Mistaken Beliefs about Uncertainty Acceptance and OCD

The simplest, or perhaps the most all-encompassing conceptualization of OCD is to understand it as a deficit in uncertainty tolerance.  Those who are anything but new to the diagnosis, who have seen any therapist remotely acquainted with it, are likely to have heard, “Well, you will have to accept the uncertainty that your fear may be true in order to overcome it.”  There is no getting around this, no matter how absurd or irrational (or abhorrent) the fear may appear to you.  However, a limited understanding of what it means to truly accept uncertainty can lead OCD sufferers (and their therapists) toward ineffective interventions and even additional suffering.  In my clinical practice and in the online support groups I contribute to, I often encounter people who are repeatedly telling themselves incredibly negative things about reality assuming that this is the only way to do exposure.  Though exposure is scary and often painful, learning to accept uncertainty about obsessions need not be viewed as a form of defeat.  Here I will discuss a few common mistaken beliefs about what it means to accept uncertainty:

Mistaken Belief 1: Uncertainty Means 50/50

Obsessions often begin with the words “what if” and follow with some description of an event the thinker finds intolerable.  What if there is disease-causing bacteria on my hands? What if I snap and harm a loved one?  What if the faucet isn’t closed all the way and my home floods while I’m at work?  Compulsions are designed to increase certainty about these unwanted outcomes.  Using the above examples, a person might wash his/her hands, avoid being around knives, or go back home to check that the faucet is indeed closed.  Failure to do the OCD’s bidding results in anxiety, disgust, or some other unwanted internal state, often coupled with vivid mental storylines of brutal consequences.  No amount of thinking through the problem is likely to result in the kind of illusion of certainty provided by actual compulsive cleaning, avoiding, or checking.  This issue may be best exemplified by the OCD sufferer who becomes aware of the thought that he/she might have harmed someone in the past and then meticulously reviews his/her memories to get a sense that the harm could not have taken place.  Since this effort never really works in the end, either because the compulsions intensify the obsessions by validating their existence or because the compulsions ultimately feel unsatisfying when the truth can’t be locked down, the thinker is left with only one option – accept uncertainty that the feared concept could be true.  

Accepting uncertainty does not mean accepting that there is a “1 out of 2” shot that your fear could be true.  What it means is you have abandoned the mandate to determine what the odds are in the first place.  As I write this, I am accepting the possibility, however small, that my computer is emitting some kind of toxic substance that may be giving me some kind of health issue.  I am further accepting that, merely by attending to writing this, I may be failing to attend to a more important matter, such as whether I may have committed some kind of crime earlier in the day.  To say these things is not to say that I believe these concerns are as likely to be true as a flip of the coin.  What I am saying is that the possibility simply exists at a level greater than absolute zero.  This allows for the understanding that the possibility may be so low, that I can treat it with such disinterest such that I refuse to even analyze how low the possibility is.  

Resistance to accepting uncertainty about things that seem unacceptable (e.g. harm to a child, violating religious laws, burning down your house, etc.) is heightened by a mistaken belief that accepting uncertainty must mean accepting some meaningful level of probability.  It doesn’t have to be framed that way.  Rather than 1 out of 2, it can also be looked at as 1 in some number so big that to attempt its calculation would be an inefficient use of our finite time on Earth.  All that uncertainty acceptance truly requires is the number 1.  The number this is out of can be as high as you want.  Just don’t try to calculate it.  The aim is not to compulsively reassure yourself that the probability of your fear being true is low.  The aim is to live as if this is already understood and no math is required.

Mistaken Belief 2: There Are Things We Cannot Accept Uncertainty about

This belief betrays a poor understanding of the nature of certainty and how it differs from confidence.  Certainty is an illusion, an assessment that events (e.g. triggers) and responses to those events in the universe can remain constant.  The closest thing to a certainty might be that we all die.  All people who have once lived and live no more, have died.  So this we can be certain of.  Except that I have not carefully examined all people who have lived and live no more.  You might also be certain about particular chemical reactions, that if you make two molecules interact, there may be some predictable response 100% of the time (I’m going to assume Neil deGrasse Tyson won’t be reading this and that if I am wrong, the larger message still holds true that some things may get close to being certain).  Still, chemicals may respond unpredictably if me observing them affects their behavior somehow.  So we may get close, but certainty is still not a thing.  At some point we say, “Good enough, I’m calling it, the sky is blue.”

Mostly we use the word certainty interchangeably with the word “confidence”.  Confidence is a feeling.  It is a sense that, given certain triggers, certain responses are predictable.  I am confident that if I tell my wife I love her, she will reply with the same or something similar.  I am confident because this interaction has been repeated multiple times.  I may say that I am certain because I feel confident, but I am in fact not certain.  She may or may not reply the same next time, but I assume so strongly that she will, I can’t bring myself to analyze the reasons why she would not.  Embracing this difference between the feeling of confidence and the state of certainty is easy when the consequences seem tolerable.  Though it would break my heart if she ceased to reciprocate my love, I can envision a life in which I cope with and even tolerate living with a broken heart.  For people with OCD who experience intrusive thoughts about being pedophiles, murderers, banished to an eternal hellfire, or responsible for the untimely death of innocent people, they may struggle to envision a world in which they cope with these outcomes.  This gets translated as a reason to commit to compulsive behavior because they simply have to, because there appears to them to be no way uncertainty about this issue could be tolerated.  The problem is, certainty doesn’t exist.  Only confidence exists.  And compulsions are the very thing that deplete confidence.  They are the behaviors that send the message to the brain, “warning: confidence is lacking.”  We must accept uncertainty about all things, not because all things are likely or even worth any attention at all, but because certainty does not exist.  There is only confidence.  When confidence is absent, we can find it by engaging in the behaviors of confident people, not by certainty-seeking.

