OCD IN A NUTSHELL
OCD is a condition in which the brain attempts to help the sufferer survive against serious threats. The only problem is that these “threats” are never legitimate. After listening to a lengthy description of the mechanisms of OCD in the brain, a patient summed it up nicely by saying, “So basically, OCD is a malfunctioning amygdala looking for a thematic justification for the intense emotional discord.” The irrational mental associations that constitute these threats are given credence by sufferers only because they are accompanied by intense emotional emergency signals that produce a compelling need to seek safety.
Those suffering from OCD often mention that their obsessional concerns feel legitimate. Their emotional responses to the irrational associations of the disorder are identical to those they would experience when confronting legitimate threats to their lives or safety. Because of this, one often finds very intelligent and rational individuals engaging in elaborate rituals to escape nonsensical risks. As another of my patients put it, “Steve, this is a very stupid disorder that carries a very powerful and compelling emotional persuasiveness.” The fear of catching AIDS from a doorknob is irrational. A loving mother’s concern that the sexual associations generated by her brain in relation to her daughter are evidence of her own deviancy is unfounded, and yet she worries about it for hours each day.
To be diagnosed with OCD, patients must exhibit behavior resulting from anxiety and their efforts to escape from distress that is disruptive and handicapping to their life in a significant way. More than 80% of the adult population admits to having bizarre automatic mental associations, and the nature and content of these mental associations are no different for those suffering from OCD. However, the associations of OCD sufferers are accompanied by an overwhelming sense of panic and desperation. I came up with the term “spike” for the pairing of these mental associations with anxiety to reflect the painful way they “pierce” sufferers’ consciousness.
If individuals endorse the belief that their spontaneous, irrational associations reflect deep and meaningful truths about their basic nature, they may be resistant to treatment. Those who adopt such a perspective also often evaluate the success of their treatment by whether these mental associations and the painful emotions that accompany them have stopped or at least decreased in frequency. However, since it is natural for human beings to have these associative thoughts, the goal of ending them is not realistic. Unfortunately, a great deal of time and effort is often devoted to convincing patients that they cannot measure their progress by whether or not they continue to have these associations. Since the primary goal of behavior therapy is to convey to the brain that these threatening associations are meaningless and irrelevant, choosing to accept the presence of these thoughts actually constitutes a significant step toward recovery.
Autonomy is a reflection of a person’s unique and independent perspective. For the purposes of this writing, the word “autonomy” will be defined as the awareness and acceptance of one’s responsibility for choosing one’s own beliefs, values, opinions, and agenda and for having one’s own perspective. To be autonomous is to act upon the belief that you, the Gatekeeper, are responsible for making independent choices and for choosing your own beliefs, as well as for the consequences of your independence of thought and your unique understanding of the world. Autonomy is the recognition that although you are not responsible for the creation of most of the ideas in your head, you are responsible for choosing the ideas that you endorse. Essentially, autonomy is what makes us human. The most important factor in the successful treatment of OCD with behavior therapy undoubtedly is the patient’s understanding and application of what is called “autonomous choice.” Since for someone with OCD, the brain’s agenda is to keep the sufferer safe from “threats” that do not really exist, only in making an autonomous choice that contradicts the “machine’s” (the brain’s) inclinations can the individual liberate him- or herself from the quicksand of ritualization.
When one speaks about autonomy, the concept of “centeredness” is always close at hand. To be centered requires that you engage in the disciplined evaluation of your own perspective, and that you strive to develop ideas and views that are independent of those of your peers. Centeredness is also critical to one’s awareness of and differentiation from the brain’s wishes and impulses. It is very important to engage in the mental discipline of remaining centered, even as the brain sends to your conscious awareness automatic involuntary thoughts that confound and contradict your genuine perspective. Being centered is integral to the maintenance of an emotional “stronghold” in which you are unaffected by the judgments of others. For example, if you were to remain centered when someone tells you that he thinks you are a good person, you would remind yourself that the person who complemented you is merely celebrating your favorable qualities, and your sense of what your desirable qualities are would not be altered or influenced by this person’s judgment about you. In other words, being centered means your assessment of your self-worth is not influenced either by the positive or negative statements that others make about you.
In a state of centeredness, you are focused on your own agenda. This is not to be confused with selfishness. Being giving, empathic, generous and forgiving can foster emotional growth and reflect tremendous centeredness. In this context, “focused on your own agenda,” means that you always endeavor to stay in touch with your own understanding of the world without attempting to impose your perspective on others.
The following anecdote illustrates how being centered can contribute to friendship and communication:
Sam tells his good friend, John what a good time he had at the party he attended the previous night, with its fun people and great music. John, who was not invited, feels left out and finds it difficult to express happiness about the enjoyable time Sam had. But he makes an effort to stay centered, and being mindful that he is enjoying Sam’s company right now despite his disappointment at not being invited to the party, he reminds himself that even though he was not a part of Sam’s enjoyable experience, he still can share in Sam’s celebration, and he can take pleasure in the close friendship that they share.
When you hold the door open for a perfect stranger, and the person doesn’t even say “Thank you,” what are you to do? Should you give in to the temptation to say, “You’re welcome!” in a sarcastic and disgruntled tone? Is it your duty to inform this stranger that that he was supposed to have gratefully acknowledged this random act of kindness? Your brain may send you a message that this person needs to be taught a lesson, and you may find yourself inclined to act in accordance with this impulse to retaliate. The centered response, however, is to look to your own values, which may guide you to take the emotional high ground and remain silent, with the understanding that you have followed your agenda and upheld your values by this small act of kindness.
Remaining centered also can be very helpful with the sense of vulnerability that often is experienced in the early stages of a romantic relationship. Every moment you are apart from your love interest, you desperately want to be reassured that your partner still is attracted to you and remains invested in the relationship. Being centered means maintaining the emotional discipline to remind yourself that the only information that is relevant in this situation is that you still are excited to see your partner again, and that you do not need to be reassured about your partner’s reciprocal interest.
WHO IS DRIVING THE BOAT?
How do you make your most important life choices? Are you controlled by your own brain’s impulses? When your brain says jump, do you say, “How high?” Or can you behave in a way that is independent of the automatic thoughts sent to you by your brain? OCD is a condition in which these automatic thoughts are accompanied by powerful emotions that originate in a part of the brain that simply reacts, where autonomy does not exist. When you have OCD, if you do not remain constantly vigilant about making choices that are directed toward your recovery, if you allow yourself to be manipulated by the reactive signals from your brain, you will find yourself surrendering more and more control to the disorder.
