Tormenting Thoughts and Secret Rituals Page 13

  In the case of Melissa, I strongly recommended starting medications immediately, and she did not object. Melissa’s treatment proved somewhat complicated. Prozac was started at a dose of 20 milligrams per day, and she seemed to do well on this, noting a decrease in the intensity of her obsessional questions within the first week or two of treatment. But after six to eight weeks, she complained of disturbing feelings, quite foreign to her, of irritability and even rage. “I got so angry I was snapping out at people and running over curbs,” she told me. In addition, she began to have vivid, horrible nightmares—in one dream, rats were eating her feet. We switched to Anafranil (clomipramine), but immediately she felt too groggy. “I can’t think straight on this stuff,” she said. Sertraline (Zoloft) was then tried, but again, the side effect of vivid dreams emerged after one to two months of treatment. Finally, a combination of a relatively low dose of fluvoxamine (Luvox), 50 milligrams, accompanied by a small dose of clomipramine (Anafranil), 50 milligrams, proved helpful and did not cause side effects.

  Melissa is convinced that medications have been very beneficial—that’s why she has put up with all the problems they have caused her. Her obsessive questions are not as insistent; she is able to let go of them more easily. Another apparent benefit of the medication is that Melissa has become more assertive. She has experienced the type of beneficial personality change that Peter Kramer talks about in his book Listening to Prozac. Before, she wouldn’t speak up; once on medication she assertively confronted her sister for the first time in her life. “People notice a complete change.” Melissa reported. “I like it.”

  IS TAKING MEDICATION A SIGN OF WEAKNESS?

  Like Sherry, many people think that medications are a copout, that taking them is to shrink from a personal challenge that should be met. This view is even promoted by some psychiatrists, notably Peter Breggin, author of Talking Back to Prozac and Toxic Psychiatry. Dr. Breggin, who rails against the use of all psychiatric medicines, including those that are used to treat very serious disorders such as schizophrenia, views all drugs that affect the mind as escapes from the suffering of intense feelings, suffering that should be lived through and dealt with as a means of personal growth. What people should do, Dr. Breggin says, is try to understand the roots of their problems, not escape them through drugs.

  The error in this line of reasoning is the assumption that OCD has deep psychological “roots.” It is now widely agreed that OCD has little or nothing to do with unconscious conflicts or hidden hang-ups. As discussed fully in Chapter 9, research has now proven that OCD is a discrete, partially genetic, brain disorder. Importantly, OCD is often brought on by life stresses, and they should be addressed in therapy. But far from being an escape, medications are used to treat the direct, physiologic cause of OCD so that, rather than wasting their time looking for imaginary roots to their problems, OCDers can get back on their feet and begin meeting life’s real challenges.

  I myself have taken an anti-OCD medication on a regular basis for four years now. I had never before taken a psychiatric medication, but at the age of forty-seven I considered the following: (1) I used to have diagnosable OCD; (2) I still had problems with obsessional worries—subclinical OCD, if you will; and (3) I was very impressed with the results of these medications in my practice. Resolving to give myself a trial on an SRI, I found medication to be both helpful and free of side effects. As an example of their benefit, I am now able to drive on long trips comfortably, without my usual excessive dilemmas, such as whether I should be going faster or slower, or whether I should be in the right or the left lane. I function, I would say, somewhat better all-around: sleep a little better, put in a longer day’s work. I do not regard my taking medication as a sign of weakness.

  Medications, specifically the serotonin reuptake inhibitors, are an indispensable part of therapy for the majority of OCD sufferers. These medications, now conclusively proven to be a specific treatment for OCD, represent a truly remarkable advance in the medical treatment of brain disorders. Relatively free of side effects, easy to take, and apparently safe for long-term use, these drugs can offer dramatic relief from crippling suffering. OCD patients should not hesitate to make use of them, nor should they feel guilty when they do.

