The Dharma of OCD – Part I
(Please Note: What follows is a first draft of this exploration. Feedback and discussion of these issues is much appreciated.)
I have been living with Obsessive Compulsive Disorder for at least 30 years (but probably my whole life). I’ve been practicing Buddhist meditation almost as long. For years I’ve noticed similarities between Buddhist practice and the primary cognitive-behavioral tool I’ve used to work with my OCD, Exposure/Response Prevention (ERP). I’ve been looking for teachings on the intersections of long-term meditation and ERP practices from a Buddhist point of view. I haven’t found anything, so I figure the universe is telling me I have to start providing some of the teachings myself. I hope that this writing is of benefit to any who is suffering with OCD or related experiences. I envision it sparking an open-source dialogue and eventually a text of some kind that explores The Dharma of OCD.
In writing this, I’m calling on the teacher principle that I believe can be found within every one of us, to “teach myself the Dharma.” “You have to teach yourself the Dharma,” is a phrase I remember my primary meditation teacher, Stephen Levine say often. It implies that we already know at some level everything that we need to know, and by assuming the teacher role with ourselves we can sometimes uncover dormant wisdom. “Dharma” is a Sanskrit word that refers to “the way of things,” or “the Truth.” It is a term also used to describe the Buddha’s teachings. As an aside: it is important for me to remember that the Buddha was not a Buddhist. Just like Jesus was not a Christian. They were just people who looked deeply into the nature of reality and then shared their findings. The labels and vast institutions that sprouted around these visionaries’ teachings came much later. For me, the word “Dharma” points to the underlying, fundamental nature of reality. It includes everything, seen and unseen. It is beyond any religion. It is beyond anything we can capture in words. And yet we try…
Exposure/Response Prevention Meditation Practice
In this writing I’ll be exploring connections between my understandings of Buddhist practice and ERP. I’m not an expert in either. My Buddhist practice has been eclectic and non-traditional. As has my ERP practice. When I give definitions of terms or concepts in either tradition, I will be speaking from my own experience and limited knowledge. I’m sure there are many other ways of understanding each one.
I began meditating shortly after my first full-fledged, knock-down, completely-fall-apart OCD flare up. I was 15 and didn’t yet know what to call this thing happening in my head, but my obsessive fears were making it nearly impossible to get through each day, let alone have any semblance of positive relationships. After about four months of this, I discovered Transcendental Meditation (TM). Meditating twice daily with my TM mantra saved my life. It didn’t fix everything, but it gave me an anchor and allowed me to “come back to my life.”
After a couple of years, I let go of the TM practice on a regular basis because I was becoming too anxious with OCD symptoms to sit still so long. I turned to physical exercise instead.
In my second year of college, I had an even more devastating OCD onslaught, that tore apart everything I used to steady myself and make decisions. I was terrified first of never reaching enlightenment, and then of being sent to Hell when I died, and then of the Devil—none of which I actually believed in deep down. Each time I convinced myself that I didn’t have to take seriously the warnings of terrible suffering for all eternity that my mind was throwing at me, then my OCD found a new image to frighten me with. All of them had a similar energetic texture. It felt like the worst possible thing was going to happen to me and it would be all my fault, and it was crucial that I think about this right this instant, until I found the correct remedy and the thoughts and feelings completely went away.
As anyone knows who has experienced OCD, or been close with someone who has, the thoughts and feelings never go away completely, and the inner dialogues with the thoughts only make them stronger and more insistent. The OCD mindset is incredibly clever and finds endless ways to keep us distracted, afraid, and reactive. I had not been raised religiously, and so found the religious imagery in my obsessive fears confusing. As I began to find some moments of sanity and peace through work with a courageous and unconventional therapist, I felt drawn to study comparative religion, and through that discovered Buddhism. I restarted a daily meditation practice, this time working with Buddhist mindfulness principles, that has continued to this day (with brief forays into other meditative forms.)
Like medication (which I’ve taken since I was 19,) meditation has not stopped my OCD, but it has taken the sharper edges off. It’s given me more space inside from which to respond to the thoughts and impulses. It’s allowed me to grow and to bit by bit, trust life more.
