By Andrew GottWorth
Thinking thinking thinking… wait, am I obsessively thinking or compulsively thinking? Oh no. I don’t know!
Hi there! If we’ve not met before - I’m Andrew. I’m 33 which is only relevant to say that I’ve been dealing with OCD since childhood, so 25 years give or take. I was only diagnosed a few years ago though, which is one of the reasons I signed up to be an advocate - to help others get diagnosed and receive treatment earlier. OCD shows up as things needing to be “just right” (perfectionism), somatic (fixing or fixating on the way things feel on or in my body), relationship OCD, and more to various extents.
What I want to talk about today though, is a tricky one - mental compulsions and rumination.This is what I am working on now, and I’m by no means an expert, but I’d like to talk a bit about how it differs from physical compulsions, how it shows up for me, and what’s working so far (and what’s not working).
“Physical Compulsions”
If you don’t know about OCD treatment, please start with learning about Exposure and Response Prevention (ERP). This is called “the gold standard” for treatment and certainly was for me. I was in other types of therapy for 10+ years before discovering ERP and it made all the difference. (It does still work for Mental Compulsions. More on this later).
I did 10 days of Intensive Outpatient (IOP) ERP, then twice a week, down to once a week, then down to once a month. To me, the ERP processes over this time were very tangible, physical actions. Here are some examples of my concern area and what I did in ERP:
- Blood and veins
- Held a knife
- Touched my veins
- Touched other people’s veins
- Talked about blood
- Talked about a blood draw
- Clothing and colors
- I bought jeans for the first time!
- Wore red
- Wore mismatched socks
- Wore colors that “clashed”
- “Just right” and texting/emailing
- Sent an email without rereading multiple times
- Sent a text and put my phone away - didn’t wait for a response or send a follow up
- Sent an email without doing “external research” first
- “Just right” and chores
- Made the bed wrong
- Did the dishes slowly
- Fears
- Looked out the dark window at night
- Watched videos about spiders and snakes
- Read/watched content about death
- Somatic
- Put the seam of my sweatshirt in the “wrong” place
- Intentionality have my hair touch my ear and let it grow longer
- Let things touch the back of my hand
ERP actions are highly specialized with the help of a trained therapist. My experience during the first 2-3 years of ERP was that everything I did was tangible. It was an action… even when it was an inaction like not sending a clarifying text…it was something concrete.
But I knew there was something more.
Mental Compulsions & Rumination
Let’s start by looking at those words. A mental compulsion to me is when I feel compelled (feel a need to) do something mental (think a certain way). Then rumination - as you might have heard before, like a cow “ruminates” - to continuously chew and rechew the same thing over and over.
But, as I asked during an online IOCDF conference - how do I know when a thought is an obsession and when it is a compulsion?
Fellow advocate and Therapist, Kimberley Quinlan has developed a great resource / 6 part podcast series called How to Manage Mental Compulsions.
I’d like to highlight a few that really show up in my brain, but I encourage you to check out the full resource! I quote her resource, then give some examples of how they show up for me:
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- Mental Review - “reviewing and replaying past situations, figuring out the meaning of internal experiences.”
- I said the wrong thing. How did they react? What could I have said differently?
- I felt off at the work party, what does that mean? Is my work bad? Should I not be around those colleagues? Is it all about to go bad?
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- Mental Catastrophization - “mentally going over all of the potential terrible, catastrophic situations.”
- It’s going to rain and it’s going to be canceled, and I’ll miss it and never have that opportunity again, and I’ll never…
- This meeting is going to go terribly, and then I’ll be “found out” that I’m not very good at this job, then I’ll be fired, and then we won’t have enough money, then we’ll have to move back home, then…
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- Mental Solving- “anticipating future situations with or without potential what-if scenarios.”
- Ok, so if the event is too crowded, we’ll need a backup room. And if the power goes out we’ll need a generator. And just in case someone brings peanuts and someone has an allergy, we can have EpiPens. And a defibrillator. And…
- We should invite them over for dinner. But what if they broke up? I should ask beforehand. But what if they get upset about me asking? Or what if it’s the other way, and they are so happy together right now, they don’t want to go out? But what if they are upset that we didn’t invite them to anything?
I would also add Mental Rehearsing to Kimberley’s list. Personally, it is so frequent it earns its own category. I feel like my brain is constantly practicing for a future conversation, argument, speech, social media post, or even something like this article. I’m rehearsing what I will say and repeatedly editing and rephrasing. The majority of these “future conversations” I never have, and the few times I do, there’s no relief from having practiced! (Instead, it usually turns to the Review that criticizes what I said and tries to think of what to say differently.)
It’s exhausting! It is so important to realize that these are compulsions too and not just because they reinforce anxiety like “physical compulsions” but because they are harder to notice. You might be doing the homework of avoiding physical compulsions, but unknowingly still doing a mental one, which reduces the effectiveness of doing your homework!
So…what do we do about it? Well, there’s a slight mix in the community of what works best. Let’s dig in.
Treatment
Like medication, motivation, or even music taste - what works for some may not work for others. I’d like to share what didn’t work for me (though it might work for you), and what’s helping me currently.
Once you distinguish between obsessive thinking and compulsive thinking, we can treat the compulsion l with ERP - we can practice mindfulness, exposure statements, and non-engagement responses in order to not do the compulsive thinking. However, listening to some advice on stopping mental compulsions came across to me as “just stop”. That didn’t work for me.
Others speak of the delight of knowing that they have more power in the situation. If you’re doing the dishes and you decide to stop, you just stop - same with compulsive thinking or rumination.
Well, I personally didn’t feel I had that power. So that “empowering” message left me feeling powerless, frustrated, and defeated. But to each their own - for some, pressure makes diamonds. For me (and maybe you), it - well - squishes.
Detour to get to a point - I used to work in Adult Education and non-profits that particularly worked with those that had obstacles in their lives. That experience, coupled with my mental health journey, led me to develop a mantra: “until you have the tools, you don’t have the tools”. If you didn’t have a hammer, you can’t really be blamed for not getting the nails in properly. Until you have study skills, and obstacles removed from your life, you’re not going to sit and learn about exponents very well.
And back from the detour - I was delighted to hear the Director of The Center of OCD and Anxiety,Jon Hershfield, MFT say essentially the same thing about rumination. Until you have the skill set to notice rumination and return from being carried away, there’s no need to add guilt to that experience.
I started crying when I heard that on the rumination podcast series. I had so much frustration from constantly being lost in thought, then reinforced frustration and guilt from not just being better yet - not being able to “just stop” ruminating.
Shooo… I’m ok. We’re ok. If you’re like me, you’ve been ruminating for years. At this point, it is automatic. It’s only with patience and practice and self-compassion that we can start noticing when our brains kidnap us and return to what we wanted to do. And then it will run away again. And we return again. And we keep practicing, but for me, with an added dose of compassion.
So to recap - mental compulsions and rumination are not as tangible as “physical compulsions” but are just as important to treat. They can show up like reviewing, rehearsing, counting, replacing, catastrophizing, etc. They can be treated like anything else with ERP. Use the same tools you’ve received from your therapist and IOCDF, and keep practicing noticing. Then give yourself a break on the times you didn’t notice. Then try again. And again. And we’ll get better together!
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