In the treatment of OCD and in living a disciplined life, there is no word more important than “choice.”
The conscious, independent behavior (physical or mental) of selecting, making and or acting upon a decision when faced with two or more possibilities: the choice between good and evil, skilled and unskilled as well as, fight or flight.
• A range of possibilities from which one or more may be selected.
• A course of action (mental or physical), object, or person that is selected or decided upon and summarily put into effect.
This writing is a call to arms! Its purpose is to inspire readers to establish a more honest relationship between the goals they have in life and the choices that are required to achieve them. Unfortunately, our schools do not teach us that our brains are comprised of many systems, some of which can function with considerable independence from the others. This independence of these systems is reflected in the way individuals with OCD respond to episodes of extreme anxiety. Like all other human beings, those with OCD have a strong basic survival instinct, and are likely to experience great distress at the prospect of leaving a perceived threat unresolved. However, when what they experience as a threat is actually a function of their OCD (and, thus, essentially is the product of misfiring brain circuitry), they still react to this perceived threat as if their very lives were in danger. A conflict of independent systems also can affect those who do not have OCD. For example, an individual may have the goal of exercising, but when the opportunity to do so presents itself, she may find herself thinking, “I’ll begin tomorrow.” Similarly, when tempted, someone whose goal is to save money may find himself thinking, “Yes, but this sale is so tremendous! Look at all the money I’d be saving!” The point is that we only can make disciplined and values-based choices that challenge instinctive or self-defeating urges when we are mindful of the contradictory agendas presented to us by our brains.
To date, the focus of my writing has been on educating sufferers and professionals alike about the various forms of anxiety and the methods of behavioral treatment I have found to be effective. In contrast, this article attempts to identify the essential qualities within the patient that contribute to the success or failure of treatment. In my discussion of this subject, I will give considerable attention to such concepts as agency, mindfulness, and autonomy. Agency can be defined as the faith we have in our capacity to respond effectively to challenges in our lives. Mindfulness is the non-judgmental, awareness of an experience in real time – that is, as that experience is unfolding – and an acknowledgement of our responsibility for the choices we make and/or the beliefs or perspectives we endorse in relation to that experience. The willingness of patients to be accountable for the choices they make has a profound effect on both the recovery process and the achievement of their goals in life. And finally the term autonomy refers to the choices and actions of the “Gatekeeper” – the “I” or “me” – who, based upon his or her goals and values, makes the final decisions on matters of importance to the individual.
Behavior therapy is an extremely powerful clinical intervention with specific replicable guidelines. “Exposure with Ritual Prevention (ERP),” a research-based treatment for anxiety disorders is a prescribed approach. Any experienced clinician can apply the techniques of ERP such that if the patient complies with the treatment protocols, there is a high probability that the desired outcome eventually will be achieved. I want to emphasize, however, that the success of ERP is dependent upon the patient’s day-to-day adherence to the guidelines established by the therapist in sessions. One of the reasons I chose to specialize in OCD and other anxiety disorders was the scientific and objective approach of this type of treatment.
John Parrish, Ph.D., my “mentor” at Johns Hopkins University Hospital, once said, “The mystery of therapy is not what works, but the aspects of therapy or qualities within the patient that contribute to treatment failure.” After treating OCD for more than twenty-five years, I am convinced that the patient’s understanding of what making a choice really means has a powerful influence on the success or failure of treatment.
All too often, patients are unaware of how certain basic misunderstandings interfere with the process of making a choice. For example, many patients seem to want to assign the responsibility for the choices they make to others – particularly their therapists. This tendency can seriously hamper the treatment process. In this article, I will highlight what I believe is required to truly take responsibility for one’s own choices. I also will focus on the ways in which people tend to relinquish their autonomy in the sense of being accountable for living in accordance with their chosen goals.
“CAN YOU HELP ME DOC?”
The question most often asked during the initial phase of therapy is, “Doc, do you think you can help me?” To this question, I always respond with some version of the following:
“It may come as a shock to you, but my job is not to help you, but to work with you. Therapy is a partnership in which you, the patient, decide whether this is a good time in your life to take on a great challenge. In therapy, your hands are on the steering wheel, and your foot is either on the accelerator or the brake. As your partner, I hold a map with directions and instructions, but where we go and how fast we get there is entirely up to you.”