I first discovered the cognitive-behavioral psychology practices of ERP after a difficult OCD flare up around age 30. Before that I’d clocked countless hours of talk-therapy, which helped some areas of my life, but not so much my OCD. Working with my new ERP therapist to consciously come into contact with things that sparked my obsessions, and then to attempt to refrain from doing anything to counter the intense anxiety that arose was very difficult. It was some of the hardest work on myself I had ever had to do. But it seemed to be working. I was slowly feeling more courageous and at home in my mind.
We eventually started working with the book Brainlock by Jeffrey Schwarz. It was a revelation. I was especially drawn to the book because it was dedicated to Mahasi Sayadaw, one of the most important Buddhist meditation teachers of the 20th century, and the teacher of most of my Buddhist teachers. Previously I had been suspicious of primarily psychological/medical methods of working with my mind. They often felt superficial, reductionist and “unenlightened.” They didn’t seem to take the full picture of existence into account. Too many psychologists seemed to stay in the observable and measurable, and often didn’t strike me as deeply happy or embodied. My obsessive fears were in the realm of mysterious spiritual energies that defied logic, so it seemed I needed to work with spiritual methods gleaned from actual mystics of some sort. But the fact that Schwarz was connected to my meditation lineage, encouraged me to give him and his book a chance.
And then the primary practice that Schwarz outlined reminded me of meditation. Schwarz encouraged daily practice that could be done without a therapist present. He taught his patients to:
- Re-Label: Label the obsessive thought and/or urge to perform a compulsion to relieve the anxiety as OCD. I silently say to myself “This is my OCD.”
- Re-Attribute: Remind yourself that the cause for these intrusive thoughts and strong, unwanted urges is a medical condition, called OCD.
- Re-Focus: Change your behavior to something else. Do whatever you need to not to perform the compulsion, at least for a few minutes.
- Re-Value: Do not believe the OCD thought or take it at face-value. Once the strong urge has lessened, reflect on how OCD thoughts are actually false messages from the brain.
In my experiments with Schwarz’ “Four Steps” I felt like I was doing applied Buddhist mindfulness meditation. In basic mindfulness meditation, the instructions are to spend time in stillness, bringing our attention to the sensations of the breath (or other objects of meditation: candle flame, repeated sacred word, body sensations, visualization of deities, chanting, or phrases of loving-kindness and compassion.) Pretty quickly most people notice mind activity increasing. We get distracted. We get lost in fantasy. For us OCD folks, we tend to get consumed by loops of overwhelming worry and anxiety. In mindfulness meditation we are instructed to let go of whatever has taken us away, and come back to the object of meditation.
The Many Flavors of Practice
Many Buddhist traditions have specific tools to use for bringing the attention back—or in Schwarz’ language, “for re-labeling and re-focusing.” In Vipassana meditation (Theravada Buddhism) we are instructed to make mental notes of emotions, mind-states and types of thoughts as they occur, and then return to the breath or body sensations. I was taught to note, “fear, fear,” or “anger, anger,” or “planning, planning” for as long as the distraction captivated my attention, and then as it began to fade, to refocus.
The Zen meditation teachers that I studied with often encouraged us to count our breaths, one to ten, and then to start over. And if we noticed we had gotten distracted, to just return to the breath-counting. Zen also focuses a lot on mindful body posture and returning to the sensations of posture along with the breath.
Shambhala Buddhism (an adaptation of Tibetan Buddhist practices by meditation master Chogyam Trungpa Rinpoche) urges practitioners to focus on certain parts of the breath, and to use the mental note “thinking” for any thought, feeling, mind-state or other distraction that arises. The mental notes bring us back into the present moment and remind us what to focus on. Calling everything “thinking” reminds us that any phenomena that distracts us only does so because our thinking mind gets caught in it.
In each of these traditions we are taught to pay attention, re-label and re-focus the attention over and over in sitting meditation, walking meditation, and all the tasks of daily life. We are reminded repeatedly that all thoughts and feelings are “empty.” This means that all thoughts and feelings arise and pass away, have no enduring nature, and are ultimately unreliable tools for happiness. This is not to disrespect thoughts and feelings. They are crucial aspects of being human. When responded to mindfully they help us shape our lives skillfully, but when handled unconsciously they can cause great suffering. As Stephen Levine said often, “The mind is a great servant but a lousy master,” and “The mind has a mind of its own.” Thoughts come and go. They are not who we are. They are not solid things. And it takes a lot of practice to not be controlled by our fleeting thoughts, especially when we have OCD.
