Most patients enter therapy in considerable distress, and at that point are determined to follow the treatment protocol with unwavering commitment and fortitude. As their treatment progresses, however, the distress they experience from the disorder tends gradually to decrease. Indeed, those who diligently adhere to the treatment protocols generally experience a good deal of symptom relief. A common pitfall that patients encounter at this stage of the treatment process is the phenomenon of “diminishing returns.” As I’ve said repeatedly throughout this article, success with this type of therapy depends upon patients continuing to perform the required exposure exercises on a regular basis. If, as a result of the decrease in their level of distress, patients become less conscientious about performing these exposures, then their rate of progress will slow. Thus, it is critical that patients sustain the momentum they have achieved by continuing to do the exposure exercises with undiminished diligence even as their symptoms begin to decrease. It takes considerable courage and determination at this point in the therapy to continue to invite the pain and anxiety of the OCD into their lives, but it is essential that patients do so if they want to complete their recovery from the disorder.
THE AUTONOMY DRAINS
I believe that in life it is very difficult to consistently uphold our values and continue progressing toward our goals. Sustaining disciplined living is a little like swimming upstream against the current in a river. When we rest on our laurels and stop swimming, we lose momentum and may begin to drift back downstream. Even maintaining the status quo takes some effort, because just staying in one place requires that we resist the current, which is always pushing us downstream. It is quite common for patients to look another’s success and conclude that the individual they admire is “special” in some way. They may say things like, “Wow, I wish I had that kind of discipline. I could never do that,” summarily dismissing their capacity to achieve similar goals. Even worse, they may conclude that they simply are lazy. It is too common and terribly tragic when patients regard themselves as members of some kind of “subclass” of humanity that lacks the ability to successfully undertake tasks that require a sustained and disciplined effort. Achieving success in the treatment of OCD is a goal that requires great perseverance, commitment, sacrifice, and fortitude. The treatment requires that patients consistently take the initiative to disregard a miscued survival instinct and choose not to respond to their brains’ misguided attempts to keep them safe. Unfortunately, many patients see themselves as victims of circumstance and believe that they have certain inherent limitations that make it difficult, if not impossible, for them to achieve their goals in life. They live in an “I-can’t-do-it” frame of mind. Encouraging such patients to test their emotional resilience can result in a “backlash” response wherein the patient conveys some version of the following to the therapist: “If only you understood me better, doc, you would realize that I have limitations that make this task impossible. You’re just like the others, who encourage me to try because they are unaware of the profound handicaps with which I was born. Your faith in me is actually a sign that you really don’t understand how limited my abilities are, and that makes me less confident that you can actually help me get well.” Patients who see themselves as victims require a special therapeutic process. These patients do not benefit from encouragement because they feel that they are constitutionally incapable of making the changes that are necessary to recover from the disorder, and they may interpret encouragement as an indication that they simply are not understood. This can leave them feeling alienated and alone. Sometimes, to facilitate the partnering alliance, a therapist must go along with the patient’s feelings of impotence. In such cases, I may tell these patients that I am not going to suggest techniques that can facilitate recovery from the disorder until they can assure me that they are fully aware of how they perceive themselves and their limitations, and can acknowledge their own role in maintaining this perspective. Until this moment of insight is achieved, I often try to see the world through their eyes, even if this means occasionally agreeing with their assertion that they are helpless. Being empathic to patients’ view of themselves as weak can serve as a mirror in which they can see how they are selling themselves short, and this finally may enable them to reject their self-defeating perspective.
When you watch top athletes discussing the factors that have contributed to their success, they often say very similar things. For example, they frequently thank God for their good fortune. They also may state that they are just ordinary people who were willing to commit themselves fully to something about which they cared deeply. They are more likely to talk about perseverance than talent. In fact, they rarely attribute their success to having been born with special talents or abilities. Instead, they may suggest that they believe the same potential for excellence exists within all of us.
