If you struggle with contamination-focused OCD (or any OCD), cognitive behavioral therapy with an emphasis on exposure with response prevention and mindfulness can teach you how to win back that time, spend it with your loved ones, on your career, out in public experiencing the world.
Time. This is the answer I usually get when I ask a client what he has lost most to his OCD. All compulsions take time, whether they involve washing, repeating, or just separating yourself from the present moment to analyze your thoughts and feelings. Though a fear of getting sick and a disgust response to the generic issue of “germs” most certainly burdens a large number of contamination-focused OCD sufferers, I have seen no single issue take as much time from a person as the fear of and disgust with human bodily waste.
The human body is a system. Systems take in fuel and turn it into energy, which creates a waste byproduct that is eventually removed from the system. While inside the system, as long as it is within reasonable limits, this waste causes no problem to the system itself. This is true also of how humans think about it. Right now, as you read this, there is waste inside your body. This typically does not cause any automatic reaction. It’s like being aware that there is trash in the trash bin, where it belongs. But if the same trash is on your pillow, you feel differently about it. Now consider your perfectly situated bodily waste outside the body, improperly disposed somehow. For this, we are wired to shrink in disapproval.
Fear or disgust of bodily waste is near the top of the list of contamination fears when assessing obsessive compulsive disorder using the common Yale Brown Obsessive Compulsive Scale. Though people may not like to talk about it out of politeness, this very common obsessive concern can disrupt and impair healthy functioning on multiple levels.
Common obsessive concerns with bodily waste:
- I will spread e. coli or some other dangerous bacteria/virus
- I will be seen spreading urine or feces somehow and will be humiliated in public, judged by my peers
- I will get bodily waste on objects I want to be clean, or objects I use every day, and will contaminate and rec-contaminate myself over and over again
- People will find bodily waste on me or on my clothes and mock me, shun me
- I will get a terrible disease from someone’s bodily waste or give a terrible disease to someone else
- I will find bodily waste somewhere (on me or near me) and I will become so overwhelmed with disgust that it will render me incapacitated
- An object was once in contact with bodily waste and I can’t bear to think of ever touching it again
- I will never attain the feeling of “clean” again
Common compulsions associated with fear of bodily waste:
- Excessive/ritualized hand washing or showering (both generally and specifically before and after using the toilet)
- Excessive wiping after elimination (even to the extent of bleeding)
- Excessive checking of toilet paper, studying to get certainty that no traces of fecal matter remain on the paper
- Avoidance of washing other parts of the body in the shower after having washed anus or genitals
- Avoidance of public restrooms or other environments where bodily waste may not be properly handled
- Excessive checking for brown marks on objects or other visual cues that could be considered signs of bodily waste
- Reassurance seeking about whether items have been contaminated
- Attempting to control the behavior of others to ensure that they meet OCD hygienic standards
- Compulsive repetition (with or without superstitious numbers) for wiping and washing away bodily waste
- Avoidance of objects believed to have been contacted with unclean hands, even after multiple levels of indirect contact
- Avoidance of objects believed to be contaminated at one time, despite having been cleaned
- Avoidance of body parts or of clothing that may have touched body part associated with bodily waste
- Excessive or ritualized washing of toilet before/after using
- Throwing away clothes or objects associated with contamination
- Avoidance of social activities for fear of becoming contaminated or having a humiliating “accident”
- Mental review of what things have or have not been contaminated
Cognitive Behavioral Therapy for OCD When it Comes to Bodily Waste
As with other contamination concerns, the most common mistaken beliefs are a result of black and white thinking and catastrophizing. The OCD sufferers sees the world as being 100% free of bodily waste or 100% contaminated by it. This leads either to compulsive attempts to wash away perceived contamination or compulsive checking to ensure the absence of contamination. In terms of catastrophic belief systems, a sufferer may find himself saying or believing, “If there is even a molecule of fecal matter on this, it’s the end of the world.” The core error in catastrophizing is not just the false assumption that we can predict the future, but that we will fail to cope with the future being different from the way we want. So, a thought about spreading fecal matter is not just a distorted assumption about a future event, it is also an obsessive concern with not being able to handle such a discovery.
