Step 1. RELABEL
Step 2. Reattribute
Step 3. Refocus
Step 4. Revalue
Step 1: Relabel answers the question, “What are these bothersome, intrusive thoughts?” The important point to keep in mind is that you must Relabel these unwanted thoughts, urges, and behaviors. You must call them what they really are: They are obsessions and compulsions. You must make a conscious effort to keep firmly grounded in reality. You must strive to avoid being tricked into thinking that the feeling that you need to check or to count or to wash, for example, is a real need. It is not.
Your thoughts and urges are symptoms of obsessive-compulsive disorder (OCD), a medical disease.
In working with patients with OCD, our UCLA team has had excellent results using behavior therapy, sometimes in conjunction with medication. Ours is not a sink-or-swim approach but, rather, a long-term self-directed therapy we call cognitive-biobehavioral self-treatment.
Typically, our first consultation with a person with OCD begins with the person explaining with a considerable amount of embarrassment, “Doctor, I know this sounds kind of crazy, but…”
The person then describes one or more from a checklist of classic OCD symptoms: compulsive washing or checking, irrational violent or blasphemous thoughts, or feelings of impending doom or catastrophe unless some bizarre or senseless ritual is performed.
These people usually know that no one is supposed to think such weird thoughts. As a consequence, they feel humiliated and at their wit’s end. Their self-esteem has plummeted, their OCD may well have affected their ability to perform on the job, and they may even have become socially dysfunctional, withdrawing from family and friends in an attempt to hide these awful behaviors.
IT’S NOT INSANITY, IT’S BRAIN LOCK
In treatment, the person is first assured that the diagnosis is just OCD. It is just the brain sending false messages. We show pictures of the brains of people with OCD that prove conclusively that OCD is associated with a biochemical problem that causes the underside of the front part of the brain to overheat.
In short, the person is suffering from Brain Lock. The brain has become stuck in an inappropriate groove. The key to unlocking the brain is behavior therapy, and that begins with the Relabeling step.
Relabeling simply means calling the unwanted thoughts and urges by their real names—obsessive thoughts and compulsive urges. These are not just uncomfortable feelings like “maybe it’s dirty,” but gnawing and unremitting obsessions. Not just bothersome urges to check for the fourth or the fifth time, but brutal, compulsive urges.
This is war, and the enemy is OCD. In fighting back, it is critical to keep in mind what that enemy really is. The person with OCD has a powerful weapon: the knowledge that “It’s not me—it’s OCD.” He or she works constantly to prevent confusing the true self with the voice of OCD.
All well and good, you may say, but OCD has a mind of its own. It won’t shut up. To this I reply, “Yes it will, but it takes time.” Praying for OCD to go away won’t instantly make it happen, nor will idle and futile cursing.
If you wish to pray, what you should pray for is the strength to help yourself. God helps those who help themselves, and it’s only reasonable to believe that God would help someone engaged in such a worthwhile struggle. In this case, it means concentrating on doing the right thing, while letting go of an excessive concern with feelings and comfort level. This is, in the best sense, performing a good work!
At the same time, it is medical self-treatment that begins with accepting what you cannot change—at least in the short term.
Right off, it is vital to understand that the simple act of Relabeling will not make your OCD disappear. But when you see this enemy for what it is, OCD, you sap its strength and you, in turn, become stronger.
In time, it won’t matter that much to you whether the bothersome thoughts totally go away because you are not going to act on them. Furthermore, the more you are able to dismiss the importance of your OCD, the more you will feel in control and the more it will go away. On the other hand, the more you focus on it, wishing and hoping and begging for it to leave you alone, the more intense and bothersome the feelings will become.
TALKING BACK TO OCD
Because OCD can be a fiendishly clever opponent and a demonically self-protective one, it will deny that it is simply a false message from your brain. You may say, “A plane is not going to crash because I didn’t wash my hands again.” But OCD will say, “Oh, yes it will, and many people will die.” That’s the time to show some faith and strength because you know what the truth is.
You can’t afford to listen. If you sit and fret about whether OCD is going to invade your life on a given day, you’re only assuring yourself more dread and pain. You must say, “Go ahead, make my day. Just try to make me wash my hands one more time.”
