What Causes OCD?

My brother has OCD. Can it be fixed? Is there hope?

First let’s talk about how this term is used. OCD stands for Obsessive Compulsive Disorder. As is often the case with psychological diagnostic terms, this is an extremely broad and rather vague term which can easily be stretched to include every human on the planet at some point in their lives. This is because we all have “obsessive” thoughts when we are stressed, and there are times when those thoughts cause us to feel an overwhelming need to do some kind of “compulsive” behaviour. For example, Jane is all set for bed when she remembers the upsetting article she read earlier that day about how her own neighbourhood was recently burgled. As Jane gets into bed and tries to fall asleep, the details of that article play over and over in her mind and this causes her to feel increasingly upset. At this point we could say Jane is obsessing, because she is. Well, now all of Jane’s obsessing over the concept of burglary is morphing into fears that her own home might be the next target. Did she remember to lock the front door? She is sure she did, but still…maybe she didn’t. The focus of Jane’s obsessive thinking now shifts to images of her own front door standing unlocked and easy for any scary intruder to enter. After squirming uncomfortably in her bed for another two minutes, Jane can’t take the pressure any more. She knows she won’t have any chance of sleeping unless she gets up and checks her front door. In other words, Jane is feeling compelled or driven to do a specific behaviour in order to calm some of the angst in her head. This is how compulsive behaviours work in Obsessive Compulsive Disorders. The problem with this term is that we all experience the sort of angst Jane just went through, and if we were in her slippers, we’d be checking our front doors, too. So what? Do such moments of angst qualify us as having a mental disorder? Just where is the line between normal human behaviour and a disorder?

It’s useful to understand that the vagueness of many mental health labels leaves a lot of room for personal bias to play a role in how quickly a therapist officially diagnoses someone as having a specific disorder. As you can see from the example of Jane, a counsellor who was keen to label his clients as soon as possible could easily find an excuse to diagnose people as having OCD long before he should. One of the things I really like about working outside of the system is I can lay off the labelling. While mental disorder labels have some value in helping people communicate, and while they have some practical value in getting access to certain services and insurance refunds, they also have a major downside. Once you have been formally diagnosed as having a specific mental disorder, that label can hound you for the rest of your life and cause all kinds of hassle. As a counsellor, I prefer to work with people where they are at, and help them understand and deal with symptoms that are bothering them. I don’t bother with using a bunch of fancy jargon. When clients come to me having already attached some scary labels to themselves (which they usually got by reading articles on the internet), I try to discourage them from focusing on the dramatic wording so they can focus on their symptoms instead. When root causes are properly dealt with, symptoms will subside, at which point it is no longer productive or fair to have to go around forever identified by some issue you had in the past.

Now as far as when you should consider someone as having OCD, my guiding principle is that we shouldn’t start viewing obsessive thoughts and compulsive behaviours as a signs of a disorder until those things are significantly hampering someone’s quality of life over an extended period of time. We also need to consider context. It’s quite normal for a new mother to anxiously check if her baby is breathing properly several times throughout the night. She’ll likely keep this behaviour up for quite a while before eventually calming down. When people’s life circumstances significantly change, they should be allowed time to adjust without being told something is seriously wrong with them.

Root Causes of OCD

Now assuming your brother is actually having a problem with OCD and that this isn’t just a case of family members overreacting, let’s talk about root causes. In all cases of OCD, the behaviours feel very important to the person doing them. To outside observers, those same behaviours often seem like a ridiculous waste of time, a bizarre habit, or even a harmful action that is posing a serious threat to someone’s health.

Now my example of Jane was very straightforward, and the behaviour that she felt compelled to do would seem pretty reasonable to most of us. After all, it’s easy to forget to lock your front door at night. But if Jane were to keep getting up to check her door over and over again until she racks up 40 checks in one night, then her behaviour would seem quite unreasonable to other people, plus it would seem like Jane’s compulsions were harming her because she wasn’t getting any proper sleep. This is a common theme with OCD behaviours: they seem over-the-top, excessive and often harmful. But to the person doing the behaviours, their actions feel reasonable, necessary, and important, so they will often take offense if you suggest they are behaving strangely. How can we account for this major difference in perspectives?

