Self-Determination Theory and OCD
The Diagnostic and Statistical Manual for Mental Disorders-the DSM, is viewed as a major source of authority in mental health. It has its uses in providing diagnostic language and can be helpful for communicating to both clients and other professionals. However, if you ever take the time to actually flip through it, you will find that it mentions almost nothing about causes and maintaining factors in mental health problems (in fairness, this was not an objective in the creation of the manual). Certainly, it will acknowledge genetic and environmental contributions, but it will provide no greater detail. Indeed, a thorough assessment of symptoms is a critical part of providing sound mental health care. However, iIn my view, ultimately it is not very helpful for both clients and professionals to understand a list of symptoms describing a mental illness, but to have no real sense of what causes and maintains the distress. To state it plainly, we stand a much better chance in improving a problem if we understand the underlying issues driving it. To be clear, we do not have anything close to a complete etiological explanation of each mental disorder, but we actually do not need one to help clients get better. To take a simple example, we do not fully understand what causes migraines, but we do have many good treatments for them.
While we do have excellent treatment for OCD, we still do not understand why some people develop OCD and others do not. However, this does not keep us from putting together a clear case formulation for why OCD creates so much suffering and why ERP treatment creates improvement. One particular framework, Self-Determination Theory (SDT), asserts that humans have three fundamental psychological needs: autonomy, competence, and relatedness. This theory, developed by Richard Ryan and Edward Deci, holds that, across cultures and domains (including sports, exercise, health care, and the workplace), psychological problems will tend to worsen when someone’s psychological needs are thwarted. In other words, rather than merely reviewing a client’s clinical symptoms (racing thoughts, rapid heart rate, sleep difficulty), it is often more productive to explore how satisfied they feel in meeting their needs, and of course to identify what may be blocking them from meeting these needs. One can make a strong case that virtually any diagnosable mental disorder can create issues in finding these psychological nutrients. Since I specialize in OCD, I can describe some hypothetical examples of how I would work with a client in meeting these needs, while also treating OCD. To reiterate: we do not have a complete understanding of what causes OCD, and I am not suggesting that OCD is always caused by these needs going unfulfilled. Instead, I am suggesting that OCD interferes with meeting each need, exacerbating psychological distress.
First, some definitions of each need:
Autonomy: Feeling like one’s life is truly authored by oneself
Competence: Feeling effective and capable in the world
Relatedness: Feeling connected to others in a meaningful way
OCD may interfere with a sense of autonomy in a number of ways. In general, compulsions often interfere with one’s sense of self, as the compulsions are not in alignment with who an individual wishes to be in the world. For example, a client may become very focused on checking behaviors related to health concerns, to the point they are perpetually preoccupied and less present with their family, even though being present to their family is a deeply held value. In addition, these checks often feel ego dystonic (not aligned with their sense of self), further eroding their autonomy. In order for this client to address this, the client would benefit from seeing OCD as something external that distracts from their values (sometimes it’s helpful to think of it as a bully), which can be crucial for resisting compulsions. Moreover, sometimes clients' compulsions have become so time-consuming that they may feel uncertain of what they value or the direction that they would like to take in life. Again, resisting compulsions will create room for the client to feel more deeply about the kind of life they would like to create. As a therapist, I have had many experiences where a client became more clear on their career path or dating decisions once they were able to resist OCD’s demands for certainty.
As for competence, OCD is disruptive on multiple levels. While it may not be clear at first, OCD can erode one’s sense of competence because while compulsions provide momentary relief from anxiety, they do not provide any lasting resolution to the anxiety and its triggers. Thus, clients are often in a state of continuous hyperarousal or preoccupation without much sense that they can master what makes them anxious, or that they can learn to live fulfilling lives even when they are anxious. In other words, the client has not learned that they can be effective while feeling anxious, and may instead be learning that they are only capable of addressing anxiety by engaging in compulsions. To use the example of a client with health anxiety, instead of learning that they can accept some uncertainty about their health and move forward, the client instead learns that they can only make decisions when they get reassurance from their doctor, AI chatbot, or other internet searches. Furthermore, if a client has been suffering from OCD for years, often their compulsions may have taken time away from developing their skills and talents in other areas, diminishing their sense of competence. Often, OCD can drain clients of so much energy that they are less likely to challenge themselves productively in the rest of life. Again, the more this client learns that they can live with uncertainty and resist compulsions, the more time and energy they will have to build a sense of competence in domains that matter to them. For instance, a client who spends less time in a cycle of reassurance with health anxiety may have more energy to challenge themselves in their line of work or in a hobby. Research shows that we feel the deepest sense of competence when we are challenged, occasionally fail, and find ways to overcome those failures.
Finally, relatedness. In my experience, clients often have the most pain in recognizing the way that OCD has disrupted their relationships. For instance, continually seeking reassurance from loved ones can create an exhausting cycle for everyone, and can erode connection over time. Often, family members report that it can be hard to connect with someone who is suffering from OCD, as OCD consumes so much time and energy that relationships suffer. While looking at these patterns can be painful, I have found it can be highly motivating for clients as the human connections in their life are often what is most important to them. To return to our hypothetical client with health anxiety, identifying how compulsions interfere with their engagement with their spouse can create motivation to resist compulsions. For example, a client may decide to spend less time seeking reassurance via the internet and more time attending to the needs of their spouse and children. This in turn, will help them feel more needed and make them more likely to receive reciprocal care from their family.
The DSM-5 contains 157 distinct disorders. With that statistic in mind, you might conclude that clients that come to therapy may have wildly different sources of distress. While clients vary widely in their symptoms, diagnoses, and life circumstances, I find that they have much more in common when viewed through the lens of meeting their psychological needs. To be clear, this is not to say that all psychological problems are explained by SDT (schizophrenia, bipolar disorder, and OCD, for instance, contain a large genetic loading), only that this can be a much more helpful framing to help clients see a path forward to improved well-being and functioning. No matter one’s background or life history, we all have a need to feel like we are moving towards the person we would like to be in the world, a sense that we are effective in what we do, and meaningful connections with the important people in our lives.