“Lazy” is undoubtedly the most common self-limiting word that we use to describe ourselves. Endorsing the concept of laziness is an example of what I call an “autonomy drain.” Here we are arbitrarily setting limits on our capacity to make difficult choices based upon non-autonomous factors. In this case, the non-autonomous factor is our assessment of ourselves as undisciplined. A patient may conclude “Since I’m lazy, I lack the qualities that patients who actually do their assignments have.” As a psychologist and as the patient’s partner in the therapeutic process, I never accept this excuse. It is vital that patients own – that is, take responsibility for – their willingness or lack of willingness to experience pain. “The assignment was too difficult – I couldn’t do it,” is replaced with, “I was not willing to endure the discomfort.” or “The anticipated discomfort of doing an exposure exercise that challenging was more than I was willing to face.” I often have witnessed the beneficial effects of patients taking responsibility for the choices they make. We tend to make more disciplined choices when we are mindfully aware of all the options available to us, and when we acknowledge our responsibility and accountability for making the final decisions.
I wish I had a dime for every time I’ve heard a patient say, “I can’t do it.” This is just another form of “toxic” verbiage. Deploying a careful strategy and taking responsibility for deciding whether to follow through with it is much more productive. If you decide not to complete an assignment, then acknowledging that you are consciously choosing that course of action is a much healthier approach than not taking responsibility for having mindfully chosen the “non-disciplined” path and for letting your emotional experience (your feelings) rule the day. “Is it really that you can’t do it, or does the thought of exposing yourself to this challenge seem overwhelming? Are you willing to follow through on your agenda and risk experiencing a possible emotional backlash as a result of taking on this challenge?” Asking these questions represents a therapeutic communication strategy that facilitates mindfulness and autonomy.
Additional “autonomy drains” include statements with words like “need,” “have to,” “must,” and “should” (as in, “I have to do this exercise.”) Such expressions impose demands upon our brain, conjuring up some mythical “taskmaster” who can compel us to follow through with the assigned task. People tend to resent feeling obliged to perform any task, and are likely to resist such expectations, regardless of whether they come from others or from themselves.
TOO SICK TO TAKE THE MEDICINE
Tragically, there exists a small percentage of patients who are earnest in their desire to achieve therapeutic success but adamantly declare that they are too impaired to make choices which might lead to recovery. It seems that for some reason with this minority group that their autonomy has been replaced by the voice of their condition. They can conceptually desire to achieve a therapeutic benefit, but the voice of trepidation regularly overwhelms their agency in making independent choices. Their anxiety says, “jump” and they ask “how high?” They often attend therapy sessions looking for the therapist to instill conviction, motivation and or determination. Since these persons are so lacking in an independent will to manage the challenges their prognosis is very poor. Over time they find that the therapist in not able to give them the resilience that is required to succeed with E&RP and drop out or seek yet another therapist who might offer some hope in being the “one “ who might instill fortitude.
MAKING A CHOICE
With all of the ways human beings seem to be able to avoid making healthy life choices, it is vital that we identify the mental mechanisms that actually support the process of making choices that support the achievement of our goals.
Every choice involves the possibility of loss in the sense of the “road not taken.” My choice of a beach vacation means that I will miss the adventure of skiing this year. Choosing to run Saturday morning means that I will be sacrificing the possibility of quietly enjoying some leisure time and a well deserved rest after a hard week of work. Attending my daughter’s 3rd grade school play means that I will miss my weekly card game with the guys. Obviously, some sacrifices are easier to make than others, but a consideration of what we are willing to do without is essential if we are to achieve our chosen goals. When we find ourselves tempted to choose the path that requires the least amount of sacrifice, it would be wise first to consider which choice would best represent our values and serve our long-term interests.
To recover from OCD, you must be willing to make sacrifices. With this condition, your brain sends false signals that you, someone you love, or innocent people are in danger, and you must decide whether – for the sake of your long-term recovery – you are willing to sacrifice the quick relief from your anxiety that your brain says you can secure if you just perform certain behavioral or cognitive rituals. Of course, according to your brain, not performing this safety-seeking behavior would be foolish, but it is important to remember that you have the option of foregoing the promised relief for the sake of ultimately overcoming the disorder, itself. The gatekeeper must decide whether he is willing to sacrifice feelings of safety in order to prevail over the temptation to ritualize and maintain a false sense of security. According to the brain, it would be foolish to not perform a safety seeking behavior or cognition. The gatekeeper has the option to consider whether to concede to the brain’s emotional demand, or to sacrifice emotional peace in working towards recovery. A skilled patient might say, “If I sacrifice this moment’s peace and comfort, I will be taking a healthy step toward my long term recovery.”