In cases of OCD, the purpose of the compulsive behaviours is to manage internal stress. But here is where things get a bit tricky, because OCD behaviours are very symbolic to the person doing them. Once symbolism is added to the mix, we can end up with behaviours that make no logical sense to outside observers. For example, Mason washes his hands over 100 times a day. Not because he’s worried about germs, and not because he’s constantly getting his hands dirty. He just randomly gets up, goes to the sink, and starts washing. He might be in the middle of a meal. He might be in the middle of watching a movie. He might even be in the middle of a conversation. Mason’s friends can’t make any sense of Mason’s behaviour. After all, this is the man who doesn’t hesitate to pop a chocolate into his mouth after it’s been dropped on the floor. The irony of Mason is that he doesn’t wash his hands when it seems obvious that he should–such as when he troops in from rooting around in the garden and picks up his lunch sandwich with mud covered hands. Mason’s wife can’t figure out why she has to nag her husband to wash his hands in moments like that, yet he’ll abruptly leave in the middle of a conversation just to go wash his hands when they aren’t even dirty. All of this excess washing isn’t doing Mason’s skin any favours. His hands are so dried out and irritated that they’re starting to develop a rash, yet he still keeps making a beeline for the nearest sink at random moments, and if anyone gets in his way, his reacts with an alarming degree of anger.

So what’s happening with Mason? Well, what none of his people know is that he was molested as a child, and the molester coerced Mason into touching him in ways that Mason found extremely upsetting. Trauma worsens over time if it is not dealt with, and Mason’s stress over this event in his past has been growing more intense over the years. Mason is now in his 40s and he finds images from that original assault intruding into his thoughts many times a day. Every time those upsetting memories surface, Mason feels morally dirty for the way he engaged with his molester. He then feels an overwhelming need to try to symbolically cleanse himself through handwashing.

Mason’s situation helps us understand a very important point about OCD: this is a coping method that can be driven by the subconscious or the soul. To identify which alpha element is pushing for the behaviour, you need to understand what the behaviour means to the person doing it. Be careful about relying on your own logic here, because as Mason’s case demonstrates, compulsive behaviours can be very symbolic. You can’t eliminate moral guilt through physical actions, yet it is moral guilt that Mason is trying to ease through his handwashing. He is not doing this specific behaviour for psychological reasons. Even though he is currently dealing with a lot of psychological stress over what happened to him, the handwashing is specifically tied to spiritual stress for him, and that’s not going to be an obvious connection for other people.

Now in these cases, the person doing the behaviour will often have a logical explanation for why they do what they do which they consciously focus on at the time they do the behaviour. Trying to get them to share that explanation with you is often the first step to identifying root causes, but approach is very important here. If you use a critical, disapproving tone, you will likely cause the person to shut down and not want to talk to you. Remember that no matter how bizarre the behaviour seems to you, it feels very important to the person doing it. If you want to have any kind of productive conversation, you need to sound interested, not critical. You also need to sound respectful, not condescending.

Now once the logical explanation is given, a mistake people often make is to start a debate in which they try to poke holes in the person’s reasons for doing what they do. For example, Billy spends the majority of his days carefully constructing enormous wooden models of lions…entirely out of toothpicks. Hundreds of thousands of toothpicks. Billy has become so consumed with this “hobby” that he quit a well-paying job and is now spending a good 14 hours a day in his parents’ basement working on his models. Progress is extremely slow when toothpicks are the medium of choice, yet Billy’s perseverance seems to be unlimited as he doggedly presses on every day, slowly constructing his life size models. From an artistic perspective, Billy’s creations are impressive. But from a parental perspective, it’s more than a little disturbing to watch a grown man spend all day every day gluing tiny sticks together. Billy’s parents are completely baffled and quite embarrassed by their son’s behaviour. Billy’s father has given up trying to talk to his son because he just loses his temper and starts yelling at Billy to get a life. Billy’s mother has tried to take a more supportive approach, but even that gets hard when Billy keeps smashing projects that he’s invested hundreds of hours in because they “weren’t right.” It seems Billy has a very specific and narrow definition of how his lions ought to look and he’s determined to create the “perfect” look. In fact, the term “perfect” comes up quite a bit when Billy talks about his lions, and this recurring principle gives us an important clue as to why Billy is doing what he’s doing.

In a case like Billy’s trying to get him to see why using toothpicks is such a poor choice is a waste of time. Efficiency and practicality are often considered of very little value in OCD behaviours, so when you start debating with someone about why their behaviours seem wasteful or impractical, you’re wasting your breath. The goal here is to reduce psychological and/or spiritual stress using highly symbolic behaviours. Rather than focus on the details of what a person is doing, you need to listen for clues about what their overall psychological or spiritual goals are. Very common goals in cases of OCD are trying to gain a sense of power or control, trying to defend against harm, trying to prepare for an attack, trying to ease moral guilt, and trying to keep the conscious distracted so it won’t focus on stressful thoughts.

