Tormenting Thoughts and Secret Rituals Page 15

  LAURA: My OCD is getting bad, again. It’s the same routines over and over—I mean like all the time, all day long. I have to imagine dozens of different faces; I have to clearly picture a face and have a positive thought at the same time I’m doing it or something bad will happen to that person. First I do family members, then close friends, and then acquaintances. This involves everybody that’s important to me. There must be twenty or thirty different people. While I’m doing it, other pictures come into my mind, “interrupter people,” who mess things up. Then I have to start over. I can’t even read a book.

  STUDENT 1: Can’t you fight them? You need to remind yourself that those people are going to get along fine without your thinking about them.

  LAURA: Nothing works. The thoughts are too strong.

  GROUP LEADER: (after a pause) Can anyone else relate to this?

  STUDENT 2: I used to have the same rituals. I couldn’t go to sleep until I clearly visualized the faces of all the members of my family—and I’ve got a big family—with a certain expression on their faces, and all this had to happen while I was lying a certain way and saying a certain prayer. But a big problem happened when I came to college: I didn’t see these people for months at a time, and I would lose their images in my head. That drove me nuts. Like nuts. I would lie there and get so mad at myself that it gave me insomnia.

  GROUP LEADER: What was helpful to you to break those compulsions?

  STUDENT 2: I told myself, “You’ve got to stop this. You’re a big girl, now.”

  LAURA: I can tell myself to stop, but the thoughts come back even stronger. I’m like totally gone.

  STUDENT 1: Laura, maybe you can try this. Don’t stop the ritual all together, just cut down on the number of faces you are imaging. Maybe that will work. Just visualize the five most important people, then stop for a while.

  To my surprise, Laura benefitted from this suggestion. When it was brought up, I had thought it overly simple. In fact, I was ready to write Laura another medical withdrawal. This experience clearly demonstrates one of the great benefits of group therapy: People who are actively fighting OCD have insight that others lack into what works.

  Limiting a ritual also worked for a middle-aged woman in our community mental health center group who suffered from compulsive reading and hoarding. Picking up Good Housekeeping, for instance, her eye would catch an article on aging. Even though the subject was boring, she would feel that she had to read the article so that she wouldn’t miss something important for her family’s health. Attempting to do so, however, she would find that she wasn’t able to attend fully to the article. She would then have to reread it. Invariably, she would never gain certainty that she had sufficiently absorbed the article’s information, and she would have to save the magazine so that she could refer to it later. Stacks of magazines lay in piles on her floors and littered her attic. Group members helped her break her compulsions by suggesting that she throw them away a half-dozen at a time. It worked. She was able to accomplish this by telling herself, “There are so many magazines here that throwing away a few of them isn’t going to matter.”

  Postponing rituals, a similar strategy, can also be quite effective. Another middle-aged woman suffered from handwashing compulsions that left her sinks clogged with soap and her hands chapped and occasionally bloody. Group members gave her the homework assignment of resisting the urge to wash her hands for ten minutes after using the toilet. This caused her tremendous anxiety, but she did it—holding up her hands like a surgeon, fearful to touch anything at all. Over subsequent weeks she stretched the interval to twenty minutes, then thirty, and finally to two hours, after which the obsession lost its strength. She did it by telling herself, “I’ve just got to hold off for a few more minutes, then I can wash.”

  Melissa once reported that when no other strategy worked, postponing did. When faced with an agonizing need to analyze a conversation over and over, it was all she could do to put off the compulsion by telling herself, “Just wait for twenty minutes, and then think about it. There will still be plenty of time to call and apologize if I need to.” By the end of the twenty minutes, her need to review the conversation was no longer powerful, and she could use reason to deal with it.

  STRATEGY NO. 9: LEAD AN ACTIVE LIFE

  A middle-aged carpenter who had been tormented by fears that his house was infested with insects told our group:

  Keeping busy is good for me. If I let myself sit around I start thinking about those termites. I imagine them in the wall, in the attic, in the floor, everywhere. I start walking around looking for little piles of their sawdust. So I work on my car, clean the house, buy groceries, start my mother-in-law’s wood stove—whatever needs to be done is better for me than watching TV. If I just sit around I start to dwell on things.

