To accept or not to accept

Most writing about OCD emphasises that acceptance is something you need to learn. But what exactly are you being asked to accept? There are many misconceptions about this, and I recently had some important conversations with one of my clients about that very question. In this article, the client is called Michael, but of course that is not his real name.

Michael’s OCD had suddenly become focused on death, and he felt that this theme was different from his other OCD themes, because he felt he would never be able to accept death, and death is, in itself, unavoidable. This preoccupation with death showed up as images of no longer being here, losing himself and leaving others behind. Together, this created an intense, unbearable feeling that triggered a strong need to act. He therefore felt that this was an unsolvable OCD problem that would never go away. That is, of course, not how OCD works, but it made it necessary for Michael to consider carefully what acceptance actually means.

What needs to be accepted?

Is it the content of the OCD thoughts that you have to learn to accept, and what does acceptance even mean? Therapists, well-meaning advice found online, or AI-generated answers will often suggest that you simply say to yourself: “It may well be that I…”, followed by whatever you are afraid of being. You can try completing the sentence yourself with different OCD themes: for example “that I kill my partner”, “that I have been unfaithful” or “that I am a paedophile”. This approach suggests that you should be able to accept the possibility of being a terrible person, and that is absurd in itself. Who wants to be a bad person? Would that not always go against your values? Of course it would, and the person making the suggestion has misunderstood what it is you need to accept. When someone who is not affected by OCD thinks about being a bad person, it is easy. It also feels easy to accept that they might be one, because the thought does not challenge them. The thought carries no emotional charge. They are emotionally neutral and quickly move on. That makes it easy to assume that this is simply what the person affected by OCD needs to do: accept the thought, because that is what I do myself. But some important differences are overlooked when you do not yourself have an OCD-like relationship to your thoughts. It is more complex than that. It is easy to stand at the finish line and say that you should just do what I do. Like a professional footballer saying: “Look, you just need to do what I do. It is easy.”

Acceptance is about the relationship to the thought

When you do not have an OCD-like relationship to your thoughts, it is easy to accept the content of the thoughts, because you simply make space for the thought without engaging with its content. You do not have an empathetic reaction to the content. Thoughts are just thoughts. If we turn this upside down, you may start to believe that you must be able to imagine something unpleasant without reacting to it in order to have achieved acceptance. This is where the misconceptions arise. Let us say that you have OCD about being able to harm someone, and OCD has created a story that you could become an emotionless psychopath who kills someone. In this situation, it is very common to carry out checking behaviour, where you imagine harming someone and then assess your own reaction to the mental image. Here we have a situation where, according to OCD’s rules, you have to force an empathetic reaction to the mental image in order to prove that you are not a cold, unfeeling psychopath. The natural response would be to have no reaction, to remain neutral and very quickly move on, because it is a completely irrelevant mental image. This is not a sign of being emotionless, but OCD will make it seem that way. In this case, acceptance means allowing the thought to be there without being affected by it. Acceptance is therefore not about accepting the possibility of being a bad person, but instead about accepting that you can have thoughts about being a bad person. Having this thought without following up on it: “Why am I having this thought?”, as if thoughts must have a reason for being there; as if it must mean that somewhere, in some vague way, you could be a bad person, even though you do not even feel that you are one. Here, of course, we overlook the fact that thoughts arise randomly, but that this very “Why?” relationship to the thought maintains it and increases the frequency of the thought. It is therefore the relationship to the thought that acts as the “glue” for the thought, not the thought itself. If you start looking for reasons why you might be a bad person, the brain, in its endless helpfulness, starts looking for those reasons and coming up with suggestions about how and why this might be the case. A search begins for reasons to support the claim that you are a bad person, or that something catastrophic could happen, and suggestions appear. Those suggestions are then given significance through the special relationship you have with your thoughts.

What do you need to make space for?

So how do you get to a place where you no longer have an OCD-like relationship to your thoughts, so it becomes easier to accept your thoughts?

In order to have unpleasant thoughts without engaging with their content, we need, for example, to be able to make space for:

• negative stories about our character and values
• the urge to investigate why the thoughts arise
• strong negative feelings such as shame, fear of regret, responsibility and guilt
• the feeling that making space means overlooking something important - that it is simply being “swept under the rug”
• a deep feeling of emptiness
• the feeling that you have accepted the premise: that now you are the bad person you do not want to be - and of course are not

We can see, then, that there is a lot that needs to be made space for. Perhaps it is not so strange that this is not straightforward?

Michael and the thought of death

Let us return to Michael. Michael had become preoccupied with the idea that he had to come to terms with the fact that he was going to die. He talked to many people about death and could not understand how they could live with the fact that everyone has to die, without also being in a state of panic. He considered, without being especially religious, speaking to a priest in the hope that this might help him reach acceptance of having to die. But being 30 years old and trying to check whether you feel okay about dying, and thereby having achieved acceptance, is almost impossible. No one is okay with dying except perhaps when they have reached the end of life - not when they are in the middle of life and full of vitality and joy. This was not an ordinary thought being examined with academic curiosity and wonder, but an anxiety-filled obsessive thought that kept taking up space and creating anxiety, where the apparent solution was to find peace with the thought so that it would go away.

Not actively seeking calm

The problem, of course, is that the very act of engaging with the thought creates the disturbance, and it is therefore not possible both to hold the thought in mind and at the same time experience inner calm. It is like imagining that you have shaken a glass with sand and water. The water has become completely cloudy because the sand has been stirred up, but you keep shaking the glass while expecting all the sand to settle calmly at the bottom. What else is there to do but stop shaking the glass? Michael had to make space for the thoughts and everything that came with them, without seeking calm. He had to practise taking a passive stance toward something that felt as if it demanded immediate attention, but which at the same time maintained the high anxiety. Because of his previous work with OCD, a good “OCD toolbox” and strong willpower, Michael managed to remain passive, and over the course of 14 days the anxiety reduced to a level where he could relate to the topic more rationally. As a good sign, his familiar OCD themes returned, and everyday life became normal again.

Letting go of engagement with the thought

In metacognitive therapy, one of our favourite images is conveyor belt sushi, where you only take the dishes you feel like eating and simply let the others continue along the belt. In many ways, it is a very good image of the fact that we can choose - and decline - what we engage with in our thoughts and actions. A common problem with the way this is implemented, however, is that although you only take the dish you want to eat, while chewing it you keep anxiously watching the other dishes, as if at any moment they could jump onto your table, or at least as if their presence is somehow dangerous. You could say that the negative dishes remain on the belt and create negative feelings even though they are not being eaten. The important thing is to take the dish you want and leave the restaurant, rather than staying there watching the conveyor belt. Metacognitive therapy can rarely stand alone in OCD treatment, because it was not developed as a standalone intervention for OCD. That is why at OCD Klinikken we use an integrated method with several cognitive approaches tailored specifically to OCD.

Conclusion

We can see that understanding what acceptance means can make a decisive difference. There is a lot that needs to be made space for, and in many ways the phrase make space for is more accurate than the word acceptance.