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Externalizing the Struggle with OCD (2022)

Mark Beauregard, LCAT, RfG-CP, RDT-BCT


Diyah, a first-generation Indian American female journalist in her late twenties, initially sought treatment with me to better manage her Obsessive Compulsive Disorder (OCD), including intrusive thoughts, compulsive checking behaviors and self-doubt. Additionally, she wanted to increase her confidence in managing her significant anxiety and in establishing healthier, more independent boundaries with family/friend relationships. She came to me drawn to trying non-traditional therapy approaches and particularly wanting to increase her own creativity in life.

As a younger first-generation American child of immigrants who exerted strong cultural and familial influence, Diyah spoke frequently about her guilt over her family’s sacrifice of their own aspirations in order to provide opportunity for her. She was a high achieving and hardworking journalist, always questioning if she was “doing enough”, “working hard enough”, “caring enough” for her family, and often reported feeling like she loses her voice in trying to please everyone, in her work, relationship and family. The tension between her position as a journalist and the ever-present OCD critic always sitting on her shoulder was extremely high.

Over the course of our work together we explored many themes: trusting her gut vs. bending to self-criticism or questioning; addressing guilt over focusing on her own needs and wants over the wishes of other; finding more of her own voice without losing it to family, work, boyfriend, etc. We focused frequently both on her own agency over her OCD symptoms and the unwanted role of perfectionist, and shifting toward celebrating mistakes, as improv teaches us, in order to grow, accept herself and find opportunity. We explored her experiences as a first generation Indian American in a relationship with a white man, dealing with oppression, microaggressions, and frequently being misunderstood and devalued by society Despite the strain of contending with enormous constant internal anxiety and self-doubt, Diyah always maintained an outwardly pleasant disposition as cheery, smiley, fast, energetic, and a problem solver. This was in part her personality and character, and also the role presentation most ingrained from her upbringing.

It was this feeling of push and pull resonating throughout so many facets of Diyah’s life that led me to suggest we play the RfG exercise “Tug of War,” (TOW) sparked in the moment when she talked about feeling tethered to and trapped by her OCD. I suggested we explore that metaphor with TOW. Diyah was very receptive. As that exercise is most often conducted, we initially played as ourselves, not in character, just exploring- what it felt like to hold the rope under tension, committing to mutual pulling and yielding, exploring the physicality of what it meant to be pulled back and forth, neither losing or winning, just staying tethered, pulling and yielding.

After a while, we smiled at each other and put down our ends of the rope. When I asked Diyah about her experience, she remarked that it had been actually quite enjoyable to hold the tension with me, that she felt connected and that it was playful and fun, in stark contrast to the tugs of war she typically experiences with  more loaded situations/persons, especially when her OCD was activated. I was not surprised to hear this as I also found this experience of connection enjoyable as well. During the Post-Enactment Processing, Diyah offered to explore and to go further with this exercise. In a previous session we had externalized her OCD as a character, something she had found helpful. Accordingly, I suggested we explore TOW in its game format in which I took on the role of “OCD,” having already safely established my taking on that charged role with her as Diyah’s opponent. She eagerly agreed.

During the next TOW enactment, in character as “OCD,” I began offering critical statements that I had heard previously from her from her such as, “you didn’t think through that”, “you missed that part”, “you’re not good enough,” “check again”, etc.

In role as “OCD,” I began to playfully poke at her, asking if she was ready to pick up the rope, that I bet she was scared and what was she waiting for. She accepted the offer to play and we both picked up the imaginary rope, holding a tight grip with tension.  “Oh really”, I said, “You know I’m going to win”. She shot back with an enthusiastic “Try me!”, and we engaged in a steady push and pull, back and forth. There was a sense of fight and empowerment that I could feel coming from her. I paused; switching roles to myself, the director/therapist, I next suggested we play out three scenarios: one where each of us won while the other lost, and one where she chose just to let go of the rope and walk away. I gave the directive to walk away specifically to see how she would experience the choice to just disengage from the conflict.

After playing out these scenarios and de-roling, we then processed the entire experience. I asked her what had been like for her, whether anything surprised her from the experience, and what she may have noticed in herself. She reflected on feeling generally much more energized and driven to fight in the beginning, having more of a sense of hope for winning, much more than she normally does when she engages with the challenges of OCD, feeling overwhelmed and like a failure. “I liked the rush and feeling of strength,” she said, “I felt like I could meet you face on.” She reflected on feeling amazing, empowered, and strong when she won, having never felt close to that in real-life, and enjoying watching my character get so angry and flustered.

Losing was, however, harder for Diyah. She expressed it was far closer to her real-life experience of feeling like a failure, not good enough, and once again succumbing to the overpowering criticism of OCD, who “just never goes away”. That was a harder moment to experience for Diyah. I then asked her about her experience of dropping the rope, having previously noted there being an interesting shift in the play where she just let go and walked to a different section of the office. Despite my cajoling in character to get her to re-engage in the conflict, she had turned her back, stretched and took a deep breath, ignoring my character. “That was the biggest surprise for me”, she said. She remarked about how she was relieved to have had that directive. When she was given permission to just walk away and disengage, it felt freeing, at times harder to not respond or take in the cajoling, but definitely freer and in charge. I reflected that I had noticed how she stretched and took a deep breath, to which she smiled and said, “It felt so good to do that.” She was struck by how she could use the metaphor of letting go of the rope, not just with OCD, but with others in her life with whom she tends to remain in continual back and forth. And though it was harder for her to let go in real-life scenarios, she reported being energized in those life moments over the next week where she could try to ‘let go of the rope.’ Scenarios with friends, and particularly with family members entered her mind, leading to her  wonder how they would respond, and how much that might be better for her own mental health and affect those  boundaries that she struggles to maintain.

These experiments with TOW were not meant to cure or conquer Diyah’s OCD, but rather to provide an in vivo experience of what alternative possibilities could feel like and provide a vision of how to expand these scenarios into her real life. At the end of the session, I invited to take with her into her week anything from this session that might help. “I’ll take that confidence, fight and vigor, and also the permission to let go,” she replied.