Do you have to tolerate uncertainty to recover from OCD?

Not necessarily!

“Tolerating uncertainty” is often seen as a cornerstone of OCD treatment. The idea behind the catchphrase is that we cannot be certain of anything and, therefore, benefit from leaving OCD’s question’s unanswered without performing compulsive rituals in the pursuit of some kind of perfect certainty that does not exist.

While some people with OCD do struggle with an intolerance of uncertainty, a transdiagnostic cognitive bias/disposition characterized by difficulty tolerating both the unknown and the emotional experience of the unknown, not everyone living with the condition does.

For me, OCD was more about a doubt of what I did know (that I was not attracted to dogs, family members, my boss, kids, etc.) than a lack of knowledge. I have known in my bones, for as long as I can remember, that I was born to be a mother. I was the elementary school kid delighted by the toddlers in the neighborhood, the 8^th grader who treated her flour baby in home economics class with the same care and enthusiasm I would a real newborn, the teenager who would distend her stomach in the mirror to see what she’d look like pregnant, and the college student who adored her job at the daycare on campus—though interacting with kids hardly felt like a job. It was a privilege.

Before my sudden onset of OCD, I had never experienced a scary thought about a child or animal or family member. I was never anxious around kids, never worried that I could be attracted to dogs, never thought about my parents naked (literally barf). Nothing of the sort ever crossed my mind—not until I was 19 years old and, in a split second, I experienced the first of millions of unwanted, intrusive sexual thoughts that derailed my life.

If you’re unfamiliar with OCD, it is a mental health condition characterized by obsessions (repetitive and persistent thoughts or images that are experienced as intrusive, unwanted, and distressing) and compulsions (mental or physical acts a person feels compelled to carry out in response to obsessions to alleviate discomfort, resolve the obsession, and/or prevent something bad from happening).

Indeed, the intrusive thoughts were distressing—so much so that I thought about suicide often. It’s not that I wanted to die. I wanted to stop experiencing the scary thoughts—thoughts that were so terrorizing not because I was uncertain about myself, but because I knew that I was not a pedophilic, incestuous person into bestiality. I knew that the thoughts were so opposite to my desires, beliefs, and self-concept, a psychological term known as egodystonic. OCD is an egodystonic mental health condition. I knew who I was and couldn’t understand why my brain wouldn’t stop producing and getting stuck on thoughts so opposite to my sense of self.

Over time, the unrelenting presence of the intrusive thoughts—and how real they felt—made me start to doubt myself. If I’m having these thoughts so frequently, is there some kind of truth to them, I worried. That worry was unfounded. Thoughts are not facts, something I learned through metacognitive therapy that helped me resolve the irrational doubt stemming from OCD. You can have the same stuck thought a million times and it doesn’t make it any more true than a thought you have once.

Rather than uncertainty, defined by Miriam-Webster as not having certain knowledge, I was dealing with doubt, a word defined as distrust or to lack confidence in. The very fact that I was having the thoughts made me distrust myself.

While doubt and uncertainty may seem like the same thing, there is a difference between not knowing something and not trusting what we do know (Inference-based Cognitive Behavioral Therapy breaks this down well).

I knew I was not a sexual predator. I doubted what I knew about myself because of the onset of intrusive thoughts and images. My work in treatment was not to tolerate uncertainty about myself but to resolve obsessional doubt (irrational doubt that is not rooted in reality) and learn how to accept the presence of unwanted thoughts without judgment and resistance.

If this is confusing, here’s another example:

I am not certain who I will marry because I haven’t met them yet (I think?). I don’t have that knowledge available to me and, therefore, must tolerate the uncertainty around it. Sometimes it’s hard because I want to get married. I want to meet and know and love who i’ll marry. I want that part of my life to start. I know this. If my OCD were to latch onto marriage and bombard me with thoughts like “What if you don’t actually want to get married?” the goal of treatment would be to resolve the obsessional doubt that OCD is creating about my desires, not to tolerate uncertainty (because I know that I want to get married).

So do we have to tolerate uncertainty to recover from OCD? This is a long way of saying that we don’t always have to. When we have the information available to us, we don’t have to tolerate not knowing.

In fact, telling someone with POCD or Harm OCD that they need to tolerate uncertainty and cannot know whether or not they’re a pedophile or serial killer can lead to more obsessional doubt. It can also really harm a person. My therapist never told me to tolerate uncertainty about myself and if she did, I don’t know that I’d be alive today.

Just like people without OCD, people with OCD get to know and trust who they are. We don’t have to tolerate any more uncertainty than people without OCD.

Is tolerating uncertainty never helpful? I’m not saying that either. Sometimes we do lack information (re: our health, let’s say) and tolerating uncertainty can be a useful tool.

What I am saying is that there is a difference between doubt and uncertainty and that treatment will look a bit different through the lens of resolving doubt as opposed to tolerating uncertainty.

On that note, I want to end with this: tolerating uncertainty is not synonymous with response prevention. So often, I see clinicians say “tolerate the uncertainty…stop ruminating”. They substitute “stop performing compulsions” with “tolerate the uncertainty” when those are two different things. Choosing to not engage compulsively with an obsession (response prevention) is not the same as accepting that you genuinely don’t know something (being uncertain). We can both know that we are not a pedophile, murderer, or sacrilegious person and not compulsively ruminate about it.

I’m in recovery and I know who I am. No uncertainty necessary.