Patients who simply attend therapy looking for help are at a disadvantage from the start. Often, they have experienced failure in their efforts with traditional psychotherapy and/or interventions like acupuncture or hypnosis, in which they are the passive recipient of treatment, rather than an active participant in their own recovery. A patient’s willingness to take responsibility for actively contributing to the treatment process is critical to the success of the behavior therapy.
Even patients who have made significant progress in therapy often will say something like, “Steve you have helped me immensely.” My response usually is, “You have made a tremendous investment in your own recovery, and I am privileged to have been a contributing partner in your dedication to success, but it was you who made the moment-to-moment choices necessary to achieve this wonderful goal.”
WE ARE NOT OUR BRAIN
The power and intractability of the condition we call OCD has puzzled sufferers, clinicians, and researchers alike for years. How is it that highly intelligent people with well-developed reasoning skills can react so strongly to, and be so effectively manipulated by, ideas that are so irrational? The answer, I believe, is that our brains are capable of independently sending signals that we experience as thoughts, feelings, and/or physiological responses independent of our conscious, volitional control. For example, if a person stubs his toe, he may find himself thinking, “You’re a clumsy idiot!” What’s important here is not the content of such thoughts, but the fact that no one can prevent his or her brain from sending messages like this in the first place. The automatic, involuntary manner in which such thoughts arise suggests that they are products of what I call independent systems in the brain. Unfortunately, patients often find it difficult to distinguish such reflexive thoughts from those that reflect their core beliefs, and may mistake them for sincere insights about themselves. And since these automatic thoughts can be harshly self-critical, patients may agonize over what this internal dialogue suggests about their potential for good or ill. If my brain says that I find that child sexy, does that mean I’m a pedophile? The thoughts are actually there and I’m feeling very guilty now. If my brain says I’m a loser because that boy broke up with me, does that mean I really am a loser? I’m feeling so inadequate and depressed. The psychologically astute answer is “actually, NO!” These thoughts and feelings are nothing but old tapes programed many years ago and these words have no bearing on being a legitimate measure of ones self-perception.
The question then arises, what do our feelings say about our fundamental beliefs? I believe that the answer to this question is, “Not necessarily very much.” Our feelings are not a reliable measure of our self-perception. Why? Because automatic thoughts can create feelings that are just as convincing as thoughts that reflect our deeply held beliefs. So, it is vital that we do not reflexively take the thoughts and feelings that our brains send to us at face value.
In the example above about someone who stubs his toe, this individual’s reflexive self-criticism may well contradict his actual perception of his ambulant composure. Patients with OCD often state that despite being painfully aware of the fact that the actual risks they face from what their brain has identified as a threat actually are negligible, they still experience profound fear, guilt, anger, or depression at the prospect of not attempting to resolve or escape from this “threat.” Indeed, at such times, reason and logic are rendered ineffective as a means of restoring one’s emotional equilibrium. Patients often find that the feelings they are experiencing seem so authentic and compelling that it is very difficult for them to accept that their fears are unjustified. They feel that they are confronting threats from which they must escape, and they become desperate to eliminate these threats and restore their sense of safety. Patients say things like, “I know that I can’t catch AIDS from touching that door knob, but it feels so dangerous that I actually believe I’m at risk.” These individuals are not delusional, but because they are using their feelings as a measure of the legitimacy of their concerns, they find it extremely difficult to ignore their brain’s irrational assertions.
In the treatment of anxeity, how patients view their own perspective can have a profound influence on treatment outcome. My hope is that this article will shed some light on how patients can reframe the way in which they view themselves and the world so as to acknowledge that their perspective is a choice, not something determined by the experiences they have had. It is essential that patients view their perspective as something that is under their conscious control, rather than seeing themselves as victims of their own perspective.
Fundamental to the treatment of OCD is the concept of irrelevance. Since OCD is a condition in which sufferers feel compelled to resolve or escape from imagined threats, the goal of treatment is for the patient to become habituated to that which the disorder identifies as a threat. For habituation to take place and the symptoms of anxiety to decrease, patients must make a fundamental shift in how they relate to the signals the OCD is sending them. First and foremost, they must stop taking them at face value and choose to see them as irrelevant. These signals may well include messages of doom or impending disaster that can provoke anxiety, guilt, depression, anger and other powerful emotions, and it is precisely because of the presence of these emotional components that reframing the disorder’s messages as irrelevant is so difficult. But that is the task that must be accomplished if the treatment is to be successful.
I often use the two versions of the following account to demonstrate, first, how those with OCD respond to the signals of the disorder before treatment, and second, how those who have successfully undergone treatment have become habituated to these signals by reclassifying them as irrelevant.
