Rethinking the Unthinkable(cont)
For the person suffering with the "Pure-O", a tremendous amount of anxiety and/or guilt accompanies the spike. The mental ritual (rumination) is the volitional effort to shut off the anxiety, either by attempting to gain reassurance, solve the question, or avoid having the thought recur. The tormenting thought (spike) typically entails two parts. The first is the idea that the thought, in and of itself, is deviant and signifies something horrible about the person who has it. “I must be a sick, mentally unstable person to have had this thought occur.” Or, “Only a ‘bad’ person could think such a thing.” The second part is the great emotional and physical discomfort accompanying the intrusive idea. The symptoms of anxiety can include, but are not limited to: rapid and heavy heartbeat, upset stomach, excessive perspiration, muscle fatigue, mental thoughts and/or muscular tension. These symptoms are what make people with OCD “feel” that the spike is so problematic. It is during the rumination phase that the person's mind becomes extremely preoccupied and distracted. It is not unusual for someone with the “Pure-O” to spend endless hours trying to “escape” from these thoughts. The perceived need to stop these thoughts is tremendous. A common misconception among “Pure-O” sufferers is that there is a way to turn off the obsession, and that they just have to keep obsessing until they hit upon that way. If they can find “the answer,” the right thought, then the obsessing will just vanish completely. Most sufferers realize this is an impossibility, but they cannot give up the search.
The accompanying diagram illustrates the endless cycle of spiking and ruminating. On the left-hand side of the diagram you will see references to “subconscious mental processes” and the “anxiety center." The subconscious mental processes are located in the outer portion of the brain and represent parts of the brain that are creative and always on the lookout for pertinent information. Evidence of its existence lies in a phenomenon known as the "Tip-of-the-Tongue" effect (Brown & McNeil, 1966). All of us have had the experience of searching for a word or fact that is just on the tip of our tongue, but continues to elude us. So we give up trying to recall it and go about our business. Then, later, it pops into our consciousness, even though our mind is preoccupied with another topic. I believe that there is a non-conscious portion of the brain that searches our meaningful material and sends this information to one’s consciousness. One tends to more readily notice information that has a strong association component with significant material than non-relevant information. For example, when we see a red light, we immediately react to it as a warning (i.e., unconsciously, we associate a red light with the idea of a hazard). For the "Pure-O" sufferer plagued with thoughts of violence, the sight of a knife might spike the thought of stabbing a loved one. The “Anxiety Center” (left side of the diagram) is closely associated with the “Subconscious Mental Processes” (see diagram). This part of the brain is called the amygdala. Brain mapping studies suggest that the amygdala is active when we experience emotional upheaval. On occasion, the amygdala is triggered by an external stimulus, e.g., finding a snake in one’s camping tent. In the case of panic attacks, seemingly random events can trigger the amygdala to misfire and send the same types of signals. The Anxiety Center is responsible for the fight-or-flight response. Brain mapping studies suggest that the amygdala is the center of visceral awareness that there is an urgent threat demanding immediate attention. The Anxiety Center activates psychological responses to emotional information, such as, rapid heart rate, racing thoughts or upset stomach. The resource center transmits information to our conscious awareness that deems material relevant or significant. It is at this juncture that most “Pure-O‘s” becomes fixated and distraught.
The transmission of the information from these subconscious processes to our conscious awareness is a purely reflexive one and beyond our control. However, it is not beyond our influence. When the spike reaches our “conscious awareness", we have a choice as to how to process the thought (represented by the two arrows in the attached diagram). The arrow pointing upward suggests that the person experiencing the stimulus chooses to believe that the spike thought represents or reflects something deep and meaningful about the person; e.g., "only a vicious, loathsome human being could possibly think of stabbing their loved one." This is referred to as the “instinctive response” (IR) because it is inherent within each person to resist anything which feels so threatening. People with OCD are not less tolerant of these upsetting ideas, which most humans report are a natural part of their daily existence. It is just that people with OCD experience a “misfire” in the brain, which makes them “feel” as if the idea is problematic. Usually, an effort is made to seek reassurance and disqualify the legitimacy of these upsetting ideas and threatening experiences.
The instinctive responses naturally produce the strong desire to engage in resistance and relief seeking. This represents, as Albert Ellis (1987, 1991) has suggested, a dysfunctional emotional response. The tremendous effort one puts into escaping the unwanted thoughts or preventing their recurrence (e.g. hiding knives), in effect reinforces (e.g. strengthens the association) its importance to the non-conscious brain and thereby feeds the vicious cycle. This process is represented in the accompanying diagram by the arrow pointing from the top box back toward the anxiety center. Similar notions have been proposed by Wenzlaff, Wegner, & Roper (1988). These authors suggest that attempting to suppress thoughts has the effect of making them stronger. Recognizing that you are upset by a thought and then reacting with resistance places a mental marker on it and, therefore, increases the likelihood of the thought reoccurring. For the sufferer with "Pure-O," the spike is a double barrel shot of anxiety. First, there is anxiety for having such an unpleasant or deviant thought. Then, the tremendous, uncontrollable repetitiousness of the thoughts makes the sufferer think he is losing his mind. The uncertainty regarding mental loss of control can be a very anxiety provoking experience.
