Fear of Sadness and OCD
In order to maximize the effectiveness of ERP for OCD, it’s important that we don’t only focus on surface level fears. We need to explore, identify, and connect with the chain of fears underlying our triggering moments. The bottom of this chain is an important source of our anxiety and, as a result, our ongoing OCD symptoms.
But what if the root of our fears isn’t just about feelings of anxiety about a scary, unwanted event? What if the root of our fears is, at least in part, a fear of sadness. This is the idea we’ll explore in this post. To do that, we’ll review an example of core fear identification in a clinical setting, the relationship between core fears and safety behaviors, the role of reducing safety behaviors in ERP treatment, and, finally, the relationship between OCD, anxiety, and sadness. My hope is that anyone reading this is motivated to spend more time exploring, identifying, accepting, and validating their sad feelings as a normal, understandable, and important part of living (and living with OCD).
An example of Core Fear Identification:
Mendy came to see me because of her OCD-related experiences around her emails.
Mendy: “William, sometimes I check my work email inbox for three or four hours each night. No matter how long I check my email, I keep having the thought, What if I’m missing an important email? I’ll sit on my couch at home, staring at my inbox, scrolling through my emails, making sure I’ve responded to each one. And then I’ll get worried that I might have accidentally deleted an email instead of replying to it and so I obsessively check my “trash” folder. On top of all this, I also really struggle with emails I have sent. I worry I might have, somehow, wrote something absolutely terrible in the email. What if I used a racial slur? Or profanity? So, I read and reread my sent emails over and over. It’s ruining my life.”
What a painful situation. Mendy is concerned that she might have missed an important email or, alternatively, wrote something awful in an email she’s sent. These thoughts make Mendy feel very anxious and, motivated by this anxiety, Mendy checks her inbox and trash, sometimes for hours, to do her best to make sure that she’s not missed an email, not written something terrible, and that she’s going to be safe.
What Mendy’s reviewed with me so far is important. But, in ERP treatment, we go further:
William: “Mendy, it sounds like you have thoughts that something related to your email could result in something bad happening. It seems like these thoughts make you anxious, which makes a lot of sense. Your anxiety’s job is to keep you safe. You’re having thoughts that you might not be safe and, thus, your anxiety activates and motivates you to do whatever you need to do in order to transition from not safe to safe. Is this sounding about right so far?”
Mendy: “Yes, that’s exactly right. I get so scared that something bad might have happened with my emails. Like you said, that’s why I spend so long checking my emails.”
William: “Mhm. And I think I’m hearing you say that there are other thoughts related to your email. Thoughts like, I didn’t see any racial slurs in the email I just reviewed, but what if I didn’t read the email right and I somehow skipped over a racial slur that I inexplicably wrote in the email?”
Mendy: “Yeah, that’s there too.”
William: “And you’ve let me know that even though these thoughts really do make you feel anxious, another part of you has this sense that something is off. That you don’t want to spend three hours every evening checking and re-checking your inbox.”
Mendy: “I hate it so much, William. My kids will want to spend time with me and I shoo them away because I feel like I need to be fully concentrated on my inbox.”
William: “On the one hand, you want to protect yourself from your inbox. But, on the other hand, you have this feeling that something is wrong with how much time you're obsessed, anxious, and stuck looking at your inbox.”
Mendy: “That’s right. I don’t know what to do.”
What Mendy and I have done so far is to identify the initial sorts of experiences that have led her to see me. She finds herself getting stuck with thoughts and feelings about email-related disasters and her current way of managing these thoughts and feelings is to spend hour after hour checking her email in an attempt to be certain that nothing bad will happen.
Identifying Core Fears
Unfortunately, no matter how much time she spends doing this, the unwanted, distracting thoughts and related painful, anxious feelings come back again. These thoughts and feelings motivate her to spend more time checking, resulting in her feeling stuck and missing out on time with her children. She has the sense that something is “off” about this entire experience, that she “shouldn’t” be so obsessed, anxious, and participating in hours of email checking. But she finds it very painful to stop checking.
One of Mendy’s next steps is to go further into her fears. Currently, Mendy’s fears are implied but not explicit. We want to explore and then, as precisely as we can, identify what fears underlie her experiences.
