The DSM-V is a catalog of mental health disorders as determined by the American Psychiatric Association with the input of many mental health experts around the world. The way it works is it identifies symptoms (behaviors we engage in and our internal experience of thoughts, feelings, and sensations) and clusters them into groups. It then adds to that a number of relevant factors, such as how long you may have had these symptoms, how long they tend to last, and how much impairment they cause you. If you have a number of symptoms in the cluster and a number of the additional relevant factors, then you have something called a disorder, or a mental health condition. I have one, apparently, or so have said every mental health professional I have asked help from. Being able to name disorders is essential for being able to study them, which is how we identify the treatments that are most likely to be effective. A treatment is considered effective when it results in a reduction of the symptoms and other factors that make up the disorder. By definition, once the symptoms and other factors fundamentally change or reduce, the disorder ceases to exist per the definition in the DSM-V.
But is this a cure?
The answer is complicated, because a funny thing happens on the way to this debate. It turns out the most effective treatment for OCD, the name of the disorder that explained to me what was causing so much unnecessary suffering, is cognitive behavioral therapy (CBT) with an emphasis on exposure and response prevention (ERP). What happens in CBT with ERP is you learn how to navigate your experience differently, how to confront your fears and how to choose different behaviors in response to your thoughts, feelings, and sensations than you might instinctively choose. More specifically:
- Notice that thinking is a behavior and that different ways of thinking about your experience may make you more or less likely to choose effective behavioral responses
- Recognize that you are not a bad person for having unwanted thoughts, feelings, and sensations, that these experiences are part of being human and that blaming yourself for them is part of your disorder’s thinking style
- Lean in, open up, embrace, and even celebrate your unwanted thoughts, feelings, and sensations because this gives them free passage through your mind instead of keeping them stuck
- Practice staying with and observing urges to get reassurance, avoid, wash, clean, review, etc. so you can be a witness to the coming and going nature of these urges and stop responding to them like they must be sated or destroyed
- Learn to appreciate yourself for who and how you are, and instead of devoting every waking moment to getting rid of your unwanted thoughts, train yourself to instinctively invest in the present moment as it is, and take the risk of accepting uncertainty
All of the above are desired outcomes of CBT and ERP and for a significant number of OCD sufferers, these outcomes are truly accessible and really result in a reduction of the symptoms and other factors that define having OCD. So you might presume that this means CBT with ERP cures the disorder because it disqualifies you from meeting the American Psychiatric Association’s definition of the disorder.
But there’s an ironic twist.
In order for any or all of the above to occur, you fundamentally must foster an identity that frames OCD as a part of who you are, not a thing that’s broken about you. Believing that you’re defective merchandise to be taped up and put back on the shelf is the mentality that leads to self-hatred and more compulsive behavior. Believing that you are a “loudthinker” (what I called myself in online support groups during my treatment), and that embracing all of the above leads to mastery of this OCD experience, is what actually makes the treatment stick. The best CBT and ERP in the world shoots you down the path to this mastery, but the rest is a life’s work.
My kids are super cute and fill me with pride every day. When I catch either of them at their most spectacular, I think two things with regularity: 1) I am the luckiest dad alive and 2) I am going to die early, probably in front of them, and their lives will be defined by having lost their father. I no longer meet the DSM’s clinical criteria for OCD, so the book can tell me I don’t have OCD, and I am not distressed by that second thought at all. I expect nothing else and if it gets any rise out of me, it’s a laugh. Didn’t used to be that way. I used to spend an inordinate amount of time crying and not being able to explain to people why (or worse, being able to explain it to them and having them tell me that’s not a reason to be upset). Thanks to CBT and ERP, and obviously mindfulness, I don’t have to do the things I used to do that earned me the DSM’s label. I don’t have OCD, but only because I know that I have OCD.
I still get stuck in stories from time to time.
We call these relapses. They commandeer my attention for a few days at a time and they come up 2-3 times a year. I don’t meet the criteria for OCD, but I have OCD relapses. Even in the eye of an OCD storm, I score too low on the impairment, resistance, and control measurements of the Yale Brown Obsessive Compulsive Scale to be considered clinically significant. Even when my OCD is at its worst, I apparently don’t “have” OCD. Even right now, noticing the italicized word in the last sentence does not have an italicized quote at the beginning, but does at the end, I apparently don’t have the DSM’s OCD. I’m not going to fix the typo. This choice isn’t because I was cured of the disorder. This choice is because I understand that I have the disorder. It is a part of what I am and understanding this is what made treatment work!
So in the end, the “cure” for OCD is to understand that there is no such thing as a cure for OCD. There is no thing to be cured. There are thoughts, feelings, and sensations, and by being a student of them instead of a victim of them, you can change your relationship to them and live a joyful, mostly unimpaired life. When you do this, you get dumped by the DSM. The book can call me cured. But if I want to stay cured in the book’s eyes, I must, categorically, call myself something else. Perhaps I can just identify myself as being somewhere along the path to mastery of my mind. That is, my mind, the one with OCD.
P.S. Inspiration and input from Shala Nicely, LPC on this subject was an essential ingredient in the post above.