So, you’re a failure. Fine. Get on with your life! In my work as a psychologist treating anxiety disorders, I’ve learned that often an underlying driving fear in my patients is the worry that they are failures. (My patients and I use a more colorful term, but for editorial purposes I’ve changed the phrase.) They have intrusive thoughts that they have or will mess things up in some way and cause harm to themselves or others. Their surface fears may involve worry about contamination, feeling socially awkward, having a panic attack, etc., but if I drill down to underlying intrusive thoughts, I often find that the patient is ruminating about being a failure. Unless we deal with the underlying fears, treatment is less than successful. I help the patient identify those fears and the behaviors/thoughts they are using that maintain the fear. I use Exposure and Response Prevention (ERP) to help the patient gain control over their intrusive thoughts. The following case is an illustration of how ERP can be used with a patient presenting with generalized anxiety and depression.

A man in his early 40s was referred to me by his psychiatrist for treatment for anxiety and depression, after having had years of traditional psychotherapy (and trials of SSRIs) with little success. Since college, he had struggled with procrastination and a belief that he was never good enough. He was a successful writer/editor, father, and husband, but was consumed with thoughts that he was a failure. He engaged in constant rumination about whether he was successful or not. His ruminations consumed his time and energy and created loads of anxiety, but were fruitless in quelling his uncertainty. Down the rabbit hole he went every time he thought that he wasn’t good enough. He became paralyzed with inaction to the point where he felt he couldn’t attend to the basic tasks of living.

Psychodynamic psychotherapy looked for the root causes of his belief that he wasn’t successful and traditional CBT asked him to stop his negative self-talk and to challenge his assessment of failure with evidence of his successes. Both of these forms of psychotherapy engaged the patient with the content of the thought: “I’m a failure and I will fail in the future.” Both of these approaches didn’t work. To get better, the patient needed to accept the thought that he may indeed be a failure. He didn’t need to understand why he felt he was failure. He didn’t need to challenge it. He just needed to accept it: “I may be a failure and I’m likely to mess things up in the future.”

In conceptualizing this man’s struggles in the framework of OCD, the obsession (the unwelcome intrusive thought) is, “I’m a failure”. The compulsions are avoidance of work (and other obligations) and mental compulsions consisting of rumination (the constant analysis and arguing with himself whether he was or wasn’t a failure.)

Treatment of OCD with ERP (the gold standard treatment of OCD) requires that the OCD sufferer accept (or even seek out) the obsession (with all it’s concomitant anxiety and dread) along with not performing any compulsions/rituals to counter the obsession or the feelings associated with the obsession.

In this case, the client needed to invite and agree with the thought that he was indeed a failure and would likely fail in anything he attempted to do in the future. He wasn’t to argue with that thought, nor analyze it, nor attempt to figure out why he believed that thought to be true. He needed to engage in activities that generated his intrusive thoughts and he needed to refrain from performing compulsions (mental of physical). I employed a number of techniques such as delaying and writing down the ruminations (compulsive thinking) for limited periods of time and having a planner where he wrote down the tasks of the day and instructed him to do them even when he didn’t want to. He was to seek out experiences where the obsessions would be triggered and we also constructed scripts which he would listen to repeatedly throughout the day that suggested how much he was messing things up and what the disastrous consequences would be for those behaviors.

Fairly rapidly he was able to recognize his ruminations and avoidance as unproductive and detrimental to him getting on with his life. He

eventually allowed the obsession of being a failure just to be in his mind and not get tangled up in it. He told himself, “I may or may not be a failure. I can never know that for sure. Spending hours arguing with that thought and avoiding tasks that need to be done only takes up energy and distracts me from doing the things I need to do and a life I want to enjoy living.”

Once he stopped arguing and analyzing his thoughts and could put his energy and focus into his work and engage more fully with his friends and family, his anxiety and depression abated. He could live life being productive and joyful with the thought he might indeed be a failure.