Speak of the Devil
by Dr. Steven Phillipson, Ph.D.
Clinical Director, The Center for Cognitive Behavioral Psychotherapy
Since becoming a specialist in the treatment of OCD I have taken a particular interest in the chronic losing battle between the rational self (as represented by an individual's futile attempts at using reason to combat the disorder) and the brain's capacity to create unreasonable automatic thoughts accompanied by uncontrolled emotional upheaval. This dichotomy within the sufferer's mind is best exemplified by examining the frequently reported experience of remaining cognitively aware of the absurdity of the disorder while still feeling (emotionally) that the threat is totally legitimate.
Despite repeated research suggesting that an academic insight into the dynamics of OCD provides limited to zero benefit to the client in treatment, I believe that a basic understanding of this disorder's game plan may nevertheless facilitate behavioral procedures. This paper will attempt to take some of the mystery out of the disorder and give the client the advantage in battling obsessions and compulsions. I strongly believe that the game plan of this diabolical disorder is often misunderstood by clients. Once people can come to anticipate the motives and rules of OCD, they gain a tremendous emotional edge.
The substance of this article will attempt to provide, as an adjunct to behavioral treatment techniques, a perspective which utilizes specific courses of mental action. These will be designed to help OCD sufferers respond more effectively to the destructive inner voices which seem to manipulate them so persistently. The following suggestions are in no way intended to substitute for the behavioral homework assignments which are an essential feature of a successful therapeutic regimen.
Accordingly, this paper will explain how progress can be enhanced by enlightening the client to a number of key principles about the disorder, among them:
- That OCD doesn't indicate a malfunctioning brain or a lack of reasoning capacity.
- That the disorder is merely a garden variety bully or demon that can be understood and outfoxed.
- That recognizing the key warning signs of an OC episode -- especially the onset of anxiety -- is a necessary prerequisite to tackling the disorder.
- That learning effective battle responses and attitudes can bring satisfying results.
- That the client's overall game plan is only effective if accompanied by a resolve to fight as hard as necessary and live with pain as long as necessary -- rather than to merely throw hollow words at the disorder.
I will first formulate a theoretical foundation on which the primary premise will be based. Utilizing a knowledge of basic brain anatomy along with the recent advances in mapping brain functioning, it becomes clearer why people with OCD experience a conflict between their rational knowledge and the irrational, yet nevertheless remain thoroughly convinced that they are at risk.
It is well documented that the great majority of people with OCD are aware that their rituals are meaningless, yet they still experience a tremendous urge or impulse to escape the irrational threat by engaging in these rituals. Recently, it has been established that OCD's locus in the brain is in the brain stem, specifically the limbic system. This system is found in the primitive part of the brain and is responsible for regulating sleep cycles, appetite, and the "fight or flight" response to anxiety or stress. A person's ability to reason is located in the brain's outer surface, the neo-cortex. It is important to understand that the brain does not function as a singular, harmonious unit. Various parts of the brain present different levels of priorities or experiences of urgency. This duplicity of experience explains a key phenomenon: as the primitive part of the brain is misfiring biologically, the reasonable neo-cortex is confused by the false alarm. No experience carries a greater sense of urgency than a perception of imminent threat to one's self or to a loved one.
A common example of the multiplicity regarding the brain's functioning is experienced by the dieter who restricts caloric intake. The goals and aesthetic interests of the individual frequently clash with the body's craving for a balanced sugar level and nourishment. Similarly, the alcoholic who understands, logically, that drinking will kill him, is still seduced emotionally and physically by the brain to give in to the urges (e.g. "just one drink couldn't do any harm").
In the case of OCD sufferers, the primitive brain is falsely reacting to a perceived threat while the rational brain is painfully aware that the threat is only a perceived one and in fact does not exist. In this case, the primitive brain might make an association between toilet seats and the possibility of an AIDS risk, while the rational brain remains aware that the risk is extremely remote. Hence, it is common for a person to say, "I feel as if I'm in danger, even though I know rationally that I'm not." Conversely, persons with contamination concerns will wash their hands until they "feel" clean, although they have a realization that they may not have been dirty in the first place.
This aspect of the disorder generates the most frustration and confusion for the sufferer. People who generally are accustomed to relying on their superior reasoning ability are completely at a loss to come up with a healthier way of responding to the threat. An analogy that I often use is that, "it is as if one were placed in a maze, with an urgent impulse to escape, and all the doors marked exit merely brought you deeper into the labyrinth."
In early sessions with clients, I spend considerable time teaching them to make a clear distinction between what their primitive brain is telling them and what their rational brain or neo-cortex tells them. Although this understanding has no power over the disorder per se, it provides a basis for understanding and responding more effectively to this dichotomy. Having clients learn that the primitive brain is behind perceived threats can be helpful in formulating a strategy to help them end their continual mental victimization. Such understanding can further assist in alleviating some of the guilt and shame associated with this disorder.