  A young woman with handwashing and cleaning compulsions who worked as a hospital aide noted, “The best thing I’ve found is to schedule my days so that each hour is accounted for. When I have things to do, I don’t obsess so much.”

  I was skeptical of the utility of “lead an active life” when I first started specializing in OCD. A person should learn to be able to enjoy free time, I thought, and not be driven to activity. But I didn’t know much about OCD back then. The fact is that the strategy of keeping active can be extremely helpful.

  A man with severe OCD shared a reminiscence that was both touching and edifying. During his twenties, when his OCD was at its absolute worst, the only thing that kept him out of the hospital was keeping busy by helping others. Every day he would go his relatives’ houses and ask if anyone needed anything done. He would fix a furnace, mow a lawn, chop firewood, anything at all. He became a sort of legend in his family for his good works. Yet, he told us, all this activity served a dual purpose. It kept his mind occupied so that he was not constantly tormented by obsessions; and, at a time when he was filled with agonizing self-doubt, it made him feel good about himself.

  What helps OCD sufferers the most is being involved in tasks that are challenging and creative, tasks that provide a sense of accomplishment. Perhaps that is why Winston Churchill, who suffered tormenting obsessions himself, once said: “Those whose work and pleasures are one are fortune’s favorite children.” The child in the excellent movie The Touching Tree (available through the OC Foundation) discovers that his OCD is completely quieted when he acts on stage. A good strategy for anyone, but especially for OCDers, is to find a creative endeavor, a mission, and be devoted to it 100 percent.

  STRATEGY NO. 10: ACCEPT OCD AS A CHRONIC DISORDER

  In a group discussion not too long ago, members talked of the advantage of developing a realistic, long-term view of OCD:

  GROUP MEMBER 1: I just accept that I’m going to have OCD forever. But I also know that it’s not going to stop me from living my life. When I get a bad obsession, I tell myself, “You’ve gone through this hundreds and hundreds of times, and you’ll go through it hundred and hundreds more. It’s not going to ruin you. The less attention you give it, the better.”

  GROUP MEMBER 2: I’ve learned to live with OCD, too. What really helps is knowing that the symptoms will come and go. Even if I’m having a hard time now, I know that I’ve done very well in the past and I will in the future, too.

  RAYMOND: It’s helpful for me to tell myself, “I have OCD, and I’m probably going to have it the rest of my life. So I better just deal with this obsession as best I can, because there’s no escaping from it.”

  GROUP MEMBER 3: I’m not ashamed of having OCD any more. I think positively about it. For some reason God made me with a bizarrely creative mind. He must have known what he was doing.

  People with moderate to severe OCD usually have some symptoms all their lives. Recognizing and adapting to this can be a crucial step in therapy.

  These ten strategies are the ones most frequently mentioned in my group therapy sessions, but many others work well. Relaxation methods such as self-hypnosis and transcendental meditation can be helpful, esp
ecially if put to use immediately when a person is hit by an obsession. OCD experts Jeffrey Schwartz and John March recommend “mindful awareness,” a Buddhist Vipassana meditation technique that involves focusing attention carefully on the various movements of the body and mind. Mindful awareness results in increased psychological distance between the self and obsessions, an excellent way to build tolerance to obsessions and make progress in behavior therapy.

  Some of my OCDers report that they can “trick” themselves out of performing compulsions. A student who touched the table six times to “prevent” her mother from having an accident would say to herself at the last minute, “If I touch the table, my mother will have an accident.” This stopped her ritual in its tracks. Another strategy fairly popular among my group members is the “split screen” technique: Allow the obsession to occupy a part of your mind; get on with your life in the other.

