The May BABCP blog article is written by Ashley Fulwood and discusses an article from the Cognitive Behaviour Therapist, “Understanding why people with OCD do what they do, and why other people get involved: supporting people with OCD and loved ones to move from safety-seeking behaviours to approach-supporting behaviours” by Nicola Philpot, Richard Thwaites and Mark Freeston.

“it is essential to understand the language of the individual (and family members) and ensure that we adapt our explanations to match.”

I have long been an advocate of the importance of language when talking about Obsessive-Compulsive Disorder (OCD) both within therapeutic setting and within the wider community, so it was refreshing to see Philpot, Thwaites and Freeston (2022) address this in their paper.

As somebody with lived experience of OCD, I know only too well the challenges faced when communicating about my OCD with therapists. Equally when I am talking to people with OCD who are just starting on their therapeutic journey in OCD treatment, I am often reminded that not everybody will have yet read literature around OCD and the terminology and acronyms we use daily are simply confusing to them.  So, it was refreshing to see this paper offer clear plain English advice on how therapists could communicate with patients and their families.

Whilst the principles and objectives the paper is advocating are to be welcomed, I would like to initiate a conversation around the language the paper uses in its title and throughout, which subtly, could create negative connotations.  Let me explain…

Philpot, Thwaites and Freeston write in their final key practice point:

“Our role is to help the person with OCD and those around them reduce their safety-seeking behaviours and reassurance seeking“

I will shortly be presenting myself for further treatment and when I do if the therapist tells me their role is to help me ‘reduce’ my compulsions then I will most likely walk out the door. You see I am looking for compulsion stopping recovery, not slightly less OCD behaviours and that single word changes the entire context of that line for this service-user.  It’s a very subtle point, but the success or failure of therapy can sometimes be language specific subtle too.

That’s not to say for some who may have been living with OCD for decades would not welcome better management of OCD symptoms, but we must also be mindful of the more recently diagnosed whose first impression from the therapist must be one that promotes the message of recovery, not just symptom reduction.

You will also notice that I did not use the term ‘safety seeking behaviours’. Whilst this is a great way to help service-users/families understand why we do what we do, in my work for OCD-UK I will rarely use the phrase, in part because it doesn’t provide ‘safety’, the behaviours or rather compulsions bring nothing but abject misery and to quote Professor Salkovskis, ‘the solution becomes the problem’.

Additionally the other problem with the term is that it’s not always an accurate way of describing what is happening, because in many cases we are carrying out compulsions not to prevent a feared consequence, but to ‘feel’ just right. But there’s another potential problem we should be exploring which is if the constant use of the word ‘safety’ could potentially lead some who are yet to understand the OCD process to subconscious reinforcement that the behaviour is actually a safety action and still the right thing to do?

Which is why I started this by emphasising the importance of language when talking about Obsessive-Compulsive Disorder.

‘Approach-supporting behaviours’ is another term which is only more recently been used in an OCD/CBT context. For service-users this is actually more clinical jargon that is perhaps unnecessary and doesn’t really say what it is on the tin. Therefore, a better explanation/phrase should be explored for when talking to service-users and their families to explain this approach.

That’s not to say I am not a huge advocate of the approach, because I am and which I have used in my own therapy journey to achieve a treatment objective (to pick up dog faeces).  I am not sure all therapists have fully realised the potential of this approach to help patients achieve their therapeutic objective from the stories I hear. If you’re reading this and are not familiar with the phrase perhaps my experience can help illustrate. What they are suggesting is that ‘approach-supporting behaviours’ are those behaviours I used to prepare for picking up the dog faeces. For example, I took a different step each day for a week. Each step designed to build up and prepare me for my ultimate therapeutic objective at the end. The penultimate step was to pick up the dog faeces with disposable gloves. Whilst that is still an avoidance/compulsion, it was done with the objective that eventually, in my case the next day, I would do so without the gloves, which I did.

If I was asked to verbalise that I would have called it a stepped therapeutic behavioural exercise; I was stepping myself up to the therapeutic objective, which, arguably is perhaps more plain English way of describing approach-supporting behaviours.

So back to the original paper, I fully endorse the objectives that Philpot, Thwaites and Freeston are attempting to recommend. Clinical language can be scary and confusing,

and whilst they do make the important point that if therapists start to use terms such as safety-seeking behaviours check that the person has a shared understanding of the terms you use. Whilst that is brilliant advice, perhaps I could make a case for the fact that if you’re having to do that in the first place, that might suggest it’s not a good idea to use that term?

This highlights the value that we all have to be mindful of the language we use when talking about OCD to service-users, because language can have the potential to help and inspire or reinforce or even generate negative beliefs.

Author Biography

Ashley Fulwood has worked for the national charity OCD-UK since 2004, which he co-founded.  OCD-UK is completely service-user led, everyone involved in the organisation have personal experience of OCD, including Ashley.  During the last 18 years he has worked to offer a voice for people affected by OCD and to offer advice, support and most importantly to offer hope through the difficult times. For more information about the charity please visit https://www.ocduk.org.