Then you must deal with the ever-present uncertainty, “How can I be sure that this is not me, just my OCD?” Well, perhaps there are no metaphysical guarantees that there is no possible relationship between hand washing and a plane crash, but I can guarantee that if you give in and wash your hands again, things will only get worse and the OCD will only get stronger. On the other hand, within a few minutes of Refocusing on another behavior and not responding to the OCD, the fear of some dreadful consequence will begin to fade, and you will begin to see the OCD compulsion as the ridiculous nonsense it is.
The decision is clear-cut: Listen to your OCD and have your life disrupted and ultimately destroyed, or fight back, secure in the knowledge that within a few minutes you will begin to feel more and more certain that planes aren’t going to fly into mountains and cars aren’t going to crash just because you didn’t wash your hands or check the lock again.
It is a matter of exerting effort so that good triumphs over evil.
IT’S JUST A CHEMICAL
At UCLA, our patients have come up with amazingly creative ways of applying the Four Steps—Relabel, Reattribute, Refocus, Revalue.
Chet, who has since successfully controlled his OCD through behavior therapy and is now in dental school, was obsessed by violent thoughts. If he saw a fire, he thought he had started it. If he heard that someone had been fatally shot across town, he obsessed that he had done it. He would walk around saying to himself, “Man, you’re just one messed-up guy. You’re a bad person.” He was in a dead-end job that he hated and was dealing with debt. These factors made his stress level escalate and his OCD symptoms worsen. Stress commonly heightens OCD anxieties.
At first, when Chet began Relabeling, telling himself that his violent thoughts were just OCD, his OCD would talk back, “Oh, is this upsetting you? Why? Maybe because you really will do it.” By gaining the knowledge that OCD is a biochemical imbalance in the brain, Chet was eventually able to use this phrase with his OCD: “Don’t be polemical—it’s just a chemical.”
Anticipation is an important substep in Relabeling, and Chet understood it perfectly. Watching a movie in which he knew a violent scene was coming, he would tell himself, “Okay, here comes my obsessive thought.” When he did that, it didn’t hurt as much.
In combating his OCD, Chet was both pragmatic and philosophical. He had always wished that he were six inches taller, he reasoned, but he knew that wishing wasn’t going to make him grow and he could deal with being short. He realized it was the same with OCD: Wishing wouldn’t make it go away, but he could learn to deal with it.
Chet found another way to best the OCD: Every time he had an OCD thought, he would do something nice for his fiancée—buy her roses, perhaps, or cook her dinner. Whenever the OCD wanted to make him miserable, he would make himself happy by making his fiancée happy.
A deeply religious man, Chet also turned to the Scriptures for inspiration and found comfort in the passage “The Lord searcheth all hearts and He understands all the imaginations of the mind” (I Chronicles 28:9). Chet clearly understood how this passage applied to him: God understands my heart and knows that my mind is messed up. I must work to stop beating myself up over it.
It’s interesting to note that there is a centuries-old precedent for this. John Bunyan, the seventeenth-century British author of The Pilgrim’s Progress, suffered from what we now know was OCD. Because Bunyan was an intensely religious man (an itinerant preacher who was imprisoned for preaching without a license), he agonized over his OCD-induced blasphemous thoughts. He dealt with his guilt—as does Chet—through a conviction that God would be upset with him for punishing himself for having false and meaningless thoughts. For this brilliant insight, I consider Bunyan the father of cognitive-behavior therapy for OCD.
THE IMPARTIAL SPECTATOR
In learning to Relabel, it is not enough to shrug and say, “It’s not me—it’s my OCD” in an automaton-like manner. Mindful awareness is essential. Mindful awareness differs from simple, superficial awareness in that it requires you to consciously recognize and make a mental note of that unpleasant feeling, Relabeling it as an OCD symptom caused by a false message from the brain. As the feeling sweeps over you, you must say to yourself, “I don’t think or feel that my hands are dirty; rather, I’m having an obsession that my hands are dirty.” “I don’t feel the need to check that lock; rather, I’m having a compulsive urge to check that lock.” This will not make the urge go away, but it will set the stage for actively resisting the OCD thoughts and urges.