To be accountable to ourselves or to others for our actions can help ensure that we make disciplined choices. One way we can do this is by keeping daily charts of the goals we set and the actions we have taken to achieve them. Research has shown that the mere act of keeping an accurate daily log can bolster your commitment to achieving your goals. The problem behavior for which such “self-monitoring” can be helpful includes overeating, exercise avoidance, smoking, compulsive hair pulling, and ritualizing in response to spikes from your OCD. In addition to keeping your own log, having a spouse or close friend to whom you report can heighten your commitment to make disciplined choices. I regularly encourage my patients to keep a record on paper or on their computers, tablets, or other digital devices of both the disciplined and the relief-seeking choices they make. When they feel tempted to avoid making disciplined choices, the fact that they will be keeping records of these choices can improve the chances that they will choose actions that support their long-term goals.
Occasionally, when patients are finding it hard to follow through on their weekly homework assignments, I suggest what is called a “behavioral contract.” The terms of this contract are as follows: The patient puts a certain amount of money in an envelope and addresses the envelope to an organization that he or she despises. The patient then agrees that if he or she fails to complete a minimum amount of the homework over a specified period of time, the envelope will be stamped and mailed out.
Here’s how this arrangement worked with one of my patients. Sheldon had not been completing his homework assignments on a consistent basis, and he agreed to enter into a “behavioral contract” with me. He placed $50 in an envelope, and addressed the envelope to the National Rifle Association. Now Sheldon was a staunch Democrat who strongly supported gun control, and he would have done almost anything to avoid making a contribution to an organization he hated as much as this one. To increase his incentive, I warned him that once he contributed to the National Rifle Association, he would be inundated with solicitations for money from every right wing organization in the country. This prospect so horrified him that he very quickly brought his level of compliance up to about 90%, which was well within the terms of the contract.
THE UNALTERED PATH
Of course, before you can reap the rewards of following an “unaltered path,” you need to have a path to follow in the first place! A good way to begin is to set goals for relatively short time periods – an hour, a day, or perhaps a week. Beware of getting sidetracked by the kind of “conceptualized’ choices previously discussed. Do not set goals that remain forever in the future – that is, goals you cannot begin to pursue right now. Setting a goal for the next hour can become the cornerstone of a disciplined, purposeful life.
The saying, “man plans and God laughs” highlights the dichotomy that can develop between our conceptualized goals and actually doing what is necessary to achieve them. In addition, unforeseen events in life can make the pursuit of our goals more difficult. Your goals can be as simple and straightforward as walking the dog or folding the laundry, or they can be more ambitious, like making 500 cold calls at work or starting each day with a five mile run or, for that matter, performing 10 exposure exercises every day.
People engaged in the treatment of OCD often face a quandary when they have an opportunity to do an impromptu exposure exercise. The brain “machine” may say, “If you don’t do this exposure exercise right now, you won’t recover from your OCD,” but if you had not planned on doing an exposure at this time, what are you, as a treatment-compliant patient, to do? Many of my patients are surprised when I suggest not doing the impromptu exposure. People desperate for recovery can become overly zealous in their efforts to overcome the disorder, and frequent unplanned exposures can have disruptive effects upon their lives.
Following an “unaltered path” involves setting specific goals for the day. You select an agenda for the day, and rigorously stick to it. We do not have a choice in the way we feel, nor can we control the life events that unfold around us, but if we proceed through the day and keep to our intended path, we can have a major impact on our mood stability. Again, if you want to know how you are doing with the therapy, look at how you are choosing, not how you are feeling. Completing all the tasks and commitments that you set out to do in a given day despite having been anxious, exhausted, sad or distracted can boost your morale tremendously. Keep in mind that the anticipation of the pain you believe will accompany a particular activity is usually more uncomfortable than the pain, itself. Recognizing that at each moment we are living our life as we had intended can be a source of great satisfaction – even in the midst of an emotional storm raging around us.
It goes without saying that unemployment can be a source of great emotional distress. The absence of the imposed structure of a job can send many people into deep depression and despair. When every day is like a weekend, we have little to which to look forward (like celebrating the end of another workweek!). I consider unemployment a major contributor to both depression and “behavioral disregulation” (allowing one’s mood to determine the choices one makes). This is a very dangerous state of mind in which to find yourself. Establishing some kind of day-to-day structure while unemployed is essential to maintaining your autonomy and emotional equilibrium. Set a hard wakeup time, and make sure you get up when the alarm sounds. This simple act can jumpstart a day of disciplined choices. “I committed to waking up at this time, and, sure enough, that is exactly when I got out of bed. I did this despite the enormous emotional pull to reset the alarm and delay the pain of actually starting the day.” People for whom procrastination is a problem in their lives will be especially tempted to push the “snooze button,” one of the most autonomy-defeating inventions ever created! So, get up, go through your normal morning routines, and get out of the house – even if it’s just for a quick walk around the block. Plan your activities, and most importantly, look for another job.
