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  1. #1

    OCD - Thinking the Unthinkable

    Thinking the Unthinkable
    by Steven Phillipson, Ph.D., Center for Cognitive-Behavioral Psychotherapy
    Originally printed in the Obsessive-Compulsive Newsletter, 5 (4), 1991

    As I conceptualize Obsessive-Compulsive Disorder, the tree of the overall syndrome has three main branches: the "obsessive-compulsive," the "responsibility O-C," and the focus of this paper, the purely obsessional thinker "Pure-O" (Baer, 1994). With this branch the anxiety emerges in response to an unwanted thought or question, which in the future will be referred to as a "spike." The ritual involves pushing away the thought, avoiding the recurrence of the thought, or attempting to solve the question. Keep in mind that most persons who come into therapy tend to have a combination of these problems. Successfully treating one branch typically has minimal effect on the others.

    The "Pure-O" is manifested by a two part process: the originating unwanted thought (spike) and the mental activity which attempts to escape, solve, or undo the spike, called rumination. The following are examples of these varieties of spikes:

    A man is involved in sexual relations with his female lover. Just prior to orgasm the thought of his friend Bob pops into his head. This is the fourth time in a month that this has happened. In response to this he becomes very upset and wonders whether he is gay. His sexual activity is terminated in order to avoid having to deal with this concern.

    A mother is changing the diapers of her infant. As she lovingly looks down at this helpless child the thought occurs to her to "take a pillow and smother the child." In response to this thought, the mother panics and runs to another room to diminish the possibility of acting on this thought, since she figures that being able to think such a thing may be similar to acting on it.

    For the "Pure-O" a tremendous amount of anxiety accompanies the spike, and the mental ritual is an attempt to shut off the anxiety, either by attempting to solve the question or avoid having the thought recur. It is during the rumination phase that the person's mind becomes extremely preoccupied and distracted. Spending eight hours a day with one's thoughts wrapped up with this endless mental escape is not unusual. The emotional pull to undue the thought is tremendous. Perhaps it would be comparable to what it would be like if a loved one were on a plane that crashed and all you knew was that there was a fifty percent survival rate. Imagine what it would be like if you were asked not to problem solve in an attempt to ascertain the condition of your loved one. A common misnomer among "Pure-O" sufferers is that they can mentally find the key to turn off the obsessing. It seems that with each new spike, if they could only get that perfect answer, the whole disorder would just vanish. A large majority are aware that this is an impossible task, but the temptation to unlock their mental chains is tremendous with each ensuing spike.

    I've illustrated this endless cycle of spiking and ruminating in the accompanying diagram. Start out with the top left symbol, a circled "R". This represents a part of the brain that is creative and always on the lookout for pertinent information. I refer to this as the resource part of the brain. Proof of its existence lies in a phenomenon known as the "Tip-of-the-Tongue" effect (Brown & McNeil, 1966). I'm sure, on many occasions while searching for a name or significant memory, you have given up your active conscious search just to have it pop into your consciousness later while your mind is preoccupied with another topic. It would seem that there exists a non-conscious portion of the brain which searches out meaningful material and sends this information to one's consciousness if it deems this information as significant. Another aspect of the resource center is our brain's reliance on associations which facilitate information processing. An example of an association would be when the sight of a red light draws our attention that a hazard might exist. For the "Pure-O," the sight of a knife might spike the thought of stabbing a loved one. The resource center transmits information to our conscious awareness "C" as it deems material relevant or significant. It is at this juncture that most "Pure-O's" become fixated and distraught.

    The transmission of the information from "R" to our "C" is a purely reflexive one and completely beyond our control but not beyond our influence. When the spike reaches our "C" we have a choice as to how to process the thought. (Note the two descending arrows.) The arrow to the left suggests that the thought represents or reflects something deep and meaningful about the person, e.g. "only a vicious loathsome human being could possible think of stabbing their loved one." This represents, as Albert Ellis (1987, 1991) would suggest, a dysfunctional emotional response "ER." The tremendous effort one puts into escaping the unwanted thoughts or preventing their recurrence (e.g. hiding knives), in effect reinforces its importance to the nonconscious brain and thereby feeds the vicious cycle. Similar notions have been proposed by Wenzlaff, Wegner, & Roper (1988). These authors suggest that attempting to suppress thoughts has the effect of a mental boomerang whereby the cognitive backlash is actually stronger as one makes more efforts to bury the thoughts. Becoming upset over a thought places a mental marker on it and therefore increases the likelihood of the thought recurring. For the "Pure-O," the spike is a double barrel shot of anxiety. On the one hand, there is anxiety for having such an unpleasant thought, and on the other, the tremendous repetition of the thoughts gives the appearance that one is losing his or her mind and this is a very anxiety provoking experience. This vicious cycle is applicable for both the spiking and rumination type "Pure-O."

    The pertinent issue, though, 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. Before discussing what works, first it is critical to discuss what does not work.

    Thought stopping, either 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 would in effect sensitize the brain to the unwanted thought by alerting the "R" that potential punishment is associated with the spike. Theoretically, the spikes would thus increase due to this heightened sensitivity. Future research may bare this out.

