Tormenting Thoughts and Secret Rituals Page 9

  Using his daily diaries as a starting point, Raymond then constructed a list of all the various situations in which compulsions commonly arose and ranked these situations according to the degree of anxiety he experienced when the obsession struck. His anxiety ratings were purely subjective—estimates of his level of anxiety during certain situations relative to others. To rate the anxiety, he used an “anxiety thermometer,” on which “0” represented no anxiety at all and “100” was the most anxious that it was possible for him to feel. We divided the OCD situations into those involving “spill” and those involving “poison” obsessions.

  OCD SITUATIONS RANKED ACCORDING TO ANXIETY LEVEL, AUGUST 2

  * * *

  SITUATIONS TRIGGERING SPILL OBSESSIONS ANXIETY LEVEL

  Getting up in the morning 100

  In car driving to work and trucks blast by 100

  Trying to leave a large store 100

  Arrive at home after work 80

  Leaving work (spill in mail room) 50

  Driving back from work passing church 40

  Watching TV in evening (spill at parents’) 40

  Walking down hallways at work 40

  Leaving restaurant at lunch

  30

  SITUATIONS TRIGGERING POISON OBSESSIONS

  Watching TV (kids drinking or eating something) 80

  Arriving home (refrigerator) 50

  At work getting coffee 30

  Dinner time, wife serving drinks 20

  With the critical data in hand, Raymond was ready to begin the action phase of behavior therapy. During this stage, I met with Raymond every other week to help him methodically implement exposure and response prevention.

  It is best to start with a task that is not too difficult. I asked Raymond to pick an OCD situation that he thought he could confront without severe distress. He chose “leaving a restaurant at lunch,” a compulsion that involved stopping somewhere between the checkout counter and the door of the restaurant and staring intently all around the restaurant for thirty seconds to a minute and sometimes pretending that he left something at his table in order to once more walk through the aisles of the restaurant, carefully checking for spills.

  For his first behavior therapy assignment, Raymond agreed that he would go into the restaurant as usual (exposure) but would prevent himself from doing any checking (response prevention). He would perform this task at least three times a week. In addition to this primary behavior therapy homework, he would, as much as he felt up to it, limit or delay other compulsions throughout the day. In order to track his progress, Raymond would keep a daily journal, noting both how the day went in general and how he did on his specific homework assignment.

  An excerpt from his journal after two weeks of active behavior therapy illustrates his progress.

  August 20—Overwhelming sensations all day that something has just spilt in my house, at work, in the next room, or wherever. Checked a number of times, just walking around and looking. When I couldn’t do that, used the whooshing ritual.

  For lunch I went to Bill’s Sports Club. After I finish I usually go on a pivot, studying the carpet, the steps, everything. But today I psyched myself up, walked right over to the cash register, ignored my surroundings, and escaped to my car easily. I knew that if I turned around and looked it would be really bad, so I didn’t let myself. Driving back to work I kept worrying that my mind would come up with a catastrophe that would make me go back and check, but it never happened.

  Carrying out his first assignment was fairly easy. Raymond never once had to return to a restaurant for extra checking. Since the goal in a behavioral assignment is a success rate of 80 percent or greater, we were ready to move on.

  Over the next month, Raymond worked on two more exposure and response tasks: driving by his church on the way home from work and not checking it, which he had been doing at least every other day; and watching TV as usual, suffering the spill-at-his-parents’-house obsession, and not checking their house, which he had been doing almost every evening. During this time Raymond made excellent progress, not only in combatting these two compulsions, but also with a number of others, as is illustrated by this journal entry:

  September 19—I’m proud of the things I’ve done today. On the way home from work I drove by the church and my mind reached out and created a terrible vision of a container of disease. I have a key, and it would have been the easiest thing in the world to go in and check. Instead, I drove right by. I kept looking back in my mirror and I wanted to stop so bad it hurt. I kept thinking, “How am I going to live with this?” I was in dire straits, but I didn’t go back. About an hour later it was not as real.

