Meta OCD
Obsessing about OCD
I am astounded that Meta OCD isn’t spoken about more, as it is one of the most common potential treatment blockers that I encounter in my work. It happens all the time: a client comes in seeking treatment for OCD, but at some point in our work together their theme begins to shift. Instead of just worrying about the OCD theme they initially came into treatment for, they begin to obsess about the treatment itself. This can manifest through a whole slew of different fears. Patients may start to worry:
How do I know if I’m doing exposures right?
What if my OCD is untreatable?
How do I know if I’m seeing the wrong therapist?
What if exposure and response prevention (ERP) doesn’t work for me?
Will I suffer from OCD forever?
How often should I be doing exposures?
What should an exposure feel like?
Meta OCD Compulsions
Clients may engage in compulsions such as obsessively googling information about ERP and OCD, trying to do exposures until they experience a “just right” feeling, doing exposures too frequently (e.g. over three times a day, and with the intent of doing exposures to “get rid” of distress), asking their therapist repeatedly if therapy is on the right track and if the client is treatable, or repeatedly asking for clarification about how to do exposures in order to double, triple, and quadruple check that the client is “doing it right”.
An Overlooked Part of OCD Treatment
The Meta OCD theme can be so sneaky! Many patients and clinicians alike fail to understand that this is just more OCD. It’s no different. Even though the obsession is about the treatment itself, this cannot be made an exception when it comes to applying response prevention skills. When a client asks me to re-explain how to do an exposure or engage in response prevention, of course it is my primary duty to ensure that they have an adequate understanding of the treatment. However, if these questions become repetitive despite it being clear that the client is able to provide a good “best guess” answer to their own question, it’s time to fold this theme into the treatment itself.
How to Treat Multiple OCD Themes
In fact, it is important to treat this theme before any other co-occurring themes. The logic here is self-evident: if a clinician tries to do an exposure on any other theme, the Meta OCD will rear its head and become the primary obsession during the exposure, blocking any ability to fully engage in the exercise. For example, when trying to do an exposure for someone with sexual orientation OCD, the patient will be consumed not by thoughts of “am I correct in identifying my sexual orientation”, but rather “am I doing this exposure right”. The patient must first be taught to tolerate the distress and uncertainty on this meta-layer before being able to access the sexual orientation related distress.
Exposures for Meta OCD
How do we do this? Exposures about exposures! OCD treatment about OCD treatment! I help clients sit with the “maybe”s as they apply to this scenario, coaching them to skillfully sit with and allow their brain to make thoughts and fears such as:
Maybe I’m doing this therapy wrong
Maybe I’m untreatable
Maybe my therapist doesn’t know what they’re talking about
Maybe right now I’m doing this exposure incorrectly.
Is Meta OCD Treatable?
Through these exposures, the client begins to understand that their job is to be able to tolerate uncertainty no matter what the topic is, even if the topic is their ability to sit with uncertainty. Once this is integrated into treatment, I have seen no differences between treatment results of those with Meta OCD versus those without. It is simply one small additional step in the process. Like many things in effective OCD treatment, it is at the same time a small nuance and an essential consideration.