    Although logically pointing out the absurdity of the "Pure-O's" mental rituals is very tempting, it is often insulting and clearly ineffective. You can not "outlogic" OCD. Similarly, the use of analytic interpretations to provide insight is absurd and harmful. A person's natural inclination is to investigate what implications certain spikes might signify. A therapist who reinforces this inclination is naive and incompetent. Whether it be stabbing one's loved ones, or having sex with one's mother, these thoughts will only become more deeply entrenched by placing emotionally laden meanings on them, such as underlying aggressive impulses or unresolved Oedipal conflicts.

    Ultimately, as with all forms of OCD, living 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 a person's intolerance of having bizarre and noxious thoughts. The efforts a person makes to avoid or escape these thoughts reinforces their recurrence. Therefore, the removal of the reinforcement (extinction) entails the following.

    But first - a warning. You will know the disorder is getting better when the frequency of spikes increases. Our brain is resistant to change and will be predictably inclined to throwing tantrums, as one attempts to make space for what has been given for so long a great deal of importance in getting rid of. A common occurrence is that a person who previously would spike four times a day, but ruminate incessantly for the duration of the day, will often spike much more frequently as their amount of rumination substantially decreases.

    THE CRITICAL VARIABLE IS THE RUMINATION AND NOT THE NUMBER OF SPIKES! This statement is paramount for a successful treatment. The target response is having the person not respond to the spike, it is not to have the spikes go away. The long term effect of not attending to the spike will be that the spikes will decrease in frequency and emotional intensity. This will happen only if the person becomes desensitized to these thoughts by allowing them to occur. A common phrase often mentioned in my groups is "let the thoughts be there," give yourself permission to have the thoughts. In conclusion, four suggestions are offered. These procedures have been very successful in turning lives around and freeing up thoughts for contemplation of more meaningful material. 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 subject adheres to the procedures (Dar & Greist, 1992).

    The Antidote:
    The spike often presents itself as a paramount question or disastrous scenario. A response which answers the spike in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Using the antidote procedure, a cognitive response would be one in which the subject accepts this possibility and is willing to take the risk of his mother dying of cancer or the question recurring for eternity. No effort is expended in directly answering the question in an effort to find resolution. In another example, the spike would 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 has no aspect of answering the question to it.

    Let it Be There:
    Using this procedure, it is suggested that the person create a mental pigeon hole for the 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 create unsolvable questions so as to fill up the register. The more unsolved questions the better. It is critical that the "Pure-O" acknowledge the presence of the thought but pay no further attention to it, as in the form of problem solving. The brain can only juggle a certain amount of information at one time. If you purposely overload the brain, rather than insanity, your brain's response would be to just give up trying. As can be imagined, attempting this goal takes a lot of faith and trust in the person suggesting it.

    The Capsule Technique:
    During the initial phases of therapy, there is a great resistance to letting go of the rumination. A procedure which addresses this resistance is to set aside a specified period of time, perhaps once or twice a day, to purposely ruminate. It is suggested that the time periods be predetermined and time limited. At exactly 8:15 am and 8:15 pm I will ruminate for exactly 45 minutes. As thoughts occur to me 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 10 times a day. After the 50th day, her actual spiking dramatically decreased.

    Creating 4-5 Larger Spikes:
    Rather than attempting to escape the spikes, the "Pure-O" is encouraged to purposely create the thought repeatedly following it's occurrence. 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; and I can't wait to drive home tonight and kill the other half."

    Some people report that they have difficulty distinguishing between spikes and "legitimate important thoughts." A fool proof litmus test for telling the difference is to ask yourself did the thought or question come with an associated anxiety or feeling of guilt. Ultimately all such thoughts can be placed in the realm of OCD. When asked "What if it's not OCD," I say "Take the risk and live with the uncertainty."

    At this point, my skills as a therapist are not nearly as valuable as the client's willingness to utilize the procedures. Unless you are 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 continuing to mentally run away from it.

    References
    Baer, L. (1994). Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders. Journal of Clinical Psychiatry, 55(3, Suppl), 18-23.

    Brown, R. W., & McNeil, D. (1966). The "tip-of-the-tongue" phenomenon. Journal of Verbal Learning and Verbal Behavior, 5, 325-337.

    Dar, R., & Greist, J. H. (1992). Behavior therapy for obsessive compulsive disorder. Psychiatric Clinics of North America, 15(4), 885-894.

    Ellis, A. (1987). The Practice of Rational Emotive Therapy. New York: Springer.

    Ellis, A. (1991). The revised ABC's of rational emotive therapy (RET). Journal of Rational-Emotive and Cognitive Behavior Therapy, 9(3), 139-172.

    Wenzlaff, R. M., Wegner, D. M., & Roper, D. W. (1988). Depression and mental control: The resurgence of unwanted negative thoughts. Journal of Personality and Social Psychology, 55(6), 882-892.

  2. #2

    Re: OCD - Thinking the Unthinkable

    More articles by the same author:

    OCD ONLINE - Articles by Dr. Steven Phillipson

    From his followup article Rethinking the Unthinkable, which was also written in 2004:

    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.

    OCD ONLINE - Rethinking the Unthinkable
    "What lies behind us and what lies before us are tiny matters compared to what lies within us." ~ Ralph Waldo Emerson

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