Accepting and Dismantling Uncertainty

In the last post, I explored the question of why intrusive thoughts are so scary in the first place, and offered two perspectives as to why that may be the case. ERP suggests that it is because of the appraisals and feared outcomes that are attached to those worries, whereas I-CBT suggests it is because of inferential confusion, difficulty in differentiating doubt grounded story versus reality. In both of these scenarios, uncertainty lies at the heart. The question is how we work with this uncertainty. I want to explore two paths, Acceptance and Insight, shifting away from using clinical language to convey the emotional reality behind the terms I’ve introduced so far in this series (i.e. response prevention, inferential confusion, appraisals, safety learning, etc…).

Loss: The Red Pill or Blue Pill

We are all vulnerable. Our lives are finite. Our time on this earth is uncertain. I truly don’t know what tomorrow brings, let alone this next hour. We are enmeshed in a world filled with unknowns where we and those we care about the most are susceptible to injury, loss, and death. It is truly a mystery as to why we are not anxious, stressed, or overwhelmed all the time (though I’m sure many of us feel that way right now at the time being). How is it that we can carry on with our lives, cultivate connection, love, contentment, or any other positive state, in a world that is flooded with threats, vulnerabilities, and uncertainties? This is both an intriguing mystery and testament to the better angles of our nature, our deep resilience as a species.

In the case of OCD, however, this deep existential quandary - which for most people remains beyond conscious awareness - is vibrantly ever present. Often, the core fears and doubts that are at the center of our OCD exist in the future or the past in stories of what could be. This adds a layer of difficulty to doing Exposure and Response Prevention (ERP), since the anchor and source of our suffering exists in possibility and potential. For instance, the OCD sufferer who has intrusive doubts of whether or not they hit someone with their car, is entangled in an obsessional narrative that doesn’t make contact with the here and now, but rather, the then and there. The tragic catch-22 of this fact is that any attempt to seek certainty (rumination, hypervigilance of their behaviors, calling others to seek reassurance, etc.) will forever come up short. Take the OCD sufferer who experiences intrusive thoughts of stabbing or killing their children, who fears that they might do it one day, or doubts what it means about them. Again, these core fears - fearing that they might accidentally murder their children or fears that they are murderous - exist in the future, in potential. Thus, there is no amount of searching, reassurance seeking, or any other kind of safety seeking that could ever allow them to be 100% certain that it won’t happen. After all, no matter how bad we want to be or think we are, we aren’t fortune tellers.

But then, the question is, how do we resolve and come to terms with these fears and build comfort in what might be, since we can’t directly access them? What would need to happen for someone to go from doubting whether or not they might harm their children, will suffer from a terminal illness, or whether or not they have hit someone with their car, to not doing so? This is where we are at a crossroads between two paths: Acceptance or Dismantling. According to Dr. Jonathan Greyson, the success or failure of treatment revolves around the answer to what he terms, The Question: “Are you willing to learn to live with uncertainty?” (Greyson, 2014). At face value most people would answer yes, but let’s sit on what this means for a second. The willingness to live with uncertainty involves a loss, learning to live with the possibility of your deepest fears becoming true - to live in a world where you may harm your loved ones; where you may “go crazy”; where you may in fact contract a terminal illness; where the anxiety or distressing thoughts you fear may persist indefinitely. The non-acceptance of our OCD uncertainties is the very thing that drives compulsive checking, reassurance seeking, and rumination, a subtle non-acknowledging or non-acceptance of reality itself, which will forever have uncertainty.

Thus, true acceptance of and willingness to live with uncertainty is going to involve a loss of the very things that we cling to the most - reassurance, control, or certainty. After all, acceptance and loss go hand in hand. To truly accept something is to lay to rest what could be. The question, then, is whether the loss of reassurance, certainty, or control is a worthwhile trade-off for reconnecting with your deepest values and intentions? Learning to accept or be willing to live with these losses is the first and hardest step towards recovering from OCD (Greyson, 2014).

