Early in treatment for anxiety disorders and obsessive-compulsive disorder, therapists explain to patients about rituals. Rituals are physical or mental behaviors that reduce our distress or discomfort and offer relief but no pleasure. Common mental rituals are distraction/avoidance, checking and reviewing, thinking a safe thought, and self-reassurance. Some of the most common physical rituals are avoidance, checking and reviewing, having a safe person nearby, decontaminating, and seeking reassurance.
Self-reassurance is telling oneself that something is going to be okay or isn’t dangerous, but doing so in an often-frantic manner. This isn’t like an internal pep-talk; it’s more of a plea that nothing bad is going to happen. Reassurance as a physical ritual typically includes either asking another person to confirm something – such as whether an action is safe – or doing research, often online.
For those reading this and starting to panic as they think, “That sounds like me!” – rest assured that rituals in and of themselves aren’t dangerous or harmful. When I walk in my front door, there are three hooks. I hang up my keys and my dog’s leash, and now my facemask. That’s a ritual, because it reduces my stress that I will forget something I need when I leave home. It also eliminates any time I might waste searching for these items.
The difference between normal, functional rituals and compulsive ones is the level of distress that would result if they were changed or interfered with. If my items were on different hooks, or I placed them on the hooks in a different order, or I didn’t put them on the hooks at all, I wouldn’t be distressed (just annoyed if I were running late and couldn’t find my items). However, people with maladaptive rituals believe that the only reason something terrible didn’t happen is that they performed the compulsion, thereby leading them to conclude that the only safe option is to carry on ritualizing and reinforcing the harmful cycle. And for those with an anxiety disorder or OCD who have ritualized for an extended period of time, normal behaviors aren’t just scary or unfamiliar – they might be unknown.
For example, someone with decontaminating rituals might literally not know how frequently a typical person washes bath towels or how much toilet paper to use. Similarly, a person with relationship OCD who’s never been in a serious romantic relationship or dated much might be unsure how much time a couple “should” spend together at different stages of a relationship, or even how long a stage should last. A person concerned with physical symptoms might not agree with one doctor’s assessment, but how many second opinions is too many might be a complete unknown.
In such situations, it’s appropriate for a person to become educated on a topic or gain a reasonable amount of information. However, there is riskiness in the ambiguity of the “right” amount of information and number of sources, and/or opinions. It’s common for exposure therapists to assist patients in setting these boundaries, such as using only a single-predetermined news source or following guidance from a specific doctor. A therapist might also provide anecdotal information about what people typically do.
Because anxiety disorders and especially OCD want thinking and behaviors to be as black-and-white as possible, accepting only one source of credible information can be scary, and it can be challenging to not seek reassurance. However, there’s another perspective to take. It can feel distressing, disturbing, and anxiety-provoking to trust only one opinion, but that’s exactly what people do when they ritualize – they are choosing to ignore doctors, government agencies, friends, and family, all because of an intangible nagging belief that by not performing a compulsion they are encouraging danger to enter into their lives or the lives of loved ones.
So, how can someone struggling with the fuzzy line between education and reassurance figure out which they are doing? One way is to examine the function of the behavior. If the goal is to reduce distress, it’s likely a ritual. But if the goal is to gain information not out of uncertainty but because of a true lack of knowledge, then it’s likely information-gathering. Another approach is to track the behavior. If a question is asked once and that information gathered is generally accepted as fact, we can attribute that to education. However, if the same question is being asked of multiple sources, or of the same source but repetitively, then it’s likely more compulsive. Finally, consider the thinking prior to the behavior. If a person says, “I really don’t know what’s normal. I’m going to Google it,” that’s an educational endeavor. Meanwhile, if in a panic a person “must” know the answer and can’t handle the uncertainty, then we’re looking at reassurance.
Ultimately, the goal for all patients is to be able to identify and change maladaptive thinking and behaviors. This is why it’s crucial that patients aren’t just told something is a ritual. Patients need to truly understand their behavior, and how it’s interfering with them living their best life.