As per the “Conscious Awareness” box in the diagram, the arrows pointing downward represent the least likely response, but, ultimately, the most therapeutic one. The extinction response entails recognizing the existence of the “bad” thought, but assigns no blame to the person for having it. This response allows the upsetting ideas to exist, despite the presence of the accompanying extreme anxiety. Many cognitive-behavioral psychologists believe that the absence of this response is what distinguishes people with OCD from the “normal” population. In contrast, the cognitive psychologist believes that just by shedding light on either the irrationality of the idea of being a bad person or on the person not being responsible for the initiation of the thought, relief from anxiety will result. However, those with OCD might suggest that, in order for psychologists to fully understand what they experience, their amygdalas could be stimulated to the point of feeling like the world is ending. The experience of feeling compelled to then “run for the hills” would be shared. The extinction response is not the reflexive one, nor does it occur naturally when feeling so unsettled. In fact, the extinction response feels so unnatural because it is diametrically opposed to what we are evolutionarily wired to do when faced with anxiety. Therefore it is crucial for the patient to understand that OCD involves faulty wiring, not an irrational belief system.
For a behavioral psychologist, the key issue is not how or why these thoughts become out of control, but what to do about them when they're racing around in one's head eight hours a day. It is extremely distressing that this form of OCD continues to present such confusion for mental health professionals. There remains a good deal of ignorance regarding appropriate treatment strategies and conceptualizations. Today the most common trend for cognitive-behavioral psychologists is the use of “rational responding” as a means of managing Pure-O. Although people with OCD “feel” as if the obsessive thought is legitimate, they typically remain steadfastly aware that they are performing extensive or elaborate escape responses for no logical reason. Clearly, it does not make sense that the therapeutic objective should be to help the patient “find the evidence” that the thought is illegitimate.
But before discussing what works, first it is critical to discuss what does not work!
Thought stopping, both through shouting, “STOP” or snapping a rubber band in response to the spike, is clearly not recommended and may actually be detrimental. As discussed previously, this technique sensitizes the brain to the unwanted thought by alerting the anxiety center that potential punishment is associated with the spike. Theoretically, the spikes would thus increase due to this heightened sensitivity. Research to date has demonstrated that these techniques are not effective treatments of OCD.
Although logically pointing out the absurdity of the "pure-O" patient’s mental rituals is very tempting, it is often insulting and clearly ineffective. You cannot "outlogic" OCD. People with OCD are understandably drawn to this type of therapy because the therapist is actually reassuring the patient by helping the desperately anxious patient see the irrational nature of these threatening ideas. This type of treatment ultimately can make the patient dependent on the therapist’s determinations of what is rational and what is not, and is therefore an ineffective treatment approach.
Another treatment approach involves the use of analytic interpretations. This approach assigns meaning and significance to the content of the spike and attempts to instruct the patient to “understand” this meaning. This understanding or insight supposedly is both necessary and sufficient to produce change. However, we now believe that this approach for OCD is not only ineffective, but actually is detrimental and may further fuel and reinforce the OCD process. Nevertheless, many people with untreated Pure-O are unfortunately still drawn to this type of therapy approach, as they have a natural inclination to investigate, make meaning of their spikes, and find solutions to their upsetting thoughts. The process of trying to find solutions to alleviate the anxiety and upset is referred to as rumination, and is clearly part of the maladaptive management of the disorder. Initially, when an OCD patient begins behavior therapy after years of analytic or insight therapy, he needs to be deprogrammed. Only then can the full benefit of behavior therapy be achieved.
In 2004, while there is a great deal of scientific evidence that thought stopping, rubber band therapy, and analytical therapy are not recommended and are ineffective for treating OCD, many psychologists are debating whether or not there is any benefit to using cognitive strategies as an additional component to behavior therapy. The idea behind fundamental behaviorism is to change brain chemistry through conditioning. The underlying belief is that patients with anxiety disorders do not have defects in their thinking processes. In a well-known study done by Freeston, et al. (1997), the treatment consisted of cognitive strategies as well as traditional behavioral strategies. The combining of therapies makes it difficult to know whether the cognitive approach added to or detracted from the patients’ recoveries.
Ultimately, as with all forms of OCD, learning to live 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 disorder is perpetuated by the patient’s need to try to rationalize and control any random, bizarre, and `noxious thoughts that occur to him. This intolerance exists due to a misfiring brain function, which makes the patient feel that the thought itself is equal to acting on such a thought. The efforts a person makes to avoid or escape these thoughts reinforce their reoccurrence.
It is given that a patient’s spike will increase when he begins using ERP. The human is resistant to change. Commonly a person who, before treatment, would spoke many times per day and then ruminate incessantly for the duration of the day, will, after behavior therapy, spike much more frequently, but ruminate much less. The goal of this therapy is not to make the thought go away or to achieve anxiety relief. Although this statement sounds peculiar, it should be repeated often and emphasized during the initial stages of therapy. Rather, the goal of this therapy is to provide specific guidelines for effectively managing this condition so that the brain can naturally readjust to a non-reactive state.
The critical point to be made is that eliminating rumination is the goal, not eliminating the number of spikes! It’s how we manage challenges that determines the quality of our lives. The goal of therapy is to not respond to the spike. The goal is not to eliminate the existence of the spikes. Interestingly, though, the long-term effect of not attending to the spike will be that the spikes in fact will decrease in frequency and emotional intensity. However, this will happen only if the person becomes desensitized to these thoughts by allowing them to occur. A common phrase often mentioned in cognitive-behavioral groups that I run is "Let the thoughts be there, Give yourself permission to have the thoughts.” A patient has to learn to be able to manage that the occurrence of any thought, no matter how bizarre or horrific, has no meaning.