Does the tail wag the dog? Do our constantly changing emotional states determine what we choose at any given moment? Does the successful treatment of OCD depend upon the brain’s perceived readiness to take on the challenges of daily ERP assignments, or does it depend upon the patient’s determination to do whatever is necessary to be successful? It takes constant vigilance to assume responsibility on a consistent basis for making the conscious and deliberate choices that express our autonomy. At the end of the day, we need to choose our path based upon our autonomous goals, not the feeling states of our pleasure-seeking, discomfort-avoiding brain. In therapy sessions, I regularly ask my patients, “Who is driving the boat?” This question challenges patients to examine whether they are making mindful, deliberate choices that fulfill their agenda for recovery. To paraphrase Viktor Frankl, between stimulus and response, there is an opportunity for all of us to be mindful of our freedom to choose a response that serves our best interests and furthers the expression of our highest values.
Emily is considering performing an exposure exercise at a higher emotional threat level than any she has attempted thus far in her treatment. Her brain tells her that she is overreaching and that she will not be able to withstand the intensity of the stress she will experience with this exposure. Her involuntary thought is that this exercise is too great a challenge for her to take on at this point in her treatment. As a result, Emily now feels immobilized. She feels that she must wait for her brain to release her from its emotional grip before she can take on this challenge. However, seeking permission from her own brain to engage in this exercise removes her from the captain’s chair in life and puts her in the back of the boat as a passenger being taken for a ride. I ask her, “Who is driving the boat?” I remind her that if she waits for her brain to give her the green light and lower the emotional wall of terror, her recovery will depend on a malfunctioning system that is trying to protect her from dangers that never existed in the first place.
A lack of agency occurs when people decide that they lack the ability or potential to achieve a goal. This often happens when they endorse their brain’s negative programming that is based upon their personal history. A common response reflecting a lack of agency is when patients say to me that they did not accomplish a task because they “couldn’t find the time.” I usually respond to this by saying, “I think you’ll find some time hiding under the cushions of the living room couch.” Time is not found! It is allocated by one’s own choices. When I see patients who claim that they are “incapable” of making growth-oriented choices, I quote John Bach’s words, “Argue for your limitations, and sure enough, they’re yours.” Patients often complain that the exposure exercises assigned to them are too difficult. “The anxiety was overwhelming,” they may say. Such ideas convey a belief that our freedom to make choices is contingent either upon external influences or securing permission from our own brain to proceed.
It can be unpleasant to take full responsibility for the way we choose to allocate our time. We often regard life’s processes as a series of obligations, “musts,” and responsibilities. In other words, we tend not to “own” our own time. A lack of agency is demonstrated when you say, “I can’t do this,” instead of, “I’m choosing to not endure the discomfort.” When you use the word “can’t,” you are taking the possibility of making an autonomous choice out of the picture, and you miss the opportunity to honestly assess your resources or resilience in relation to the challenge you are considering.
How often have we set out to achieve a goal only to find that because of a perceived lack of control, our efforts were unsuccessful? In such cases, do we blame external circumstances or, even worse, do we then conclude that we simply were incapable of achieving the goal? If we are not mindful of who has the right and the responsibility to make our choices, then the emotional difficulty of the tasks we face most likely will determine what we choose. When we feel weak, we may make the non-disciplined decision – the path of least resistance can be very seductive. “Hit the snooze button; it’s too painful to get out of bed now.” Left to its own devices, the mind does not always choose the path that will be most beneficial in the long run. If you are going to a club in the evening, decide in the sobriety of the morning how many drinks you will allow yourself to consume that night. Then as the evening wears on, see if you can keep the commitment you made to yourself and disregard your brain’s seductive invitations to have just one more. The brain tends to seek pleasure above all else. If you do not distinguish between this pleasure-seeking internal voice and the more disciplined agenda of your autonomous self, you are likely to end up repeating many of the choices that you have come to regret.
As stated earlier, when you have OCD, your brain sends you the most compelling messages it can to get you to perform ritualistic behavior to obtain relief. According to your brain, you are in grave danger and desperately need to extricate yourself from the perceived peril. Without being mindful of your ability to identify signals with an OCD theme, you most likely will give in to your brain’s impulse to escape. Unfortunately, the more you give in to your OCD, the more entrapped by it and the less functional you become. When you obey the brain’s directives to stay safe at all costs, this life-limiting cycle is potentially endless. On the other hand, when you are educated about your condition and learn the skills that allow you to assert your independence from the disorder, you can instead make choices that reflect your autonomous values and interests. In the tremendous tug-of-war between your autonomy and the brain’s urgent efforts to “protect” you, unless you ensure that you always remain in the captain’s chair, you will find yourself living a more and more handicapped, anxiety-ridden existence.
FEELINGS ARE NOT THE GOAL
Why try to affect something over which you have no control?
Obsessive-Compulsive Disorder is characterized by a malfunctioning emotional alarm system in the brain. Although it repeatedly issues what essentially are “false alarms,” the emotions that accompany these warnings feel completely authentic. However, if patients make relevant life choices based on these emotional distress signals rather than on their autonomous goals, their condition will inevitably deteriorate. Remember that even when misguided, the instinct for survival remains one of the most powerful instincts we have, and the illusions created by the disorder that one’s survival is in jeopardy are absolutely convincing. And yet, the treatment for OCD requires that patients disregard this instinct and engage in the extraordinarily difficult task of not heeding their brain’s warning while still accepting the possibility that the threat is real. Needless to say, this can be quite painful, because ignoring what feels like a legitimate warning from your brain that you are about to be harmed can feel like you are about to jump off a cliff. When engaging in this process, bear in mind that “feeling good” is not the immediate goal of the treatment. You must first go through the pain of ignoring your brain’s false alarms in order to feel better in the long run. Remember, when you have OCD, you cannot use your feelings to determine if a threat is “real.” Doing so is a little like asking the Devil for directions to Heaven.
For the past few months, Kathy has been struggling with the question of whether she is a lesbian, and at this point, she is desperate to find the answer and put an end to the torment of not knowing. She leans in for a kiss from her long-term boyfriend, and hopes that this time she will feel the passion that seems to have been missing from their relationship since her struggles with the issue of her sexual orientation began. When he kisses her, however, she feels nothing. This absence of passion only increases her anxiety that she might be gay, and she wonders how much longer she can sustain her relationship with him when so little of the passion and excitement she used to feel when they were together remains.