We can learn from the writings of the eighteenth-century Scottish philosopher Adam Smith, who developed the concept of “the impartial and well-informed spectator,” which is nothing more or less than “the person within.” Each of us has access to this person inside us who, while fully aware of our feelings and circumstances, is nonetheless capable of taking on the role of spectator or impartial observer. This is simply another way of understanding mindful awareness: It enhances our ability to make mental notes, such as “That’s just OCD.”
In Relabeling, you bring into play the Impartial Spectator, a concept that Adam Smith used as the central feature of his book The Theory of Moral Sentiments. He defined the Impartial Spectator as the capacity to stand outside yourself and watch yourself in action, which is essentially the same mental action as the ancient Buddhist concept of mindful awareness. People with OCD use the Impartial Spectator when they step back and say to themselves, “This is just my brain sending me a false message. If I change my behavior, I’ll actually be changing how my brain works.” It is inspirational to watch people with OCD shift from a superficial understanding of their disorder to a deep mindfulness that allows them to overcome their fears and anxieties, to mentally organize their responses, to shift gears, and to change their behavior. This process is the basis for overcoming OCD.
Once a person with OCD learns behavior therapy and resolves to change his or her response to an intrusive, painful thought by not performing some pathological behavior, a willful resolve kicks in: “I’m not going to wash my hands. I’m going to practice the violin instead.” But, in the beginning, the person is beset with fear and dread and may very well have catastrophic thoughts, such as, “But then my violin will get contaminated….”
Adam Smith understood that keeping the perspective of the Impartial Spectator under painful circumstances is hard work, requiring, in his words, the “utmost and most fatiguing exertions.” Why? Because focusing on a useful behavior when your brain is bombarding you with distracting doubts and disturbing mental aberrations takes a great deal of work.
Of course, performing a compulsive behavior repetitively, ad nauseum, is also exhausting. But it is exhaustion with no positive payoff. When the Impartial Spectator is attended to, when an action is done mindfully, it makes a significant difference in how the brain functions. And that is the key to overcoming Brain Lock. This is what our scientific research at UCLA has shown.
WHO’S IN CHARGE HERE?
There will be times when the pain is too great and the effort required too debilitating, and you will give in and do a compulsion. Think of it as a tiny backward step. Tell yourself that you’ll win next time. As Jeremy, a man with OCD, put it, “Even when you fail, you succeed—so long as you persevere. So long as you take on this enemy, OCD, with mindful awareness.”
Anna, a philosophy student, described how she used the Relabel step in battling an obsession that her boyfriend (now her husband) was unfaithful to her. Although she knew her fears had no basis in fact, she would bombard him with questions about past romances, about whether he had ever looked at pornographic magazines, about what he drank and how much, what he ate, and where he was every minute of the day. Her relentless interrogations almost led to the breakup of their relationship. Anna recalls, “The first step in beginning to conquer my OCD was to learn to Relabel my thoughts and urges. The second step was to Reattribute them to OCD. In my treatment, these went hand in hand. On an intellectual level, I knew that OCD was a chemical problem in my brain and that the sensations this problem produced were more or less meaningless side effects of the chemical problem. Still, it is one thing to know this intellectually and another to be able to say while in the midst of an OCD attack that what you are feeling really isn’t important per se. The irritating thing about OCD is that when you have it, your worries, urges, and obsessions seem like the most important things in the world. Stepping back from them long enough to identify them as OCD-generated is thus no mean feat.”
In the early stages of Anna’s learning to Relabel, her boyfriend, Guy, kept reminding her that her obsessions were “just OCD,” but he could not always convince her. Over time—and with practice—she became, in her words, “pretty good at recognizing what is OCD and what is a ‘real’ worry or anxiety. As a result, I can frequently avoid buying into OCD when it strikes. I no longer become mentally distressed each and every time an obsessive-type thought enters my mind. Often, I can look beyond it and say to myself, ‘You know, it won’t do any good to get all upset about this thought. I’ve been through all this before, and it doesn’t accomplish anything to allow myself to be sucked into OCD’s tricks.’ Doing this allows a certain calm and satisfying detachment.” Anna found that the intrusive thought—or at least the intense anxiety surrounding it—dissipates, usually within fifteen to thirty minutes.
