A Response to Rose Cartwright’s Guardian Article - I was the poster girl for OCD. Then I began to question everything I’d been told about mental illness

Rose’s Guardian article is a brave, vulnerable and insightful description of her ongoing OCD and mental health recovery journey. It’s fantastically written and you can see why her books (including the recently released Maps We Carry) and TV work is so impactful. I agree with a huge amount of the article. She has directed people who wish to respond to the article to her new book and I am currently reading it. The book is also brilliantly written, interesting and creatively intriguing. The article has sparked a few thoughts I have regarding OCD recovery which I want to explore in this post.

The two therapy modalities that have most influenced my approach are Acceptance and Commitment Therapy (ACT) and Compassion Focused Therapy (CFT). Both modalities would align with Rose’s critique of the medical model for mental illness. The way ‘disorders’ are categorised with large heterogeneity, the lack of understanding of the underlying common psychological processes and the omission of the importance of one’s past attachment, trauma and learning history on experiences in the present. They both agree with the importance Rose places on the systemic factors on mental health (I hope she doesn’t mind me using her first name, rather than Cartwright!). In fact, Steven Hayes of ACT has increased the prominence of this in his updated work in ‘Process Based Therapy’ adding socio-cultural factors as a core pillar of the complex system of a person’s mental health. In a recent training I did with Russ Harris, he said that ACT can work within DSM/ICD frameworks, but holds the labels lightly, seeing mental health difficulties as ‘human difficulties’ that we all share on a range of severity. Paul Gilbert in CFT, talks about the bio-psycho-social model of mental health difficulties and has written extensively (and critiqued) the systems that maintain psychological stress at the socio-political level (also in the Guardian). I would agree with much of her critique on this topic, although it still holds that OCD is a specific cluster of features, consistent amongst groups of sufferers, that cause huge distress and dysfunction to individuals. 

Nature Vs Nurture Causation

In terms of the nature vs nurture arguments for the origins of mental health difficulties, I think Rose and I have had a similar reading list! I have certainly been baffled by highly intelligent scientists/writers putting forward convincing arguments for both sides of this debate. Twin studies pointing to the power of genetics on the one hand vs the ‘common sense’ experience that we are all emotionally impacted by our early life, school and beyond. When there are convincing arguments on both sides, I tend to think that indicates the truth is a combination of both hypotheses. And the interplay is highly complex and beyond our current understanding. Good old uncertainty! Nature (including epigenetic changes from our family lineage) and nurture, but fundamentally we don’t know how these things fully interact yet - no matter how charismatic and convincing Gabe Maté or Steven Pinker are!

In my own family system, my father had OCD symptoms as a child but never developed the intense disorder. I on the other hand, developed very acute symptoms of OCD at a young age, that then persisted along with anxiety/panic, depression, depersonalization disorder for over 30 years. My father and I had different childhood and early life experiences. I think we were both vulnerable to OCD but the interplay of attachment, trauma, epigenetics, random chance, comorbidities and other bio-psycho-social factors led to different outcomes. Two complex systems! Most experts will agree there is likely biological vulnerability for OCD, but life stressors activate the underlying potential. I have had clients with the same long term health condition where one has developed OCD (activated by the health condition) and the other is dealing with depression due to the health condition. It seems to me in the clinical setting that people have different vulnerabilities, the same stressors and trauma activate OCD in one person, PTSD in another, major depression and other disorders depending on these vulnerabilities. 

I think critiquing the claims that are made at the neuroscience level is fair, as most established neuroscientists will say that the field is in its infancy. However, the argument also applies in the other direction, in that the field is growing in accuracy and precision each year. It may be that in the next 10 years we can zoom in on specific patterns and clusters of neurons implicated in OCD. If you read the work of Karl Deisseroth, you will see major recent breakthroughs in precision through the technique of Optogenetics and recent findings on unique identifiable patterns of electrical signals of ADHD. Findings such as this may mean we are heading towards being able to read specific disorder patterns in the brain. We may be able to then read vulnerabilities to these brain patterns in children. I don’t think it has been proven definitely either way, much like nature and nurture, but the precision of investigating smaller and smaller networks of neurons has increased greatly in the last ten years. Lisa Feldman-Barrett’s work also points to the sheer complexity of the brain and that there rarely are single locations of specific neural functions. The brain is an integrated complex system (the most complex system we know of) and so decoding it may be many years away. I agree we are not there yet, and brain scans of OCD are used with too much confidence. However, we also are yet to disprove that there are biological signatures of OCD, that might also be identifiable in childhood before stress activation.

