AN EXAMPLE OF TREATING OCD
The formal name for the specific CBT of Obsessive-Compulsive Disorder (OCD) is “Exposure and Ritual Response Prevention” or sometimes, just “Exposure and Response Prevention.” All forms of OCD are treated with the anxiety tools discussed in the section on anxiety in my book. Exposure means confronting what is being avoided. Ritual Response Prevention means not doing the things (rituals) that were being done instead of confronting them. In other words, Ritual Response Prevention means those with OCD don’t get to use their Safety Behaviors, which are really just a form of avoiding. For example, people with contamination obsessions need to be exposed to the things they are fearful of and to quit doing the cleaning, washing, etc., which are Safety Behaviors.
People with aggressive or sexual obsessions are very fearful that they may act on their horrific thoughts. However, it is extremely uncommon for those with OCD to do so. Not surprisingly, the harder they try not to have horrific thoughts, the more persistent they become. Often, they will do Safety Behaviors like hiding objects such as knives. Others might avoid normal behaviors like changing one’s own baby to ensure they can’t act on their disturbing thoughts of sexually molesting their baby.
Carol graduated from nursing school, married her sweetheart, and moved away from her family to Los Angeles to begin a new life and career. Working in a geriatric men’s unit with dying and demented old men didn’t match the fantasies about nursing that she had as she worked her way through nursing school. As the new nurse on the unit, she had to work different shifts, including nights and weekends, which is very physically and psychologically stressful. The daydreams that she’d had about marriage were tarnished by the realities of learning to live intimately with someone very different from herself. I’d treated her mother and an older sister for Generalized Anxiety Disorder (GAD so Carol probably had a genetic tendency toward developing anxiety. She also was perfectionistic, with too high expectations of herself and others and a somewhat rigid way of viewing life.
All of the changes, poor sleep, and increased demands made her depressed and increasingly anxious. Soon Carol began to have terrible thoughts and images she couldn’t control, things like stabbing the old men with whom she worked as a nurse. This horrified her and made her question if she were evil at heart or going crazy. The more she tried to put the horrific images out of her mind, the more they returned. Her sleep, marriage, and work were unraveling. Desperate, she returned to her former home area alone and sought my help.
I prescribed Prozac for her, the first of a new class of medications we call SSRIs, which often help anxiety, including OCD. It improved her sleep and her mood, but her awful obsessions continued. On the Yale-Brown Obsessive Compulsive Scale, her obsessions are listed under “Aggressive Obsessions,” specifically under the section “Fear might harm others.” As with the overwhelming majority of people with aggressive obsessions, her thoughts and images were fears, not her desires or intentions. The obsessions and compulsions of OCD are ego-dystonic, not ego-syntonic. This means that those afflicted do not enjoy the obsessions and compulsions. They are distressed by them.
We addressed the major issues with her work and her marriage. Then, just as my book gives psychoeducation about anxiety in general, Carol was given psychoeducation about OCD. This gave her understanding, hope, and faith in her treatment. I explained that being away from familiar places and situations had made her feel less secure. Beginning both marriage and her career at the same time with so many adjustments and new things to learn and do, along with fragmented sleep from working different shifts, had overwhelmed her. All these things combined made her doubtful about her abilities and even her choices. Also, she had some resentments and disappointments she couldn’t openly admit. Possibly her anxieties, doubts about her choices, and her resentments had been displaced into these aggressive thoughts. We have theories about why people develop particular OCD symptoms, but they’re postulations, not facts.
There is a Far Side cartoon created by Gary Larson that illustrated what she was doing wrong. I really like that cartoon and I have used it with all of my patients with OCD since I discovered it. I attempted to license its use, but they are not licensing it to anyone at this time. If you have access to the cartoon, copy it. It is useful as a reminder of what not to do if you have GAD or OCD. If you are a therapist, it is a teaching tool and reminder for those you assist.
The cartoon shows a school door with a sign nearby that reads, “Midvale School for the Gifted.” The door has the word “Pull” on it. A funny-looking kid is holding his books in one hand and pushing with all his might with the other hand, trying to get the door open. Carol, like the funny-looking “gifted” kid, was trying to push the door open when she should have been pulling.
As long as Carol tried to push the thoughts and images out of her mind, they kept coming back. They were out of her conscious control. She needed to pull (confront) instead of pushing (avoiding) them out. Inviting the thoughts voluntarily would make them under her control. Since they would be under her control, she would soon tire of them and let them go.
I reminded Carol that she had never had a thought or act so delightful that she wished to continue that thought or act indefinitely. The human mind continually changes the subject of its thoughts. She was terrified that she would act on these aggressive obsessions and harm someone. I reassured her that these were fears, not desires. From my training and experience, I was certain she wouldn’t act on them. If she really wanted to harm someone, she would have already done just that, harming them instead of trying so hard to not even have the thoughts.
I explained that attempting to “push” the horrific thoughts out only made them worse because they were then not under her control. Her attempts to "push" out the thoughts were a form of avoidance. She was told that if she would “pull,” or in other words confront those awful thoughts on her terms, she would now be in control, and they would shortly disappear. Of course, she was very fearful that if she ever chose to think of them, they would become stuck for good, and she’d never be able to think of anything else. You recognize that as a big cognitive distortion.
She was also taught that since her fears were not based on real intent or desire, we could neutralize them by ridiculing them. I MODELED this by pretending I had a knife and that I was chopping and stabbing old people in a preposterous manner. While doing this I said things like, “I’m stabbing and chopping people, stab, stab, stab! I’m having so much fun I just want to do this all day long.” Note in this case, her distorted fears were spoken and acted out by me in a deliberate exaggeration that made fun of them (MODELING). It is hard to be afraid of something you can make fun of.
Not surprisingly, it took several sessions of psychoeducation and reassurance before she would even attempt to model what I had done. I told her I would time her on each effort. Her first efforts were very brief, just seconds. I teased her about what a lousy job she was doing of stabbing and chopping people up. Her heart just wasn’t really in it. Surely, she could do much better than that? Did I explore with her the psychological theories of why she had developed these obsessions, or what the deeper psychodynamics might possibly be? No, not really. Psychoanalytical therapy has a poor track record of treating OCD, unlike Cognitive Behavioral Therapy (CBT).
Once she actually began to confront her fearful thoughts instead of avoiding them (IN VIVO EXPOSURE), her OCD rapidly resolved. Her mood quickly improved, her obsessions disappeared and her confidence in herself and her career choice reappeared. She soon returned to Los Angeles and had no more OCD.