In the Midst of Daily Life
My teachers constantly encouraged finding ways to practice mindfulness in daily life. Many said that the goal of meditation is not to be a good Buddhist or a good meditator, but to live our lives fully. The mind can just be so seductive. Daily practice can keep us on track. I think Schwarz would say the same thing. His four steps could be understood as an adaptation of basic Buddhist mindfulness practice, geared towards those with OCD.
My OCD thoughts, urges and compulsions seem to most closely resemble those of “Pure O.” My understanding of Pure O is that it is OCD that doesn’t have accompanying outer physical compulsions to perform in order to attempt to reduce anxiety. Instead it all takes place inside the mind. Much of ERP is based on refraining from performing actions that we temporarily believe will relieve the devastating anxiety of OCD thoughts. However, when the obsessions and compulsions are all thought-based, it can be very difficult to refrain from performing compulsions, or as Schwarz puts it, to “re-focus.”
In Brainlock Schwarz suggests doing anything instead of what your OCD thoughts are telling you to do. In the case of obsessive hand-washing, one is instructed to do anything you can to not wash your hands again once you realize it is just an OCD compulsion, rather than a logical step towards good hygiene. My fears of eternal damnation and the compulsion to think the “correct” thoughts in response to the OCD thoughts could all take place no matter what outer activity I was performing. In fact, I had become a master at continuing on with conversations, meals, tasks, driving, and even creative projects while simultaneously giving in to my compulsions to think about and re-think about and re-re-think about some magical thought I could have that would save me from unimaginable suffering after I died. Most people would never know how fast and furious my mind was working underneath my neutral demeanor.
This is where Buddhist mindfulness practice came to my rescue. The activity that I “re-focus” on in order to not give in to my compulsions is to feel the present-moment-sensations in my body. The OCD thoughts can continue—and they even sometimes get worse. But I keep coming back to my bodily sensations over and over, just like in meditation practice. I focus on my breath, or the sensations at the bottom of my feet, or the sensations of movement, or the surges of energy that come with anxiety. It’s uncomfortable. I want the anxiety to go away as soon as possible. But it’s nowhere near as painful as being stuck in the loops of obsessional fear and compulsive thinking that the OCD can lead me into. My meditation teachers say over and over that it doesn’t matter how many times you lose your focus, or even how long it lasts. What matters is that you come back. I practice coming back. Thousands of times every day.
When I’m not able to come back because the OCD thoughts are too convincing, I recall the advice of Buddhist teacher Pema Chodron. She tells us to “Let go of the storyline and come back to the energy.” The storyline in this case is the OCD thoughts and the compulsions to engage with the thoughts. I do my best to let the thoughts continue, and just tune in to the energy in my body, that is changing moment by moment. Pema also once gave the meditation instruction to use 25% of your attention to anchor you in the present, and let the other 75% of your attention be open to everything else you experience. I find that very useful in my meditation practice and in moments of mild OCD anxiety. However, when my OCD gets almost too intense to bear, I reverse it. I use 75% of my attention to stay anchored in my body sensations—whether that be the breath or energy sensations or both. Then I let perhaps 25% of the attention follow what my thoughts are doing. It feels similar to sitting on a train or in the passenger seat of a car and feeling myself sitting in the chair, while I also watch things flash by outside the window. I don’t avoid seeing what’s flashing by, but I also don’t give it much focus.
Groundless and Grounded
There’s a fascinating paradox in both Buddhist meditation practice and ERP. In both we are instructed to practice skills of re-focusing our attention away from OCD thinking and towards more positive aspects of our experience. In both our aspirations towards inner stability, peace and acceptance are encouraged and returned to over and over. These skills and aspirations ground us. They help us grow our mindfulness and clarity “muscles.” They anchor us in our present-moment-experience of our body and give us something to hold onto in the midst of terrifying inner storms. And at the same time, both traditions continuously point us towards facing the ultimate groundlessness of life. Everything changes. Uncertainty is the nature of reality. We can never know for sure what the outcome of any action will be. We can never know for sure what the future will bring.