David and Ester had just viewed the house of their dreams. For some reason, the house also was a great bargain, and they wondered why the asking price was so low. Nevertheless, everything seemed to check out, so they negotiated a price and purchased the house, and soon they had begun their new life in their dream home. Three days after the couple moved in, however, as they were getting ready for bed, they noticed a distant rumbling that rapidly became a roar, accompanied by a shaking and rattling of the house. David ran out into the backyard and, peering through some foliage at the edge of his property, was shocked to discover that the noise was coming from a freight train that was passing only a short distance from their property line. The railroad tracks had been hidden from view by the foliage at the edge of the property, and the previous owner had elected not to inform them of the house’s proximity to the tracks. The next day, the unhappy couple confirmed that twice a week their lives would be disrupted by the roar of a freight train passing in the night. The couple’s dreams had been shattered. They realized that they had been deceived, and repeatedly asked themselves why they hadn’t done a better job checking out the house and the neighborhood. In the years that followed, every time a train passed by, they cursed the day they had made the ill-begotten choice to purchase this house.
Now consider the following version of the story:
David and Ester had just viewed the house of their dreams. For some reason, the house also was a great bargain, and they wondered why the asking price was so low. They took a look at a map of the property and the surrounding area and discovered that there were railroad tracks running behind the house only a short distance from the property line. Further research revealed that twice a week, freight trains were scheduled to pass by the house at night. Now they understood why the house was such a bargain. Ordinarily, they would not have been able to afford such a large and well-maintained home. Armed with this knowledge, they engaged in some tough negotiations, and soon settled on an agreeable price. Two months later, they moved into their beautiful new home. On the six-month anniversary of purchasing the house, the couple had a party to celebrate their good fortune. At one point during the festivities, there was a distant rumbling that rapidly grew to a roar, accompanied by a shaking and rattling of the house. Alarmed, the guests asked the couple what was causing all the noise. David and Ester looked at each other and smiling, together responded, “What noise?”
In the first story, the noise of the train is viewed as the predominant feature of a flawed situation. In the second, the couple’s attitude is that because it enabled them to purchase such a wonderful home, the noise is irrelevant. Because they did not find the noise of the train distressing, their brains stopped processing this otherwise powerful signal.
Since OCD involves the brain’s attempt to warn the individual about something it has (incorrectly) identified as a threat, I encourage patients to consider responding to the warning signal with a degree of “appreciation” for their brain’s attempt – albeit, a misguided one – to protect them. These warning signals originate from the brain’s primitive “fight or flight” center, and they reach our conscious minds accompanied by intense emotions and sensations. But since our brains are capable of sending us involuntary thoughts that reflect nothing meaningful about us, we can independently reject such thoughts – even when they assume the form of self-critical insights.
THE GHOST IN THE MACHINE
In many respects, the functioning of our brain is very mechanistic. Numerous metabolic functions are regulated automatically by the brain without any conscious input from us. And yet, the part of us that possesses values and exercises choice – what I call the “Gatekeeper” – constitutes what we consider to be our “identity” despite the fact that it has no clear seat in any specific center of the brain. Its influence is preeminent, yet it remains somehow hard to define, and it seems to have an existence that is independent of the “machine” we call our brain. In that sense, it is the “ghost” in the machine.
The “ghost,” so to speak, represents our unique and independent volitional thought capacity, our ability to choose the thoughts on which we focus and to which we assign relevance. The Gatekeeper makes the final decisions when we are mindfully aware of the options available to us. For example, when I am standing on a high balcony, the thought that I should jump might enter my consciousness, but the Gatekeeper, the “I” or “me,” who is accountable for choosing the thoughts and feelings I endorse and those I reject, has the ability to examine such an idea and to dismiss it as a passing thought with no significance. The Gatekeeper enables each of us to decide which part of our body to move, which ideas are pertinent to our goals in life, and which conversations have meaning and value for us. We can focus our attention on certain ideas in our mind and ignore others. It is interesting to note that although brain mapping studies have located the specific regions of the brain from which speech or emotions originate, no one has been able to locate the area of the brain from which free will originates.
The words of Viktor E. Frankl remind us what the concept of autonomy means when he says, “…between stimulus and response there is a space. In that space, there is a freedom to choose our responses. In choosing a response, we affirm our potential for growth and our freedom.” To effectively exercise this freedom to choose, the discipline of mindfulness is required, so that we can make choices in accordance with our values, rather than our conditioning, impulses or instincts.