Kathy’s reaction is an unskilled one. If she were a skilled veteran of OCD therapy, she would have given herself credit for having gone ahead with her commitment to being affectionate with her boyfriend and understood that the absence of an emotional response on her part was not a relevant factor at the time. She would have recognized that her lack of responsiveness had much more to do with the anxiety she felt about her sexual orientation than any problems in their relationship. Both OCD and depression are conditions that are driven by powerful emotions like anxiety, guilt, despair, a sense of fragility or weakness, distress, panic, hopelessness, and demoralization. But feelings, like thoughts, can be created by independent systems within our brain. When feelings are spontaneously generated in this way, the Gatekeeper has no control over the process. We cannot consciously shape our emotional responses; we simply experience them. Feelings also can be the “dividend” of the choices that we make. And one of the basic premises of cognitive therapy is that feelings are the products of the meaning we assign to our experience. In other words, our interpretations of the events in our lives determine our emotional responses. Other factors that can influence emotional variability include sleep deprivation, dietary choices, brain chemistry, circadian rhythms, diabetes, and hormonal changes during the menstrual cycle.
The work of Steven Hayes, who developed Acceptance and Commitment Therapy (ACT), closely parallels the treatment protocols of behavior therapy. In speaking about the sadness a patient of his experienced upon the death of his hamster, he says, “A CBT expert would say that his sadness was not caused by the event of his hamster dying. This expert would acknowledge that the pain was a result of the love he freely gave his hamster. CBT has unfortunately neglected to take into account that feelings can vary even without a cognitive component.” Acceptance and Commitment Therapy (ACT) encourages patients to live their lives with daily structure and to remain loyal to their life processes, independent of the emotional variability that in the past has thwarted disciplined living.
“Don’t let the tail wag the dog!” In reference to our feelings, this familiar saying serves as a reminder of the importance of not letting our emotions determine the choices we make in life. A patient with issues of mood instability is making a clinically dangerous choice when he takes a day off from work because he is “not feeling up to it.” This so called “mental health day” is usually spent in bed or just hanging around the individual’s home. Such a choice, the purpose of which is to mollify the pain of the morning, actually can exacerbate the patient’s negative mood and create a spiral of negative, unproductive choices. Often, the temptation the next morning to stay home again will be even stronger. When we allow our emotions to determine the choices we make, we tend to yield to our negative emotions and avoid challenges, rather than making disciplined choices reflecting our autonomous values and beliefs.
As stated earlier in this article, helping the patient being treated for OCD learn to regard the prompts and themes of the disorder as irrelevant is by far the most important goal of behavior therapy. The choice to classify something as irrelevant falls under the purview of the Gatekeeper. The psychological dividends of regarding the “spikes” (the irrational, disruptive warnings) from the disorder as irrelevant – even in the face of acute anxiety – are habituation to the spikes, which leads to their extinction. Habituation is the brain’s tendency no longer to react with anxiety after the patient has repeatedly chosen to expose him- or herself to the stimulus (spike) without seeking to escape from the “threat.”
When considering the therapeutic goal of choosing irrelevance, the greatest quandary that patients face is that the spikes do not feel irrelevant. The warnings of impending doom that they are receiving from their brains feel as authentic as those they would experience when facing bona fide threats to their well-being. So, when your mind is sending you signals (spikes) that feel relevant, how do you demonstrate the irrelevance of these thoughts and feelings to your brain? By not altering your choices and plans – your life path – in any way to accommodate the spikes, no matter how turbulent and painful your emotions may be. By unmistakably communicating to your brain that the irrational warnings it is sending you will have no effect whatsoever on your behavior, you are making it clear that there is no point in continuing to send them, and eventually, your brain will get the message and stop.
Sometimes, one finds that an event or experience that has been celebrated by others does not live up to one’s expectations. Some years ago, I was told by my friends that “Forrest Gump” was “like the best movie ever,” but when I finally got around to watching it, I was very disappointed. In fact, it wasn’t until I saw it for the third time that I began to appreciate its genius. Initially, however, my anticipation of how much I was going to love this movie was not matched by the actual experience of seeing it that first time. Patients in therapy for OCD often will receive a bit of symptom relief after aggressively applying one of the therapeutic techniques they have learned to a challenge from the disorder. However, subsequent applications of newly-learned techniques often do not produce the same degree of relief as was obtained with that initial application. Moreover, the expectation that future aggressive exposures will bring as much relief as the first might actually cause the patient to panic when the that level of relief is not obtained. Patients may think, “The technique ‘worked’ before. How come it’s not working now?”
The paradox of OCD is that very intelligent and rational people behave in extraordinarily irrational ways. Sufferers’ brains are sending them signals of terror linked to what often are nonsensical ideas. These sane, intelligent and rational people already know, on some level, that their fears are unreasonable, and yet the disorder’s spikes are experienced as legitimate and compelling to such a degree that the patient feels driven to perform escape responses. Choosing not to alter one’s plans despite the panic one feels requires tremendous fortitude because this choice involves disregarding one of the most powerful basic human instincts – the instinct to survive. In therapy, patients are directed to bypass their feelings and act with emotional independence. The willingness to confront one’s fear and repeatedly demonstrate its irrelevance is at the heart of Exposure with Ritual Prevention (ERP).
If your goal is to have “positive feelings” on a consistent basis, then you are setting yourself up for much disappointment and despair in life! A more productive goal is to keep your focus on the choices that “set the stage” for such rewards. Positive feelings can be a dividend of having made choices that are in accordance with your autonomous goals, choices that can be as simple and straightforward as those that enable you to do things you enjoy. For example, I attended the US Open this year with my family and had a great time. That is not surprising – I have always enjoyed this event, and I go every year. When I plan my next trip, however, I will focus on the actions that make it possible for me to be there, like purchasing the tickets, arranging for a place to stay, and actually getting to the event, rather than the joy I anticipate experiencing when I am there.
Many of my patients believe that I hate the word “feel.” Nothing could be further from the truth. A patient once abruptly terminated treatment after I said to him, “I don’t care how you feel.” While he assumed that the remark was indicative of callousness on my part, I was merely trying to teach him to focus his attention on the healthiness of the choices he made, rather than the chronic low feelings he was experiencing. After each skilled life choice, he quickly would examine whether he felt better as a result. His attachment to the potential rewards of making healthy life choices made it difficult for him simply to allow himself to experience (and enjoy) feeling good when it occurred naturally. Patients often joke with me by saying “I know, Steve, you don’t care how I feel.” They understand that my priority with them is to be vigilantly focused on their choices being skilled and independent of the moment-to-moment variations in their mood.