REMAINING ENGAGED IN THE PROCESS
Sometimes, when the world seems to be crumbling around you, and you feel that life is most definitely not worth living, the best you can do is to remind yourself that you are “engaged in the process.” This is a mental tactic borrowed from the discipline of “mindfulness.”
While driving to work on a Monday morning, Brian finds himself being bombarded by disturbing thoughts and emotional experiences to such an extent that he seriously considers turning around and going back to bed. Before making that decision, however, he examines the choices available to him. He can continue on his current course and remain committed to his unaltered path, or he can call in sick and hope that tomorrow is a more emotionally hospitable day. Brian chooses to place one foot in front of the other and continue to work. At the end of the day, he feels a distinct satisfaction about having “chosen well” by fulfilling his original goal for the day, even though his feelings that morning ran counter to his intention. To focus on the little choices we make in the course of conducting the day’s activities can be very centering. When we behave with autonomy, we recharge our emotional resources. The importance of making disciplined choices, even when those choices are not supported by our feelings, cannot be exaggerated.
To remain on the unaltered path is a crucial component of the discipline that is required to recover from OCD. The therapy involves a great number of daily commitments called exposure exercises. Despite a tremendous amount of emotional and cognitive push back from your brain, it is essential that you consistently do these exercises and follow all the other treatment protocols. In other words, even when you are challenged by anxiety, you need to have the discipline to keep yourself on course with the therapy. By sticking to your chosen path, you achieve the primary goal of the therapy, which is to demonstrate to your brain that the spikes and the attendant anxiety are irrelevant to the choices that you make. Of course, the OCD can create a compelling illusion of the relevance of its themes, which is why my patients often say to me, “Hey, doc, how can I treat my spikes as irrelevant when they feel so relevant?” The answer I always give is to “choose irrelevance” and show your brain that despite the disruptive thoughts and seemingly overwhelming emotional distress, you continue to follow your chosen path, and nothing in your life process has changed.
Another common stumbling block for those being treated for OCD is the demoralization they feel when they realize they have no control over the disruptive activity of their brains. At its worst, OCD can flood you with feelings of terror, guilt, distraction, and fatigue. You may begin to feel like you barely know yourself anymore. It may seem that you are functioning at a level far below that of which you are capable, that you are a sorry excuse for the person you could be. You may feel like giving up and giving in. To circumvent these feelings of demoralization, I use what might seem odd phrase to describe the therapeutic response. I suggest to my patients that they be willing to “live on the crumbs.” What I mean by this is that patients should take whatever small part of their choice-making capacity that remains and should continue their life processes with whatever resources they still have. I urge them to take some satisfaction from the fact that they are still “in the game.” Don’t be crushed in spirit because you are functioning at only 20% of your capacity. By remaining engaged in the process, you have the opportunity to continue to pursue your agenda, to continue to make progress towards recovery. It bears repeating that you should make choosing well, not feeling well your priority. To remain engaged in the process despite the inherent variability of your emotions is the real victory.
Make your decisions and your actions count! Uphold your values. Be guided by your morals. Follow the path defined by your agenda and goals. Don’t wait for the “motivation” – the emotional drive or energy – that you think is necessary to pursue your goals. Plan ahead, allocate the time, and make an unwavering commitment to every step in the journey toward recovery. when confronted with challenges from the disorder, make sure your autonomous choice always has the last word.
Mindfulness is an essential tool in the treatment of OCD. Patients are instructed to be “aware in the present moment” of the independent activity of their brain as it generates the distress signals that characterize the disorder. Patients also are guided to observe rather than react to the aversive experiences and distressing cognitive associations that are produced by their brains. The therapeutic effects of employing this “observational method” can be enhanced by having patients describe their anxiety symptoms using concrete and objective terms. Rather than exclaiming “Oh, my God, I just had the thought that I might harm my baby while changing her diaper! I feel like I’m losing it,” the skilled patient would say, “My brain has just produced the thought that I might harm my child, and my heart is now racing, my stomach feels like I drank drain opener, and my head feels like it is in a vice.” This strategy enhances the Gatekeeper’s sense of independence from the pain, anxiety, and/or guilt that accompany the brain’s warnings of danger, and leads to a decrease in the intensity of the pain that this emotional turmoil causes.