As I said before, the human brain controls numerous processes without any conscious input from us. When we have OCD, however, the brain (the “machine”) also sends disruptive involuntary signals to our conscious awareness that can cause acute emotional distress and make it more difficult to function. The Gatekeeper is presented with powerful emotional distress signals and thoughts that typically include some threatening component. If you, the Gatekeeper, find these emotional distress signals overwhelming, you may choose to seek reassurance or safety, especially if (as is often the case) you are unaware that you are being prompted by your own brain. In fact, patients often feel terrible guilt and frustration about the compulsions and obsessions that plague them because they mistakenly believe that they – as the Gatekeepers – are responsible for the cognitive components (what I call “spikes”) and the painful emotions that accompany them. This belief is completely unjustified, however, as the symptoms they experience result from messages that are generated automatically by their brains, and over which they have no control.
Differentiating mechanistic brain activity from the activity of the Gatekeeper is facilitated by understanding that anything about which we are not able to make a choice is not a representation of “us.” Dreams, mental associations, panic, sleep, and even sexual arousal are just a few of the aspects of human experience over which we often mistakenly believe we have volitional control. Associative thoughts might include the pairing of the sight of a knife with the thought of stabbing someone.
Old-time movies sometimes depicted the use of an archaic therapeutic device called “word association,” in which the psychologist would say a word and then have the patient say the first thing that came to mind. For example, the therapist would say “mom” and the patient might respond by saying, “love.” This technique supposedly was used to uncover deep-seated feelings or desires, or suppressed memories of the patient. Unfortunately, what this unscientific method of inquiry inadvertently instilled in the mind of the public was the belief that our spontaneous and involuntary mental associations can reveal valuable or meaningful data about us. This concept, along with many other Freudian postulates, has set psychological theory back many decades.
One of psychology’s greatest clinicians, Albert Ellis, advanced the concept of “automatic thoughts.” He posited the idea that our mind independently sends spontaneous irrational messages to our conscious awareness, and that each of us has the capacity either to endorse or disqualify these ideas. He applied his theories to the treatment of clinical conditions like depression and low self-esteem. His approach was to help patients identify their automatic thoughts, and to dispute these irrational ideas and replace them with more rational beliefs. To build upon what I said earlier in this article, I find it inexcusable that our schools do not teach us that the messages our brain automatically sends us are not necessarily significant or meaningful. Although Albert Ellis’ work is not directly applicable to the treatment of OCD, his basic premise affords all of us the opportunity not to be misled by our involuntary irrational thoughts.
VISITING THE CAVEMAN
As therapists, it is crucial that we work to help those suffering from psychological malady’s learn to “forgive” themselves for having their disorders and to understand why their own brain seems to work against their best interests. OCD sufferers are not weaker, emotionally, than other human beings. Rather, they are confronted with an emotional distress signal from one of the most powerful of all human instincts – the instinct to survive. OCD is a faulty expression of this fundamental instinct. Compulsively performing an escape ritual in the face of a perceived threat is not weakness, but rather the most functional response to an instinct designed to protect us from danger. Indeed, it requires considerable strength, fortitude and insight not to respond to prompts from one’s OCD as if they were warnings of legitimate threats.
Research has shown that OCD is caused by a malfunction of a tiny brain structure called “amygdala,” which is responsible for activating the familiar “fight or flight” emotional response. With this information in mind, the symptoms of OCD can be viewed as misguided attempts by the brain to carry out one of its basic functions – to protect you from harm. Your brain is warning you of a potential threat so that you can escape and avoid similar situations in the future. The only problem is that the “danger” does not really exist.
Our instinct for survival is a vital safeguard against legitimate dangers, but for those suffering from OCD, this instinct is activated needlessly and repeatedly in relation to improbable or absurd possibilities. Nevertheless the anxiety, fear, and other emotions that accompany these false alarms feel as authentic as any you might experience when facing a legitimate threat to your life or safety. Furthermore, prior experience of such false alarms does not in any way lesson the strength and urgency of the current warning. Each occurrence of the alarm feels as intense and compelling as the first. Thus, it is pointless to try to draw on one’s memory of similar events in an effort to convince your brain that it is being fooled. The emotional distress you are experiencing at the moment will overwhelm any attempt to logically and reasonably disqualify the legitimacy of the perceived threat. You can resist this miscued survival instinct, however, by choosing to disregard the warning signals your brain is sending you, and purposefully exposing yourself to the perceived danger while accepting the possibility that the threat is real. In making this choice, the OCD sufferer is engaging in an “exposure exercise” with ritual prevention. To know how this exercise might feel, imagine yourself standing on the railroad tracks as a speeding train bears down upon you, and as it is about to hit you, deciding not to step off of the tracks.