Before I explore the next themes, let me say I truly hope Rose has found lasting supports for her OCD and mental health recovery. That her ‘symptoms’ remain as low/absent as she reports in the article and her happiness and wellbeing remain high. I would love to hear that this lasts and then for her experience to be explored in first person research (along with other people who achieve this through these methods) to feed into our treatment methodologies in the future. I really hope that is the case. However, recovery is a very person-centred thing and what helps one person (may help others) but unfortunately not everyone. Additionally, unfortunately short-lived placebo effects can be a huge component within psychological therapy. So, it’s very important to see how treatment approaches fair over the longer term – looking at the long-term view is also true of existing ‘gold standard’ methods of treatment like Exposure and Response Prevention (ERP) Therapy, I think there is far more room for long term research on them as well.

Unfortunately, I am hardened by having tried many purported miracle bullets for psychological distress. So, for better or worse I bring a sceptical mindset into how I interpret recovery methods. I have had the wool pulled over my eyes so many times in the past that I lived in a knitted sleeping bag for at least a decade! It’s a hard truth to swallow, but at present there are no magic bullets for mental health recovery (look at all the outcome research and hear stories in the recovery communities if you don’t believe me). That doesn’t mean we don’t have processes that help and that you can’t get to an awesome place in your life – you can. It’s that unfortunately this comes through acceptance/wilful tolerance/response prevention (whatever you want to call it) and pursuing valued life paths and goals (with a large dose of self-compassion). Go through the recovery stories that you hear in our OCD community and these flavours are always present (sometimes with different labels). I think all of the processes she identifies have some truth in them as supports to mental health, but be very wary when something doesn’t have a large evidence base of many years and many studies. We also need a convincing mechanistic explanation for why things help.

Psychedelics

In terms of psychedelics, I agree that they are showing potential for helping people get unstuck from unhelpful thought, emotion and behavioural patterns. I follow this research and we have members of our team that are training in this area. As a long-term sufferer of depersonalization/derealization disorder (DPDR), I personally stayed clear of psychedelics. I knew the potential for them to worsen DPDR and did not want to subject myself to this risk. I am now happy with my brain and don’t feel the need to explore them at present. I have had many clients with DPDR, Panic and other difficulties that were started by difficult experiences on psychedelics. They have often been ‘victim blamed’ that they didn’t surrender to the drugs enough or it was their fault for the long-lasting difficulty. To me that is like blaming someone with a vulnerability for knee injuries for not being able to run an Iron Man. I have worked with many clients with schizophrenia and psychosis where psychedelics were the trigger. Even the podcaster Tim Ferris, who has been a huge funder of psychedelic research (and proponent for their use in processing his own major depressive disorder) has said there is not enough attention and study being done on who is vulnerable to adverse experiences. I know Rose mentions caution with this, but if you are struggling with OCD and read the article and are a budding ‘psychonaut’, I think you would be likely to go and try this. I don’t want to scaremonger here as I know statistically it is a small proportion of people that have difficulties. However, I have worked with many people and have seen the devastating impact it can have on someone’s life – so people need to be aware of the risks. In the UK some of the trials have been micro-dosing psilocybin for OCD, this seems a sensible place to begin an exploration (as a participant in a genuine scientific study) for people wanting to explore this. I think Rose may have said she did this approach herself to build up confidence before doing her ‘heroic doses’.

Even on the positive side, I have had many clients using psychedelics as an adjunct to therapy. This has included people with OCD. The most positive results I have seen have been profound and rewarding life experiences, some loosening of unhelpful beliefs and mental habits (that unfortunately came back over time and required further therapy to work on), positive shifts in sense of self and more. No one has had a miraculous significant improvement in OCD symptoms (or any other difficulties) that I have seen. What I have seen anecdotally has reflected that they may support an opening of neuroplasticity, diminish the believability and power of thoughts, and positive changes in sense of self (this one seems to last the most). All good stuff, but they should be pursued in well supported scientific conditions. Even in these conditions I have heard of a client who’s ‘treatment resistant’ depression was made significantly worse through the trial and was not supported ongoing following the trial.