  Then this evening I had a stabbing vision of a spill at my parents’ house. I didn’t know how I would cope with it. Usually I would have gone over and peered in the window, or if they weren’t home I would have gone in and walked around. But I told myself it wasn’t real and that I could go over later if I needed to. It was hard, hard work, but I waited it out.

  I also have had many victories this week with the whooshing compulsion. I am not going through the mental gymnastics of a month ago when I would work myself up into a frenzy. I just keep telling myself that this ritual is absurd. My mind can’t do magic.

  The next behavior assignment was to deliberately enter large stores (exposure) and not check the aisles (response prevention). As indicated on the OCD situations list, these situations were associated with a considerably higher anxiety level. Raymond worked on this assignment for four weeks, and by the end of that time he was able to enter and leave stores without resorting to time-consuming rituals. Again, an excerpt from his journal demonstrates his progress.

  October 14—Went to the Sears store and deliberately walked from one end to the other and out again. I only had to look back down an aisle with cans of paint a couple of times. It was very hard for me to leave because I was afraid that five minutes down the road uncertainty would jump into my mind and say, “Are you sure there wasn’t a wet spot on the floor down that aisle?” After I left the store I could feel it coming: Terror rushed into me and my mind conjured up a very real image of a bucket about two feet high filled with some liquid that would make people sick. I knew that this was absolutely at the edge of reality, but I felt I had the responsibility to go back and check. I was really hurting. I forced myself not to, and about a half an hour later, I realized that what I was thinking about was probably not true. That was a terrific feeling: I won a big victory by not checking.

  I am convinced that to lick this OCD the key is tons of exposure and response prevention. I am making every effort. No one understands this, but I am literally fighting for my life.

  After this string of successes, Raymond chose to work on preventing the ritual of asking for reassurance from his kids that they had not eaten or drunk anything that he didn’t know about. It had been the extreme embarrassment resulting from this ritual that had driven him to seek help in the first place:

  November 12—I have gone for two whole days without asking my kids whether they’ve drunk or eaten anything. It is very painful, because this obsession is so strong. No one knows how much pain and embarrassment it causes. When the obsession hits, I am going into the next room and just letting myself soak in the anxiety, telling myself that it’s not real. I also tell myself that if it gets too bad, I can go into my kids’ rooms and ask. But my fear usually lightens up within an hour.

  This afternoon was wonderful. I took my boy to the football field. As I was leaving, I was beside myself because my mind kept presenting me with visions of him sitting on the bench and drinking a can of something that had been sitting there for about a week and had AIDS in it. It hurt a ton, but I didn’t check and I never asked him about it later.

  At the end of six months, instead of living in almost continual torment, Raymond was living a normal life. He put it this way:

  When I first came here, I was at a real squeeze point. I thought there was no way out. The fears wouldn’t go
away unless I checked, but when I checked one thing, it always led to another. Now I have reached a level of understanding where I am sure that my spill fears are based on false thoughts, and when they jump into my head, I don’t react to them so much. And now I know that there is a way for me to deal with my obsessions. I have confidence that when a spill fantasy hits, it will go away. I just stick in there and sweat it out.

  COMBATTING AVOIDANCE: THE CASE OF SHERRY

  Raymond’s case illustrates the basics of behavior therapy for OCD: exposure to obsessions accompanied by prevention of compulsions. But there is another aspect of treatment that can be of great importance: prevention of avoidance. Avoidance occurs when a person stops doing certain things or going certain places that bring on self-tormenting thoughts. Like compulsions, it is a way of trying to escape from obsessions.

  Severe avoidance frequently accompanies obsessions of doing violent harm to others, perhaps because there is no obvious ritual to perform to escape from this type of tormenting thought. Obsessions of contaminated hands lead naturally to washing; obsessions of electrical fires lead directly to checking the light switch; obsessions of offending God lead to confessing; but nothing provides easy relief from an obsession to stab your daughter.