The brain is programmed to escape or confront threats, to seek basic necessities, such as food and shelter, and to pursue pleasure, and avoid pain. Left to these primal instincts, the brain will seek the path of least resistance in its attempt to get these needs met. The nature of this basic programming explains why the treatment of OCD is so difficult. To be effective, the treatment requires that the individual – the Gatekeeper – repeatedly engage in daily exposure exercises that contradict the brain’s basic programming to avoid or escape from danger. In other words, to be in compliance with the treatment protocols, patients must repeatedly make an autonomous choice to disregard their instinct to stay safe. Needless to say, this is not an easy task. Often, Patients must choose to disregard threats that they or those that they love will die or suffer some other terrible fate if they do not ritualize. On the other hand, there also are many OCD themes for which treatment does not require deliberate exposure to perceived risks, other than that the experience of distress, itself, will not abate. For example, patients may spend hours trying to figure out how to rid themselves of distracting thoughts. Because such spikes do not involve catastrophic threats, the associated obsessional responses are referred to as “neutral” obsessions.
One of the greatest mistakes persons make repeatedly when confronted with the challenges of anxiety, is to debate, discuss or consider the issues presented by the disorder, as if they were legitimate. “How do I differ from an actual child molester?” The mechanisms in our brain, which instill the “experience” of legitimacy, have no language capability so engaging in any cognitive efforts to a swage oneself of the actual risk is wasted effort. How do I know that I’m not actually dying of a heart attack? I refer to discussing or entertaining the issues of OCD or any anxiety as “speaking to the barking dog”. Yes, the dog’s bark is fierce and menacing. But responding to the actual topic as if it has any legitimacy is a waste of time and actually reinforces the brains sense of legitimacy. Patients who have harm obsessions will often discuss what life will be like for them, after they are arrested. “Who will ever speak to me again after I have been discovered molesting a child?” “How badly will I be treated in prison when it is discovered that I killed my own family?”
Those who believe in self-esteem, like those who believe in ghosts, will be haunted by their beliefs. How is it that we can hate our “selves?” As previously stated, the brain is programmed to ensure that certain basic needs are met. To maximize the chances of success, it constantly evaluates the individual’s performance and places a weighted bias on any deficiencies it finds. Now, if the process stopped at this point – with the brain’s identification of specific aspects of one’s behavior needing improvement – this would not lead to low self-esteem. However, the human brain tends to create generalizations based upon the behavioral problems it finds, such that the individual’s “personhood” is judged, rather than elements of his or her behavior. The result is that the person is labeled as deficient, not just their behavior. To illustrate this point, consider the following tongue-in-cheek account of the unfortunate “caveman” below. The story goes that this caveman has developed great skill at winning the affections of cavewomen. He is known by the tribe as quite the cave-ladies’ man! On the other hand, his spear-throwing skills are woefully underdeveloped, and he is not considered much of an asset in hunting mammoth. Instead of looking with pride upon his reproductive skills and seeking out the most adept spear-throwing cavemen in the tribe to teach him how to throw spears more accurately, his brain generalizes about his “personhood” based upon his deficits and tells him that he is a “loser” because no self-respecting cave woman would want someone who was consistently unsuccessful as a hunter and would have trouble providing for his family. In the case of modern day Homo sapiens, a person may have a great job, a wonderful education, a loving family, lots of friends, and live in a beautiful home, but still hate himself because his brain generates automatic thoughts about doing harm to others, and he believes that these dreadful associations indicate that he is an evil person.
The antidote to “low self-esteem” is “NO self-esteem.” Yes, we as humans can choose to live life accepting ourselves as human and to engage in any qualitative judgments about our aggregate selves. We can accept that increasing our dedication to honesty does not actually make us a better person but instead increases our commitment to a single value. Living life where we consciously reject all labels for ourselves and others can create a great deal of emotional peace. “Labels are for jars, not people” is a fun saying brought to us from the CBT community. From this day forward, the guy who is driving aggressively on the street and cut you off is no longer a “jerk,” but now merely a fellow human who’s driving style is different from your own. I am fully aware of how satisfying it is to just label the guy, but for the sake of emotional harmony I actually choose to correct my brain when it throws these judgments at others.