The "Just Right" Feeling: When OCD Isn't About Fear & How to Treat It with ERP

“My compulsion isn't about preventing a bad thing. I just feel like I have to do it until it feels 'right.' What is that, and how do I do ERP on it?”

What is OCD? How Does OCD Work?

I always act like every OCD article is someone’s first, so forgive me for explaining if you are a seasoned veteran. Obsessive-compulsive disorder (OCD) is made up of obsessions and compulsions that repeat. Obsessions are basically “what if” questions that pop into somebody’s mind and cause an anxious response. Compulsions are the things they do to make themselves feel better: ruminating on answers, seeking reassurance from others or from online searches, or any action that helps settle the “what if” and gives them temporary relief. When compulsions become too exhausting or ineffective, they start avoiding things that cause them to feel anxious. What makes it a disorder is that the obsession and compulsion/avoidance cycle becomes all-consuming and the relief that someone gets from reassurance or compulsions is very short-lived. OCD sufferers' lives get smaller and smaller in an effort to manage the stress and anxiety, and they often feel stuck until they receive a highly effective treatment called Exposure and Response Prevention (ERP).

Just Right OCD: When OCD Isn’t Really About Fear

So, what about those who aren’t really struggling with a “what if” question, but instead they feel like they can’t handle something not being just right? How do you do exposure and response prevention for just right OCD?

Just right OCD normally presents as someone who has to do a variety of tasks a certain way or else they feel like they’ll be anxious or terribly uncomfortable forever—or at least for a lot longer than they want to. They leave the radio or TV volume on the same number every time they turn it off, or they leave it on the number it was on when they turned it on initially. They walk certain routes and don’t feel like they can alter them. They check certain apps on their phones a certain amount of times before bed. They do certain tasks in the same exact sequence every morning and evening. Sometimes somatic OCD and just right OCD are closely related, and the person feels like they have to blink or breathe a certain way or number of times. The rituals can be endless and incredibly complicated. The obsessions or cues to do the rituals aren’t necessarily super anxiety-inducing or as scary as they can be in other OCD subtypes. The thought that the person needs to do something a certain way is just there, and the person with just right OCD feels like they must obey it. Once it’s obeyed once, the person feels like they have to keep obeying it for a long time. The details depend completely on whatever pattern feels right to the person. It doesn’t have to make sense to anyone else.

What makes this OCD subtype unique is that they don’t always have a big fear that they are trying to solve. Most OCD has a background fear of scanning the past to see if they did something awful, feeling like they are capable of something terrible now, or wondering if they’ll snap and do something terrible in the future. Just right OCD can have elements of those fears entangled in it, but it is sometimes as simple as not liking the way something feels in the here and now.

Sometimes there is a superstition behind just right OCD rituals, like believing that something bad will be prevented if they keep them up perfectly. Example: "It will feel less likely that I hit someone with my car last week (when I was a little distracted and I heard a knock under my car) if I wear certain clothing that feels just right each day." If there is, it’s important to recognize that so you can name it and keep that causal connection in mind while doing exposures. OCD heals best when you are fully conscious of the reasons you are actually maintaining your compulsions.

Often there is no superstition behind just right OCD, though. The main thing this group of folks is struggling with is a very unsettled feeling and increased anxiety if they mess up their performance more than they can justify or tolerate. Although they may not be superstitious, worried about a big existential fear, or researching an answer to a question obsessively on Reddit, they do have a fear. The details of their fears are slightly different for every person, but ultimately they fear discomfort. They fear sitting with the pain of not following their routine and wonder if they do break their routine if they’ll still be able to fall asleep, study, be social, or enjoy anything in life.

Exposure and Response Prevention (ERP) For Just Right OCD

Exposure and Response Prevention (ERP) for the just right OCD subtype typically focuses on exposures that prove one lesson: Slowly and systematically doing your typical just right compulsions the wrong way actually decreases your overall distress rather than increasing it.