  The case of Sherry demonstrates the treatment of harm obsessions accompanied by disabling problems with avoidance. In such cases, two behavior techniques are especially helpful: direct limitation of avoidance, and prolonged exposure to obsessions in the imagination.

  Sherry, you may recall, presented in a panic because of violent fantasies of the worst types imaginable, including stabbing her daughter, slitting her own throat, and crashing her car. Each obsession was a split-second mini-series of images, urges, and ideas that jarred her like a knockout combination. Compulsions were not a significant problem; she was primarily disabled by the terror caused by her obsessions and her avoidance of the many different situations that brought them on. She often could not cook because of her fear of using knives. Sometimes she could not bring herself to drive the car. Occasionally, she would stay in her bed almost all day long out of fear that she might act on one of her violent urges.

  After three sessions spent gathering history and educating Sherry on the nature of OCD, I asked Sherry to keep a diary of her symptoms as they occurred throughout the day. Her fear of her obsessions was so strong, however, that this proved too painful. “Please don’t make me try that again,” she begged. We compromised, and Sherry agreed to write a short note each evening. Here is a sample of her first week of journaling, her fourth week in treatment overall:

  Tuesday—Woke up in the middle of night and again in the morning with the obsession of stabbing myself. Thought how I could walk down to the kitchen and get a knife and push it in my stomach. Saw blood everywhere. Bob wakes up and I’m dying, covered with blood.

  Avoidance: Stayed away from knives all day. Did go in the kitchen, but used “alternative cooking.”

  Wednesday—Obsessions while driving were constant: Crash into this car, swerve over and hit that little boy. I’m praying, “God, get me through this.” I must really be sick to have these thoughts. Helped to remember that the doctor said that everyone has crazy thoughts. Didn’t want to cook dinner, but I did and I forced myself to use knife (a dull one). Hurrah!

  Thursday—Awful day. Started with obsessions of slitting my throat while shaving my legs in the shower. Thoughts of knives all day long. Read magazines to get away from them. Watched TV. Tried to go to sleep as fast as possible.

  Avoidance: Spent a lot of time in bed today. Didn’t cook with knives.

  Friday—Better than yesterday. 99 percent of obsessions today were knife thoughts. Was vacuuming the floor and had the thought to grab a knife and slit my throat. Or to stab myself in the belly. Same ones over and over. At dinner time the thought of knifing Bob. I kept telling myself: “This is gross. Stop it!”

  Saturday—Obsessions in and out of my mind all day long. Thought of stepping out in front of a truck. Then while I was driving I thought of running off the road. At Art Alliance, thought: “I could chop all their heads off.” Gross. At dinner time, thought of grabbing a knife and slitting Bob’s throat. The thoughts just pop in and out, but when they occur they’re so powerful.

  Avoidance: Some avoidance of knives and driving. Increased time in bed.

  Based on her journal, Sherry and I constructed an OCD situations hierarchy.

  OCD SITUATIONS RANKED ACCORDING

  TO ANXIETY LEVEL

  * * *

  SITUATIONS TRIGGERING KNIFE OBSESSIONS ANXIETY LEVEL

  In kitchen: slitting my throat or my wrists or stabbing myself in the stomach with the kitchen knife, or else stabbing Megan or Bob 100

  In shower: slitting my throat or my wrists with a razor while shaving my legs 90

  In bed: stabbing Bob in the stomach while he’s sleeping 50

  In bed: slicing up Bob while we’re making love 30

  Anywhere: slitting Megan’s or Bob’s throat or stabbing them 20

  Meetings, malls: stabbing people, cutting their heads off, etc.

  20

  SITUATIONS CAUSING CAR CRASH OBSESSIONS ANXIETY LEVEL

  In car: seeing little kids and swerving my car to hit them 70

  In car: truck or overpass coming and pulling the wheel and swerving into it 60

  Anytime in car: crashing it 30

  Our goal in behavior therapy was to expose Sherry to her obsessions and to continue her exposure long enough for habituation to take place. But before describing that treatment in detail, let me point out one other extremely important aspect of Sherry’s therapy.

