One of my patients wrote this account of his treatment for Obsessive Compulsive Disorder. It first appeared in the OC Foundation Newsletter, and is reprinted here with his permission.
One of the advantages of this newsletter is that laypeople that suffer from OCD can share their experiences with each other. Our symptoms can often make us feel isolated and “weird,” even ashamed. Going to a doctor or therapist is going to an “authority figure,” which, we usually assume, knows about our suffering only from books and through his or her practice. It’s consoling to hear from other laypeople out there that have had experiences similar to one’s own. It’s encouraging to hear from people who have managed to get some control over their disorder. This is the spirit in which I share some of my own experiences with OCD.
I began suffering from obsessive thoughts at the age of 12. After a two-year remission of my symptoms, the OCD returned when I was 20 years old. By this time, I was aware that I had a psychological disorder and began classic psychoanalysis. I didn’t know that this would be the beginning of 12 years I would spend, intermittently between 1970 and 1996, with a number of psychotherapists—the analyst, two psychodynamically oriented therapists, and a cognitive therapist.
My obsessive thoughts consisted mainly of unwanted and repulsive sexual images. More recently I have also been experiencing violent thoughts, although many of the sexual thoughts themselves could better by described as violent rather than erotic. I have also experienced the mental torture that comes from wanting absolute certainty in making a decision, being endlessly pulled back and forth in my mind by arguments in favor of and against a course of action. For many years I considered myself a pure obsessional, since I had none of the usual external compulsions. But it gradually became clear tome that I had been having internal mental compulsions all along. I would often have the need to check back mentally on an attack of obsessive thoughts, trying to assure myself that I didn’t want them and that I had fought them valiantly. I might have had to repeat this ritual of self-assurance for half an hour or more, trying to get some relief from the anxiety and frustration that accompanied the obsessive thoughts, just as a hand washer tries to get some relief through repeated hand washing.
Although I learned some things about myself in the 12 years of talk therapy, I can say in retrospect that it did nothing to relieve my symptoms in any significant or permanent way. My worst crisis occurred, in fact, during my last period of talk therapy. I felt that I was on the verge of a breakdown and, for the first time in my life, sought the help of medication, against the recommendation of my therapist, whom I left shortly afterwards. With the help of Anafranil (clomipramine), at a top dose of 150 mg a day, I got back on my feet again. But although the medication calmed me down physically as well as mentally, allowed me to sleep well, and softened my symptoms, the OCD was still there. It was then that I sought out behavioral therapy and the exposure and response prevention method (ERP).
ERP in the last three years has literally changed the quality of my everyday life. It is the only technique that has significantly weakened, if not totally eliminated, ingrained patterns of experiencing and unsuccessfully trying to cope with obsessions. I wish that is had turned to it much sooner! For a long time I was influenced by the prejudice that talk therapy was the only serious approach to mental disorders. But partly out of desperation and partly because of information I was getting from the Obsessive Compulsive Foundation and from books such as Gail Steketee and Kerring White’s When Once is Not Enough (1990) and Edna Foa and Reid Wilson’s Stop Obsessing (1991). I finally turned to a behaviorist and got to work.
ERP is simple, if counterintuitive, method. Instead of fighting or fleeing from anxiety-provoking obsessions, you wallow in them; and instead of engaging in compulsive, anxiety-reducing responses to the obsessions, you refrain from them. To reduce anxiety inn the long run, you intensify it in the short run. You put your head right in to the lion’s mouth instead of spending your life running away from the beast. Under the guidance of my therapist, I worked up a hierarchy of my obsessive thoughts and images, from least upsetting to most upsetting, and began to do two 30-45 minute exposure sessions a day, working my way up the hierarchical ladder. I would lie on my couch, close my eyes, vividly thing the anxiety-provoking thought, exaggerate it, and let myself feel the discomfort, which would lessen as the exposure continued. Meanwhile, when obsessions occurred during the day, I tried to refrain from compulsive mental rituals of self –assurance. For the first time in 30 years, I was experiencing my obsessions in a different way. I was habituating myself to them and the anxiety they provoked. Within weeks, after I began ERP, the frequency, the intensity and the duration my obsessions began to lessen. After about six months I got a good enough result that I no longer needed to do exposures as frequently as I had been doing, though I continue to do them in persistently troublesome situations, as I explain in the next paragraph, and occasionally for maintenance and reinforcement.
