Guilt Beyond a Reasonable Doubt
by Steven Phillipson, Ph.D., Center for Cognitive-Behavioral Psychotherapy
Other Articles by Dr. Steven Phillipson
In my recent article "Thinking the Unthinkable" (OCD Newsletter, Vol. 5, No. 4) I suggested that there are in fact three forms of OCD rather then the two most often discussed. The most familiar type, which (like the overall syndrome) generally is referred to simply as "Obsessive Compulsive Disorder," involves the performance of distinct behavioral "rituals" through which the OCD sufferer seeks to relieve his or her anxiety. The second type -- less common and more difficult to treat -- I call "Pure O," as it involves the experience of unwanted, intrusive, and persistent thoughts (obsessions) with no accompanying behavioral component (ritual). The third form of OCD, and one which, I believe, has been given little attention in both the professional literature and in clinical texts, I call "Responsibility OC," and it is this form of the disorder that I propose to discuss here.
What distinguishes Responsibility OC from other forms of the disorder is the presence of guilt -- whether accompanied by anxiety or not. It is primarily the experience of guilt that plagues those suffering from this form of OCD when they fail to carry out a ritual, and in these cases, the ritual generally involves the protection of some other individual or individuals. There are powerful cognitive elements at work -- the sufferer's belief that his or her self-worth is at stake and that their value as a human being depends on their response to the particular situation they are facing.
For most of us, living day-to-day with occasional feelings of low self-esteem is a nuisance, sometimes painful, but rarely debilitating. But for those with Responsibility OC, defending their self-esteem is the primary motivation for performing the ritual.
I would like to take a moment to state that I view the disorder as an entity entirely separate and distinct from the OCD sufferer's "genuineness" or personhood -- the unique sensibility and thought processes that distinguish him or her as an individual. The large majority of OCD sufferers realizes that the warnings their brain is sending them are absurd and not related to their sense of "reality," and it is extremely important -- for both client and therapist alike -- to distinguish between what the disorder is saying and the genuine desires of the affected individual.
I stress this point because it is quite common for the disorder to suggest that a given spike (prompt to perform a ritual) is valid or "real," i.e., "People might really be hurt if I don't pick up those shards of glass from the street." Those with Responsibility OC often debate within themselves whether it is their innate concern for others -- their "real" values -- or the disorder that is prompting them to act. When confronted with this internal debate, the essential question to ask is "Am I motivated to perform this action out of a sense of guilt and/or anxiety?" -- that is, "Am I experiencing guilt and/or anxiety in association with this spike?" If the answer is yes, then conclude that the spike is OCD-related, and take the risk of not attending to the demands of the disorder.
The symptoms of Responsibility OC manifest themselves in a variety of ways. A client might present to the therapist what appears at face value to be a Pure O concern -- for example, persistent and recurrent thoughts about someone important in their life being injured or becoming ill. The clue that this is Responsibility OC and not simply purely obsessive thinking comes when the client suggests that the fact that he or she has these recurrent thoughts means that he or she really has a hidden desire to see harm come to that individual -- in other words, that he or she poses a danger -- if only in his or her malevolent wishes -- to the object of his or her obsessions. Symptoms also might present themselves in a more typically obsessive compulsive fashion, as in the case of the person who repeatedly and compulsively washes his or her hands. The difference here is one of motivation, not the specific action involved in the ritual itself. Whereas the Obsessive Compulsive may wash his or her hands out of anxiety related to concern for his or her own health or cleanliness, the Responsibility OC performs the same type of activity (i.e. hand-washing) in order to protect others from harm (in this case, to prevent him- or herself from spreading infection or disease). Again, what distinguishes these two cases as Responsibility OC rather than another form of the disorder is that they both center around a single theme: the client's belief or fear that he or she may in some way be a source of -- or fail to prevent -- some harm from coming to another.
The most characteristic Responsibility OC rituals cause sufferers to act upon their environment in such a way as to ensure the safety of -- or at least minimize the risk to -- others' safety. Those with Responsibility OC often will go to great lengths to reassure themselves that they have not inadvertently harmed (or contributed in any way to the harm of) another individual or other individuals through either their actions or their inaction in a given situation.
Certainly, this hyper-sensitivity to possible threats to others' well-being is a feature that all individuals with Responsibility OC share. In addition, those with the disorder often believe that they may have been the only ones to have noticed a given hazard, and that it is, therefore, their obligation, their moral duty, either to warn others of the danger or to take actions themselves to eliminate the threat.