Statements about one’s feelings tend to place too much emphasis on an aspect of life over which we have no control – our moods. All too often, I hear sentences like, “I feel anxious about my hands being dirty,” or “I feel guilty that I had a sexual thought regarding my mother-in-law.” A much healthier approach is to say something like “I chose not to wash my hands, even though I felt anxiety about the possibility of getting sick if I didn’t wash them.” In statements like this, the focus is kept on the constructive actions that were taken, rather than on the painful feelings that accompanied them.
I feel happy when I play cards with my family or friends. I feel exhilaration and joy when I am on a sailboat, whether I’m racing or just cruising. I do not engage in these activities with a guarantee that I will experience such positive feelings, but instead, the increased probability that I will experience such positive feelings when I participate in these activities motivates me to choose to do them. I believe that our tendency to surrender our autonomy to our feelings leads to much despair and frustration in life. When we expect to be rewarded with positive feelings for participating in certain activities, we may find ourselves looking desperately for these “rewards” once these activities have concluded, and this, itself, may prevent us from experiencing such feelings simply as the natural by-products of having engaged in these activities in the first place. What a “buzz-kill” when the wise guy at a party says, “Hey, are we having fun yet?” If things really haven’t gotten going yet, a question like this only increases the pressure on host and guests alike to make the party live up to everyone’s expectations. And in such cases, it rarely does.
Determining how well we are doing based upon how we feel really is “the tail wagging the dog.” One’s capacity to make mood-independent choices is a much better measure of success. To be able to make a disciplined choice despite a diminished affect (a less than optimal emotional state) is a great accomplishment, deserving of praise and respect.
CHASING THE DRAGON
People who use heroin report that the experience of their first high is absolutely the ultimate state of euphoria, and that all their subsequent experiences with the drug amount to little more than attempts to recreate that initial euphoric experience. This futile and dangerous quest is called “chasing the dragon.” Similarly, individuals who suffer from OCD tend to be aware of a time in their life when they were not tormented by their brain’s constant, attempts to escape from illusory threats, and people who have experienced remission or previous treatment success tend to fixate upon the time when they were relatively free of the disruptive effects of the OCD. This focus on recreating a state in which they did not experience the burdens of their disorder creates an urgency in their desire to see their brain stop generating all the spikes and anxiety they experience. However, since the brain’s purpose in creating these symptoms is to warn them about dangers they face (albeit nonexistent ones), impatiently looking for this protective mechanism to stop is antithetical to the basic programming of our survival instinct. Similarly, the desire of sufferers to see their OCD go away and to re-experience a time when they were free of its disruptive effects contradicts the processes and philosophy of behavior therapy. If relating to the spikes of their OCD as irrelevant is critical to patients’ recovery, then consider the adverse effects of desperately looking for the brain to stop producing these challenges. A question frequently faced by behavioral psychologists is, “If I’m attending therapy to feel better, then why shouldn’t I be frustrated when, after this amount of time and money, I’m still feeling lousy?” A skilled response involves reminding the patient that the goal of behavior therapy is for them to consistently be able to make disciplined choices, regardless of how they feel or of the expected emotional dividend. Patients are encouraged to allow an improvement in their emotional state to occur on its own and at its own pace. The primary goal of this type of treatment is to enable the patient to demonstrate to his or her brain that the prompts from the disorder are inconsequential. The indirect effect of achieving this goal is that both the frequency and intensity of these prompts will decrease progressively over time.
A significant number of my patients enter therapy with the belief that they have the potential to live “the good life.” They take stock of their background and current “assets” – friends, family, finances, connections, etc. – and conclude that if they could rid themselves of their OCD, they would finally be able to enjoy the wonderful life almost within their reach. Unfortunately, the dogged insistence of such patients that life can truly to be that good creates a kind of desperation for recovery which, along with their resentment of the disorder’s presence and challenges only impedes that process. Mind you, I am fully aware of how disruptive to one’s life OCD can be. Being tormented relentlessly about inane, nonsensical topics is terribly painful, unfair, and burdensome. But to idealize life without OCD is to misrepresent the realities of human experience. Indeed, if the OCD were somehow to be magically removed from these patients’ lives, they simply would join the rest of humanity in living flawed lives marked by inconsistency, moments of weakness, and handicaps. In order to challenge these patients’ idealization of life without OCD, I sometimes tell them that as human beings, we are all “stuck in the mud hole.” We are all slogging through the “muck,” we are all equally dirty, and we all “stink,” but we give meaning to our lives by pursuing our goals and overcoming challenges.
What does being human really mean? This certainly is one of life’s most important questions, and how we answer it can have a powerful effect upon of our lives. It is my belief that embracing our humanity means accepting our respective craziness and understanding that we all can be inconsistent and weak. But it also means that we all have the capacity for greatness, and we all can reap the rewards of living purposeful, disciplined lives.
You may be wondering why we give so much attention to the subject of independent systems in an article about the nature of choice. The answer is that many patients waste a great deal of time and energy and experience considerable frustration living with the mistaken belief that we as human beings can or should be able to avoid, control, or alter independent mind-body systems. Independent systems are processes within our mind and body that are not subject to our choice-making ability. We cannot start or stop these processes.
There is a pledge that people in AA, who are attempting to recover from alcohol abuse, make to each other: “May I possess the strength to change the things in my life I can, the patience to accept the things in my life I’m not able to change, and the wisdom to know the difference.” Being educated about the things in our lives that are not within our control can contribute significantly to the maintenance of our emotional equilibrium and can facilitate the healing process.
The independent systems involved in OCD are 1) the physiological/sensory manifestations of emotions like anxiety, guilt, anger, and depression, and 2) the spontaneous cognitions that constitute the disorder’s spikes. Keep in mind that these spontaneous thoughts would have little relevance to us if not for the tidal wave of emotional distress that accompanies them.