Relational Healing

I agree with the importance of our relationships in psychological well-being, and that many of us carry scars from the past that impact our connections and relating in the present. These impacts are huge stressors for mental health. Alongside this, sometimes we have learnt messages about our emotions that are unhelpful and feed emotional suppression (for example we may have been taught that some emotions are ‘bad/wrong’ like anger or sadness). I see mental health as a large complex system with some of the inputs being from our learning history and relationships. But I don’t think this is a simple direct linear cause for ‘symptoms’. Occasionally the stress causing a symptom can be a simpler link i.e. suppressed anger in a dysfunctional relationship triggering anxiety or OCD spikes as a result. But I am not convinced that anyone has proven definitively that OCD is a defence mechanism or is necessarily functional, nor that subtypes and themes tell us anything about the persons relationships or emotions – sometimes they may influence them like the interplay between trauma and an OCD theme, but nothing is simple and linear when it comes to mental health difficulties.

Like chronic pain, there can be functional levels of pain that are adaptive and then pain can become linked to our threat system and turn in on itself and become chronic. Like a microphone placed near a speaker giving a feedback amplification, our reactions/compulsions toward the pain or intrusive thoughts, self-amplify the symptom. Often our reactions are unconscious and habitual after years of reactivity (and need time to practice to release them). So, anxiety is often functional but when it turns back on itself in anxiety disorders and OCD it becomes more like chronic pain, or another example might be autoimmune disorders where the healthy immune system turns back on itself and attacks the body.

As someone with an avoidant attachment pattern and a tendency to self-sufficiency to a fault, I looked to relational healing as potentially a solution to my distress in the past. I had various rounds of trauma therapy and relational psychodynamic work, attended workshops, read every book I could find, worked on my relationships and found that there was no secret elixir found for OCD if I could ‘earn secure attachment’, ‘express healthy anger in relationships’, ‘show vulnerability to connect’, ‘connect to more embodied attunement’, ‘understand my internal working attachment models’, ‘discharge/process/regulate trauma’ and many other ways relational therapy describes healing. These things all became solving compulsions for me, trying to ‘heal’ my OCD and other difficulties.

My undergraduate training was on an integrative course where many tutors favoured relational psychoanalytic and somatic trauma therapy (alongside other modalities including CBT). I heard many bold claims about the power of relational healing to reduce psychiatric symptoms like OCD. But I have never met anyone that has convinced me of this from their own experience. I have met, and know many people with long-term stable recoveries where relational therapy has been a helpful piece of the emotional wellbeing puzzle. But not a magic bullet.

I continue to work on my patterns in relationship, extend self-compassion to my wounds from the past, work my skills with the presentation of my past in the present and accepting my reactive nervous system that reflects my past. All these things are helpful for our mental health ‘complex system’ (as long as we don’t sit and co-ruminate with a therapist, become internally hyper focused on our body ‘keeping the score’ or trigger ‘solving compulsions’ through chasing different therapy modalities). Understanding how our past might have taught us to be shaming rather than self-compassionate, underestimate our strength, lead us to unhelpful relationships, caused us to blunt emotions is all very helpful. There are just no magic bullets. Even the gold standard evidence approaches of ERP has limitations (high dropout and relapse rates, higher presence of intrusive thoughts even after successful treatment than non-OCD sufferers etc). This is why acceptance, self-compassion and pursuing meaningful life values/goals are such powerful recovery tools to me.

This is where ACT is very different. The emphasis on building up the skills to handle difficult thoughts and feelings whilst pursuing valued life directions and meaningful goals. ‘Handle’ in the sense of not struggling, following, fixating and attempting to fix intense feelings in ways that make them self-amplify and give them all our time, energy and attention. Instead putting this physical energy/action and attention into valued life directions. The metric of success is doing more values based/valued actions and having more attention and engagement in those actions (including relationships). Other versions of CBT also integrate acceptance processes (like Martin Seif and Sally Winston, Reid Wilson, David Carbonell, Mathew McKay, David Barlow, Marsha Linehan, Mark Williams etc).  

My own experience of recovery matches this and that is why I am so passionate about the message. It was only when I started to drop all my attempts to control my intrusive thoughts and overwhelming feelings (trying to control them with different therapy modalities, meditation practices, personal development, wellbeing hacks, thinking strategies, avoidance etc) that paradoxically everything improved. I had 3 rounds of ERP with well-known experts before I started to approach ERP with an acceptance and skills-based frame and then exposure was helpful. There are lots of ways to perform ERP and some of them can be with a compulsive controlling agenda. As Rose writes in her book these approaches can temporarily numb symptoms. I agree and that this approach to ERP doesn’t necessarily produce a lasting change that helps the client handle psychological difficulties across their lifespan. But exposure is an ancient tool that we find in most historical cultures and it sticks around for a reason. We need to approach ERP with the right attitude, goals and an emphasis on skills to do the difficult task of letting go of compulsions (particularly the insidious mental compulsions of monitoring, checking and ruminating). Unfortunately, the habituation model of ERP can lead to all these compulsions reflecting back on the process of exposure (monitoring and checking symptoms, ruminating about recovery etc). Fortunately, inhibitory learning lends itself far better to the agenda of acceptance of intrusive thoughts/feelings and the pursuit of engaged, valued living.