  6

  THE LESSONS OF GROUP:

  TEN STRATEGIES FOR

  COPING WITH OCD

  Behavior therapy and medications are the two best treatments for OCD, and thus far they are the only ones that have been proven effective in clinical trials. In practice, however, it is obvious that a number of other treatments—including individual psychotherapy, family therapy, and group therapy—can also be helpful. Of these, group therapy is perhaps the most important. I lead OCD groups at both a community mental health center and a university counseling service, and the majority of my patients attend group at one time or another. Most of them benefit markedly. Indeed, for those with relatively mild symptoms, group therapy may be the only treatment necessary.

  The type of group I refer to is neither an “encounter” group (“Beth, tell Jennifer why you are angry with her”) nor a personal issues group (“Bill, how did your separation affect your self-esteem?”). Instead, what OCD sufferers need is education and support: a group that teaches positive strategies for coping with obsessions and compulsions while providing a sympathetic, enlightened atmosphere to counter the strong negative feelings that accompany the disorder.

  Consider the typical OCD sufferer. She is saddled with a problem that no one seems to comprehend, least of all herself. Her symptoms, if observed, are likely to elicit ridicule rather than understanding. And instead of sympathy, the attitude most people take toward OCD is, “Why don’t you snap out of it?” Not surprisingly, she will try to hide her symptoms, fueling feelings such as guilt, self-doubt, and discouragement.

  Group therapy is uniquely helpful because it relieves this burden of secrecy in a way no other therapy can. In group, the OCD sufferer makes a remarkable discovery: Those who share the disorder are likable and responsible individuals. A young woman with tormenting sexual obsessions observed: “The people in group have become friends who are like family. I look up to them. I admire them so much. I’m amazed at how well some of them do despite having really bad compulsions. Most of all, though, they understand the pain of OCD, and nobody else does.” The shame of self-tormenting thoughts and senseless rituals dissipates when it becomes clear that they are the result of a common, chemical disorder that occurs in normal—actually, nicer than normal—folks.

  Guilt is the most pervasive of the many punishing feelings shouldered by OCDers. Indeed, the tendency to suffer guilt in an exaggerated form is regarded as a cornerstone of the OCD personality. The following excerpt illustrates how self-blame can be soothed in a group setting. Included are comments from Melissa, Jeff, and Raymond, whose cases were introduced in Chapter 1.

  MELISSA: I was obsessing about being disrespectful to my father. He asked me if I wanted to drive over to State College, and I said no. Afterwards, I wondered: Was I short with him? Was I disrespectful? What would people think if they heard me talk to him this way? It was a terrible time. I felt so guilty that I almost got suicidal. Finally, two hours later, I apologized, long after he had forgotten about it.

  GROUP MEMBER: When I get breakfast for my kids I have to wash my hands a dozen times because I think that if I get sick, the whole family could get sick. Then if the kids miss school, I wouldn’t be able to take care of them. Everything would be my fault. What I can’t stand is the thought that I would be to blame.

  JEFF: I used to feel guilty all the time. I thought I was such a horrible person that I shouldn’t even be allowed out of my house. But now I say a couple of things to myself: “Okay, I’m not perfect and I never will be,” or, “That’s normal, every human being does that once in a while.”

  RAYMOND: Back when I first started checking everything, it was because I didn’t want anyone to ever be able to say that if Raymond had only been more careful, some bad thin
g wouldn’t have happened. My wife said, “Raymond, what’s the matter with you? All of a sudden, you’re afraid to fail.” She was right. We can’t be afraid to fail. We just have to accept that we might fail, and be able to deal with that guilt.

  Discouragement is another feeling frequently shared in group. A new group member tearfully described changing her baby’s diaper over and over, using up whole packages of diapers before finding one that seemed clean enough. “The anxiety is just wearing me down. I am very discouraged. I can’t take this much longer,” she said. In response, one person shared how he had once been hospitalized for depression from his OCD and how his life had turned around after he got help. Two others emphasized that having compulsions is not a reason for despair; compulsions are part of OCD, and they can be treated. As a result of this discussion, she mustered the courage to keep fighting her disorder and started to make progress.