Contrary to popular belief, feelings are not the direct result of our choices; rather, they are indirect responses that are likely to be experienced after a choice is made. Your feelings can be influenced by your perspective, but you have no direct control over the particular emotions you experience. What most people don’t realize, however, is that independent systems within the brain have the capacity to generate emotions as well as thoughts. Thus, when you give in to the brain’s natural instinct to seek safety during moments of anxiety, you are inadvertently substantiating the output of these independent systems. Giving in to the need to escape from what your brain determines to be a threat because it “feels” dangerous gives credence to the automatic thoughts that have caused a malfunctioning amygdala to activate your brain’s instinct for survival and deprives you of the resolution of your anxiety that you are so desperately seeking.
Behavior therapy does offer methods to influence the independent systems discussed above. However, the changes that may occur as a result of implementing the skills learned in behavior therapy often are not immediate. Many years ago, a very determined and therapeutically aggressive patient complained to me that he was not being sufficiently challenged to recover quickly enough, and I told him that his aggressive pursuit of challenges was actually inhibiting his brain’s need to warn him of danger. I explained that since his OCD was based upon his brain’s programming to make him aware of potential threats, if he actively sought out these threats, his brain might interpret this to mean that the warnings no longer were necessary.
Below is a list of common spontaneous reactions created independently by our body and brain, and over which we have no direct control.
Feeling anxiety or having a panic attack: Rapid heartbeat, lightheadedness, tingling sensations, dizziness, sweaty palms, racing thoughts, pressure in the temple, constriction of the throat, nausea, stomach upset, and feelings of depersonalization.
Chronic pain: Chronic pain of the back, neck, or legs consists of independent symptoms that usually are associated with stress. People spend millions of dollars each year trying to treat these issues medically when they actually result from mismanaged stress and anger.
Feelings of muscle weakness, twitches or spasms: These experiences are all too often mistaken for MS, Lou Gehrig’s disease (ALS), or Parkinson’s disease.
Mood states: People can experience feelings of sadness, depression, or elation for no apparent reason. There is a subset of OCD sufferers who experience anxiety and desperation in relation to any dip in their mood because of their over-attentiveness to such changes. They tend to say things like, “I’m terrified that I’m slipping into a deep depression.”
Conscious awareness: Being aware of each blink, each swallow, and each breath. The mind can also make us aware of parts and functions of our body to which we typically pay little or no attention.
Falling asleep or waking up: As all of us know, we have no control over going to sleep or staying asleep. I could easily author an entire article entitled “Sleep, the Hostage of Anxiety.”
Sexual arousal: No one, man or woman, can produce a state of sexual arousal or sexual climax on demand, although, paradoxically, people can experience symptoms of arousal when it is the last thing on earth they would want.
Blinking: This normally happens reflexively.
The symptoms cited above represent some of the ways in which our human physiology demonstrates to us that we are not in full control of our bodily reactions and mental associations. When these independent systems cause disturbances in our lives and we respond with intolerance, desperation and frustration, we become even more acutely conscious of the very symptoms we want to see go away. And believing that we should be able to control these symptoms only deepens the disruption they cause in our lives.
There is a distinct subset of OCD sufferers who become preoccupied with independent systems to which we usually pay little attention. For example, they may become painfully aware of each time they swallow, blink, or breathe, or they may become obsessed with visual floaters, etc. Since we have the capacity to “choose” when to breathe, blink, or swallow, people become obsessed with the challenge of deciding when is the “correct” time to perform one of these actions. The OCD sufferer experiences considerable distress because he or she constantly is being reminded of these options. Since we “ought not to be made aware of our own breath, heartbeat, blink, or swallow response,” the constant reminder of these events becomes maddening. That our own mind keeps us alerted to each occurrence seems to us like a betrayal. The ensuing desperation not to be aware of these processes paradoxically creates a heightened sensitivity to, and panic and distress about, being constantly reminded of them. People with this kind of OCD also often have perfectionistic tendencies. They may be painfully aware of their unrealized potential for living a gifted life, and may feel that these distractions prevent them from developing their talents. The chronic distraction of constantly being made aware of systems that most people hardly notice casts an emotional pall over their sense of mental clarity and freedom.
Other OCD sufferers find themselves subjected to their brain’s constant generation of thoughts with sexual content. Individuals with this variant of the disorder often try to prove to themselves that they are not sexually aroused by these thoughts to reassure themselves that they are not “perverts.” Since sexual response is involuntary, however, their attempt to reassure themselves can backfire as, to their horror, they find themselves responding sexually to these thoughts. For these sufferers, the realization that they have become sexually aroused leads them to the inexorable conclusion that they truly are sexual deviants. One patient I worked with would have an erection each time he approached a coffin. He was appalled by this response and concluded that he had a deviant sexual attraction to death. A female patient would notice significant vaginal lubrication when she had her daughter sit on her lap for a bedtime story. She was mortified by this, believing that this response indicated that she could not be trusted to be alone with her daughter.
A frame of mind I often encourage with my patients is “If I’m not choosing it, let it be!” The headache, the sudden urge to vomit, the panic, the sleep disturbances, and the scary mental associations are just ways we experience the spontaneous output of the machine that is our brain. The brain does not have a desire to torment us; it sends us these reminders to test the acceptability of these prompts. The brain’s creative mental associations are a natural part of our mental processes. For example, when you are waiting at a stoplight, watching a mother push a stroller across the street in front of you, and the idea of running them over comes to mind, this is not evidence that you are deranged or evil; this is the kind of association the brain typically makes. It is imperative that one does not assign any significance to the occurrence of such thoughts because doing so most likely will increase the chances that they will recur again and again, bringing with them more distress each time they surface. The dynamics of this process are very much like those at work in the mental game of “Try not to think of a pink elephant.”
All too often, my patients believe that recovery means a discontinuation of such upsetting associative thoughts. Frank started off his last appointment by saying, “I got challenged five times today, and the anxiety was overwhelming. I can’t believe after all this therapy that I’m still being defeated like this! What is wrong with me?” The problem here is that he is focusing on the wrong elements as measures of his recovery. If we focus on the activity of the automatic systems that produce anxiety, depression or apathy to determine if we have made progress in therapy, then we are sending a message to our brain that the presence of these feelings is a problem, and often the result will be that you experience more of these feelings. When we are distressed over stress, we only invite more stress. “Don’t give yourself a headache for having a headache.” Don’t be upset for feeling depressed. A depressed mood often is the product of an automatic system, and should be managed by making mood independent choices. “I felt lousy, but I still went to the gym and did not cancel the party I had planned for that evening.”
The independent system governing the quality and/or duration of one’s sleep can have a dramatic impact on another automatic system – mood. The best way not to get caught in the negative gravitational field of an automatic system is to make sure that your life choices are not determined by your emotional states and that your autonomous goals guide your decisions every minute of every day.