  Humor deserves special note. Sherry once noted, “If I’m having a bad knife obsession, I’ll tell my husband about it, and he’ll begin to hum the tune from Jaws when the shark is ready to bite somebody. I crack up. The obsession seems so ridiculous it doesn’t bother me anymore.” John March once treated a boy who suffered obsessions of stabbing his mother by having him sing, to the tune of “The Farmer in the Dell,” “I’m going to stab my mother, I’m going to stab my mother.…” When it works, humor is an excellent way to increase psychological distance from obsessions.

  What works best of all is to try different strategies and see which ones are most helpful. Sometimes a particular method is effective for a few months and then loses its power. Other times, the same strategy retains its effectiveness for years. At the very least, starting a strategy fosters hope and brings focus to the fight against OCD.

  Lastly, OCDers should keep a watchful eye that a useful strategy does not itself turn into a compulsion. This snare occurs when a strategy is no longer used as a method for dealing with obsessions and compulsions but rather is simply repeated over and over without variation. In other words, the strategy becomes a ritual to chase away unwanted thoughts, rather than a method to learn to live with them.

  In the case of Melissa, for instance, the strategy of bringing reason to bear on an obsession turned into a ritual when she started to spend hours going over the minute details of conversations. Similarly, praying turned into a compulsion for her when prayers ceased to be acts of worship and turned into magical incantations. The strategy of relying on other people backfired as well when she started to call family and ministers many times a day, not to learn anything new but just for reassurance.

  In practice, fortunately, it is not difficult to tell when a helpful strategy has turned into a ritual. Patients themselves are usually easily able to spot the self-defeating, clearly excessive nature of a compulsion. It is helpful to remember that a useful strategy changes the way a person looks at, or thinks about, obsessions and compulsions, allowing them to be more easily tolerated. A ritual causes no change in perspective; it only chases obsessions from the mind.

  To recap, many OCD sufferers insist that group therapy is the most helpful of all the treatments that they have received. It lifts the burden of secrecy. It addresses, in a way more powerful than individual therapy, negative feelings such as guilt, self-doubt, and discouragement. And group therapy allows OCDers to learn at firsthand, from the people who really know, the strategies that are successful in the battle with OCD.

  7

  OCD IN THE FAMILY

  One of the most poignant cases of OCD I have treated is that of Jerry, who was a close friend of mine in sixth grade. Growing up, Jerry lived only a block away; we enjoyed playing golf, chess, and ping pong together. He was a dark-complected, handsome boy with greasy black hair, every strand of which was plastered perfectly in place by an excessive amount of hair cream. Shy and rather nervous, Jerry was always eager to have my friendship. A memory that strikes me vividly: Jerry and I are sitting in my living room playing chess, laughing heartily as we sing along to a record about a rebellious cannibal boy who refused to eat people. We play this tune over and over, having a great time. The song must have struck some deep chord, both of us being, like the cannibal boy, peacemakers and timid by nature. In junior high school, though, Jerry and I developed new friends. Or at least I did. I found out what happened to Jerry when he visited me as a patient thirty years later.

  It will be instructive to tell Jerry’s story primarily from the standpoint of his mother, Mrs. Kaufmann. She is a short, wiry, intense woman who I have remained in contact with over the years, even as I lost track of Jerry himself. I sometimes would ask Mrs. Kaufmann how my old friend was doing, but it was only after Jerry came to see me that she would openly discuss his OCD. By then she was able to look back on the tough times with impressive objectivity and forgiveness—for herself, for Jerry, and for the professionals who had only made matters worse.

  It was when Jerry started kindergarten, in 1952, that she realized she had a problem on her hands. Jerry was never on time for school; indeed, he could not be made to be on time. The car pool would arrive; he would be assembling blocks. “Come on, we’re waiting,” she would yell, rushing him along. But Jerry wouldn’t move—as if he didn’t hear her. Soon she would be shouting, “You’re going to be late, hurry!” Yet it was only after several minutes of escalating screams and threats that Jerry finally arrived at the car. This happened every single day.

