Rethinking the Unthinkable​(cont. 2)

The following useful suggestions are offered towards managing obsessions.

The research is still preliminary, but the treatment outcomes have been significant enough to spread the word. As with all forms of OCD, behavioral therapy is effective to the extent that the patient adheres to the procedures (Dar & Greist, 1992). Since this article’s original version, two procedures (index card therapy and spike hunts) have been added to the therapeutic arsenal and have been proven effective. I am just outlining these procedures because behavior therapy needs to be done with an experienced practitioner. Attempting to implement these techniques without expert guidance can be problematic and prevent goal attainment.

1. The Antidote Procedure

The spike often presents itself either as a question or potential disastrous scenario. A response, which answers the spike in a way that leaves ambiguity, is the antidote to preventing rumination. For instance, if the patient has the thought "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Under the Antidote Procedure, to manage the obsession, the most therapeutic response a patient can have is to accept this possibility and be willing to take the risk of his mother dying cancer or the question reoccurring for eternity. There is often a question regarding the degree to which one “really needs to believe” that their mother might die. In response, it is important to understand that ones’ beliefs are really not a significant component of treatment success. Instead, the behaviors and choices one engages in are key to conveying to one’s brain that the theme is no longer going to be any importance The goal is to expend the least amount of effort is responding to the question. In another example, a spike might be, "Maybe I said something offensive to my boss yesterday." A recommended response would be, "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure, it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response does not answer the question posed by a spike.

2. Let It Be There:

Using this procedure, it is suggested that the person create a mental pigeon hole for the disturbing thoughts and accept the presence of the thoughts into one's preconscious (those thoughts which are not currently in one's awareness but can easily be brought there by turning one's attention to them, i.e. your name or phone number). It is suggested that a mental "hotel" be created whereby you encourage your brain to store all the unsolvable questions so as to fill up the register. The more unsolved questions the better. It is critical that the person suffering from the “Pure-O” acknowledge the presence of these thoughts, but pay no further attention to them by trying to solve the problems presented by them. The brain can only juggle a certain amount of information at one time. If you purposely overload the brain, rather than going insane, your brain’s response will be to just give up trying. A key to this technique is that the person trying it has to have a great deal of faith and trust in the therapist suggesting it.

3. Spike Hunt

Very similar to the “let it be there” approach is the spike hunt. Using this procedure the patient is encouraged to purposely seek out spikes. This process actually is a 180-degree reversal of the reflexive OCD momentum. Most people’s OCD desperately hope for the associations to go away and never return. This frame of mind actually increases the susceptibility of the mind to these thoughts and exacerbates the condition.


A good example of a spike hunt is:

Patient X is terrified that he might get up in the middle of the night and violently assault his wife and child. He is so fearful that he might act on these thoughts, that any bump or strange shadow in the bedroom prompts him to consider that it might be a place where he’s hidden a knife or a gun with which to harm his family. Even familiar objects, which are out-of-place, seem to suggest that he is capable of acting in a non-conscious way and thereby lend support to the idea that his family is in danger of his uncontrollable/non-conscious actions. Using the spike hunt, this patient was instructed to purposely find unidentifiable shadows or mysteriously placed objects and gather together evidence that the world of the unknown lurks out there and represents possible unforeseen peril. After using this technique for two months and sleeping next to a steak knife, the patient achieved approximately 75% symptom relief. The rationale for this seemingly contradictory approach lies in the behavioral principles of reconditioning. Reconditioning retrains the brain to consider its warnings to be non-relevant. For human brains non-relevant information equals experiences that are not perceived.

4. The Capsule Technique

During the initial phases of therapy, there is a great resistance to letting go of the rumination. A procedure to handle this resistance is to have the person with OCD to set aside a specified period of time, perhaps once or twice a day, to purposefully ruminate. It is suggested that the time periods be predetermined and time limited. The patient should tell himself “At exactly 8:15 a.m. and 8:15 p.m. I will ruminate for exactly 45 minutes. As thoughts occur to me other times during the day, I can feel comforted that the problem solving will be given sufficient time later that evening or early the next morning.” Typically, people report that it is difficult to fill the allotted rumination time. Regardless, every minute must be spent on the designated topic so the brain can habituate to these irrelevant thoughts. A novel application of this technique was reported in the Journal of Behavior Therapy and Experimental Psychiatry. Using audiotaped spiking material a woman was desensitized to her obsessional themes by exposing herself to them ten times a day. After the fiftieth day, her actual spiking dramatically decreased.