MANAGING THE INDEPENDENT SYSTEMS
Recently a new treatment for the independent system active in depression emerged from the field of behavioral psychology. Called “Behavioral Activation,” it is a therapeutic initiative in which the patient is encouraged to make a number of commitments to specific goals over the period of a day or a week. The patient is instructed to follow through with these plans regardless of the state of his mood or negative cognitions. Progress in treatment is not measured by the immediate elevation of mood, but rather by the degree to which patients remain committed to their goals – called Activities of Daily Living (ADL’s) – that they have selected for themselves. As the old adage goes, “Let the muscles teach the mind.” Undertake the action first, and let the reward of elevated feelings follow. Although, the desired mood elevation may not come as quickly as desired, patients are encouraged to focus on the behavioral discipline they have exercised, rather than on the emotional dividend they are seeking. It is important to keep in mind that an attachment to getting emotional relief actually can have the paradoxical effect of reminding you just how far you are from your goal, and may, in fact, prolong your suffering.
The human body is remarkable in its capacity to maintain its equilibrium in harsh or stressful conditions and to restore that equilibrium once it has been lost. The brain/body machine is constantly monitoring countless metabolic processes, and when a deviation from the norm is detected, it quickly acts to correct the problem and restore an “all-systems-normal” status. For those with OCD, a part of the brain called the amygdala, which is designed to warn us of threats to our survival, malfunctions, causing it to send repeated emergency signals to our conscious awareness. When this occurs, it is natural for human beings to seek safety. If we do this, however, we inadvertently provide the brain with confirmation that these alarms are necessary because we are responding to them. On the other hand, if we give our brain permission to malfunction, and then demonstrate to it the irrelevance of the signals it is sending us by choosing not to respond to them, the mind eventually will recognize that sending us these warnings is ineffective, and it gradually will stop issuing them. This accepting relationship between the Gatekeeper and the independent systems of our mind and body in which we make allowances for malfunctions can greatly facilitate the healing of commonly disrupted systems such as sleep, sexual responsiveness, and chronic pain.
In life, it is much more important to prioritize acting with strength over feeling strong. Focus on making therapeutic choices, rather than on your constantly changing emotional experiences. If you gauge how well you are doing by how you feel from one moment to the next, then you are likely to make choices based upon transitory emotional experiences, rather than long-term priorities and goals. A diminishing sense of agency can result from attempting to regulate independent systems – systems over which you have little or no control – and repeatedly failing in your efforts. This can result in feelings of helplessness and demoralization.
THE DANGERS OF MOTIVATION
The definitions of words like “motivation” are often vague or inconsistent. After much discussion, debate, and research, it seems to me that the most useful definition is, “Emotional energy directed towards a goal, based upon some internal or external incentive.” Concluding that you “lack motivation” is even more self-limiting than calling yourself “lazy.” It also is based upon a false premise. People tend to view motivation as an energetic or emotional state that they “need” to have in order to go about achieving their goals. Motivation generally is defined as a response to the provision of an incentive or the application of a compelling force that results in the active pursuit of one’s goals. This definition highlights a common difficulty that patients encounter in therapy, such that they decide whether to follow through on assignments based upon how motivated they feel. However, exposure exercises by their very nature are aversive, and if patients were to proceed with them only when they felt “motivated” to do so, no one would choose behavior therapy in the first place. Perhaps that is why people often try behavior therapy only after other types of therapy have failed.
Often, patients seem to seek some external factor to provide them with an incentive to pursue therapeutic goals, rather than basing their decision upon their autonomous goals and priorities. Too many people come to therapy to find or improve their motivation. (Revisit the section of this article entitled, “Can you help me, doc?”) For most patients dealing with the torment of OCD, the factor that drives them – at least initially – to try behavior therapy is their desperation to get rid of the constant pain associated with their anxiety, obsessions, and compulsive rituals. But the urgency to end the pain they experience cannot sustain patients for long because the therapy involves deliberate repeated exposure to the stimuli that induce the pain, and the reduction or elimination of the pain is not so much a goal as it is a byproduct of learning to treat the symptoms of the disorder as irrelevant. Following through on our commitments should not be dependent upon our feelings, especially something as intangible as motivation. In behavior therapy, the ill-defined phenomenon of motivation is replaced by a commitment to pursue our goals independent of how inspired we feel to do so. The patient is encouraged to be engaged in a values-based process in which the emphasis is not on the level of inspiration, but on making a conscious and deliberate choice to observe the treatment protocols. The false premise that some kind of emotional impetus is required for us to be able to make disciplined choices is abandoned. Runners engage in a similar process when they dedicate the time and energy necessary to reach their mileage goals as a matter of course, instead of waiting to experience the emotional “inspiration” to do so.
The perspective I encourage my patients to develop is to be willing to commit to a non-negotiable choice. A non-negotiable choice is one in which we are mindful of our brain’s temptation not to honor our decision to pursue our goals, and we consciously affirm that our commitment to achieving them is not up for negotiation or modification. Our dogged adherence to our goals is considered unalterable and irrevocable. Despite the mind’s seductive entreaties to avoid the pain that might accompany the required exposure exercises, I encourage patients to independently commit themselves to the completion of these home-based assignments, irrespective of the pain they might experience.
It may seem counterproductive for a psychologist to say, “I don’t care how you feel; I care how you choose.” It is essential, however, that patients understand the difference between “feeling weak” and “choosing weak.” In regard to facing anxiety, the author, Clair Weekes writes, “Weak knees can still carry you across a room.”
A great deal of time is devoted in therapy sessions to patients' discussions of the anxiety-related challenges they faced the preceding week. However, patients often tend to focus on extraneous aspects of the anxiety-producing thoughts (spikes), like the subject matter of the spikes or the degree of discomfort they felt in relation to these spikes. A case in point: John has been a patient for six months. He has worked his way up the hierarchy of spike exposures to a level of five out of ten. He starts this particular session by disclosing that the prevailing theme of his spikes (that he is a pedophile) has morphed a bit, such that he now is spiking that he wants to harm his children in other ways than by molesting them. He is distressed and frustrated that instead of going away, his OCD has shifted the focus of its spikes to a different theme. Amazingly, he no longer finds the idea of having sexual contact with his children disturbing. As I listen to him talk, however, I am dismayed to find that he says nothing about how he managed to free himself of the anxiety and upset he had been experiencing when he had thoughts about molesting his children. The new subject of his spikes presented a therapeutic opportunity for John to write these new thoughts down on cards and review them ten times a day. Doing so would give him the opportunity to demonstrate to his brain that he was just as willing to accept having thoughts about the new theme as the old. Instead, John’s main focus was on how emotionally distressing he found the new associations. The effect of prioritizing his upset about having these new thoughts was to send a message to his brain that these thoughts had significance, which only increased the likelihood that he would have more of them.