Consistent research has determined that when we are mindful of our painful experiences and make a conscious choice not to seek relief, the effect is a reduction in the severity of the pain. Thus, choosing to engage in an exposure exercise while simultaneously being willing to face the ensuing emotional discord tends to lessen the brain’s inclination to deliver the anticipated emotional backlash.
John inadvertently comes in contact with an item that he believes to be contaminated. In response, he experiences a strong cognitive and emotional impulse to wash his hands. At first, he yields to that impulse and reflexively starts to walk toward the sink, with the intention of relieving his anxiety by washing away the imagined contaminants. Just as he reaches the sink and turns on the water, however, he says to himself, “I am now experiencing a level 6 on the “Subjective Units of Distress (SUDs)” scale, and I am consciously choosing to wash my hands and give into my anxiety.” John is aware of the beating of his racing heart. He is aware of his nausea, his sweaty palms and his weak knees. He says to himself, “I’m now giving into the anxiety, and I acknowledge that I am forfeiting my freedom by giving into the threat and performing this ritual.” But as he reaches for the soap, he realizes that he has the opportunity at this moment to make a different choice. He pauses, puts the soap down, and walks away from the sink, having decided to take the discomfort with him. At that moment, John determined that he was willing to make the resilient choice and resist the temptation to wash his hands. In other words, he refused to allow his emotional responses to dictate his actions. In so doing, John exercised the discipline of mindfulness. He did not judge himself for having had an anxious moment; he simply examined his choices and made a commitment to his recovery. And even if John had washed his hands, he would have done so while remaining mindful of the fact that he was in control of his destiny, thus taking full responsibility for giving in to his anxiety.
When you engage in an exposure exercise or face an “inadvertent challenge” (an unanticipated exposure), there is likely to be an opportunity for you to mindfully respond to the independent system responsible for your anxiety. At such times, it is very centering to ask yourself, “In this moment, am I managing this challenge skillfully (without any resistance), or am I ritualizing and trying to escape from or avoid it?” In other words, “Am I responding with resilience, rather than resistance?” If the answer to this question is “yes,” then you can be confident that you are doing the best you can, regardless of how you feel.
Like mindfulness, a strategy called “paradoxical intent” also can help you to respond in an autonomous manner to challenges from your OCD. Paradoxical intent is a therapeutic technique most often associated with “reverse psychology.” We are employing paradoxical intent when we say to a shouting friend, “Talk louder – I can’t quite hear you.”
Bob realizes that at social gatherings, he always talks about his favorite topic – himself – and his wife brings to his attention that this is considered a social faux pas. Bob resolves that at subsequent events, things will be different. However, every time he attends another event, he falls back into his old pattern of behavior. Paradoxically, Bob’s conviction that he is going to change his behavior reduces his brain’s vigilance about searching for the problem. Many patients make this mistake again and again when they say things like “I absolutely will not wash my hands the next time I get anxious,” or “I won’t eat dessert at my favorite restaurant tonight, even though it’s my birthday.” After a string of such failures, it is very easy to fall prey to feelings of frustration, impotence, and hopelessness. Bob discusses his frustration with his close friend, Kurt, who suggests the following strategy: Instead of expecting or hoping for success in changing his behavior, Bob actually should predict that he will fail completely to make this change, and that he will spend the whole evening talking only about himself. This technique can be very effective because it alerts the brain to the fact that this problem behavior is very likely to occur, and as a result, the brain watches carefully for its appearance.
Early in my career, I worked with a patient who would leave my office every week filled with excitement about conquering his OCD. He repeatedly made the mistake of believing that his rejuvenated spirit and faith in his resolve would carry him through to his long-term recovery. As it turned out, his progress would falter by the second day after our session. I finally told him to start each day with a prediction as to how many times he would succumb to his brain’s impulse to ritualize. This approach deployed two very powerful components of the treatment: Self-monitoring and paradoxical intent.
