in motion the OCD spiral, instead of assuming there is a starting buried fear (inherited from unresolved childhood issues if one believes in psychoanalytic ideas) fueling OCD.
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I think it’s pretty common for unmanaged OCD to undermine one’s confidence. Yes, the OCD cycle is a vicious one that can continue to be fed by continuing to do any part of it. That would be operant and classical conditioning (reinforcement). OCD specialists in the last several years have realized that the underlying core fear of an individual’s OCD needs to be addressed, not just the superficial fears, otherwise their OCD will end up playing a game of whack-a-mole. It will just show up as a different theme or an additional theme. Michael Greenberg, OCD specialist, approaches core fears from a psychoanalytic approach but most OCD specialists don’t use a psychoanalytic approach. There can be an infinite number of core fears related to OCD but there are several common ones. The IOCDF Ask the Experts livestream has had a couple of episodes where core fears are discussed. Liz McIngvale, Ph.D., OCD specialist, goes into detail explaining why addressing the person’s core fear is essential for long-term recovery. There is also an article on the IOCDF website regarding common myths about OCD treatment where addressing the core fear is described as essential. It is pointed out that accepting the uncertainty of the core fear is the goal.
Thank you for your response. I'd like to be sure (reasonably sure, not absolutely sure 🙂) I grasp the concept of core fears vs. superficial fears, and its usefulness. I found 70 "Ask The Experts" videos on the IOCDF website. How do I know which one treats the topic of core fears?
I love your sense of humor (sure, reasonably sure, not absolutely sure)! I goofed and gave you the wrong name of the livestream. Sorry about that. It was Lunch and Learn, not Ask the Experts. It was a year ago and the title is Addressing Core Fears in OCD Treatment. Michelle Massi was the guest. She and the hosts are all OCD specialists. The livestream I was originally thinking of was an Ask the Exoerts one where Liz McIngvale talked very briefly about core fears but this Lunch and Learn one is devoted to core fears.
You’re welcome. I think Jon Grayson has the worksheets for the down arrow method of identifying your core fear in his book Freedom from OCD. Don’t quote me on that though.
Interesting video indeed. In particular, I liked the role-play of a session devoted to core fear identification (11:40-15:05). Chris Trondsen was able to realize, with the help of Michelle Massi’s questions, he was obsessionally afraid of otherwise harmless chemicals because he was afraid they gave him cancer, and he was afraid of cancer because he was afraid of physical frailty and being a burden to others, states usually associated with cancer. So, the ERP exercise was for him to be exposed, within reason, to household chemicals, sit with all the intrusive thoughts about physical frailty and being a burden to others (his core fear) that flooded his mind, and let them gradually subside. The idea was to break down the core fear, so his present OCD theme wouldn’t morph later on into another one. Excellent.
However, that strategy doesn’t seem to go far enough. If Chris Trondsen’s ultimate desire was to be physically fit and reasonably independent (or ultimate fear was to be physically frail and a burden to others), he also needed to give himself reasons to believe he had good chances to see his desire satisfied (or his fear not materialized), otherwise his desire (or fear) would always be there ready to manifest itself in another form. It may be why ACT is generally a good complement to ERP.
Both Chris and Liz are strong advocates of ACT and Mindfulness as supplements to ERP and use the term values-based ERP. Chris’ values were the incentive to accepting the uncertainty of his core fear. His values were the reason , so to speak. Doing the values-based ERP while accepting the uncertainty of his core fear showed him that he could take on OCD and even have freedom from it. Not just well-managed OCD but actual freedom from it it. He has a “bring it on” attitude towards OCD. OCD doesn’t phase him anymore because he’s not scared of it now. He stresses the importance of living an ERP lifestyle to be proactive with recovery.
His core fear goes a little deeper than just fear of being a burden to others because of physical fraility. Keep in mind, Chris and Michelle were doing a role play. He did touch on his own actual story though. When someone is in the depths of their OCD hell they probably aren’t going to believe they can overcome it. They are more likely to believe OCD’s scams instead of believing in and trusting themselves. It literally takes a leap of faith to take on OCD and one’s core fear that drives it. The leap of faith is trusting in the process without reasons for the trust. That leap is usually tiny hops instead of a big leap. One usually doesn’t start out with good reasons or proof that they can address their core fear. Moving towards one’s values can be an incentive to do ERP. Jon Grayson asks , what has OCD taken away from you? That question gave me the incentive to take on OCD no matter how terrified I got. A person can learn the difference between their voice and the voice of OCD doing values-based ERP. When the core fear is adequately addressed , the fuel for OCD is gone. There is freedom from OCD , not just managing OCD well. You can come out stronger than when you went in.
He realized that if his OCD kept going that his worst case scenario would come true. The ironic thing is that his OCD was suppose to protect him from the worst case scenario. He ended up taking action to move towards his values and away from OCD. Not everyone’s worst case scenario will come true. People with POCD aren’t going to turn into pedophiles. Back to the ego-dystonic thing.
Thank you for the additional information. In the case of Chris Trondsen, it's indeed ironic that his obsessional fear of harm would have caused the very harm he was dreading.
I agree with everything you said. I may be a tad bit more suspicious about blind faith, though. For instance, I think that the leap of faith is trusting in the process without absolute certainty (instead of “without reasons”) for the trust. Indeed, one doesn’t need irrefutable proof that a therapy will get to the root of problem in order to start it, but a therapist who, from the start, inspires confidence for good reasons is a great help.
is there any way to save this?? I am new here and trying to learn more about my daughter’s ocd. We both have anxiety, and a few other things mixed in. When I was younger I had some ocd tendencies which at that time I was told was common with anxiety disorders. I was able to curtail them and i “grew out of it” in my teens. They were never severe. My daughter on the other hand is really struggling. We were talking recently when she was losing her mind, and ended up realizing that we may figured out the core issue, as you mentioned. Her father (dx with Asperger’s) would watch murder mysteries, shows that were graphic, and didn’t see the need not to have these on when she was in the room. Through her childhood I did everything I could to keep her away from the tv when he was watching , which was all the time (was his favourite interest), but I worked and he didn’t. Anyway, her poor little girl brain took in these images. Now she will have the fear of something bad happening to a loved one, and has the imagery to go with it.
I believe she had a pre-disposition to ocd and these experiences fuelled it. Now, I don’t know how to help her. She is also on the spectrum, and possibly adhd, and so that seems to create a lot of obstacles when it comes to using suggested tools. But of course we have to keep trying.
Thank you for your post! I loved reading this perspective.
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It's too bad about your daughter being exposed to TV shows that were meant for a mature audience. I hope she recovers somehow from that traumatic experience. What gives reasons to hope is that the human mind does self-regulate and recover from bad experiences if given the right conditions. It may be tempting to spend too much time trying to figure out why your daughter feels the way she feels right now. That approach often leads to ruminations, which only makes the situation worse in the long term. It's more helpful to guide her in exercising good judgment and making good decisions in the present time despite a less-than-ideal past. Eventually good experiences and memories will replace bad experiences and memories. It takes time though. I wish you success on that at-times-difficult path.
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