Mistaken Belief 3: People With OCD Are Not as Good at Accepting Uncertainty

People with OCD may have a deficit in tolerating in some ways.  This does not mean they have a general deficit in this area.  More likely it is a reflection of the intensity and the fine detail with which they care about the things they care about and are aware of the ways in which these things could be harmed.  For example, a person without OCD may value hygiene and wash his/her hands after touching a public toilet handle.  A person with OCD in the same scenario may conceptualize hygiene as a function of social responsibility and connect it to the safety of others and the determination of their morality and thus, may be consciously grappling with whether or not e. coli has gotten on the hands, what the probability and specific health consequences are of e. coli getting from their hands to another person would be, and what the philosophical ramifications would be to a person who was indifferent to this harm.  They would then wash in a manner that ensured confidence that every millimeter of skin on and around the hands had come in contact with soap and the right kind of warm water that had not been additionally contaminated by any contact with the sink or faucet.  More succinctly, the OCD sufferer may be less willing to view the issue as a simple matter and may find more issues to be uncertain about.

However, given that OCD sufferers often see things in finer detail and become aware of what others might consider “fringe” thoughts that don’t demand attention for others, consider that OCD sufferers feel like they experience more ideas that require one to be uncertain about.   So truly, OCD sufferers are spending significantly more time accepting uncertainty, and doing it well, than people who aren’t noticing the things we have to accept uncertainty about.  It is only when the focus of attention is on a particular obsession (the focus of their OCD) that people with OCD struggle to accept uncertainty.  

For example, a person with OCD may think about the possibility of a sinkhole suddenly appearing beneath them and just write it off as nonsense.  A person without OCD might have the same thought very quietly or not even be aware of a thought like that formulating unless their attention was drawn to it, so treating it like nonsense is easy.  But a person with OCD who thinks about the sinkhole and also has an obsession with dying in a sinkhole, would be more resistant to writing it off as nonsense.  In other words, OCD sufferers are uncertainty-accepting pros.  They notice what others don’t and they allow things to be as they are more often than not.  Where they can benefit from this in treatment is learning how to generalize this skill to apply to specific obsessions, instead of only to the plethora of other thoughts on the radar.

Mistaken Belief 4: Accepting Uncertainty Means You Can’t Assume the Best

There is a myth that OCD promotes in the mind that you don’t deserve to be happy; that if you’re happy, it must be the result of not paying enough attention to something important.  So if you have OCD and try to do what happy people do, you may feel an urge to neutralize that with self-criticism or self-punishment of some kind.  Consider a person with sexual orientation obsessions who has a life history of being heterosexual, but notices an increased heart rate occurring while watching an action movie with an attractive same-sex actor performing in it.  The OCD may say, “This is evidence that you are gay.”  The urge to compulsively neutralize that by saying “No, I know I’m not gay and this is just an exciting scene in the movie” may be very strong.  A cognitive behavioral approach would be to accept uncertainty that maybe the reaction to the movie is a sign of some sexual orientation confusion.  However, accepting that your OCD could be right does not preclude assuming that it isn’t.  This is not done by repeatedly making self-reassuring statements (as in, “I assume I am straight”), but by simply responding to the increased heart rate as if it were not a threat.  This would probably look something like remaining focused on the film, taking another handful of popcorn, and staying out of the debate altogether.  

People going through OCD treatment often make themselves unnecessarily unhappy by interpreting uncertainty acceptance as a mandate to assume the worst and then dwell on it.  Rather than it having to be a net negative experience, it can be a freeing one.  If you assume your fears are untrue and engaging in behaviors that reflect this, while still allowing for the possibility that you are wrong (and hence, necessarily accepting uncertainty), you can allow yourself to enjoy the experience on your own terms.  By letting go of resistance to uncertainty, you free yourself up to act like a person who thinks things will work out fine.  For those with morality-themed obsessions, this means assuming you are good instead of trying to prove it to your OCD.  As long as you leave space for being wrong, you are accepting uncertainty even when you are framing things positively.

So…

All of the above are basically saying the same thing.  Improving your ability to open up to, accept, or even embrace uncertainty in the face of OCD is essential to getting mastery of the disorder.  But this need not be looked at as an intolerable burden or a recipe for misery.  Uncertainty is simply the absence of certainty, which is a state you are already in.  It doesn’t mean everything you care about hinges on the flip of a coin.  It means only that investing in something unattainable is less helpful than investing in the present moment and in your values.  Acknowledging that your fears could be true does not mean admitting your fears are likely or reasonable.  In fact, accepting uncertainty can mean living joyfully with the assumption that your fears are not true, that your OCD is a glitch at best, or a liar and bully at its worst. The OCD makes it seem as if the content of your specific obsession is the one thing a person should never have to accept uncertainty about.  But that’s a trap.  There is no certainty.  There is only confidence and assumptions.  

So even as the OCD stretches as far as it can into the grotesque, the sinful, or the horrifying depths of your mind, it is still simply trying to con you with the idea that it’s found the one exception to the rule.  Uncertainty is everywhere.  One in a 100 trillion is an uncertainty.  And remember, you practice uncertainty acceptance more than someone without OCD.   You make an exception for your obsession because the disorder itself creates an illusion that this content must be made certain.  Assuming everything will be fine is not a compulsion.  It is actually the greatest exposure, so long as it includes the willingness to be wrong.  

Jon Hershfield is the Director of The OCD and Anxiety Center of Greater Baltimore and a specialist in the treatment of OCD and related disorders. He has previous experience as the Associate Director of the UCLA Pediatric OCD Intensive Outpatient Program and as a Psychotherapist for the OCD Center of Los Angeles. You can read more from Jon here.