Studies on pain management suggest that our experience of pain is strongly influenced by whether we have control over the experience or not. If a patient takes responsibility for engaging in an exposure, the emotional backlash will be lessened because he or she has deliberately brought it on. Consciously deciding to experience the discomfort and bring the challenge with you in your daily activities can send a signal to the brain that you are voluntarily taking on risk and willing to accept the emotional challenge that may follow. Interestingly, in such cases the actual likelihood of experiencing that emotional challenge is reduced because the brain is less inclined to deliver distress signals when it appears that the warnings are unnecessary.
THE UNJUSTIFIED CHOICE
In the treatment of OCD, it is very common for patients to experience a desperate need to be reassured by the therapist that a particular risk or threat is not legitimate. Patients seek reassurance in a variety of ways; internet research, chat room postings, and therapist inquires are the most common. However, these efforts rarely, if ever, produce long-lasting relief and, in fact, are much more likely to exacerbate the condition. The behavioral treatment of OCD relies heavily upon exposure exercises in which the patient purposefully brings on the feared stimulus. This is accomplished either by the patient deliberately thinking about a topic that provokes anxiety, or performing some action that he or she finds threatening. Before many patients are willing to perform the exposure, however, they often want to be reassured by the therapist that the risk is not real, and that they or another person will not actually suffer any negative consequences if they undertake the exposure. “Steve, if I am successful in this treatment process, and as a result, I am no longer anxious about the possibility of harming others, then could the therapy actually increase the chances that I will harm others? It is at this juncture that my thinking departs from that of more traditional cognitive behavioral therapists. In response to this question, I encourage patients to choose to perform such exposures without any reassurance that the risks are not legitimate.
One particularly difficult form of OCD involves a fear that others may be harmed by the patient’s own negligence or by the patient’s inadvertent or accidental involvement in an activity that results in others being harmed. I refer to this type of OCD as “Responsibility OC,” as the sufferer feels compelled to protect someone other than him- or herself. What makes this form of OCD especially difficult to treat is the added component of guilt. Not only do patients experience anxiety that others may be at risk, but they also become concerned that they may be responsible for harm coming to others if they fail to perform certain rituals to protect them. Exposure exercises for this form of OCD require that patients betray their instinct to protect loved ones or innocent people from harm. Effective treatment requires that the patient show his or her brain that the emotional alarm is irrelevant. Merely telling one’s brain that a risk isn’t real is a waste of time. Successful treatment requires that patients demonstrate by their actions that they will not heed the warnings their brains are sending them about the risk that they will do harm to others or not prevent harm from coming to them.
Much time is wasted when the OCD patient debates whether the topics they fear are legitimate or not. Although this debate might seem justified to many patients, and some therapists may well consider it a part of the therapeutic process, nothing could be further from the truth. Patients often desperately want to ascertain whether or not they really are in danger, themselves, or they are endangering others, and even though their concern is understandable and may even be legitimate, an attempt to determine the answer to the question runs counter to the goal of the therapy. Those with OCD often believe that if they just could get these questions definitively answered, it would enable them to respond appropriately. Ultimately, however, recovery depends upon taking a “leap of faith,” in the sense that patients are willing to challenge the fear, anxiety, guilt or other emotions they feel in regard to a thought or action without having proof that the danger is not real.
Making an unjustified choice involves taking action without having determined to any degree of certainty whether the potential risk of making that choice is legitimate. An unjustified choice is one that we make without seeking a rationale for doing so. I once mentioned to a friend that I didn’t enjoy eating banana splits. He was very surprised by this, and asked me why I didn’t like them. My answer was simply, “I don’t like banana splits.” Why? Because I don’t like banana splits. Being centered, you do not have to justify your tastes and preferences. You can simply “own” your own perspective without having to provide an explanation for it.
It seems reasonable that in order to make an informed decision about whether to pursue a goal, it seems reasonable for you to determine how much you really want that goal in the first place and if you are willing to make the sacrifices necessary to achieve it. Before John picked up the phone to schedule his first session, he gave serious consideration to whether this was a good time in his life to begin an uncertain and potentially very challenging therapeutic process. Prior to calling a behavior therapist, he had been involved in a number of unproductive, long-term, insight-oriented types of “talk therapy,” and he was emotionally exhausted. He looked carefully at behavior therapy and concluded that it offered hope, so he decided to proceed with it. Having made his decision, he expressed a complete readiness to do whatever it would take to recover.