It’s useful to understand that many of the goals I just listed feel easier to reach if a person chooses a complex activity over a simple one. In Billy’s case, he could have chosen to use plaster, or at least used popsicle sticks. He could also be making miniature lion figures instead of huge ones. But Billy is intentionally making his projects take longer and be more tedious by using the toothpicks and insisting on making the lions life size.

So what’s the point in making a project extra complicated on purpose? Well, the more complicated something is, the more concentration you need to do it. The more you focus on your activity, the easier it is to not think about all of the other things in your life that are stressing you out. In other words, the activity acts as a kind of mental escape, while at the same time letting the person try to collect evidence that they still have some control over their own lives.

As is always the case with any coping method, OCD behaviours are driven by specific goals. In Mason’s case, his soul was trying to manage the stress of its own moral guilt. In Billy’s case, his subconscious is trying to keep him out of harm’s way. From Billy’s perspective, he’s been pushed around his whole life. His girlfriend abused him. His co-workers bullied him. Billy has never learned how to draw healthy boundaries in his relationships, and this causes him to feel defenceless whenever someone starts mistreating him. By hiding out in his parents’ basement working on a project that only he cares about, Billy feels protected from a world that scares him, plus he uses the lion project to give his life a sense of meaning and purpose.

OCD behaviours come in a wide variety of forms. John’s house is packed full of junk because he never throws anything away, plus he is always bringing home more “useful stuff” that he finds lying on the ground, discarded in people’s bins, or selling for pennies in bargain stores. John’s neighbours despise “filthy John” and his disgusting, vermin infested property. The thing is an eyesore and it is driving down the market value of the surrounding properties. But when John wades through his ever growing mounds of debris, he doesn’t see a hazard to his health. He sees security. When John was young, his family was suddenly plunged into extreme poverty. John found that experience deeply traumatizing, and he is so desperate to protect himself from going through that sort of thing again that he hordes everything he can find that seems to have any value to it.

In cases of OCD, the person must want to change before anything useful can be done. They aren’t going to want to change until they are able to admit that their current situation is miserable. As is often the case with trauma coping methods, people can be very reluctant to view their chosen method in a negative light because that is the thing they are depending on to help them survive. This means that your brother might not be willing to see his OCD behaviours as being a problem–instead, he’s more likely to defend them unless they are causing him a lot of personal hassle.

Some OCD behaviours involve direct self-harm. Cutting one’s own body is an example here. Because cutting causes a lot of pain and ugly scars, the person doing the cutting will often be more willing to admit that their coping method is problematic. But even in cases where the person agrees his behaviours are negative, you can’t expect him to instantly stop doing those things. To resolve these situations, the underlying cause of stress needs to be dealt with. For example, in many cutting cases, the underlying cause is spiritual stress with the cutter trying to symbolically punish himself for being a bad person or for causing problems for others. But in other cases, cutting is driven by psychological stress. An easy to miss issue that is sometimes happening in this second situation is severe emotional suppression. Often the person is sitting on mountains of emotional pain due to very wounding experiences they’ve been through, only they are so emotionally suppressed that they are unable to vent their pain through normal crying. As their minds become desperate to vent stress, they start trying to create situations in which they can basically have an excuse to cry without having to directly acknowledge how much pain they are in. Crying over body pain, for example, can feel safer than directly crying over emotional pain. By inflicting severe pain on his own body, a person can trigger a normal body reaction of crying to vent physical pain. Once the tears start flowing, his subconscious can use that opportunity to also vent psychological pain. Again, this sort of rerouting occurs because the subconscious feels like it is too unsafe to express its pain directly, so it comes up with a distracting cover story (“I’m not sad; I’m just crying because my arm is burning”).

In all cases of stress, there is a perceived cause of stress. This means that your brother is not only feeling stressed internally, but he also has a specific idea about who or what is responsible for making him feel so stressed. When the perceived cause of stress is a family member, then family intervention can make the problem worse, because such interventions often cause the stressing person to feel more stressed as their “enemy” tries to get more into their personal business. This is why it’s a much better idea for your brother to talk to a counsellor who has no connection to your family. An outsider is going to feel a lot safer for your brother to talk to, especially if he feels threatened by certain members of your family for any reason. Family members have a lot of shared history with each other, and while that can be a major asset in some situations, it is usually a major detriment when it comes to creating a safe environment for someone to talk about their personal struggles. You aren’t going to feel free to be totally honest with someone who you feel you depend on because there is always the fear that they might disown you if you say something they don’t like. With a counsellor who is behaving correctly, that threat is removed, as is the fear of having things you share be repeated to other people in your life. The confidentiality of the therapist-client relationship plays a key role in creating a safe environment for the client, and a person must feel safe before he is going to risk talking about his greatest fears and struggles.

This post was written in response to Mako.