The following examples illustrate some of the ways in which this painful disorder expresses itself:
When Frank goes outside, he quickly finds himself "on the lookout" for possible hazards on the street. Although this task consumes much of his time and attention, he does not truly experience his decision to watch for these dangers as a choice freely arrived at out of a genuine concern for others' safety. Rather, he feels compelled -- morally obligated -- to do so, because he believes that this is what a caring, ethical human being would do. Frank's motivation to engage in this activity comes in the form of a threat to his integrity. He thinks to himself, "What kind of person would I be if I were not to take care of this problem?" When he becomes conscious of some potential safety or health risk, his immediate thought is that unless he removes the hazard or warns others about it, he will forever condemn himself as a selfish, immoral human being, and he will be possessed by an unending flood of guilt and anxiety.
If, for example, Frank finds a Band-Aid on the sidewalk, the thought occurs to him that children might play with it and in so doing be exposed to some dangerous disease. He immediately feels that he must dispose of the item as soon as possible. But not just anywhere! A public garbage can won't do because some homeless person might, in rummaging through it, come into contact with the Band-Aid and contract the disease. A sewer on the street is unacceptable because the Band-Aid might be washed up back onto the street with the next heavy rainstorm. Frank can spend hours seeking out a safe place of disposal, proposing and rejecting one possibility after another, or, having come up with one (such as, perhaps, finding a medical waste disposal facility in a hospital), finding a way to implement his plan.
A familiar example of OCD -- and one which clearly illustrates Responsibility OC at work -- is that of the individual who drives back and forth in his car past a spot where he thinks he might have just hit a pedestrian -- even though there is no evidence of their having done so. Despite the lack of evidence, the thought that they might have hit someone and the belief that they must determine with absolute certainty whether this has happened keeps them driving back and forth or pursuing other avenues by which they seek to reassure themselves that they have done no harm. It is not uncommon for such individuals to repeatedly call the police to find out if any accidents have been reported, or to phone local hospitals inquiring whether there have been any recent admissions of accident victims. Left unchecked, this kind of obsessive concern can lead those affected to stop driving altogether.
Individuals with Responsibility OC seek through their rituals to accomplish two goals: to 1) "escape from" from their feelings of guilt and anxiety, and 2) convince themselves -- provide themselves with a sense of certainty -- that they are not terrible human beings and have not ignored the plight of others.
Treatment of this form of OCD requires both ingenuity and a profound understanding of the way in which the client sees the world. I would suggest that a standard part of any complete intake for an individual with OCD include a determination of whether the client's rituals are centered around reducing anxiety in regard some risk to themselves, or assuaging their sense of guilt about, and responsibility for, some harm that may come to others.
In performing homework assignments it is critical that clients not perceive that, because the therapist has "given them permission" to perform or not perform some action related to their rituals, they have relinquished responsibility for the consequences to the therapist. In other words, the client must not believe that the responsibility -- or blame -- for any harm that may come to others as a result of their performing the exercise rests on the therapist's shoulders and not their own. One way around this potential stumbling block is to have clients gradually take more and more of the initiative in assigning themselves the weekly challenges to their disorder.
As has been previously stated, those with Responsibility OC are fighting the "double-barreled" threat of anxiety and guilt. For the purposes of this discussion, guilt is itself defined as a two-part thought process: 1) "I did something I shouldn't have done" or which "I should have known better than to do," and 2) "The fact that I did this makes me a 'bad' person." To treat Responsibility OC most effectively, it is strongly suggested that the therapeutic package focus in some part on this belief of the client that his or her integrity and adequacy are in jeopardy.
In essence, for those with Responsibility OC, the rituals they perform amount to an avoidance of -- or an attempt to escape from -- the thought that they might be loathsome, unlovable human beings, and it is here that I have found some application of the principles of Cognitive Therapy to be of value. One of the basic premises of Cognitive Therapy is that all human beings are of equal worth -- or, to put it somewhat more abstractly, based on our actions, our worth as human beings cannot accurately be assessed, and we cannot, therefore, be judged. We can engage in regrettable acts, but the sum total of these acts has no bearing on our worth or value as a person. Without understanding and accepting this idea, those with Responsibility OC will remain vulnerable to the second barrel of the OCD shotgun -- guilt.
And finally, it is of the utmost importance that the therapy be directed towards increasing the client's tolerance of ambiguity, and towards increasing the level of risk-taking in his or her life in relation to the OCD. Work with the client to help him or her learn to tolerate the discomfort associated with the anxiety and guilt. It is being willing to tolerate such discomfort that leads to recovery.