  Self-doubt is yet another common reaction to the rigors of OCD. It often involves the fear of having a complete breakdown. A student who changed her clothes a dozen times a day described her anxieties:

  Whenever I walk on the sidewalk I get paranoid that I’ve walked in dog poop. I know it’s crazy, but I think that maybe I got it on my shoes, then onto my clothes, then onto my hands; and then if I touched someone, maybe they could get sick. I know it’s far-fetched, but I can’t stop thinking these things all day long. I must be losing my mind … or going crazy.

  One person immediately shared that she, too, had suffered such fears. Another added: “You think that sounds crazy. Let me tell you, I can top that.” And he did, describing a past obsession that he could impregnate women simply by being in the same room with them. The lesson learned from this and similar discussions was that although obsessions are very irrational, OCDers never lose contact with reality; they are never in danger of becoming truly “crazy.”

  It is hard to overemphasize the relief experienced by OCD sufferers when the burdens of guilt, discouragement, and self-doubt are lifted. An equally important benefit of group, however, is learning coping strategies for dealing with obsessions and compulsions. Here, too, group therapy is uniquely beneficial. I can and do address such strategies in individual therapy, and patients can read about them in books, but neither of these opportunities carries the weight of hearing the experiences of others at firsthand.

  It is important to note here the relevance of these coping strategies to behavior therapy. As discussed in Chapter 4, behavior therapy involves three essential steps: recognizing OCD; tolerating obsessions; and fighting compulsions and avoidance. The strategies discussed in this chapter assist in accomplishing these goals. They are aids to behavior therapy. They help people change their attitudes and outlooks, allowing OCD to be recognized more quickly, obsessions to be tolerated more easily, and compulsions to be fought more vigorously.

  In each group session, I try to ask each member: What strategy is working the best for dealing with your OCD right now? I ask that the details be spelled out and specific examples provided, so that everyone can understand exactly how the tactic is put to use. The same strategies come up again and again. Some overlap, and others can at first almost seem to be contradictory, but each one is a tried and true method of furthering the goals of behavior therapy. I have reviewed my notes and tapes from six years of group sessions. Here are the ten practical strategies that have been spoken of the most:

  STRATEGY NO. 1: IGNORE OBSESSIONS

  A student in our university health services group was struck by obsessions of loved ones becoming sick. She could only restore them to health with tapping or touching. She was devastatingly embarrassed when, as sometimes happened, her friends made light of her rituals.

  SHELLY: I get these pictures in my mind of awful things happening. Usually, it’s my Mom having a heart attack. First I see it taking place really clearly. Then I have the feeling—I know it doesn’t make sense, but I definitely have the feeling—that it might come true unless I do some little “thing.” So I tap my fingers on the table eight times—always eight—and I feel better. Or else I touch everything on the table. I hate it when someone says: “What did you do that for?” That kills me. It just kills me.

  STUDENT: I used to have almost exactly the same obsessions. I would be afraid that something bad would happen if I didn’t arrange things a certain way. Like before I went to bed, I had to touch every single thing in my room. But now I just try to ignore those thoughts. I pretend they’re some creep who’s trying to bother me.

  Ignoring obsessions is an ideal coping method. It is, after all, the way most people deal with intrusive, unwanted thoughts. They say to themselves something like, “That sure is a silly thought, I won’t pay it any attention”—a fitting response, because ignoring an obsession saps its strength, whereas fighting it only forces it to come back stronger.

  OCDers need to look on their obsessions in such a way as to allow them to stay in the forefront of consciousness. That way, habituation can take place and the unwanted thoughts will eventually go away on their own. The perfect attitude might be summed like this: It’s okay that I had that thought, and it’s okay if it stays. It’s no big deal.

