How exposure therapy helped me hack my OCD brain and eliminate my greatest fear
One day, my therapist entered the room carrying an armful of kitchen knives and laid them in front of me. Only then did the severity of my obsessive-compulsive disorder become clear.
For the past year and a half, I had constantly envisioned vivid, horrifying scenarios in which I “snapped” during minor arguments, grabbed a nearby knife and brutally murdered my friends and family.
Pleasant, everyday activities, like chopping vegetables, felt like the precursors to violent, gory tragedies. At any given moment, I was acutely aware that I could turn toward my boyfriend and, in an instant, commit a horrible crime that would upend my life and end his.
The more I tried to suppress these thoughts or remind myself I didn’t actually want to do the things I was picturing, the stronger and more painful this cycle of thoughts became. No matter what logic I tried to use to quell my fears, my brain just seemed to automatically come up with a scenario to get around it.
“Why do I keep imagining these horrible things?” I wondered repeatedly. “What does it mean that I keep imagining myself hurting people? Do I actually want to hurt them? I don’t, right? But what if I secretly do?”
The thoughts consumed me. For months, in the time leading up to my college graduation, I suffered silently. I was certain that my loved ones would think I was dangerous — that I was truly the monster I kept imagining in my head.
When I finally decided that these thoughts were too painful to keep to myself, I made an appointment with a therapist, Reed Smith — who, quite frankly, I expected to call a mental hospital and have me locked away.
Fortunately, he did nothing of the sort. He diagnosed me without much trouble. And then the exposure therapy began.
This is what OCD does to your brain
The misconceptions I had about obsessive-compulsive disorder were fairly common. I thought OCD made people unreasonably fearful of germs and preoccupied with washing their hands, or forced them to flip the lights on and off a dozen times before leaving a room — but I never really considered why they felt compelled to do these things.
But OCD, which affects about 1% of the adult population, describes a mental condition in which people become almost singularly focused on “uncontrollable, reoccurring thoughts” and engage in some kind of behavior that’s intended to alleviate the anxiety associated with these thoughts. In almost every single case of OCD, the obsessions have to do with being unable to tolerate any kind of uncertainty around a particular situation — wondering whether they’ll get sick, if they’ll “go crazy” and hurt their family or whether they turned off potentially dangerous household appliances before leaving the house, for example.
So, in the iconic OCD case of someone who is scared of germs and washes their hands over and over, the person’s fear of illness is the obsession, and the hand-washing is the compulsion intended to ensure that their fears won’t come true — but people with OCD never feel that sensation that their fear has been solved. In a phone interview, Jonathan Grayson — author of Freedom From Obsessive-Compulsive Disorder and director of the Grayson L.A. Treatment Center for Anxiety and OCD — likened OCD thoughts to a deeply rooted survival mechanism gone awry.
Jonathan Grayson likened OCD thoughts to a deeply rooted survival mechanism gone awry.
“The trouble is that with OCD, sufferers tend to be very creative, because the core of creativity is saying, ‘What if?’” Grayson said. “Sufferers are really good at that. ... The thing about creativity, is that it’s not for art as some people think. Creativity is really survival. It’s about saying, ‘Where’s the tiger? Can I make sure it doesn’t eat me?’”
But with OCD, what starts as an effort to stay safe gets out of hand and morphs into increasingly complicated, life-disrupting rituals. In reality, these rituals are little more than avoidance behaviors that prevent the person from actually processing their fears, increasing the severity of those fears over time. These fears are typically highly specific to one situation in particular.
“The thing is, in your non-OCD life, you cope with uncertainty all the time,” Grayson said. “I will ask sufferers, ‘Are your spouse and your parents alive?’ They’ll say, ‘Yes,’ and I’ll say, ‘How do you know?’”
To be clear, virtually everyone engages in behaviors to assure themselves that something is or isn’t true — walking back home when you’re halfway to the train to make sure you actually locked the door, for example — but the difference in people with OCD is that they constantly have the feeling they need to address some unanswered question. Therein lies the torture.
In my case, the obsession involved violence. The thought that there was nothing stopping me from stabbing my boyfriend while I was holding a knife paralyzed me with unbelievable fear, and I could never assure myself that I absolutely, never would act on those thoughts. It was a lot like that moment when you’re standing on the edge of a cliff and suddenly realize how easy it would be to jump, or when you unexpectedly envision yourself pushing a stranger in front of an oncoming train — but my brain held onto those images and dissected them from end to end. I simply couldn’t move past it.
The science of exposure therapy
Imagine you’re deathly afraid of holding your breath and going underwater in a swimming pool. In order to work your way up to eventually confronting that fear, at first you might just step one foot into the water. Once you get comfortable with that, maybe you put your other foot in. Then you might take another step down, until both your legs are completely submerged. Eventually, once you get used to the sensation of each iterative step, you’ll find that going completely underwater is just the next small step in the process. That’s the basic process of exposure therapy.
“Adaptation is really the key concept,” Smith, my therapist, explained over the phone. “In other words, the body and the brain have this ability to be very sensitive to things that are dangerous, to notice the little sound that was unusual in the night, for example. But it also has this ability to rule out things as they are found to be not dangerous. And so something that might scare us the first time, by the 30th time will be easily ignorable.”
