Thinking the Unthinkable
by Steven Phillipson, Ph.D.
Center for Cognitive-Behavioral Psychotherapy
Other Articles by Dr. Steven Phillipson
As I conceptualize Obsessive-Compulsive Disorder, the tree of the overall syndrome has three main branches: the "obsessive-compulsive," the "responsibility O-C," and the focus of this paper, the purely obsessional thinker "Pure-O" (Baer, 1994). With this branch, the anxiety emerges in response to an unwanted thought or question, which in the future will be referred to as a "spike." The ritual involves pushing away the thought, avoiding the recurrence of the thought, or attempting to solve the question. Keep in mind that most persons who come into therapy tend to have a combination of these problems. Successfully treating one branch typically has minimal effect on the others.
The "Pure-O" is manifested by a two-part process: the originating unwanted thought (spike) and the mental activity which attempts to escape, solve, or undo the spike, called rumination. The following are examples of varieties of spikes:
A man is involved in sexual relations with his female lover. Just prior to orgasm, the thought of his friend Bob pops into his head. This is the fourth time in a month that this has happened. In response to this, he becomes very upset and wonders whether he is gay. He terminates sexual activity in order to avoid having to deal with this concern.
A mother is changing the diapers of her infant. As she lovingly looks down at the helpless child, the thought occurs to her to take a pillow and smother the child. In response to this thought, the mother panics and runs to another room to diminish the possibility of acting on this thought, assuming that the capacity to think such thoughts may be similar to acting on them.
For the "Pure-O" a tremendous amount of anxiety accompanies the spike, and the mental ritual is an attempt to shut off the anxiety, either by attempting to solve the question or avoid having the thought recur. It is during the rumination phase that the person's mind becomes extremely preoccupied and distracted. It is not unusual for the "Pure-O" sufferer to spend eight hours a day in rumination, trying to find a way to escape. The emotional pull to undo the thought is tremendous. Perhaps it would be comparable to what it would be like if a loved one were on a plane that crashed and all you knew was that there was a fifty percent survival rate. Imagine what it would be like if you were asked not to problem solve in an attempt to ascertain the condition of your loved one. A common misnomer among "Pure-O" sufferers is that they can mentally find the key to turn off the obsessing. It seems that with each new spike, if they could only get that perfect answer, the whole disorder would just vanish. A large majority are aware that this is an impossible task, but the temptation to unlock their mental chains is tremendous with each ensuing spike.
I have illustrated this endless cycle of spiking and ruminating in the accompanying diagram. Start out with the top left symbol, a circled "R". This represents a part of the brain that is creative and always on the lookout for pertinent information. I refer to this as the resource part of the brain. The "Tip-of-the-Tongue" effect (Brown & McNeil, 1966) provides evidence for the existince of this part of the brain. I'm sure, on many occasions while searching for a name or significant memory, you have given up your active, conscious search just to have it pop into your consciousness later while your mind is preoccupied with another topic. It would seem that there exists a non-conscious portion of the brain that searches out meaningful material and sends this information to one's consciousness if it deems this information as significant. Another aspect of the resource center is our brain's reliance on associations, which facilitate information processing. An example of an association would be a red light alerting us that a hazard might exist. For the "Pure-O," the sight of a knife might spike the thought of stabbing a loved one. The resource center transmits information to our conscious awareness "C" as it deems material relevant or significant. It is at this juncture that most "Pure-O's" become fixated and distraught.