Thus, recovery from OCD is a process of learning how to be comfortable and live with these uncertainties, which is the whole point of doing exposures and refraining from compulsions. Within this perspective, recovery is similar to the decision Neo from the Matrix faced: take the red pill or the blue pill. Each involved a significant loss. To take the red pill would both shatter and reveal the underlying truth of his reality, plunging him into a deep state of confusion, despair, and existential anxiety. Taking the blue pill would let him return to his familiar life, but doubt and regret would forever haunt him, shattering his former ignorance and sense of reality. In the case of OCD, it isn’t as drastic or existential, but the impact is still there. Learning to accept your OCD fears and acknowledge the potential truth behind them is a tough pill to swallow to say the least, but what is left in its place? Paradoxically, the cessation of obsessive rumination, compulsive avoidance, checking and reassurance seeking, self-acceptance, and self-confidence, and as a result, more time to direct your attention towards what really matters to you.

Dismantling

Yet, no matter how random, disconnected, or confusing our obsessions, anxieties, narratives, or compulsions may seem, there is an underlying logic to them—contrary to conventional perspectives on OCD. (Aarmeda, 2024). We all come to believe things about ourselves and the world based on a set of identifiable variables, or reasoning factors: abstract facts, values, standards, or rules, hearsay, authorities, personal experience, or possibility, among others. (Aarmeda, 2024). Abstract facts are basic truths we understand about the world: people murder each other, natural disasters happen, and germs exist. And we all have accepted ways or rules of doing things according to an accepted principle (Aarmeda, 2024). For instance, how it is better to be “safe than sorry”. Hearsay refers to things we hear other people experience, or observational learning. For instance, learning to not go to a restaurant because your friend said it was awful. Authorities are also another source of belief influence, be it an institution, person, or organization. For instance, during covid, experts said that we should be vigilant to keep our distance and we subsequently did that mostly because we have faith in those authorities. Personal experience is another major source of belief. Our own experiences shape what we believe about ourselves and the world (I’ve gotten angry before. What’s to say that it gets to the point where I “snap”?). To go back to the covid example, we (or most of us at least) came to believe that covid actually existed because a combination of these factors: germs and superviruses exist (abstract facts); we saw on the news an outbreak of a potential supervirus (hearsay and authorities); we and our friends became ill with mysterious symptoms (hearsay and personal experience); and we put safety measures in place to mitigate the damage and spread of the virus (values, standards, and rules). And lastly, possibility refers to really anything else that doesn’t fall in the above reasoning categories and often involves implications, meanings or imaginations we attach to things that logically follows from and reinforces believed truths or facts. For example, why would I ever have a thought of murdering my child if I don’t want to? or I notice a constant tingling sensation in my groin. Each of these statements subtly adds fuel to, for instance, someone who doubts and fears committing aggressive or sexual violence.

Exploring the reasoning factors behind one’s obsessions and doubts can be a profoundly validating and insightful process. It is a chance to extend a hand of self-compassion and paradoxically gain both some perspective and distance from their influence. Doing so is one of the major components of dismantling one of what is termed the “Inner Wheel” components of the OCD cycle. These components give power to the core doubts driving the cycle of obsessions and compulsions: the obsessional narrative, the obsessional reasoning factors, and feared possible self (Aarmeda, 2024). I will explore these ideas more in future articles.

Crossroads

So to come back again to our original question, how do we resolve doubts and fears of what could or might be? Trust and Acceptance. Behind every core obsessional doubt is both a lack of trust we hold about either ourselves or the world and a subtle non-acceptance of a feared possibility that could be true. The end goal of ERP is to build comfort, tolerance, and true acceptance of uncertainty. After all, response prevention is the willingness to accept the possibility of your deepest fears coming true. The end goal of I-CBT is to cultivate self-trust by both promoting insight into the traps of obsessional narratives and subsequently reducing the need for rumination and compulsive safety seeking, which is an interesting concept I will explore in the coming weeks. Each is not mutually exclusive, so the cross roads analogy isn’t fully apt. Each complement the other and, again, the integration of both paths is the most fruitful.

Coming Up

In the next article, I am going to explore the last mentioned “Inner Wheel” factor: the Feared Possible Self, which is a profoundly interesting concept and construct within the I-CBT framework. As always, thanks for your time and attention, and see you next week!

References

Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). Guilford Press.

Aardema, F. (2024). Resolving OCD: Understanding your obsessional experience (Vol. 1). Mount Royal Publishing.

Grayson, Jonathan. Freedom from Obsessive Compulsive Disorder. Penguin Publishing Group. Kindle Edition.