Our conversation continues:
William: “Mendy, can you help me understand what might happen if you did make a mistake in your inbox? What might happen if you didn’t respond to an important email?”
Mendy: “Well, even here I know it sounds crazy. But I worry that if I miss an important email then I’ll get fired. The reason I know it sounds crazy is I always get really great reviews from my supervisor and I haven’t missed emails before. This is what my husband has told me and what my human resources person tells me. But it doesn’t really help. I always seem to come up with some scenario where the email I miss is especially important and I have to be fired even if my supervisor doesn’t want to fire me. Like one of our important clients gets so upset that an urgent email wasn’t responded to that they demand I be fired or they’ll leave and take all their business.”
William: “Oh, so you have this story that unfolds in your mind and, even though you feel like the story might be unlikely, you keep being presented with ways in which it could happen.”
Mendy: “That’s exactly right. My husband gets so frustrated because, to him, there’s just no way I’d get fired for something like that. But I still get the thoughts and feel scared.”
William: “So what might happen if you did get fired?”
Mendy: “I don’t like that idea. Just thinking about it makes me upset. I feel even worse because my husband has reviewed with me so many times that even in the unlikely situation where I do get fired, I wouldn’t have a hard time finding another job.”
William: “Have you had thoughts that, someway, somehow, you might not be able to find another job?”
Mendy: “Yes! What if my potential new employer contacts my former employer and my former employer tells them that I missed an important email, or wrote a racial slur in an email, and that keeps the new employer from hiring me?”
William: “Right. And what might happen if, not only this possible new employer doesn’t hire you, but no other employer will hire you?”
Mendy: “Yeah. That’s the idea always lurking in the background. That I won’t be able to find any other job.”
William: “What might happen if you weren’t able to find another job?”
Mendy: “I know I might be sounding like a broken record, William, but my husband has reviewed this with me so many times. He tells me that even if I couldn’t get another job, things would be really, really tight financially but we’d get by. But, this is where I start wondering, what if my husband somehow loses his job too. If we both lose our jobs, things wouldn’t just be really, really tight. It’d be a disaster.”
William: “What kind of disaster might it be?”
Mendy: “We might lose our home. My kids wouldn’t be able to participate in the activities they do now, because we wouldn’t have any money. I know this sounds way out there, but I worry that I might somehow have to give my kids up because I can’t afford to take care of them.”
William: “That sounds so painful. Is what you’re telling me, Mendy, that while most nights you’re not even thinking about the idea of losing your kids – you’re almost entirely preoccupied with the thought: ‘What if I’ve made a critical mistake in my inbox?’ – when we trace out what really scares you, way down the line, it’s the idea of one thing leading to another and your financial situation becoming so dire that you have to give up your kids?”
Mendy (begins softly crying): “I can’t remember the last time I actually thought about losing my kids. Like you said, in the heat of the moment, I’m just so focused on email, email, email and so anxious. But, that’s where it leads. The idea of losing my kids.”
From a clinical perspective, what Mendy and I have collaborated on is a deeper exploration and identification of at least one of her core fears. Mendy clearly doesn’t want to make a mistake with her emails. But making a mistake with her emails is not the real source of power behind her obsessions, anxiety, and compulsive behaviors. The real source is the powerful fear of losing her kids.
Avoidance and OCD-related Experiences
If we only focus on the surface-level presentation of her concerns, we’ll miss the underlying source of her OCD-related dynamics and her healing is not likely to be effective. Instead, in ERP treatment we include direct intervention on the deeper drivers of Mendy’s OCD-related experiences, and, as reviewed in the dialogue above, one of those deeper drivers is the very scary story of her losing her kids.
ERP intervention related to Mendy’s core fears of losing her kids wouldn’t be focused on in-vivo exposures during which Mendy responds to her emails and doesn’t check her inbox for missed emails and doesn’t check emails for racial slurs (although these sorts of exposures would still be a part of her treatment). Instead, ERP treatment for Mendy’s core fears would involve imaginal scripts in which we tell the story of Mendy’s core fears occurring. In these imaginal scripts, Mendy and I would work together in creating a story in which she does make an email mistake, which does result in her finances spiraling out of control, which, does result in Mendy losing her kids.