Systemic Issues

I massively agree with what Rose says about the importance of the system and culture surrounding an individual’s mental health. In some circumstances it is impossible for the threat system to become less reactive because the external threat never goes away. I have worked with many clients in poverty, abusive relationships, bullying, racism, toxic work environments, homo & trans-phobia, racism, disability and long-term illness, areas of high crime, involvement in gang culture, victims of crime, stalking, refugee’s etc where the system is the main factor maintaining their distress. I do think there is a place for learning psychological skills and particularly self-compassion to help with these external stressors, but the main point of intervention needs to be the system level. Often well-meaning NHS clinicians are trying to navigate these difficulties in 6-10 sessions whilst fully expecting clients to circle back around as the clients’ situation is unlikely to change. This is why many famous psychotherapists have said therapy is a political issue.  

Leaving aside the systemic issues, I think the power of these different components that Rose maps out, can be overstated on their potential to abate psychological symptoms. Even with systemic issues, a change in situation often requires ongoing therapy to help the persons’ nervous system adapt to a safer environment, and many people will carry scars from those experiences (to different degrees) for their life. When I was training in integrative therapy many times the case was made that relational psychodynamic therapy could fix all issues. Everything came back to difficulties in relationship/attachment and experience with embodied trauma and difficulties with connection/expression of emotion. I also had the same experience with trauma therapy, where the narratives that are pushed, sound like magic bullets if we process trauma in the ‘correct way’. In these modalities, every ‘symptom’ is tied back to unprocessed trauma and by using the body and therapeutic relationship and ‘titrating the release of trauma’ within one’s ‘window of tolerance’ will mean complete healing. If it doesn’t work either you haven’t done it long enough, your therapist was no good or you are using the defences of intellectualising. There is no admittance of the limitations of therapy and that no one has all the answers yet. It’s the same as the claims being made for psychedelics, meditation and other tools as elixirs for mental distress. Many times, I have worked with clients, who like me, can list twenty therapeutic, healing and other modalities that they have tried before arriving at the realisation of the need to pursue acceptance, values-based exposure and skill-based recovery. Be wary of bold claims people! Bold claims sell courses. Nuanced, honest descriptions of the limitations of therapy and the hard work involved in recovery, do not do well with the social media algorithms, and don’t make the top influencer podcasts. 

Spiritual Healing

Spirituality can also be elevated to professed magic bullet status and then blame is directed at the practitioner when it fails (or more likely they are told they need just one more healing course). I know this intimately. Before I embarked in therapy, I had spent 15 years pursuing different meditative and spiritual paths to try to improve my intrusive thoughts and difficult feelings. I was involved in many spiritual circles that talked about completing some technique, healing, spiritual path or map being the end of suffering. It left individuals just chasing one more course/retreat, another teacher, one more Satsang, chakra or meridian cleanse, a new ‘correct’ manifesting approach or a new ancient level of meditative attainment. Meditation was being sold as a global panacea for the ‘freedom from suffering’ for mental health distress but if you spend any time in spiritual circles and meditation circles, you’ll see they rarely are bastion’s of psychological well-being. Each year there are more Guru’s exposed for immoral behaviour than in most other professions.

 I have worked with a subgroup of meditators that have experienced ‘meditative adverse experiences’ (after having my own history with this phenomenon after many years of intense meditation practice). Sometimes these difficulties are as simple as noticing baseline stress levels when sitting or necessary exposure to difficult emotions and sensations that ultimately lead in a beneficial direction. But unfortunately, they can be far more distressing, debilitating and overwhelming. I have worked with clients experiencing intense difficulties evoked by meditation (normally when people are engaging in more intense retreat practice) as panic disorder, trauma re-experiencing, dissociation, depersonalization/derealisation disorder. I have worked with quite a few clients that had psychosis triggered by 10-day silent retreats and I have consulted on podcasts that tragically told the stories of people that died by suicide after experiencing psychotic breaks. This phenomenon mirrors adverse psychedelic experiences. Again, I don’t want to put unnecessary fear in people’s minds as this is a small percentage of practitioners and tends to be linked to intense practice. But again, these approaches are not simple tools to process trauma in a predictable way, experience cessation of intrusive thoughts and gain insights that reliably improve relationships. They can help with those things, but are far from simple tools.