The transmission of the information from "R" (preconscious Resource Center) to our "C" (Conscious Awareness) is reflexive and beyond our control, but not beyond our influence. When the spike reaches our "C," we have a choice as to how to process the thought. (Note the two descending arrows.) The arrow to the left suggests that the thought represents or reflects something deep and meaningful about the person, e.g. "only a vicious loathsome human being could possible think of stabbing their loved one." This represents, as Albert Ellis (1987, 1991) would suggest, a dysfunctional emotional response "ER." The tremendous effort one puts into escaping the unwanted thoughts or preventing their recurrence (e.g. hiding knives), in effect, reinforces its importance to the nonconscious brain and, thereby, feeds the vicious cycle. Wenzlaff, Wegner, & Roper (1988) have proposed similar conceptualizations. These authors suggest that attempting to suppress thoughts has the effect of a mental boomerang whereby the cognitive backlash is actually stronger as one makes more efforts to bury the thoughts. Becoming upset over a thought places a mental marker on it and, therefore, increases the likelihood of the thought recurring. For the "Pure-O," the spike is a double barrel shot of anxiety. On the one hand, there is anxiety for having such an unpleasant thought, and on the other, the tremendous repetition of the thoughts gives the impression that one is losing his or her mind, thereby provoking more anxiety. This vicious cycle is applicable for both the spiking and rumination type "Pure-O."
The pertinent issue, though, is not how or why these thoughts become out of control, but what to do about them when they are racing around in one's head eight hours a day. Before discussing what works, first it is critical to discuss what does not work.
Thought stopping, either through shouting "STOP" or snapping a rubber band in response to the spike is not recommended and may be detrimental. As discussed previously, this technique would, in effect, sensitize the brain to the unwanted thought by alerting the "R" that potential punishment is associated with the spike. Theoretically, the spikes would thus increase due to this heightened sensitivity. Future research may bare this out.
Although logically pointing out the absurdity of the "Pure-O's" mental rituals is very tempting, it is often insulting and clearly ineffective. You cannot "out-logic" OCD. Similarly, the use of analytic interpretations to provide insight is absurd and harmful. A person's natural inclination is to investigate what implications certain spikes might signify. A therapist who reinforces this inclination is naive and incompetent. Whether it be stabbing one's loved ones or having sex with one's mother, these thoughts will only become more deeply entrenched by placing emotionally laden meanings on them, such as underlying aggressive impulses or unresolved Oedipal conflicts.
Ultimately, as with all forms of OCD, living with uncertainty and risk taking are the antidotes to this disorder. The treatment of the "Pure-O" is theoretically based on the principles of classical conditioning and extinction. The person's intolerance for having bizarre and noxious thoughts only perpetuates the disorder. The efforts a person makes to avoid or escape these thoughts reinforces their recurrence. Therefore, the removal of the reinforcement (extinction) entails the following.
But first - a warning. Paradoxically, you will know the disorder is getting better when the frequency of spikes increases. Our brain is resistant to change. As one attempts to make space for thoughts that one has long spent great energy avoiding or trying to neutralize, our brain will meet this change with opposition. A common occurrence is that a person who previously would spike four times a day, but ruminate incessantly for the duration of the day, will often spike much more frequently, as their amount of rumination substantially decreases.
THE CRITICAL VARIABLE IS THE RUMINATION AND NOT THE NUMBER OF SPIKES!!! This statement is paramount for a successful treatment. The target response is having the person not respond to the spike, it is not to have the spikes go away. The long-term effect of not attending to the spike will be that the spikes will decrease in frequency and emotional intensity. This will happen only if the person desensitizes to these thoughts by allowing them to occur. A common phrase often mentioned in my groups is "let the thoughts be there," give yourself permission to have the thoughts. In conclusion, I offer four treatment suggestions. These procedures have been very successful in turning lives around and freeing up thoughts for contemplation of more meaningful material. The research is still preliminary, but the treatment outcomes have been significant enough to spread the word. As with all forms of OCD, behavioral therapy is effective to the extent that the subject adheres to the procedures (Dar & Greist, 1992).
The spike often presents itself as a paramount question or disastrous scenario. A response that answers the spike in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Using the antidote procedure, a cognitive response would be one in which the subject accepts this possibility and is willing to take the risk of his mother dying of cancer or the question recurring for eternity. No effort is expended in directly answering the question in an effort to find resolution. In another example, the spike would be, "Maybe I said something offensive to my boss yesterday." A recommended response would be, "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure, it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response does not seek to answer the question but to accept the uncertainty of the unsolved dilemma.