For Dottie, who had the obsession about her son losing his eye-sight and who coined the phrase “It’s not me—it’s my OCD,” Relabeling was the biggest help in combating her compulsion. “It was not dwelling on it, recognizing it, and saying, ‘It’s okay, it’s just a thought and that’s all it is.’ Most days, that works for me. Some days it’s a struggle. I say people with OCD will always have OCD unless they find some magical pill.” But, as you’ll learn from the stories throughout this book, the mental strength and power you gain while fighting OCD can never be gained from any “magic pill.”
Jack, the hand washer, had been looking for that magical pill. “That’s America. You take a pill and your life will be wonderful; you’ll be a whole new person, more aggressive or nicer or thinner or whatever.” But when medication did not make his OCD symptoms abate and the side effects of medication grew too bothersome, he turned to cognitive-biobehavioral therapy. For him, the first step in Relabeling was to recognize the absurdity of his hand washing and to convince himself that it was not logical. When he was at home, he washed almost continuously, but when he was out, it didn’t seem so important to wash. “In behavior therapy, I thought, ‘Wait a minute. You go out to fast-food places and you don’t wash your hands, then you handle money or they handle money, and nothing bad has happened to you yet, you know. And even if you use their rest rooms to wash your hands, it’s hard to get out without touching a doorknob.” Jack didn’t have dirty hands; he had OCD, and he was beginning to use his rational mind to overcome it.
Barbara, who had obsessions about Mr. Coffee, spoke of mindful awareness as a tool that helped her to Relabel. “By putting myself into a deliberately aware or conscious state when checking, I could walk away from the site of the compulsion with, if not the certainty that the appliance was off, at least with the real, firm knowledge that the check had been performed. I also learned to say to myself when feeling the horrible uncertainty that, say, the stove was not off, ‘This is not me—this is my OCD. It is the disease that is making me feel uncertain. Although I feel the stove is not off, I have checked it mindfully and should now walk away. The anxiety will lessen eventually, and fifteen minutes down the line I’ll feel even more certain that the stove is off.’” If you have problems with checking compulsions, take particular note of Barbara’s description. It’s excellent advice on how to perform checking behaviors in a way that prepares you to deal with compulsive urges.
Lara, who has the terrifying obsession about knives, learned to tell herself, “Lara, it’s only an obsession. It’s not reality. You’re frightened because it seems so horrific and unbelievable. This is a disorder, just like any other disorder.” Understanding that OCD is a medical condition and that obsessions are false messages with no real power or meaning “lessens their power and punch,” Lara learned. Obsessions don’t take over your will. You can always control—or at least modify—your responses to them.
Jenny developed a lingering obsession about nuclear contamination while working in the Soviet Union. Learning that she had a biochemical problem in her brain “lifted some of the burden,” she said. “I’d always been so angry with myself. ‘How can you be so strong and successful in so many areas of your life and still have this problem?’ I’d always felt that I was entirely at fault because I was not able to psychoanalyze myself. I could never get in there and find out what was bothering me or find the right mantra, the right shrink, whatever.” Now, when OCD attacks strike, she talks to herself, telling herself, “Well, I know what that is.” And, usually, she manages to move on.
Roberta, who has the obsession that she has hit someone while driving, said, “I still have the unwanted thought, but it is now controllable. Now, when I go over a bump in the road, I tell myself that it is just a bump. The thought that I hit someone is just a wrong message. It’s OCD—not me! I try not to look back or to retrace my route. I force myself to keep going forward. I am no longer afraid to drive. I understand that if the obsessive thought comes, I know that I can deal with it. When I’m getting frustrated, I even say out loud, ‘It’s not me—it’s the OCD.’ And then I’ll say, ‘Okay, Roberta, just keep going straight ahead.’”
Jeremy, an aspiring young screenwriter, is largely free of OCD after eight months of behavior therapy. Today, he says, “I still feel the anxiety of freedom. It hurts, but it is the price to pay to be a free man.”
From childhood, Jeremy had been overwhelmed by touching and checking compulsions that he performed without fail, fearing that a family member would die “and God would damn me to hell for it.” Home became a “torture chamber” of rituals. By his teens, Jeremy was seeking escape in alcohol and drugs. As a young adult, he kicked his drinking habit with the help of Alcoholics Anonymous, but he began to obsess that something he had eaten contained alcohol. It could be Rice-a-Roni or something equally nonsensical. Logic played no role here.
