I spent 3 months at the OCD Institute. Here’s what I learned. Corey Follow Apr 27 · 7 min read

Do you really understand that concept?

Are you sure your answer is right?

You’re probably missing something. There’s only one way to make sure. Review your solution again.

I think you missed something again.

These were the thoughts I had while trying to finish my multivariable calculus problem set at MIT. I didn’t understand why I was doubting myself so much. It seemed like nothing could convince me that I understood the concepts well enough. Not even getting the problems right. There was always that seed of doubt.

These thoughts slowly began to infiltrate more than my academic life. I began to doubt if I loved my family. I doubted if I was a good person. I doubted the authenticity of my friendships. I remember pacing for hours in my room. I skipped meals. I avoided showering. I ignored my friends. I repeated this cycle until I felt like my doubts were extinguished. When that happened, I would feel a sense of relief, only to find something else to doubt.

Realizing that something was wrong with me, I turned to the medical center on campus. They recommended that I take medical leave and attend an inpatient program.

Enter the OCD Institute

I was fortunate enough to have been accepted into the OCDI Institute (OCDI) at McLean Hospital. McLean Hospital, the largest psychiatric affiliate of Harvard Medical School, is ranked #1 in psychiatry. My stay there was around 3 months. I learned about different forms of OCD, various coping mechanisms, Exposure and Response Prevention (ERP) and much more. My goal is to present my key learnings and experiences from this journey and hopefully show you something new!

The Vicious Cycle

OCD is comprised of 2 main components: obsessions and compulsions. Obsessions are the unwanted, intrusive thoughts that cause distressing feelings and anxiety. Compulsions or rituals are the behaviors that one will engage in to reduce that anxiety.

In my case, the intrusive thought was my understanding of certain academic concepts was insufficient. I believed these inadequacies made me a bad student and would cause me to fail my present and future classes. To reduce the anxiety caused by that potential reality, I reviewed the concepts over and over again. Overthinking was my ritual.

Because of the relief that the ritual provides, giving into the ritual only reinforces that behavior. In other words, the hold that OCD has over an individual will only get stronger, increasing the frequency of the individual being triggered, making it more likely that the individual will submit to the ritualistic behavior.

The trigger (anxiety-evoking stimulus) and ritual relationship is shown in the following graph. Anxiety is measured:

Before being exposed to the trigger After being exposed to the trigger After performing the ritual

Note: Anxiety is measured in Subjective Units of Distress (SUDs), a self-assessment tool rated on a scale from 0 to 100.

As OCD becomes stronger, the individual often times has trouble concentrating on the ritual, making it hard to tell if they performed the ritual properly. This makes matters even worse because they can end up performing the ritual many more times to ensure that it was done “correctly”.

Now that I have gone over the basic mechanics of how OCD works, I’ll talk about the treatment I received.

Exposure and Response Prevention (ERP)

ERP is one of the most difficult treatment methods because it involves directly confronting your fears. The exposure refers to actively triggering the individual. Exposing them to the thoughts, images, and situations that make them anxious. The response prevention refers to doing exactly the opposite of what the individual would normally do. Instead of ritualizing to reduce that anxiety, they would accept the uncertainty that their worst fears may be true and then sit with those feelings. The individual makes a commitment to not give into the compulsions.

As you can imagine, their anxiety would significantly increase. However, their anxiety levels wouldn’t increase indefinitely. The rise would remain steady and then gradually decrease to normal levels over time.

As this process is repeated over and over again, the initial anxiety would decrease with each exposure. Additionally, the time it takes to reach that normal state would also decrease. The natural drop in anxiety that happens as the individual resists the rituals while staying exposed to the trigger is called habituation. That’s the logic behind ERPs. So how did it look like while I was at the OCDI?

I was assigned an ERP coach that I would meet for 2 sessions during the day. Each session was around 2 hours. The exposure involved me reading from my multivariable calculus textbook. I would read until I came across a concept that I felt I did not understand completely. OCD would ask the usual questions, “Do you really understand this?”, “Can you prove that you understand it by going over the step-by-step solution again?”. At this point, I knew I was triggered. My anxiety would spike and I would tell my coach. Now came the hard part. I had to accept the uncertainty that I may not understand what I read. I had to resist thinking about the concept. I had to resist problem solving in my head. I felt like I was thrown into the deep end of a freezing pool.

My coach would remind me of the coping mechanisms I had learned to deal with this anxiety. Progressive muscle relaxation was my go-to. Eventually, my anxiety would subside and we would try another round. These sessions were painful but became easier over time.

After several sessions, I would try self-directed ERP, in which I was my own coach. These sessions were particularly important as they helped prepared me for the “real world” outside of the OCDI. However, they were significantly more difficult. This is where my OCD toolbox became critical.

My OCD Toolbox

My OCD toolbox is a list of some effective coping mechanisms I learned at the OCDI.

Chessboard Analogy

There are usually 2 sides to my OCD thoughts. The unpleasant, anxiety-evoking thoughts are at war with the rational, positive thoughts. My rational self knows that thinking about that math concept anymore is working against me. But OCD will counter that and try and convince me otherwise.

The analogy involves placing these 2 forces against each other on a chessboard. The unpleasant thoughts are the white pieces and the rational, helpful thoughts are the black pieces.

These pieces can continue fighting while I go about my day. I imagine the chessboard that hosts this war is floating above my head. I don’t have to let it affect what I do and how I live my life. In this way, I am distancing myself from the intrusive thoughts.

The Cognitive Triangle

Often times, my trigger starts with me reading about a concept. I will have the thought, “Do I really understand this?”. These thoughts of doubt will spark feelings of worry and anxiety. My behavior will reflect those feelings as I give into my rituals (overthinking and pacing).

The idea behind the Cognitive Triangle is that your thoughts, feelings and behavior are all connected. Your thoughts influence your feelings and your feelings influence your behavior.

You don’t always have direct control over your thoughts and feelings. During times of high stress, you can’t force yourself to feel happy. During times when you are distracted, you can’t flip a switch and think about something productive. However, you can control your behavior. You can choose to go outside and get fresh air if you are feeling down. Often times, this is extremely difficult and will take practice.

In my case, the thoughts are the intrusive thoughts and the feelings are that of anxiety and distress. Instead of trying to battle these thoughts and feelings, I will take a different action like taking a walk or calling a friend. Often times, this will positively influence my thoughts and feelings. I may feel less anxious and will have fewer of those intrusive thoughts. I am using my ability to directly control my actions to influence my thoughts and feelings.

Progressive Muscle Relaxation

Progressive muscle relaxation is a technique involving tensing, or tightening, one muscle group at a time followed by a relaxation phase with release of the tension. This can be effective in reducing anxiety and stress.

Here are the steps;

While taking a deep breath in, contract one muscle group (for example, your arms) for 10 seconds, then exhale and suddenly release the tension in that muscle group. Relax for 10 to 20 seconds and then move on to the next muscle group (for example your upper thighs). Try to focus on what you’re feeling while you release the tension. Imagine the unpleasant feelings and thoughts floating away as you relax your muscles. Slowly move your way up and down the body while you contract and relax your muscle groups.

I hope that you found my key takeaways from my time at the OCDI helpful. Thank you!