It can take weeks, months, or even years for a patient to truly begin to understand and act upon the phrase, “The headline of the story is the choice you make in response to the challenge.” It is not productive to focus on the content of the mental associations that have been generated independently and spontaneously by your brain. Allowing yourself to debate whether or not to engage in an exposure exercise actually can drain you of emotional energy, and this sense of emotional depletion can become a pretext for choosing not to engage in an activity or to pursue a goal that might be experienced as aversive. Unfortunately, our brain’s basic programming to seek pleasure and avoid pain does not serve us well when we are about to do exposure exercises, which (at least for the duration of the exercise) are likely to increase our levels of stress and emotional pain.
As a child with dyslexia, I found the prospect of doing my homework quite painful because doing so involved confronting my severe academic shortcomings. I generally did my homework after dinner, and when engaged in this struggle, I wanted nothing more than to go to sleep and put an end to my suffering. When I finished my last page of schoolwork, however, I would experience a burst of energy and plead with my mother to let me stay up late to watch my favorite TV show. What I ultimately learned from this scenario was that the emotions I experienced when pursuing goals that were in my long-term best interests would not always be pleasant and could not be relied upon to provide me with the “motivation” to undertake these challenges. When you have an anxiety disorder, your emotions always will direct you to choose the path that is likely to provide relief. If you follow this guidance, however, you will empower the disorder and weaken your agency for recovery.
WHAT IS NOT A CHOICE?
Before we can understand what is involved in making an autonomous choice, it is essential that we be very clear about the factors that lead individuals to deceive themselves about what making and following through with a choice really means.
“Today was my first day of therapy; I’m finally going to put this condition behind me! If I’m going to pay this much for treatment, I will definitely be on my way to a successful recovery. I’ll just perform these last few rituals and escape the anxiety for now, so I can be in a clearer state of mind to begin my recovery.”
A very common way of avoiding choice is to engage in what I call “conceptualized choice.” A person who falls prey to conceptualized choice is substituting planning to make a choice for the choice, itself. A true choice involves follow through – taking concrete steps to realize that choice. A true choice is not just committing to make that choice at some point in the future! The saying, “The road to hell is paved with good intentions” speaks to the perils of mistaking the intention to make a choice for following through with the actions that are required to make that choice a reality. For example, the act of showing up at behavior therapy appointments is a far cry from actually doing the repeated exposure exercises that produce the changes that lead to recovery.
There are many instances in our everyday lives where our autonomous interests -- our goals and our values -- and the brain’s impulses, instincts and anxieties conflict. Essentially, the scenario is as follows: Choice A is in my best interest, and choice B reflects what I desire or what I wish to avoid. For example, John believes that it is in his best interest to wake up an hour earlier on Saturday morning and exercise, and he sets his alarm for 8:00 AM. When the alarm goes off the next morning, however, John doesn’t want to get up and thinks about how “terrible” it feels to be awake at that “ungodly” hour, and he decides that what he really needs is another hour of sleep. His decision certainly is understandable and at first sight doesn’t seem so unreasonable, but consider the demoralizing impact of starting a day in which the very first action you take upon awakening is to betray your prior intentions and allow your sensations of fatigue to determine the actions you choose. In my view, whoever invented the “snooze” button – not to mention hand sanitizer -- has made it that much easier to allow our feelings (whether of fatigue or anxiety) to divert us from the pursuit of our autonomous goals. How often have we brought a project for work or school with us on vacation with the intention of completing it, only to keep putting it off until we find ourselves on our way home? If I say I’m going to do something, like washing the car first thing in the morning, doesn’t that mean I’m really going to do it? For most of is, the answer probably is “no.” We may have had intended to do it, but when the next morning arrives and we realize how much effort following through with that choice actually will require, we allow our minds to convince us to abandon our plans. We allow thoughts like, “Well, maybe not today. After all, it’s going to rain on Tuesday,” or “Great! I let myself sleep an extra hour. Now the day is shot! I might as well just go back to sleep,” to serve as excuses for not following through with our plans.
Bob is determined not to continue to be victimized by his OCD. He is well aware that his compulsive hand washing is perpetuating his condition. When he is out, however, he accidently touches a homeless person on the street and promptly runs to a drug store to purchase some hand sanitizer. How many of us would like to lose weight, and yet find ourselves regularly giving in to the impulse to eat sugary and/or high-fat foods that inevitably cause us to gain weight? When our attention shifts from our chosen goals, or we are unwilling to confront the pain that pursuing them might bring, we ultimately are doomed to give into our impulsive desires and veer away from our goals.
The human brain seems to be engaged in a constant battle between our autonomous goals, which often require considerable effort and may involve discomfort or pain to achieve, and the brain’s attachment to pleasure and avoidance of pain. Although Daniel desires treatment success, his mind constantly finds excuses not to follow through with his home-based exposure exercises. To be successful in treatment requires tremendous discipline, because when left to its own devices, our brain will try to take the path of least resistance – seeking pleasure and avoiding pain.
Consider how many people purchase memberships to gyms, but then rarely (or never) actually go to the gym to work out. There is an enormous difference between making a mental commitment to seek a major life change and actually devoting the time and energy necessary to achieve that goal. For example, it takes a great deal of fortitude to repeatedly engage in exposure exercises, especially when these exercises might require you to tolerate very unpleasant emotional experiences. Imagine for a moment that it’s 2:00 PM and you have been anxiety-free for the past four hours. Your phone alarm buzzes, alerting you to the fact that it is time to engage in another exposure exercise. When you originally set the alarm four hours ago, it was your earnest intention to comply with the therapeutic guidelines, but now that this moment has arrived, the last thing you want to do is upset the apple cart and risk sacrificing this sense of tranquility. What are you to do? Well, if you want to continue to make progress in therapy, you need to find the strength to forego the peace of the moment for a future without the constant torment of the disorder.