In treatment, cognitive approaches to these obsessions include challenging the notion that we are 100% clean or dirty and challenging the assumption that we are incapable of handling things we don’t want to happen. As I write this, I think of my hands as clean. I washed my hands the last time I used the bathroom, and I haven’t touched much else… except the door to the bathroom, the door to my office, the arm of my desk chair, the surface of my desk, and the keys of this computer. OK, maybe my hands aren’t clean. Maybe they are just… hands.
ERP for OCD About Bodily Waste
The difference between ERP and just being a regular person doing regular activities has a lot to do with attention and intention. When a person without OCD touches a tv remote while watching her favorite show, then grabs a handful of popcorn, this is not called an exposure. When an OCD sufferer engages in the same behavior, but also experiences thoughts about bodily waste potentially being on the remote, on the hands, in the mouth etc., then this is called an exposure. The response prevention is simply staying there in the moment, watching her show, and not washing.
The key to developing a good exposure plan is looking at the area of your life that is impaired by the washing, avoiding and other compulsions, and creating a hierarchy of what you are willing to change. It may start with gradually reducing the amount of wiping or washing that takes place in the bathroom and lead up to touching items that are triggering and cross-contaminating from there. This may include touching areas of the body that are challenging because of their associations with bodily waste. It may start very indirectly, as in allowing a “clean” item to be placed on a chair that had previously been condemned as “dirty.” If family members or others are involved in accommodating compulsions, creating a plan for gradually reducing these accommodations is important as well.
Exposure therapy doesn’t always involve doing disgusting things. We joke about licking toilet seats or eating off the bathroom floor, but these on-the-nose exposures are rarely necessary (they are sometimes absolutely necessary). Generally speaking, OCD is more clever and subtle than we give it credit for, so exposures need to be tailored specifically to target more than the literal poop. It has to target the feelings above all. Most compulsions are driven by a desire to avoid feeling something, not by a rational or semi-rational desire to avoid bodily waste. Though intense exposures may involve going beyond what a sufferer may view as a cultural norm (and work effectively), I have found that people often must only believe they are approaching their OCD boundaries and feel at risk of stepping over them. For one person, this may mean leaving a public restroom without washing her hands, and for another, it may mean wearing a shirt that was hanging next to another shirt that had been touched with unclean hands. Through repetition of ERP exercises and the commitment to resist compulsions, a person with contamination OCD can learn to relate differently to thoughts and feelings about bodily waste.
Mindfulness and Bodily Waste
The thing about bodily waste obsessions is that we are all generally wired to make the same face of disgust when we think hard enough about it. This disgust feeling may have other emotional collaborators, such as shame, fear of social ridicule, and health anxiety. These thoughts and feelings are difficult to tolerate and it’s natural to put up resistance to them. The problem is when this resistance becomes so severe that the thoughts and feelings become stuck, and the only thing you can think of to unstick them is a compulsion. Developing strong mindfulness skills can enable you to observe these thoughts and feelings without judgment and allow them to come and go without the mandate to over-respond.
Taking Back the Time That is Rightfully Yours
It’s easy, too easy in fact, to find humor in our evolved human discomfort with bodily waste. But OCD sufferers with more severe contamination obsessions stare down the barrel of life every day contemplating perpetual shame, disgust, and unhappiness. This is not the way it has to be, because OCD is a treatable mental health issue. Yet it remains a daily struggle for millions of people who are either unable to access quality treatment or discouraged from doing so because of cultural stigma about mental illness and getting help for it.
Life is not short. It is long and slow. It is for this reason that we cannot spend time doing compulsions, trying to be perfect, trying to avoid feelings, because if we do, we will be doing it for a very, very long time. If you struggle with contamination-focused OCD (or any OCD), cognitive behavioral therapy with an emphasis on exposure with response prevention and mindfulness can teach you how to win back that time, spend it with your loved ones, on your career, out in public experiencing the world. By combining strategies that involve non-judgmental observation of thoughts and feelings, challenging distorted beliefs, and gradually exposing to triggering situations while reducing compulsive responses, you can develop mastery over your OCD. If you are going to spend big, it should be on something that matters to you. So, if you are going to spend large amounts of time on something, it should be on liberation, not submission to your disorder.
Jon Hershfield, MFT is a psychotherapist and director of The OCD and Anxiety Center. Follow him on Twitter and Facebook.