It is worth remembering, and it is one of the great ironies of OCD -- and of anxiety disorders in general -- that it is in attempting to escape the anxiety- or guilt-producing thoughts that the greatest damage is done, because the thoughts themselves, while unpleasant, are survivable, whereas the attempt to escape -- that is, the ritual -- distorts the sufferer's behavior and affects his or her ability to function in the world. Moreover, not facing the spike only sets up the individual for further attacks of the disorder.
Once a client has made the decision to resist a given spike, it is likely that the discomfort will dissipate within a fairly brief period of time -- often 10 to 20 minutes at most. Those who have just begun therapy sometimes find this hard to believe. Fresh in their memories are images of hours -- and sometimes days or more -- spent agonizing over some spike or getting a ritual "right." But what has become clear to me in treating numerous clients with OCD, and what clients themselves realize after some time in therapy, is that their ambivalence, their uncertainty, about whether to give in or not give in to a spike only prolongs the agony. As long as they waver in the decision to resist, they leave themselves open to the prompts of anxiety and guilt -- prompts to engage in a ritual -- that their brain is sending them. It is like leaving open the decision in a debate: as long as the process continues, both sides have the opportunity to argue their points, and no resolution is achieved. Until the OCD sufferer has made that decision -- if only to say to him- or herself, "I refuse to give in to this spike, I refuse to perform this ritual right now, at this very moment. The future be damned! Who knows what I'll do tomorrow, but right now, I will not give in!" -- the debate will continue, and so will the pain.
Similarly, it is not helpful, when in the throws of the disorder, for individuals to make the decision to resist and then spend their time monitoring their anxiety and waiting for it to subside. That, too, opens them up to continued prompts from the disorder. I believe that checking to see if the discomfort is still there keeps the connection open to the anxiety -- and guilt-producing thoughts (spikes) that the brain is generating and often only prolongs the pain. Along with the decision to resist the spike, it is important to make the decision to move on, to do other things, to shift one's attention away from the spikes, and, even if they continue to make their presence known, to go on despite the discomfort. Making such decisions tends to lead to a quick extinction of the spikes, of the impulse to perform a ritual, and the associated discomfort.
It might be useful here to illustrate these points with some examples of homework assignments that have helped clients with Responsibility OC to reduce their preoccupation with "doing the right thing."
Frank, the client mentioned earlier in this article who was obsessively concerned with attending to anything in his environment that he viewed as a threat to others, was asked to throw some pennies into the street each day. It was suggested to him that he deliberately spike, as he did this, on the thought that children who saw the coins might get hit by a car while attempting to retrieve the money. Thus, he was asked to expose himself to the kinds of thoughts (that he might be responsible for some harm coming to another) that he sought to avoid through his rituals.
Another client was instructed to touch the bottoms of her shoes four or five times a day and then to shake hands with others without those individuals being aware that her hands were "contaminated." As an additional challenge to her disorder, she suggested that she purchase items at a drug store using money that she had deliberately dropped on the floor. As one of her obsessions revolved around placing susceptible persons at risk by communicating some disease to them, this exercise -- as with Frank's assignment above -- exposed her to the thought that she might perhaps be risking another's well-being through her actions. By deliberate, continual, and gradually increasing exposure to spikes such as these, she was able to build up a tolerance to these types of thoughts.
To some, these assignments might seem somewhat extreme. However, I have found that recovery is facilitated if, when doing exercises, clients over-compensate in a direction opposite to the demands of the disorder. I often have used the "bent pole" analogy in explaining this to clients: In order to straighten a pole that has been bent in one direction, we must bend it back to an equal degree in the opposite direction. Oversimplified as this analogy is, it expresses the underlying principle, the rationale, of these exercises. By not only disregarding the disorder's demands, but taking that extra step of "upping the ante" -- challenging it even further -- clients can most effectively regain their equilibrium, the freedom and comfort in performing the routine tasks of daily life of which they have been deprived by the disorder.
To conclude, the factor that distinguishes someone who is simply conscientious or concerned from one with Responsibility OC is the amount of anxiety and/or guilt that he or she experiences in response to not performing -- or the idea of not performing -- that "good deed." There are times when observing some potential hazard in the street prompts most of us to take some kind of preemptive or preventative action. It is situations such as these that also provide us with an opportunity to ask "If I were not to do this, if I were not to be the good Samaritan, what emotions would I experience." If the answer is a significant amount of anxiety or guilt, or a strong feeling that you are "less" of a person for failing to act as your conscience dictates, this is a powerful indicator that you suffer from Responsibility OC, and it might be in your best interest to seek professional help.
Originally printed in the Obsessive-Compulsive Newsletter, published by the OCF