But why in the world would we focus on such a painful story? The ERP-based answer to this question is: Because Mendy’s current approach to thoughts, images, and feelings related to her core fears is avoidance and her avoidance maintains her OCD-related experiences, keeping her stuck.
I very much hope you’ll pause, take a deep breath, and let the paragraph above sink in (maybe even reread it). The key idea is that avoidance maintains the OCD-related experiences. This idea is so important to grasp because it points to one of the key levers for overcoming OCD, which is identifying, reducing, and eliminating avoidance behaviors.
Let’s make this key idea concrete.
Typical ERP conceptualization suggests that Mendy’s compulsive email checking is, in fact, her way of avoiding her thoughts and feelings related to losing her kids.
For instance, if Mendy has the doubt “What if I missed an email?” she instantly feels anxious. She doesn’t want to feel anxious. Since she has the sense that the doubt “What if I missed an email” caused the anxiety, she’s motivated to, somehow, get rid of the doubt. Her primary way of getting rid of the doubt is to participate in her compulsions (checking her email).
Participating in her inbox checking compulsions gives Mendy access to a new thought: “I’ve checked my inbox and I’ve not missed any emails.” Mendy then uses this new thought (“I’ve checked my inbox and I’ve not missed any emails”) to neutralize, push away, avoid, her initial doubt “What if I missed an email?”
The same process is going on in someone with the intrusive thought “What if I have a deadly germ on my hand?” That thought makes them anxious. They don’t want to feel anxious. They have a sense that the doubt “What if I have a deadly germ on my hand” caused the anxiety, so they’re motivated to, somehow, get rid of the thought. Their primary way of getting rid of the thought is via their compulsive behavior (washing). The washing gives them access to a new thought: “I don’t have a deadly germ on my hand, I just thoroughly washed my hands” and they use that new thought to neutralize, push away, avoid their initial germ thought.
Unfortunately, as is well known to anyone with OCD, this process only sets the stage for the next doubt “But what if, somehow, even though I checked my inbox I still missed an email? (or: “What if I missed a spot on my hand during my wash?”)” and on and on the OCD-cycle goes.
From the ERP conceptualization point of view, while Mendy’s anxiety is understandable (who would want to experience these sorts of thoughts and feelings?) and her attempts to get away from her anxiety are also understandable (who likes feeling like that?), her attempts to get away from her unwanted, distracting thoughts and painful, anxious feelings have resulted in her becoming stuck in a cycle that’s taking over more and more of her life. From this perspective, Mendy’s avoids her thoughts and feelings related to emails (and the underlying fear of losing her children) by compulsively checking her inbox and this compulsive checking is what researchers refer to as her safety behavior.
Although her safety behavior momentarily makes her feel better, in the long run it’s what keeps her stuck. Mendy doesn’t enjoy her safety behaviors. She hates them. But abstaining from her safety behaviors puts Mendy into contact with even more painful thoughts and feelings associated with Mendy’s core fears. Thus, she continues to use her safety behaviors to provide some relief.
Imagine someone offering Mendy a choice: “Mendy, I can cut off one of your fingers or I can cut off all of them.” Mendy doesn’t like having a finger chopped off. But she prefers to lose one finger to losing all of them. Likewise, Mendy doesn’t like sitting on the couch hour after hour checking her emails but she prefers sitting on the couch to what she’s expecting to experience if she doesn’t check her emails: Extremely distracting thoughts and related painful, anxious feelings about what might happen.
Why do I write that Mendy’s safety behaviors maintain her OCD – that Mendy’s safety behaviors keep her stuck? We won’t do a deep dive on that question here. For now, we’ll give just one example of how safety behaviors maintain OCD: Mendy’s safety behaviors prevent learning of disconfirmatory information.
What in the world does this mean? A number of things.
If we were to ask Mendy something like, “Mendy, how many times have you missed an important email?” she would probably reply, “Zero times!” And, if we followed up by asking, “Oh, how is it that you’ve kept yourself safe from ever missing an important email?” she would reply, “Because I spend three hours checking my inbox every evening.” In other words, Mendy’s interpretation of her experience is that because she participates in her compulsive email checking, she doesn’t miss any emails.