  At first Mrs. Kaufmann assumed it a case of stubbornness, or perhaps intentional disobedience. As the behavior continued, however, she became convinced there was something deeper. She went to Jerry’s kindergarten teacher, seeking advice, perhaps a referral to an expert. But she was told only that Jerry was fine and that his stubbornness would pass. This was the first in what would become a long series of incorrect or harmful professional opinions.

  In the years between kindergarten and seventh grade, there were constant problems. Mrs. Kaufmann remembers one teacher scolding that Jerry would flunk unless he got his homework in on time and another who threatened legal action because of Jerry’s habitual tardiness. Jerry also began to show inordinate concern with his appearance and to spend excessive time in the bathroom. Yet, despite all this, Jerry remained a relatively happy child throughout those years. He performed fairly well in school, had several good friends, played golf regularly, and swam competitively for a YMCA team.

  When Jerry himself looks back on those years, the only OCD symptom he remembers clearly is hair-combing rituals. He would spend ten to fifteen minutes every morning parting his hair, starting from the back and working to the front, separating out each strand, carefully combing the shorter strands to the right, the longer ones to the left, taking special care that the part was neither too high nor too low and that it formed a perfectly even line with a slight ellipse. It was a painstaking ritual, and he did not enjoy it. Yet if he skipped it, he would feel that his hair was “not quite right,” and he would become overwhelmingly anxious.

  In seventh grade Jerry took a sharp turn for the worse. He remembers it as the time when he lost his friends. Terrors of contamination began to haunt him, as well as ill-defined fears of death. Rituals snaked their way into all areas of his life. OCD took over. Before he could play golf, he now had to spend half an hour cleaning his clubs; each shaft, each head, each grip, each groove, carefully scrubbed with a stiff bristle brush, soap, and scalding water. When he finally got on the course, he had to address the ball for minutes at a time, waiting until his fingers felt just right in the overlap grip, his shoulders and feet exactly aligned, before he could swing the club.

  Jerry’s dawdling quickly irritated his golfing friends. “What are you doing, counting the dots on the ball? Let’s get going!” they would say. His behaviors soon stamped him as too different to remain a part of the group. First he was teased and then deliberately avoided.

  How did I treat him? It seems odd that I can remember vividly the good times that Jerry and I shared, yet have only a hazy recollection of these months
. I do remember that I felt embarrassed for Jerry. I also remember, however, that I didn’t stick up for my friend. Yes, I even began to think that perhaps Jerry was a little too different. Before long Jerry quit playing golf and then dropped out of competitive swimming. Isolation and loneliness set in.

  Mrs. Kaufmann remembers seventh grade as the time when Jerry’s “breakdown” occurred. Before that he had lived a normal life; afterward he couldn’t. First his hand washing became severe, and every day she needed to apply lotion to his reddened, chapped hands. Then Jerry began to wash his own clothes and the furniture in his room, too. On one occasion, Mrs. Kaufmann found Jerry putting all the clean towels from the closet through the washing machine. “Enough!” she screamed. “Don’t touch my linen closets again!” Soon Jerry was regularly changing the filters of the water system for the house and spending his allowance to buy new ones. When Mrs. Kaufmann discovered a large stash of soap hidden in Jerry’s closet, she decided to try “a test.” She took all his soap and announced that he was no longer permitted to use any soap at all. Jerry screamed and cried; he “fell apart.” She knew then that she absolutely had to get help.

  She took Jerry to see a psychologist at nearby Penn State, but after six sessions Jerry quit going. Jerry’s parents were told nothing, and nothing helpful was accomplished.

  Mrs. Kaufmann was left to deal with the OCD herself. Her husband, a successful businessman, traveled extensively during those years and was home only on weekends. Feeling sure that her husband, indeed, could not accept Jerry’s problems, Mrs. Kaufmann kept secret their seriousness. Jerry, for his part, effectively hid most of his symptoms from his father. By an unspoken agreement, the mother and son kept the disorder to themselves.