I believe we need familiarity with both grounded-ness and groundlessness to be fully alive and to not be controlled by our OCD. We need to learn concrete skills for working with our minds and developing touchpoints to return to when things get scary. And we need to have a conscious relationship with uncertainty. Buddhist teachers embody this paradox in their instructions over and over again. Pema Chodron’s book titles alone serve as key reminders to me when I lose my way:
- When Things Fall Apart;
- Comfortable with Uncertainty;
- (Go to) The Places that Scare You;
- The Wisdom of No Escape;
- Start Where You Are;
All of these point me in different ways back to the present moment. They each proclaim the truth that we can never know the future—that really it is an illusory concept. And yet they are all embedded with a call to practice. Yes, life is groundless, but I can learn to relax with that groundlessness, and ride it like a surfer rides a wave. Meditation and ERP can be understood as inner surfing training. They give us techniques for slowly acclimating ourselves to not-knowing, and to the impermanence of all phenomena. They teach us to allow for the ever-changing flow of experience. They only work if we do them in little bits, challenging ourselves continuously, but not overwhelming ourselves.
Stephen Levine would remind us that we need to work first with the 5 pound weights (like minor annoyances, small fears, small distractions, etc.) of our lives. We shouldn’t walk into the gym for the first time and try to pick up a 200-hundred-pound weight (like facing a history of abuse or going straight to our most intense OCD fears.) If we take on too much too quickly, we won’t be successful, likely get injured, and be turned off from working out at all. But we can work out all day with the 5 and 10 pound weights to build capacity. Similarly, we need to bring awareness and attention and re-focusing to all the small hurts and fears and OCD thoughts when they arise. And slowly we build our inner strength. Every moment of courage makes a difference.
The Middle Way
The Buddha talked about spiritual practice as taking “the Middle Way.” He likened it to tuning an instrument—too loose and it doesn’t sound right, too tight and it breaks. Instead we must move forward in appropriately bite-sized chunks. When we choose an obsessive thought and compulsion to challenge, it works best to pick one that generates some anxiety, but not too much. We gradually increase our tolerance for anxiety and uncertainty. This is exactly how most of my teachers talk about mindfulness practice. In Pema Chodron’s words, “The more you run it, the stronger it gets. And the stronger it gets, the more you run it.” She encourages us to think of how we’d like to respond to our current difficulties in 3 years’ time, after we’ve done another 3 years’ worth of work on ourselves. I use this one a lot. If I can’t muster the clarity to respond well to my OCD when it gets strong, I ask myself how I’d like to be able to respond to this in 3 years. I imagine myself farther along on my path, with more confidence and willpower and ease. I gently re-focus my attention on the sensations arising in my body, and let the OCD thoughts go about their merry (or not so merry) way.
Life is groundless. So we practice becoming okay with groundlessness. When our practice stops working, it’s often because it has gotten stuck somewhere—either attached to a feeling or idea and/or avoiding a feeling or idea. So we practice uprooting the stuck place and remembering groundlessness. When we get overwhelmed with uncertainty we return to our anchoring practices. Over time this process seems to become organic and automatic. We internalize it and re-focusing on the present moment in the face of OCD thoughts becomes the most natural thing in the world.
Some days the practices feel natural to me. And on other days they are excruciating and barely effective. I believe that lasting change happens in incremental steps. So every single time I realize I have gotten caught up in my OCD confusion, and then come back to my breath or my body or the energy I feel, is an important victory. No matter how many times it happens.
I’ve seen tremendous growth in both my meditation skills and my ability to re-focus away from my OCD fears over the past 30 years. I look back with great compassion on my teenage self that was devastated by this disease and it gives me courage to carry on, towards possibilities of peace of mind that I probably can’t even imagine at this point.
Those of us with OCD are getting the advanced course in courage in this lifetime. As painful as they are, the fear and the obsessions and the compulsions are ultimately increasing our capacity for courage and trust. We can’t develop courage without fear, or trust without doubt. And because our OCD can lead us into overwhelming pits of fear and doubt, let us remember that these can eventually turn into extraordinary experiences of inner confidence. These very thoughts are our path towards wholeness. They make up our perfect practice and the only way forward I can see.