Likewise, if we were to ask someone who compulsively washes their hands “How often have you died from a deadly germ?” they would reply “Zero times!” And, if we followed up by asking, “Oh, how is it that you’ve kept yourself safe from ever dying from a deadly germ?” they would reply, “Because I spend six hours washing my hands every day.”
Likewise, if we were to ask someone who compulsively stands far away from other pedestrians and always keeps their hands firmly lodged in their pockets “How often have you uncontrollably pushed someone into oncoming traffic?” they would reply “Zero times!” And, if we followed up by asking, “Oh, how is it that you’ve kept yourself safe from ever uncontrollably pushing someone into oncoming traffic?” they would reply, “Because I never go near anyone and always keep my hands firmly lodged in pockets!”
However, in all of these examples, those suffering with OCD are participating in a logical fallacy. The logical fallacy post hoc ergo propter hoc ("after this, therefore because of this") occurs when someone assumes that because one event follows another, the first event caused the second event. In the context of OCD, a person might perform a safety behavior (like excessive handwashing) and then see that nothing bad happened afterward. They may then wrongly conclude that the safety behavior prevented harm. This mistaken belief reinforces the compulsive behavior, even though the feared outcome almost certainly wouldn’t have happened regardless (“certainty” is a key idea in OCD and typically is involved in this reasoning process; learn more here and here and here). It’s a classic example of confusing correlation with causation.
But this prevention of learning disconfirmatory information doesn’t only apply to the bad events happening in the world (e.g., dying from a deadly germ; pushing the person into traffic). Another form of this prevention of learning disconfirmatory information is that the individual is never given access to the information demonstrating:
That they can handle the unwanted thoughts and feelings
They can meaningfully engage in their lives even when the unwanted thoughts and feelings are present
That the unwanted thoughts and feelings will pass on their own without neutralization or avoidance
For example, if we asked Mendy, “Hey Mendy, how many times have you had thoughts that you might have missed an email, felt really anxious about that possibility, and then done nothing (abstained from compulsions) and noticed that you could handle the thoughts and feelings, you could do other things even when the thoughts and feelings were present, and that the thoughts and feelings went away on their own without you neutralizing them?” She’d probably reply with, “Almost never!” or “I can’t focus on anything if I don’t check my emails!” or “If I don’t check my emails when I get the thought, I’ll be so anxious that I just couldn’t stand it!”
Mendy has little to no access to information about what might happen if she doesn’t participate in her safety behavior of checking her email. When she has a doubt about her email, she becomes anxious right away and instantly begins checking her inbox. Her participation in her safety behavior is typically instant, automatic, and, although unpleasant, provides some level of relief.
Although Mendy isn’t typically aware of this, underneath the surface of Mendy’s automatic anxiety (as demonstrated in the dialogue with Mendy presented above) and participation in her safety behaviors are her appraisals of what might happen if she doesn’t participate in her safety behaviors. Those appraisals are that:
She might lose her kids
Even if she doesn’t lose her kids, she would be stuck with unwanted, distracting thoughts and related painful anxious feelings that make it difficult (or “impossible”) for her to meaningfully engage in her life until she’s neutralized the unwanted thought
(“2” is an example of a metacognitive fear and it’s a big part of many peoples OCD – I discuss metacognitive fears here and here).
Both of these possibilities are scary and underlie Mendy’s unwanted, distracting thoughts and painful, anxious feelings. If, upon the activation of Mendy’s unwanted, distracting thoughts and painful, anxious feelings, she participates in her safety behaviors (checking her emails for hours), it won’t feel good (Mendy hates checking her emails) but checking her emails will feel less painful than abstaining from checking her emails. Not checking her emails will put Mendy into more direct, immersive contact with her unwanted, distracting thoughts and painful, anxious feelings (e.g., I might lose my kids and I’m not doing anything about it; I might be stuck with these thoughts and feelings all day / week / month long and I’m not doing anything about it; painful feelings in her body such as tight chest, pit in her stomach, hot head, or whatever other way her anxiety shows up physiologically).