5. Turning Up the Volume

Rather than attempting to escape the spikes, the person with "Pure-O" is encouraged to purposely create the thought, repeatedly, following its initial occurrence. One is also encouraged to take the presented topic and actually amplify the threatening component. This has the effect of desensitizing the brain to these spikes by sending the message that not only am I not going to attempt to escape these thoughts; but I am at such peace with them I can create a multitude of them. In response to the thought, "I might have run over someone on my way to work," a beneficial response would be; "There is probably a stack of bodies all along the street; I probably wiped out half the population of my home town yesterday as well. I can't wait to drive home tonight and kill the other half."

6. Index Card Therapy

The index card therapy procedure has been an extremely useful in treating people with “Pure-O.” What baffled behaviorists for years in attempting to treat this form of OCD was that there was no object with which the patient could actually perform an exposure exercise. It seemed rather difficult to have a person touch the thought “Kill my baby” or “I hate God” and then spread it all over the place. To concretize these thoughts Dr. Foa has suggested using loop tapes in which a patient would sit and listen to his/her their particular obsession played over and over ad-nausea. The possible limitation of this procedure is that the patient might become habituated to the voice on the tape and not the actual theme represented on the tape. In addition, carrying a tape recorder around with you might be cumbersome and most people do not have an hour each day to sit and just listen to the same message played over and over again. So to remedy these problems I created index card therapy, where the patient writes the topic of the spike down on an index card. The patient would also record the date, the intensity of the spike, and the level of resistance to the spike on the index card. The writer carries the index card with him at all times, preferably in a pocket. The patient periodically reviews the index card or cards, usually about six to ten times per day, until the level of associated anxiety and resistance is below a rating of two out of ten for two consecutive days.

Some people report that they have difficulty distinguishing between spikes and "legitimate important thoughts." A foolproof litmus test for telling the difference is to ask yourself, “Did the thought or question come with an associated anxiety, feeling of urgency or feelings of guilt?” Ultimately it is wise to place such thoughts in the realm of OCD and make the CHOICE to accept the risk. When asked, "What if it's not OCD," I say "Take the risk and live with the uncertainty." For those who have made significant progress in the Pure-O process, a common complication involves distinguishing a therapeutic response from a ritual.

The “Exposure and Response Prevention paradigm seems simple. If it makes you anxious, confront it! Create a hierarchy and gradually work your way toward the most challenging items. At some point most Purely Obsessional patients almost always come up with the same question: “Am I doing the therapy correctly?” It is very common obsessional reaction to someone doing behavior therapy. The mind tries to throw a monkey wrench into the therapeutic machine by asking the question, “Which is the actual therapeutic response: the performance of an exposure exercise or just accepting the risk?” The ensuing effort to secure the correct answer to this question ultimately can, unchecked, become a time-consuming ritual itself.

To illustrate this dilemma, let’s look at the naturally occurring behaviors of blinking and swallowing. For instance, the mind tells the patient to swallow or blink, now! The dilemma is as follows: “If I swallow now, won’t that be giving into the spike? If I resist giving into the command, then I’m avoiding engaging in the naturally occurring action of swallowing. What’s a good patient to do?” The very skilled patient will now accept that all blinks in the future will be the “wrong” blink and accept that all blinks are actually performing a ritual. This choice will influence the brain to stop scrutinizing “getting the therapy right.” Ultimately most Pure-O’s and people with a perfectionistic mentality end up spending a great deal of wasted time making sure that they are managing the disorder in a “correct” way. Living in a world of no answers is essential to being able to make a choice and move on.

At this point, the skills of any therapist are not nearly as valuable as the client's willingness to utilize the procedures. Unless a sufferer is thoroughly fed up with the disorder, behavior therapy will be of limited help. Often I have been informed that the treatment is as painful as the disorder. My only response is that with this treatment there is a light at the end of the tunnel. The disorder offers only endless suffering. If you find that after six months to a year there is limited movement in a positive direction, it might be worth your while to take a temporary leave of absence from therapy until you are fully committed to letting go of the problem. Published clinical notations suggest that this step might assist in bringing about an increased willingness to confront the nightmare rather than to continue to mentally run away from it.

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