Choice cont'd.
When I ask patients, “How have you been doing this past week,” I choose my words carefully. I am not really asking, “How have you been feeling this past week?” or “How much has your disorder challenged you this week?” One of the concepts that patients find most difficult to accept is that the measure of how well they are doing in therapy is the choices they make, not how they feel. Whether your brain continues to send you distress signals is not the relevant factor in determining how much progress you have made. In fact, placing an emphasis on how intense and/or how frequent the prompts from your independent brain are misses the point of the therapy entirely. If a patient says, “This was a great week because I had so few challenges from my OCD.” my response always is “And how willing would you have been to take on your brain’s challenges if they had occurred?” If your goal is for your brain to calm down about the theme of your OCD, then show your brain that the topic is not relevant. If you view the absence of challenges as the goal of the therapy, then the brain will process being challenged as a threat, and the result will be more challenges.
I regularly encourage my patients to make choices independent of their moods, as depression often accompanies OCD. This recommendation is predicated upon an understanding of the benefits of pursuing a goal regardless of how we are feeling. Whether you are combating anxiety or a depressed mood, it is critical that you be engaged in the process of mindfully keeping to our agenda, regardless of the emotional turbulence you may encounter.
As I mentioned earlier, one of the most misunderstood statements I make in sessions is, “I don’t care how you feel.” As I have said a number of times in this article, when you focus on how painful or difficult things are, rather than the choices you make in response to these challenges, you are likely to let your emotions determine your choices. OCD is an enormously compelling condition that makes you feel that you must seek relief from the emotions you are experiencing, but if you want to recover from this disorder, you must emphasize your commitment to distress tolerance over relief-seeking.
When we look back after an hour, a day, or a week and see that all the goals to which we had committed ourselves have been achieved, we can take great satisfaction in our accomplishment. Having chosen to write a lengthy article, and now seeing it nearing completion is enormously rewarding, and is in keeping with the life path I have chosen for myself.
Although rewards are an important part of living, research has consistently shown that people tend to choose immediate rewards over the long-term benefits of making disciplined choices. As a species, we have an enormously difficult time delaying gratification. When you are experiencing anxiety, and you just want it to stop, it takes great discipline and mindfulness to say, “Okay, I’m willing to face danger and I am not going to seek safety or relief.” To paraphrase Victor Frankl, between stimulus and response, there is an opportunity for us to be mindful of our freedom to choose a response that is in our best interests and reflects our highest values. I wonder, though, if Dr. Frankl was a bit optimistic….
At the end of an hour, day or week, if we can look back and see that the goals to which we had committed were actually achieved, we can take away a tremendous satisfaction. Making the choice to write a lengthy article now rather than later creates an emotional reward and further the momentum of one’s major life process. Rewards are an important part of living. Research repeatedly says that we are often swayed by immediate rewards above the benefits of making disciplined choices. We as a species have an enormously difficult time delaying gratification. When anxiety is demanding immediate relief, it takes discipline and mindfulness to say, “okay, I’m willing to face danger, but I’m not going to seek safety or relief.”
THE ILLUSION OF HAVING A CHOICE
In India, elephants are trained to be compliant in a unique way. At a very early age, they are chained to a large tree, which severely restricts their movements. When the elephant attempts to escape, it is met with the reality of its physical restraint and its limited mobility. Over time, the elephant acquiesces to the limitations of its environment. As the elephant matures, the size of the tree and the thickness of the chain are gradually reduced, and by the time the elephant reaches adolescence, it can be lead around by the handler with only a thin stick and string. At this point in its life, the elephant could easily overpower the handler and free itself. However, because it associates the string and stick with the chain and the tree that kept it restrained its whole life, it doesn’t even try to escape. Since learning of this training method, I have been haunted by the suspicion that we miss many of life’s opportunities for growth because of our blind adherence to the programming from our past.
I had an experience of the “illusion of having a choice” at the age of 40, when I went with my wife to visit my mother. As soon as we walked in the door, my mother voiced her displeasure at how much weight she believed I had gained, and commented that I must “weigh over 200 pounds.” I disagreed and suggested to her that she was mistaken, but to prove her point, she grabbed my arm and led me to a scale to weigh myself. I passively complied and stepped on the scale. Upon seeing how much I weighed, my mother looked very satisfied with the accuracy of her judgment. Shortly thereafter, my wife pulled me aside and emphatically commented that she was awestruck at how I offered no resistance to the way my mother had treated me. She reminded me that I wouldn’t have accepted that kind of treatment from anyone else, and suggested that at the very least, I could have protested this demeaning treatment. I realized that that it hadn’t even occurred to me to assert myself and resist being treated like a child. My mother had raised me in such a way that I never questioned her authority. In our lives, how many of the choices we make – or fail to question – are the products of this kind of conditioning? It is essential that we become aware of our own possibilities and potential so that we can overcome such limitations. Without the inclination to test our self-limiting perceptions, we remain, like the subservient elephant, unaware of our potential freedom.