My therapist had insisted that it was essential to get to the top of the hierarchy—that is, to expose eventually to the most anxiety-provoking thoughts, however difficult this might be. I had done this and had reached a good level of improvement. But, encouraged by this improvement, I felt that I needed and wanted to go further. What could I do to push forward? It soon became clear to me that, although I had reached the top of the hierarchy in my deliberately induced exposure sessions and had achieved a reduction of my symptoms from this technique in the ordinary course of the day, I was still having a lot of trouble with my obsessions in certain places, in certain social settings, and in the midst of certain behaviors. I saw that, for me, “reaching the top of the hierarchy,” meant “taking my exposures into the workplace”—gong from doing self-induced exposures on my couch to doing them when my obsessions occurred spontaneously in “real life” in the troublesome places and situations. I had already begun, almost from the start and with good results, to do “mini-exposures” when a routine obsessive thought occurred during the day. Now I had enough confidence to begin doing on-the-spot exposures in places and situations that were most anxiety-provoking to me. Progress here is slower because I can’t create most of these situations at will. But progress is occurring, and I am moving to higher level of improvement. The principle is the same: go into the anxiety, and don’t spare yourself any discomfort. It will lead to much less discomfort. My current dose of clomipramine is only 25mg.a day, and I will probably soon be able to come off of it completely.
I have also used a simple of form of meditation with helpful results. You simply get into a comfortable position, focusing on and counting your breaths. This is good relaxation technique, and we can all benefit from that alone. Stray thoughts will occur during meditation, and these will undoubtedly include an obsessional standard repertoire of anxiety-provoking images. When this happens, one should calmly return to breath counting. The idea is to become detached from and indifferent to any thoughts that occur. No judging, no fighting, no compulsive responses. This is a useful supplement to exposure, because our goal is to be able to let troubling thoughts pass by without engaging with them. If you can achieve this detachment in meditation, it should help you to be able to do the same in everyday life.
Another thing that can be done during meditation, or at other times, is to us reinforcing mental imager. If you brainstorm, you will be able come up with imagery that represents tranquility and mastery for you and points to the goals you are aiming for; the precise imagery that appeals to individuals will vary depending on their life experiences. I found two images to be appealing and reinforcing. In one, I see myself standing by the ocean’s edge. Powerful surf beats up against me and knocks me over. I then decide to lie down along the shore. Now the surf just rolls over me. I am not knocked down as I was when standing up and offering resistance. In this image, standing represents the counterproductive resisting of obsessive thoughts; lying down represents the indifferent, more passive response to them that we are trying to achieve. In my second image, I am standing on a cliff, looking down at a flowing stream. All my obsessive thoughts are flowing by, but I am observing them in detachment, unconnected to them, and watching them pass away. If I find myself beginning to fight an obsessive thought in my daily life, I can bring these two images to mind to remind me to stop.
The role of spirituality in recovery can also be important. We should engage body, mind, and “soul” in the process. This is the hardest dimension to write about, however, because it is so personal and difficult even to define. Spirituality does not necessarily have to have anything to do with organized religion or even a belief in a conventional God. For me, it means my connectedness to everything beyond me (hence a way to be delivered from self-absorption); my most deeply-held though not necessarily provable convictions; and what empowers me and gives meaning to my life. I have tried to see my disorder not as some bizarre curse, but as part of the human finiteness and imperfection that, in one way or another, affect us all. An omniscient God, I remind myself, knows the difference between thoughts we want and thoughts we don’t. The certainty and absolute assurances that we obsessionals seek are humanly unattainable; we have to commit to decisions we make in good faith and then “let go and let God.” The Universe is essentially nurturing; we can make ourselves more open to its nurturing forces through prayer and meditation. These are the kinds of insights and convictions that, if we genuinely hold them, can be marshaled in our fight against OCD.
My own experience has made me an unabashed advocate of ERP. ERP requires persistence. Finding the right therapist and the right medication requires patience. I wish my fellow sufferers the persistence and patience that will lead to recovery.
Robert J. Penella can be reached at rpenella@fordham.edu