  Of course, the whole problem with OCD is that a chemical disorder of the brain makes ignoring obsessions very difficult. Often it is helpful to find a metaphor that helps to put an unwanted thought in its place. It may be likened to a wino on a city street, static on the radio, flies at a picnic, or an unwanted suitor (this one works particularly well for college-age women). The response is the same: Once an obsession is recognized, pay as little attention to it as possible.

  Ignoring obsessions works best when obsessions are mild. Sometimes OCD sufferers advance to this strategy only after they have progressed in treatment. Sherry, for instance, who once suffered harm obsessions so frightful that she could hardly bear even to bring them to mind, recently told me: “What works now is just to let them happen. Not to knife myself, obviously! But just to let the thoughts come and to let the thoughts go. Ignore them. Treat them as a person I don’t want to deal with.”

  STRATEGY NO. 2: RATIONAL ARGUMENT

  Group members rallied around a young homemaker with handwashing compulsions:

  EMILY: I’m still washing my hands a lot when I’m around food. Like when I make breakfast. I wash before I take the bread out of the breadbox. Then I wash again before I open the bread, because I touched the breadbox and might have gotten them dirty. Then I wash again before I take the bread out of the toaster, because by then they feel dirty again. Then I wash before I get my juice and again after I’ve poured it.… Get the picture?

  GROUP MEMBER 1: Do you really think you will get contaminated? Why don’t you argue with those thoughts? You’ve got to keep telling yourself that they don’t make sense.

  GROUP MEMBER 2: What I do when I get one of my contamination obsessions is to sit myself down and say to myself: “This isn’t logical. It’s just another of your obsessions.” I psych myself up. Even though I’m worrying about germs I make myself eat by telling myself, “The food isn’t contaminated, it’s all in your mind.” It works. It really does.

  GROUP MEMBER 1: Could you give a try to not washing at all while you are making breakfast? Just don’t wash, no matter what. Argue back to the obsessions when they happen.

  After this discussion, Emily was able to make progress by consistently confronting her obsessions: “I’ve never heard of anybody getting sick from this; there is clearly no need to wash all the time. Other people don’t do this, so I don’t need to either.”

  A nineteen-year-old student named Allison had a number of obsessions when she parked her car, including that the emergency brake was not fully engaged and that the gearshift lever was not in the “park” position. To counteract these fears, she checked the brake over and over and often sat for five minutes or more staring at the gearshift indicator. She stared, she said, in order to insert a clear picture in her mind of the car being in park, so that if she was later surprised by the
obsession she could recall the picture and be reassured that the car would not drift downhill and injure someone.

  After a couple of months attending group and hearing how other people put obsessions in perspective through rational argument, Allison began to make excellent progress. Remembering what she had learned, she confronted her compulsions by telling herself: “I’ve checked hundreds of times, and the car has always been in park. I do not need to check again.” Or she would say: “This is an irrational compulsion, stop it.” Or: “I know this is OCD, and I know that I’ve got to get going. So do it.”

  In rational argument, OCDers learn to have discussions, “self-talk,” about what is reasonable and what is not. They learn how to stand up to obsessions by logically considering their content. Rational argument is best employed as soon as obsessions hit, before compulsions get started. Sometimes, because compulsions become such strongly ingrained habits, there seems to be no time. Yet there is always a microsecond available to interrupt the split-second program of obsession leading to compulsion with a byte of clear thinking. Slip in a little reason here, and the first step has been taken to bringing OCD under control.

  Rational argument is nothing less than the keystone to developing a workable, long-term approach to OCD. It is the strategy that is emphasized the most in group, and it forms the foundation for many of the other strategies that will be mentioned in this chapter. Here are some more quick reminders, gathered from group, useful for putting obsessions in rational perspective.

  • I’ve been in this same situation countless times, and my worst fears have never come true.

  • Just because this (urge, image, idea) feels real doesn’t mean it is.

  • The only way I’m going to overcome my OCD is to learn to live with this fear.