A mindful evaluation of our agendas and goals, independent of our perceived limitations, can lead us to test our presumed limits and discover what really is possible for us. Richard Bach wrote a book called “Illusions,” the basic premise of which is that we should not be limited by the illusions from our personal history. He wants people to be able to access their fullest capabilities. I often hear patients say emphatically, “I can’t do it, I can’t take the discomfort -- the anxiety is overwhelming.” These false perceptions are among the most compelling factors behind a patient’s failure to comply with the therapeutic guidelines.
When you have OCD, it sometimes can feel like you have no choice but to try to escape from the “threats” about which you are experiencing so much anxiety. When the brain sends you such signals, however, your goal should be to remain mindful of all the choices available to you, not just those dictated by the disorder. “Do I wash my hands and escape the threat of getting sick, or do I choose to take the risk of getting sick with me” What is important is that you choose to behave in a way that enhances your freedom and demonstrates to your brain that the “threat” about which it is warning you is irrelevant, rather than repeatedly giving in to the emotional urgency that demands that you seek relief.
“I couldn’t get out of bed yesterday.” “I didn’t have the energy to do it.” “I can’t take the overwhelming anxiety I feel when I ignore the threat.” I hear these self-limiting statements on a regular basis. As I mentioned earlier in this article, sometimes, when I attempt to dispute a patient’s assertion that he or she is too weak to handle the challenges of the disorder, I am met with great resistance and even resentment if the patient believes that I am not sympathetic to how difficult it is for him or her to choose the therapeutic response. This entrenched lack of agency on the part of the patient can lead a therapist to throw up his or her arms and capitulate to the patient’s conviction that he or she truly is that limited.
A patient who impressed me greatly flew in to New York one day, and entered my office with shaking hands and a pale white face. He looked at me as if he were about to confess to a terrible crime for which I would surely call the police. He grimly informed me that since he was 18, he had been having thoughts of violently harming those about whom he cared the most – the members of his family. Finally, at the end of his rope and no longer willing to live with this terrible secret, he collected all of his worldly possessions and personal financial documents, called his now fully-grown daughters to his side and, mortified, confessed that for many years he had been having murderous thoughts, some of which had included them. His daughters, who had been expecting an announcement of some impending disaster, breathed a sigh of relief, sat back, and said with a smile, “Dad, you just have OCD. You need treatment.” For over thirty years, this man had been silently suffering with this “secret” because he hadn’t been aware that it is completely normal for people to have such thoughts. After two months of intensive therapy, he had made so much progress that he was able to joke about how his mind was still generating these silly thoughts. The spikes had become irrelevant.
SUMMARY
The essence of everything that has been said in this article is that whether your goal is to recover from OCD or simply to live a fuller, more meaningful life, you need to take responsibility for making mindfully aware, autonomous choices that reflect your agenda, your goals, and your values. Mindfulness means being aware of the difference between the voice of your brain (an automatic system) and the voice of the Gatekeeper (your autonomous voice). Individuals involved in therapy for OCD are engaged in an enormously difficult tug-of-war between their autonomous goals and their brain’s inclination to seek the path of least resistance. The patient’s autonomous voice says, “I want to recover,” and the voice of the patient’s brain (the machine) says even louder, “Stay away or escape from danger at all costs!” To be successful in therapy, you must make some very difficult and emotionally painful choices, and it is essential that you do not try to place the responsibility for making these therapeutic choices on the shoulders of your therapist. You also must understand and expect that your brain will not automatically guide you toward your goals, regardless of how beneficial they may be.
I predict that the vast majority of people who read this lengthy essay will believe upon completing it that they have accomplished something material and significant in terms of making changes in their lives. In feeling this way, they may be fooled by their brains into believing that just reading and understanding the words will, in itself, bring about significant changes in their lives, and unfortunately, nothing could be further from the truth. Understanding and even being inspired by the words of this or any other article is only the first step in the process of making the kinds of changes I discuss. The much more difficult (and essential) step is actually to make the choices and take the actions that bring these words to life. So, don’t be satisfied with having gained some insight about OCD or about living a more purposeful and meaningful life. It is for this reason that I hate “self-help” books. The majority of people who read them think that the desired change comes as a result of having completed the reading, yet they are unaware of what it means to actually make a disciplined choice. Go out and do the work that is required to turn insight and understanding into real behavioral change. That is what this article is really about – turning understanding and inspiration into intention, and intention into action. And that is what choice really means.