  In no other type of OCD is it so important to address shame and self-reproach as in that characterized by obsessions of doing harm to others. Sherry felt wretchedly, inescapably guilty over her violent fantasies. Sometimes they piled up, each one more painful than the previous, cascades of calamitous thoughts climaxing with the ultimate guilt-inducing obsession: the idea (usually based on the misinterpretation of a slight body movement) that she was actually beginning to carry out an awful fantasy. Deep down inside, Sherry was afraid that, for reasons that were beyond her understanding, she was a sick, perverted murderer.

  Her previous two therapists had done little to relieve her guilt. Tracing her self-tormenting thoughts back to a time when her “overly perfectionistic” parents had prevented her from expressing anger, these doctors had made the standard interpretation: Sherry’s obsessions were due to bottled up hostility that leaked out of her unconscious and took the form of violent thoughts. Yes, Sherry was told that her murderous fantasies were not her fault, but she was not reassured. The theory that she had bottled-up hostility, in fact, had the perverse effect of validating her guilt by endorsing the idea that her murderous thoughts were nothing less than a very important part of her personality.

  In cases of harm obsessions, the OCD sufferer must be taught, and reminded again and again, that obsessions are not a part of one’s basic personality. They have no bearing on who a person “really is.” Intrusive, violent thoughts are normal for the human race, and overly responsible, guilt-prone OCDers are the least likely people ever to act on them. The OCD sufferer must strive continually to keep a rational perspective and a therapeutic distance from these most gut-wrenching of obsessions.

  In order to do that, Sherry kept in mind several different ways of looking at her obsessions. She often reminded herself that her obsessions were not a real part of herself but rather were due to a chemical disorder. She sometimes viewed her obsessions as a joke. When walking in the mall she would be hit by a thought “to grab strange men in the crotch.” After a while, she could look on this obsession as being so funny that it just didn’t bother her. To help herself think rationally, she used the “panhandler analogy.” Suppose a person is walking down Broadway in New York City and is suddenly accosted by a street person aggressively asking for money. What to do? Not fight. Not run away. Just turn the eyes forward and walk, ignorin
g him. Sherry, having had few encounters with panhandlers but many experiences with “jerks making passes,” sometimes changed the “panhandler” to the “unwanted suitor”: Give him the right to exist but ignore him, don’t let him bother you.

  Sherry began the active phase of behavior therapy with homework assignments directed toward confronting her avoidance. For two weeks she worked on forcing herself to get out of bed every morning and not allowing herself to retreat to her room later in the day. After accomplishing these goals, she began taking long drives in her car. Later in treatment, she exposed herself to the more fearful task of using sharp knives while preparing dinner.

  In confronting avoidance, it is important to go slowly. Exposing oneself too quickly can result in the opposite of habituation—sensitization—wherein the fear of the situation increases rather than diminishes. Sherry overdid it one day when she spotted a knife store while walking in the mall. As she told the story, she marched up to the counter, looked the salesman in the eye, and asked, “What’s the biggest goddamn knife you have?” The salesman replied, “This pig knife right here,” opening the showcase and putting a foot-long butcher’s blade in her hand. Sherry froze, then panicked, dropped the knife, ran out into the mall, and vomited. Despite that setback, which she took with admirable humor, she progressed to using knives with every meal, driving when she needed to, and keeping out of bed.

  The second emphasis in Sherry’s behavior therapy was exposure to imagined scenes. Here, the assignment was to hold an obsession, in its complete awfulness, in her mind’s eye for a sufficient length of time to allow anxiety to fade (usually twenty to sixty minutes) and habituation to take place. There are several ways to implement this technique. The most time-honored is for the therapist to talk a patient through an obsessional scene using the most vivid imagery possible. The patient can tape the session and play it back for homework. Another method is for the patient herself to produce a written rendition of an obsession and then to imagine it in great detail, bringing back the obsession every time it fades by rereading the script. Yet another method is for the patient to record an obsession on a loop cassette and play it over and over.