Let it Be There:
Using this procedure, it is suggested that the person create a mental pigeon hole for the thoughts and accept the presence of the thoughts into one's preconscious (those thoughts which are not currently in one's awareness but can easily be brought there by turning one's attention to them, i.e. your name or phone number). It is suggested that a mental "hotel" be created whereby you encourage your brain to create unsolvable questions so as to fill up the register. The more unsolved questions the better. It is critical that the "Pure-O" acknowledge the presence of the thought but pay no further attention to it, as in the form of problem solving. The brain can only juggle a certain amount of information at one time. If you purposely overload the brain, rather than insanity, your brain's response would be to give up trying. As can be imagined, attempting this goal takes a lot of faith and trust in the person suggesting it.
The Capsule Technique:
During the initial phases of therapy, there is a great resistance to letting go of the rumination. A procedure that addresses this resistance is to set aside a specified period of time, perhaps once or twice a day, to purposely ruminate. It is suggested that the time periods be predetermined and time limited. At exactly 8:15 am and 8:15 pm, I will ruminate for exactly 45 minutes. As thoughts occur to me during the day, I can feel comforted that the problem solving will be given sufficient time later that evening or early the next morning. Typically, people report that it is difficult to fill the allotted rumination time. Regardless, every minute must be spent on the designated topic so the brain can habituate to these irrelevant thoughts. The Journal of Behavior Therapy and Experimental Psychiatry reported a novel application of this technique. Using audiotaped recordings of spiking cues, a woman was desensitized to her obsessional themes by exposing herself to them 10 times a day. After the 50th day, her actual spiking dramatically decreased.
Creating 4-5 Larger Spikes:
Rather than attempting to escape the spikes, the "Pure-O" is encouraged to purposely create the thought repeatedly following its occurrence. This has the effect of desensitizing the brain to these spikes by sending the message that not only am I not going to attempt to escape these thoughts, but I am at such peace with them I can create a multitude of them. In response to the thought, "I might have run over someone on my way to work," a beneficial response would be, "There is probably a stack of bodies all along the street; I probably wiped out half the population of my home town yesterday as well; and I can't wait to drive home tonight and kill the other half."
Some people report that they have difficulty distinguishing between spikes and "legitimate important thoughts." A fool proof litmus test for telling the difference is to ask yourself whether the thought or question is coming with an associated anxiety or feeling of guilt. Ultimately, all such thoughts can be placed in the realm of OCD. When asked, "What if it's not OCD," I say, "Take the risk and live with the uncertainty."
At this point, my skills as a therapist are not nearly as valuable as the client's willingness to utilize the procedures. Unless you are thoroughly fed up with the disorder, behavior therapy will be of limited help. Often I have been informed that the treatment is as painful as the disorder. My only response is that with this treatment there is a light at the end of the tunnel. The disorder offers only endless suffering. If you find that after six months to a year there is limited movement in a positive direction, it might be worth your while to take a temporary leave of absence from therapy until you are fully committed to letting go of the problem. Published clinical notations suggest that this step might assist in bringing about an increased willingness to confront the nightmare rather than continuing, through rumination, to run away from it.
Baer, L. (1994). Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders. Journal of Clinical Psychiatry, 55(3, Suppl), 18-23.
Brown, R. W., & McNeil, D. (1966). The "tip-of-the-tongue" phenomenon. Journal of Verbal Learning and Verbal Behavior, 5, 325-337.
Dar, R., & Greist, J. H. (1992). Behavior therapy for obsessive compulsive disorder. Psychiatric Clinics of North America, 15(4), 885-894.
Ellis, A. (1987). The Practice of Rational Emotive Therapy. New York: Springer.
Ellis, A. (1991). The revised ABC's of rational emotive therapy (RET). Journal of Rational-Emotive and Cognitive Behavior Therapy, 9(3), 139-172.
Wenzlaff, R. M., Wegner, D. M., & Roper, D. W. (1988). Depression and mental control: The resurgence of unwanted negative thoughts. Journal of Personality and Social Psychology, 55(6), 882-892.
Originally printed in the Obsessive-Compulsive Newsletter, 5 (4), 1991, published by the OCF