With all this information in place, we can now connect it with the way that our imaginal exposures work. In our imaginal exposures, we tell the story of Mendy not completing her safety behaviors (because she wants to overcome her OCD), Mendy then missing an email, and, after a chain of events, Mendy losing access to her children. When we put Mendy into contact with this story (and the thoughts and feelings within the story), it won’t feel good. It will likely be very painful. Normally, Mendy avoids those painful feelings. But, in ERP, she leans into those feelings. Leaning into those feelings allows Mendy access to new information, including the new information what happens to her if she lets the unwanted, distracting thoughts and related painful, anxious feelings be there. That new information will almost certainly be that Mendy:
Can tolerate the thoughts and feelings even though they are distracting and painful
Can meaningfully engage in her life even when these thoughts and feelings are present
Notices these thoughts and feelings don’t last forever
Sees that her feared outcomes don’t occur.
Phew. We’ve covered a lot of ground. But none of it has explicitly touched on the idea of sadness. We’re now ready to circle back to the central idea of this post: The possibility that Mendy’s “core fear” isn’t just about anxiety.
Staying connected to the things we love
Time and again in my practice, the fear and avoidance of the core fear (whatever that core fear happens to be) is, in fact, on top of a deeper kind of avoidance: The fear and avoidance of sadness.
Why does this make sense? In large part, because we don’t feel anxious about things that, at bottom, wouldn’t make us sad. For instance, what would it feel like if Mendy actually lost her children? What would it feel like for her, at the very end of the day, if this tremendously scary story came to be? Sad. Deeply, heartbreakingly, sad.
Why would it be so sad? Because Mendy loves her children and deeply desires to protect them. It’s because Mendy loves her children so much, because Mendy would experience so much sadness if she was unable to protect them, that Mendy’s anxiety enters the frame. Her anxiety says, upon getting a glimpse of the heartbreakingly sad story, “NOT ON MY WATCH!” and then proceeds to provide Mendy the resources Mendy can use to prevent the sad story from happening (e.g., anxious energy, hypervigilance, etc).
That anxiety isn’t bad. That’s why human beings have anxiety: To keep us, and the people, creatures, values, and things we care about, safe. To keep us from having to feel so sad if the people, creatures, values, and things we care about are damaged or destroyed.
However, as those of us with OCD know too well, our anxiety, though well intentioned, can go off the rails if we demand that we be “100% sure” they we, and the things we care about are safe. That’s why one of the most common ideas in the world of OCD is “intolerance of uncertainty”.
But, what I’m suggesting here is that that intolerance of uncertainty might often be an underlying intolerance of sadness.
It’s understandable we wouldn’t want to experience sadness. Especially if we thought there was something we could do to prevent the event that generates the sadness from occurring. We might ask: “Why risk allowing the sad event to occur if I can still do something to prevent it?” And so our anxiety activates and provides us the energy to do whatever we can to keep the sad thing from happening. But, no matter how hard we try, there’s no 100% guarantee we can prevent the sad event from happening. So, there’s no 100% guarantee we can prevent the sad feelings from manifesting.
And really feeling those sad feelings can feel like giving up. Like surrender.
But the reality is that, no matter how hard we try, we are vulnerable in the world. Our best plans don’t guarantee the safety of the things we love. And the experience of sadness is the price we pay for loving things.
Being honest about that price isn’t surrendering. It’s staying connected to the things we love all the way to the end.
I don’t see any way around this. And, unfortunately, I see many of my clients trying, often desperately, to create some way around it. I suspect their desperation is often because they have an underdeveloped, or even adversarial, relationship with their feelings of sadness. They don’t like their sad feelings. They’re afraid of their sad feelings. They may even be ashamed of their sad feelings. So, if there’s even a small possibility that they may become sad (e.g., Mendy misses an email which does, after a series of events, result in her losing her children), they’ll do something, anything to prevent that sad feeling from manifesting.
But, just like there’s now way around uncertainty, there’s no way around sadness. To live is to love and to love is to open ourselves to sadness. Thus, perhaps the truly deep exposure for those of us with OCD is to explore, identify, accept, and validate our feelings of sadness – and the love that lives underneath.