I also notice a tendency in the article that I have followed myself. This is the inclination to imagine that all current difficulties are reflective of our current dysfunctional society and that indigenous people do not experience such things. I find myself saying the same things, I have read many of the books that explore this topic, I have studied the videos of the Hamza tribe, and I often talk about the same things with my clients. However, again I think we can oversell this. I had a client that had grown up in a tribal community and she told me about a cultural stoicism within her tribe. She said if you were upset you had to go out into the wilderness and cry on your own and then return to the tribe. She struggled greatly with vulnerable connection in therapy and she had been the victim of an abusive and controlling partner (not someone from her tribe). She was self-sufficient and distant and yet struggling greatly. How much is the capacity for the same types of struggles actually present in these communities but undisclosed because of cultural norms of stoic warrior cultures (like the trauma and mental health difficulties masked by alcohol and work ethic in post war England)? How much does the lifestyle of over 6 hours a day in active hunting and gathering, along with constant contact with the tribe, buffer against severe mental health difficulties. But the potential for ‘disorder’ is still there and moods still fluctuate and difficult intrusive thoughts still arise. Historically intrusive thoughts have been seen in spiritual contexts as external entities, and we can see how damaging this view can be in clients today. How much does being in survival mode hunting and gathering prevent the space for the same types of compulsive worry and rumination loops to take hold in the mind? Yet that doesn’t mean people are living in ecstatic, connected unity in securely attached relationships without suffering. Tribal hierarchies may prevent the ability to disclose distress. Overall wellbeing may be higher, but does that mean psychological suffering is absent or just underreported and reduced?

 So, the article is on to some really powerful additions to OCD recovery that contribute to wellbeing in a psychological system. Many of these things may bring down the stress which is exacerbating things like OCD. But equally, these methods can have a paradoxical effect of increasing OCD symptoms if they are done with the agenda of removing intrusive thoughts and feelings. The threat system pairs the behaviour or experience with ‘don’t think about white bears’ and consequently we see more white bears every time we use the method.

The power of the relationship for OCD recovery is part of another modality I am inspired by, Functional Analytic Psychotherapy (FAP). It can be also found in the psychoanalytic components of Rumination Focused ERP. Again, I would see these as supports to whole person recovery rather than ‘magic bullet symptom relievers’. Recovery in mental health is a large complex system with many inputs. A large one being relationships, another being processing learning history and past traumas and then psychological factors like receptivity to change dedication to skills practice and intervention, biophysical intervention and systemic factors. So there is a place for all the ideas in the article to be part of someone’s recovery journey (if done with judicious thinking and professional advice). But my own experience of being promised many magic bullets in the past makes me want to lower the expectations that the combination of psychedelics, trauma therapy, relational healing as the new elixir for OCD symptom resolution.

I would love to be proved wrong, and I will follow this space. I prefer to focus on using these ideas and recovery approaches as person centred options to support each individual’s recovery, whilst using the established processes of ERP with an emphasis on ACT skills (to scaffold response prevention) and values-based exposure. We are not promising dramatic overnight results, but seeing recovery as a process of skills building over time with the main metric to track, being is my behaviour and attention becoming more focused on what I value, whilst my acceptance of the automatic thoughts and feelings grows and the struggle lessens. Then the side effect will be improvement in symptoms.  I think we need to be very careful when we talk about removal of intrusive thoughts and dramatic shifts in wellbeing until we see them maintained over longer time frames and replicated in larger subject groups.  

The therapeutic tools that work for recovery now (ERP with an acceptance and values frame, response prevention skills from ACT and other metacognitive approaches), unfortunately work better if we are not chasing other magic bullets. We can’t teach our brain to accept ‘the white bears’ whilst looking for the new shiny cure to remove them. It was a great article and the book seems fascinating. I have heard many people in our community have been rocked by some of the ideas in the article. Of course, we want to get to the place in recovery where we can read any content and stay strong in our recovery skills. My advice would be, hold any claims of magic bullets for OCD cures and definitive statements of causation and brain mechanisms lightly, instead work on your skills…

Blog image of Rose’s article on The Guardian