This is probably the least cognitive of all of the OCD subtype treatments, meaning we don’t do a lot of talking about the content in the mind of the person struggling with just right OCD. The treatment is very behavioral, and the focus of treatment is on coming up with behavioral alterations to the typical just right patterns. These behavioral alterations have to be tailored to the specific person’s reason for why they are doing the compulsions in the first place.

Here are some examples:

ERP For Route Tracking Just Right OCD

Two people with OCD have to drive a certain route from their house to work, but their reasons are totally different. One person drives a route that is not the most efficient route to work because they can’t get too far from their family members for too much of the trip without facing severe anxiety. The other person does it because they simply have to complete the cycle and drive back to work the exact opposite way they came home last night. Early on in exposure and response prevention, you want to choose exposures that are in the medium range. So for the first person, I would work with them to find an alteration that gets them to work faster, but doesn’t necessarily make them the absolute farthest away from their loved ones as they could possibly get. For the second person, we would do something like messing up how we get in the car and how we get out of the car. In just right OCD, the client often has to tell me what would be wrong because only they know the intricacies of what feels right and what feels wrong in their particular system. Finding good, easy starting points like the ones I mentioned here is really important. You want to start at a place that causes some distress but that is manageable. Exposure and response prevention does not seem to work very well when you go for the hardest things first, but it also does not work well if it’s not distressing. The research shows that people with OCD have the most success when they start exposures really early in treatment, and when the exposures are difficult. But striking a balance that builds confidence and slowly erodes the fear that they can’t tolerate the distress of doing things wrong is the optimal approach for the client to build confidence and build a connection with the therapist.

ERP for Superstitious Just Right Ritual OCD

Just as we just described above, for those with just right ritual OCD that has superstitions behind it, we would want to start with exposures that are manageable but distressing enough to make a difference. If the person feels like their rituals keep something bad from happening in the past or the future, then we need to slowly and slightly disrupt those rituals to break down that belief that is keeping them stuck. What’s at stake if we don’t do this is that the person will always be living with a severe sense of dread and a lot of inflexible behaviors that steal their joy in life. Nothing is worse psychologically than trying to control things that you can’t control, and that’s especially true when the way that you are trying to control them is putting severe unnecessary restrictions on your life. So for this person, we would start by simply getting them to turn off the light switches in a different order than they typically do at bedtime or wearing their unlucky shirt instead of their lucky shirt so they can see that their tires don’t blow out, their identity doesn’t get stolen, and a tornado doesn’t hit their house.

How to Fully Overcome Just Right OCD

With all types of just right OCD, exposure and response prevention approaches need to climb the ladder. In my experience, people with just right OCD have a couple of rituals that are the most fixed and distressing to do wrong on purpose. If you do not eventually work up the ladder to the point of purposely doing those rituals wrong, people with just right OCD may never fully recover. Since those with just right OCD often make up the rules for why they do their compulsions as they go along, you have to find exposures that they can’t justify away. Example: Changing the order of the light switches at night can become the new OCD pattern, but changing the order and saying in your mind, “this will probably lead to something terrible happening tomorrow” can’t be justified. Again, why in the world would I ask someone to do something like that? I’m asking them to do that because they know deep down inside that this superstition is keeping them stuck, it isn’t actually preventing anything bad, and it’s keeping their baseline anxiety high. They can be free as they go against it on purpose and decide what they want to do and be rather than letting OCD call the shots.

The goal of exposures is for OCD triggers and fears to become noise rather than a signal. As you recover, the mind and body’s demands to do things a certain way become less and less intense, and you begin to get your life back. You’ll also notice that your overall anxiety level begins to decrease in situations unrelated to OCD. I love treating OCD because people get better, and I know you can get better too.

About Tyler Slay, Licensed Professional Counselor in Madison, Mississippi

Tyler Slay, LPC is a therapist in Madison, Mississippi specializing in OCD, Anxiety, Trauma, Stress, and Christian Counseling. Tyler sees clients in-person at 212 Key Dr. in Madison, MS and throughout the state of Mississippi online via telehealth. You can reach Tyler by calling or texting 601-790-0250 or filling out the contact form here.