I have encountered people who have been firmly resolved to start eating in a healthier way in the future, and then they actually celebrate having made this difficult choice by choosing to indulge in the unhealthy foods that they love. This is what I call a “conceptualized conviction.” Being very upset about how your life is falling apart and talking to a loved one about how you really are going to make significant life changes sometimes actually can decrease the likelihood that you will follow through with the actions that are required to bring about that change. I often suggest to people who have committed themselves to giving up smoking to refrain from telling others about the change they intend to make. If they are at a point where they are ready to embark on a course of action requiring considerable discipline, I urge them to proceed on the basis of their internal autonomy and not in the belief that sharing their intentions with others is tantamount to actually making the day-to-day sacrifices that are required to achieve this goal. Conceptualizing a choice also occurs when we say meaningless things like, “I’m going to do it,” or, even worse, “I have to do it.” These statements suggest that the decision has already been made – “It’s as good as done!” However, saying, “it’s going to happen,” does not take into account the preparation that may be necessary, the need for a sober consideration of the resistance to change that we all share, and, most importantly, the critical juncture when you demonstrate your commitment to follow through on your intentions with actions, not words.
“The pep-rally does not win the football game.” Don’t equate getting yourself all psyched up to change for the discipline that actually will be required to face the challenges that lie ahead. When you are in the grips of the terror that accompanies OCD, the inspiration and emotional fortitude you had in yesterday’s therapy session will fly out the window. Many of my patients have looked for the therapy to provide them with the inspiration to face the emotional challenges of this condition. However, when you are experiencing fear, hopelessness, guilt, depression, or other painful emotions in relation to the spikes from the disorder, you must be willing to jump into the inferno of terror whether you “feel” like it or not, and not just because you got “psyched up for it.” Many patients leave therapy sessions – or, for that matter, other venues, such as church and temple services – feeling inspired to go out and change the world. They have been infused by the psychologist, rabbi, priest, or minister with a new spirit and suddenly feel capable of living the life they seek. The problem with this “go with the spirit” approach is the short-lived nature of this experience. As I’ve stated before, don’t be fooled into mistaking the emotional incentive you may feel when leaving a therapy session for the hard work that will be required to complete the home-based assignments that are of central importance to the therapy. Being “motivated” or “inspired” is a transient experience; in the end, choice, discipline, and hard work are the agents of change.
When it comes to difficult tasks like home-based challenges, it actually is counter-productive to reassure yourself that you will successfully complete the assignment. The steps involved in completing an unpleasant task include setting aside the time, facing the discomfort of doing it, and accepting the possibility that performing this task will be a miserable experience. In addition to this, you must navigate through all the excuses to “put it off” and then actually start the activity. In fact, I often suggest that patients predict that they most likely will fail to follow through on their commitment. In making this negative prediction, they have the opportunity to confront their own mind’s non-compliance.
LESSONS FROM CHARLIE
What can Charlie Brown teach us about the difference between autonomy and an acceptance of what is likely to happen, and being seduced by what we hope will happen. Charlie Brown is a kind of “Everyman.” All of our insecurities, our hopes, our dreams, and our faith in the potential of humanity are represented in Charlie Brown’s life and character. Charlie’s nemesis is Lucy. In each episode of “Charlie Brown,” Lucy offers Charlie the opportunity to kick a football that she promises to hold for him. She has made this promise many times before, and always, at the last moment, just as Charlie is about to kick the ball, she takes the ball away, and Charlie flies through the air, distraught, as he realizes that once again he has been duped. Each time she offers to hold the ball for him, Charlie thinks “This time Lucy is completely sincere. She acknowledges that she has been deceitful in the past, but this time she is being completely honest. This time she promises things will be different. She will not fool old Chuck.” Charlie teaches all of us that “hope does not spring eternal!” Making choices based on what we hope for, rather than on what is likely to occur, is a mistake. It is essential to keep in mind that quite often reality is not what we want it to be. Reality often means finding ourselves in an undesirable place or in unpleasant circumstances.
I encourage patients to find meaning in a life process in which they are prepared to meet the challenges that life presents and make the best even of harsh circumstances that they had no part in creating. I suggest that overcoming the challenges presented by their own brains is a noble task that will foster emotional growth and development.
UPSETTING THE APPLE CART
Consider the following: In the two days since you had your therapy session, you have been very aggressive about completing all of the exposure exercises you agreed to perform. You have faithfully performed ten difficult and painful exposures on each of the past two days. It is now Thursday, and you awake to discover that you are experiencing little to no anxiety at all in relation to the central theme of your OCD. How glorious to be so free from distress! Then, the alarm from your smartphone goes off, and you are reminded that it is time to perform yet another exposure exercise. What do you do? How tempting it is simply to skip the day’s exercises! How could your therapist possibly expect you to disrupt the wonderful sense of peace you are experiencing?
This critical moment can be a significant predictor of the whether this patient will make a successful recovery. Patients who understand the nature of the therapy and the importance of being aggressive throughout the treatment – no matter how “good” they are feeling – will be willing to upset the apple cart. These patients will build upon the advances they have made despite the temptation to preserve the calm. Interestingly, patients who at this moment actively engage in the exposure and are willing to disrupt their sense of peace are likely to discover, paradoxically, that they experience yet another day of relative quiet. Most likely, their brain will interpret the conscious choice they have made to aggressively seek out and activate its warning system as a message that the target topic is not really a danger. On the other hand, patients who avoid the day’s exposure exercises in order to sustain the peace send signals to their brain that the thoughts to which they are unwilling to expose themselves are threats, and their brain will likely start to test these topics again with more frequent and more intense spikes.
Most patients enter therapy in considerable distress, and at that point are determined to follow the treatment protocol with unwavering commitment and fortitude. As their treatment progresses, however, the distress they experience from the disorder tends gradually to decrease. Indeed, those who diligently adhere to the treatment protocols generally experience a good deal of symptom relief. A common pitfall that patients encounter at this stage of the treatment process is the phenomenon of “diminishing returns.” As I’ve said repeatedly throughout this article, success with this type of therapy depends upon patients continuing to perform the required exposure exercises on a regular basis. If, as a result of the decrease in their level of distress, patients become less conscientious about performing these exposures, then their rate of progress will slow. Thus, it is critical that patients sustain the momentum they have achieved by continuing to do the exposure exercises with undiminished diligence even as their symptoms begin to decrease. It takes considerable courage and determination at this point in the therapy to continue to invite the pain and anxiety of the OCD into their lives, but it is essential that patients do so if they want to complete their recovery from the disorder.