Scientists are unsure exactly how exposure therapy works on a neurological level, but they know that it does: Current estimates show that it reduces OCD behavior in over 80% of cases. On a more macro scale, exposure therapy is simply about teaching the brain to process fear, rather than holding onto it with a death grip, Grayson said.
“I think it’s about practicing coping,” Grayson said. “It’s about learning to cope with fear — a lot of times the fear itself goes down, but they’re also coping with the feelings instead of running from them. Acceptance is a really hot topic, and so many people have the western view of acceptance, which is that I’m in zen happy land — but acceptance initially sucks. Something I don’t want is happening [and I have to think about dealing with it].”
How I started to hack my brain
The first thing Smith had me do was to write a “script,” a short bit of text that described exactly what I was afraid of and what the effects of those theoretical events would be. Since the ideas and images of violence are what frightened me most, reading this script exposed me to them in a very purposeful way, provoking that fear on purpose and helping retrain the way my brain responded to it.
“Basically, rituals are like, you’re in a hole, and your way out is to try to dig deeper,” Grayson explained. “Rituals really are the nightmare to give in to. Ultimately, if I’m going to try to live with uncertainty [and conquer OCD], I’m stuck saying, ‘My worst fears might happen. How would I try to cope with them?’”
And that’s what my script helped me do.
“If I am in the kitchen with my boyfriend,” I wrote, “it’s possible that I might suddenly become overwhelmed with anger and act out violently. I might grab the knife that I’m using to chop vegetables and stab him repeatedly.”
“If I hurt or killed my boyfriend, I would have to accept the consequences. There is no way to know for sure whether or not these fears might come true — but if they do, I will have to deal with whatever happens.”
“If I am in the kitchen with my boyfriend,” I wrote, “it’s possible that I might suddenly become overwhelmed with anger and act out violently. I might grab the knife that I’m using to chop vegetables and stab him repeatedly.”
Notice how I never say, “But I would never do this because I’m a good person,” because that’s exactly the type of thought that just triggered my fears even more. Instead of finding comfort, my brain would simply say, “But still, you might do it,” and the violent “what-if” thoughts would come back again.
The way to break my brain out of that cycle is to learn to accept that uncertainty, to say, “Yes, it’s possible I will murder my family. Oh well.”
I read this script to myself, out loud, over and over again. At first, it was excruciatingly painful. Not only was it uncomfortable to articulate, in great detail, the death of my family members, but I was mortified at the thought that someone might find what I had written.
Despite the shame, I kept at it. One day, I might read my script for 10 minutes, and the next, for five. At one point, I recorded myself reading the script out loud and just listened to it on repeat. The ultimate goal of this process was to get to a point where I could read the entire script and not feel that feeling of all-consuming dread.
Once I became bored to death with one script, I’d rewrite it, filling it with even gorier, more horrifying details — “I might stab him repeatedly, causing his blood to splash across the kitchen floor” — that would have entirely overwhelmed me a few days before.
Exposure therapy with knives helped me handle my deepest fears
This is when the kitchen knives came into play. Eventually, the scripts I had written didn’t scare me anymore, and it was time to practice holding the very tool with which I imagined myself carrying out my violent fears. During one session, Smith went into the kitchen attached to his home office and came back holding nearly every single knife he owned and set them in front of me, inviting me to pick one up and see how it felt.
Just like with the script reading, holding knives became my mental health homework.
At first, I would just hold a knife in my hand for a few minutes, turning the handle over in my palm until that no longer provoked stress. Then, maybe I’d step it up a notch and sharpen a knife, listening to that smooth, scraping sound of metal against metal. Then, I might imitate stabbing or slashing movements.
Like every other step of the process, these activities were incredibly stressful at first. I remember sitting on the couch in my therapist’s office, imagining myself lunging across the table and stabbing him. I pictured his wife entering the room, wondering how she would react when she saw Smith’s bloody corpse sprawled out on the couch. I knew that with a single, quick action, I could upend their entire lives. My heartbeat quickened with fear as it always did. Smith asked me how it felt to hold the knife, and when I told him, he seemed remarkably unperturbed.
I pictured his wife entering the room, wondering how she would react when she saw Smith’s bloody corpse sprawled out on the couch.
Eventually, after a couple weeks, holding knives was just boring — and that’s the ultimate goal of exposure therapy. I never wanted to carry out any kind of violent acts, and acclimating myself to my fears only confirmed that even more. It did not, as I feared, contort myself into some kind of murderous monster.
“One of the reasons I work with OCD is that it’s really rewarding as a therapist,” Smith said. “The clients are usually highly motivated, and they really just want some guidance and they’re the ones doing the hard work. The therapist has got the easy part, and the client is really stepping up to the plate and staring their fear in the eye. And it’s a beautiful thing to see when clients can repeatedly do that and get better.”
And for now, I am better. I still have OCD, but it’s not the intrusive force on my life it once was. I no longer struggle with overwhelming, violent thoughts; because of exposure therapy, I have the tools to deal with it when I need to.
It’s possible that in the future, my brain might fall into a seemingly never-ending cycle about something else — but for now, I’m good. OCD has taught me that I can’t really have total assurance about anything. And I’m doing my best to accept that.