Many clients express a sense of relief when they realize that their basic character (e.g. rational self or neo-cortex) has little if anything to do with the content or theme of their obsessional focus. They're also relieved to know their brain isn't malfunctioning. What clients learn is how to make a clear delineation between the neo-cortex (representing genuine ideas and values) and those impulses or urges which are motivated out of anxiety and/or guilt.
It is critically important for the client to be mindful that OCD is a disorder of associations. There are automatic connections between becoming aware of something and having an immediate reflexive thought or impulse in reaction to that awareness. Behaviorists contend that this connection comes about as a result of basic learning and therefore has no underlying meaning reflecting unconscious motives. OCD is not a condition in which a person is actually afraid of germs or killing someone. Instead the anxiety comes as a result of a reflexive association between two items which the brain links due to past learning.
Because the thoughts involve basic learning, we have no capacity to prevent their emergence into our consciousness. For this reason, attempting to treat the OCD by logically disputing the irrational nature of the concerns will have no bearing on the overall outcome. Unfortunately, sufferers and professionals alike become overly focused on providing reassurances, rather than on learning how to cope more effectively with the anxiety and its symptoms. Unknowingly, they merely facilitate the victim's suffering, rather than alleviate it!
Detecting the onset of an OC episode can help in creating an effective response. A willingness to take the risk must begin with the first awareness of the presence of anxiety, which is a key OC barometer. People who use their experience of anxiety to recognize the disorder's presence can get a jump on their ruminating. Saying to one's self that, "the risk may be real, but I won't attend to it until I feel minimal anxiety," can be a powerful mechanism which manipulates the disorder rather than the reverse.
One of the most difficult pills for the OCD sufferer to swallow is to accept taking a risk when confronted with any threat that has a component of anxiety or guilt associated with it. In my experience, I have yet to know a person with OCD to have been ruminating over a threat involving anxiety or guilt, which turned out to have any realistic significance. In conjunction with this, I have never heard a client wonder whether a concern was actually OCD and have it turn out not to be. So what an OCD client most needs to know is which emotions or thought patterns are clear indications of an OCD episode and which aren't. The client, once recognizing these, must then bite the bullet.
As clients attempt to implement this perspective, their greatest downfall is generally a result of grasping just the words and not the spirit of the therapy. A willingness to embrace the discomfort is easy to understand, but difficult to implement. Often what happens in the course of treatment is that there will be an initial decrease in anxiety as the clients faithfully put the therapy into practice. At this point, realizing that something positive has taken place, the client will frantically attempt to repeat the success, but only by parroting the words learned in the therapy sessions. Phrases such as "I'm willing to suffer throughout the day" or "I can live with this discomfort" have a great deal of potential benefit, but only if they are more than just a verbal incantation and reflect a deep (or thorough) emotional commitment.
A comment which I have heard often throughout the years, yet have not lost my disdain for, is, "The therapy is not working." This statement immediately suggests that the client has used the therapeutic responses as a rock to be thrown at the anxiety, rather than a verbal prompt to get in touch with a true willingness to absorb the discomfort for as long as the brain desires to dish it out.
How, then, does the practitioner go about treating OCD? First, the power of understanding and using a mental paradox (i.e. encouraging an exaggeration of the problem) in the daily struggle with anxiety cannot, in my opinion, be overstated. An example of understanding the application of paradox is reflected in the story of the obnoxious two-year old who throws huge temper tantrums each day. The parents were instructed to stop giving in to the demands of the child and instead were to encourage an even more exaggerated screaming or foot pounding behavior, thereby neutralizing the child's ability to intimidate through outbursts.
The portion of the brain responsible for OCD functions very much on the same emotional level as that of a two-year old. Trying to reason with either in the throes of a tantrum is senseless. So the best approach acknowledges the threats, before embracing and encouraging an even greater level of anxiety.
Without any religious connotations, conceptualizing the disorder as a demon, separate from one's own identity, seems to be an apt choice. The game plan of both a demon and this disorder can be conceptualized as follows:
- To seduce a person into doing its bidding by promising relief just around the corner. Often the OC demon will convince the victim that only one more reassurance will resolve the dilemma and provide more than momentary relief.
- To exploit moments of weakness and materialize at the worst possible times in a person's life (e.g. when it is perceived as absolutely disastrous to become anxious).
- To choke the victim more each time he struggles to get away.
The game plan of this anxiety disorder also closely resembles that of the neighborhood bully. As children, we are told that if we muster up the courage to actually challenge the bully and call his or her bluff, the aggressor will back down. Unfortunately, in real life this is not always the case. However, with the demons of OCD, it is. In my experience, those clients who have genuinely challenged the demon to do its worst, and are perfectly willing to confront and endure tremendous discomfort, even death itself, have made the most dramatic progress. They, in fact, have experienced the least amount of pain while performing exposure exercises. This exemplifies the critical nature of understanding the mental paradox. The more pain one is willing to endure, the less it is experienced.
