Doubt is Not the Core of OCD
Many people think that doubt lies at the core of all OCD. Some therapeutic approaches, such as Inference-based CBT, go further by centering doubt as the foundational feature and primary point of intervention. While it does tend to exist at varying levels of depth and intensity, doubt is not the driving force in OCD, and using it directly in treatment can be problematic.
Why doubt is often viewed as the core of OCD
Many view doubt as the observable entry point for a chain of events in the OCD thought process. A question arises, such as "did I leave the stove on?" This can lead the person with OCD to try to resolve a feared consequence (if I left the stove on, the house could burn down, so I need to go back and check).
Doubt is almost always involved somewhere in OCD. Practitioners, seeing the doubt as unreasonable, or untrue, tend to conclude that the primary key to symptom reduction is about the patient changing their behavior in such as way as to dis-confirm their feared outcome.
This conclusion ignores a few important aspects of the OCD experience and conceptualization, and can be used in ways that present problems.
When doubt is not a primary factor in OCD
Consider the following case:
The patient experiences a lot of anxiety and frustration over feeling stuck with thoughts about having to control their breathing. Additionally, they fear they will be permanently thinking about this, forced to manually control their breath forever while their life slowly falls apart. They have been living with this highly distressing fear for a long time. They have felt, over the years, that many secondary fears stemming from this have come true, as they have lost sleep, been distracted during important social events, and experienced other feared outcomes.
Obviously, doubt is involved here. Any fear about a problem being true forever could be defined as a doubtful view. But the subjective, lived experience by this patient is the relevant part. They are experiencing pain in the moment, their fears are more or less coming true, and their strategies to resolve the pain have failed. They are not only worried about what might happen if they step into a bear trap. They know they have stepped into it and are desperately trying to get free.
The pain of feeling stuck with a distressing thought or sensation is an example of Greenberg's Type 3 OCD, “when the feeling of the symptom itself is the core fear.” The patient experiences suffering related to something that is actually occurring in the moment. Things they may be worried about happening in the future are secondary.
Again, it's not that doubt isn't playing a role. It may even be beneficial for the patient to understand what they are doubting, and why. But the lived experience and their failed attempts to neutralize the thought or sensation are the central features.
Problems with using doubt in treatment
Doubt and inference
Inference-based CBT claims that in all OCD, the patient can be treated by helping them understand that the doubt they are obsessing over is a result of a faulty inference. In this view, the doubt can be “unreasoned,” and then dismissed. This makes no sense in the case above (remember, the patient knows that they are in the bear trap, and they are trying to escape).
Patients who experience Type 3 OCD are not making an inferential mistake that can be unlearned by understanding their faulty reasoning process. Instead, they need to learn how to stop ruminating or how to stop engaging with the problem at all. Once this is learned and practiced, and the patient is not justifying rumination, they may see that their doubt was unfounded. But this is only a side effect.
Actively accepting uncertainty
Many practitioners employ a “catch-all” intervention for doubt, which some call “disengagement mantras.” This often takes the form of something that sounds like “maybe, maybe not,” which is a way of saying to oneself, “maybe the consequence I am worried about is true, maybe it's not. I accept the uncertainty of any outcome.”
Greenberg discusses some problems with this in various interviews (which I've collected and expanded upon below):
Any mantra about accepting uncertainty is essentially a discussion with oneself about the problem. This doesn't give the patient a chance to practice doing nothing instead. Disengagement is the aim of the mantra, but you can't disengage by engaging in self-talk. Thus, it teaches the patient the same compulsive mechanic they have always been using — that when a fear occurs, something has to be done (it doesn't matter what the doing is, in this case, it's active acceptance).
Trying to actively accept the possibility of a feared outcome can easily lead to justifying the analysis, and therefore the continuance of rumination. For example, “maybe I'm a pedophile, maybe I'm not” often would not feel like an acceptable, or authentic proposition. Sure, if the mantra is followed, it may feel less effortful than arguing with oneself about the validity of the claim. But the outcome they are worried about is usually not something they really want. This can easily lead to a causal dismissal of the entire activity.
The object of acceptance might tacitly reinforce other beliefs related to obsessional fears. Greenberg uses an example “maybe I'm in the right relationship, maybe I'm not, ” which can perpetuate the obsessional narrative that there is a “right” relationship to begin with.
So, with active acceptance of uncertainty, a practitioner can unwittingly maintain the mechanism of engagement, provide a reason for the patient to dismiss the activity, and possibly reinforce other obsessional content.
The function of doubt
From a psychoanalytic perspective, obsessional doubt is common among individual OCD cases because it serves a defensive purpose. People with OCD live with varying degrees of “indigestion” caused by emotional conflicts and inhibited aggression. In order to defend oneself against an intolerance of unconscious, undigested feelings, a displacement into more digestible problems occurs. In other words, unprocessed feelings remain in our system, manifesting as symptoms, so we displace this into problems that are within our conscious grasp (obsessional fear and compulsive response). These problems are felt as urgent, but they are purposefully unsolvable. Doubtfulness, to any degree, is a perfectly suited cognitive state for the avoidance of unconscious feelings to reside. But all kinds of states and feelings, such as guilt, frustration, and even physical pain can expressively mask emotional issues. Doubt, then, is not a core feature of OCD, it's a by-product.
The intervention, in addition to the cognitive behavioral tool of stopping rumination, is to help the patient uncover these unconscious feelings and hold them through that.
A wider view
People with OCD have a “felt problem.” They know they are experiencing it, they have a desire to escape it, and they employ any number of strategies to resolve it. The subjective reality of their life is the gateway to intervention, not an objective sense of what is true, reasonable, or uncertain.
Addressing doubt can be useful in therapy if used to help stop rumination and understand deeper feelings. But we should not treat it as the core of OCD, and we need to be aware of its limitations and pitfalls in clinical cases.