Although the literal wording to be used in confronting the internal demon at the onset of anxiety will vary from person to person, the following represents a helpful generic phrasing: "OK brain, I feel the discomfort you're able to create. I know I've felt you many times before, but I'm willing to make room for you and acknowledge your presence without escape. I have the capacity to tolerate an increase in the level of distress you're creating. I'm willing to concede to you that I haven't solved your dilemma. I can be reminded of this on a frequent basis and I can stand you being with me throughout the day. I'm celebrating your presence, willing to think about you often for a split second each time, and seeing your arrival as a chance for me to hone my skills of living with the demon." The general strategy is to allow the unresolved conflict into the consciousness and acknowledge a willingness to suffer for as long as the brain is able to generate discomfort. If the anxiety subsides, the sufferer may even wish to reignite discomfort as a further test.
There are many instances in which the demon's threat involves one's own death or the death of a loved one. Unless the client is prepared for these events to come to fruition, the disorder will always have the upper hand. Merely saying "I'm ready to die" is meaningless without an associated internal preparedness. Although these ideas are profoundly philosophical, they have a very pragmatic and basic application.
Unfortunately, after initial success, some clients often use the therapeutic responses in a very laborious and circumscribed manner. Often this response pattern can become part of the ritualizing process and takes as much, if not more, time to engage in as performing the escape ritual itself. Instead, genuinely saying to your own brain, "OK, I'm ready to die so do your worst," cuts out a lot of time.
People with Responsibility OC will often say that they are willing to die, but they are not willing to be involved in the risk of harming others or having others remain at risk without taking action to reduce the threat. Unfortunately, unless one is willing to face the worst possible scenario, the disorder will always have the upper hand. It is important to remember that, in my clinical experience in treating this disorder, when legitimate danger is present, anxiety is not the experience. Instead, a client experiences healthy concern for an individual.
Remember that anxiety and guilt aren't the only OC warning signs. Among the other indicators are:
- Feeling that you're foolish for not completing the ritual.
- Worry that the demon won't let you relax until the ritual is performed.
- Ruminating over whether or not the problem is real or OCD.
The primary objective of cognitive-behavior therapy for OCD is to starve the demon of its nourishment (i.e. avoid any thoughts or behaviors which are reassuring, avoidant, or escapist in nature). One does not kill the disorder directly and, therefore, these procedures do not have an immediate relief effects. Impatience for the anxiety to go away is the demon's greatest ally. Choosing to embark on the long path of eliminating this disorder requires realizing that the goal of starving an enemy to death takes time. My most successful clients have taken at least four months to eliminate as much as 80% of their ritualizing time, while the average course of therapy lasts between one to two years. So it is extremely important to be patient.
If one's overriding concern is to feel better and attain immediate relief, then clients are at risk for sabotaging any benefit they might otherwise derive from behavior therapy. The overriding objective of any behavioral approach concerning anxiety is to manage discomfort in an effective way. Being focuses on symptom relief will inadvertently perpetuate the power of the anxiety. In other words, the more important it becomes to escape something, the more the brain needs to become sensitized either to be on the watch out for future symptoms or to escalate the symptoms currently being perceived.
One of the most common pitfalls of people in the recovery process of behavior therapy is to covet the periods of symptom relief. Often clients report that when they become aware the disorder is not present, that awareness itself will trigger an association and thereby create a new threat. In the scheme of things, this pattern makes perfect sense due to the tremendous importance placed on maintaining the period of relief. A highly recommended therapeutic response when one becomes aware of symptom relief is to create a willingness for the peacefulness to end. As an analogy, if your disorder were a bear sleeping in a cave, it would be important not to tiptoe across the entrance praying the bear doesn't awake, but instead to throw a rock into the cave and call out for the tyrant. I refer to this perspective as "jousting with the devil."
Making an attitude adjustment while going through the rigors of behavior therapy is critical in relation to relapse prevention. Researchers in the area of OCD treatment are well aware that the two primary concerns to the clinician are symptom reduction and maintenance of progress. The path to achieving the first goal is fairly well established, while the latter goal remains somewhat elusive. Those people who have maintained their progress for over one year, in my clinical experience, have adopted the following perspective shifts:
- They see being challenged by their disorder as an opportunity to test their efforts rather than a signal that they will never completely recover.
- Being uncomfortable is viewed as an experience to be tolerated and celebrated rather than one from which to escape.
- Since the body and brain can periodically misfire and create unexplained feeling of peril, coping with and accepting these emotional events is more important than ensuring that they do not return or attempting to escape from them.
This article has attempted to lay out a cognitive and attitudinal perspective which can greatly facilitate the often purely structural aspects of behavior therapy. Experience has consistently demonstrated that creating a willingness to be challenged and an emotional preparedness to embrace the disquieting aspects of OCD significantly contributes to rapid symptom relief. Sustaining these attitudes will enhance resistance to relapse. Understanding the game plan of this disorder has provided many people with the competitive edge which they have used in overcoming their emotional imprisonment.
Originally printed in the Obsessive-Compulsive Newsletter, published by the OCF