At his gym, Jeremy imagined that someone had used drugs or alcohol before touching the bars and weights and that he would somehow absorb it. In a public bathroom, he would be seized by the thought that a drunk had vomited in the toilet just before he used it and, through some kind of magical transference, the alcohol was going to get into his system. Mentally and emotionally, Jeremy was exhausted from dealing with his obsessions and compulsions. When he first came to UCLA seeking help, he said, “I feel like I have been through the jungle in Vietnam.”
During treatment, Jeremy kept with him a small spiral notepad on which he’d written CAUDATE NUCLEUS. That’s the part of the brain that’s not filtering out the OCD thoughts properly. This was his constant reminder that he had a brain-wiring problem, that he had OCD. It helped him to be mindful that he had to screen the OCD thoughts through his own mental power. “Once the pain had a name,” he says, “the pain wasn’t as bad.” Making mental notes eventually made his brain’s filtering system begin to work better.
Earlier, I mentioned the Relabeling substep, Anticipation. The other substep in Relabeling is Acceptance. Jeremy became adept at both. Before treatment, he had lived in fear of being caught in some imaginary dastardly act and being fired from his job as a night watchman. With behavior therapy, he was able to say, “Big deal. Nobody’s perfect. Let them fire me; I’ll get another job. Worst-case scenario? I’ll eat at soup kitchens. Hey, George Orwell did it and wrote a great book about it,” Down and Out in Paris and London. And if there really was forbidden alcohol in something he’d eaten, Jeremy would say, “Just a slip. Not intentional.” No guilt. No recriminations.
Once free of OCD symptoms, Jeremy had a reaction that is not uncommon. “For years, OCD had run—and been—my life. I thought of little else. I actually mourned my O’CD.” But this mourning period was short, and soon Jeremy began to fill the vacuum with positive, wholesome activities.
RX: ACTION
Learning to overcome OCD is like learning to ride a bicycle. Once you learn, you never forget, but getting good at it takes practice. You’ll fall off, but you must get back on. If you give up, you’ll never learn. Most patients find that it helps at first to have training wheels for the bike. That’s where the medication comes in. In combination with behavior therapy, medication has been shown to produce an 80 percent success rate.
The vast majority of those who fail to respond to this treatment combination do so because they become demoralized and throw in the towel. It is essential that you never do the compulsion and tell yourself, “I can’t avoid doing it. It’s bigger than I am.” It’s okay to feel overwhelmed by the compulsion, and even to act on it if you must, as long as you remind yourself, “This is a compulsion. Next time, I’m going to fight it.”
Passivity is your enemy. Activity is your friend. The biggest enemy is boredom. Having something else you really need to do—something much more important than that nonsensical ritual—is a great motivator. People with nothing to do may not develop the mental and emotional strength to shift those gears in the brain and move on to a positive behavior. If you have a job, you’re apt to lose it if you go home to check that lock once more, so you’ll be much more motivated to pull yourself away. When you pull yourself away, you’re treating your OCD. Idleness is indeed the devil’s workshop. If you’re not up to working, you can get a volunteer job, but the important thing is to stay busy. Make sure you have something useful to do. Being useful will increase your self-confidence and motivate you to get better because others need you. It’s also a tremendous aid to the Refocus step.
Some people are too depressed to work. Depression often, but not always, goes hand in hand with OCD. If your sleep pattern is radically altered, with repeated waking during the night; if you’re not eating properly and are losing weight; if you have poor energy and serious suicidal thoughts, you may have a severe depression. If that is the case, you must see a doctor.
As you have learned, acting on a compulsion brings only momentary relief, followed very quickly by an increased intensity in the intrusive urge or thought—a true vicious cycle.
After treating about a thousand people with OCD, I find that one of the most amazing things about OCD is that people continue to be shocked by their internal feeling that something is dreadfully wrong—that the stove is not turned off, or whatever—no matter how many times a day that thought intrudes. They would get used to, say, an electric shock after a while, but they never seem to get used to these OCD fears and urges. That is why mindful awareness, mental note taking, is so important. In step one, Relabel, you increase your insight. You call an obsession an obsession and a compulsion a compulsion.
HANGING TOUGH
After Relabeling, many patients ask, “Why the hell does this thing keep bothering me?” It does so because of a brain-wiring problem. The struggle is not to make the feeling go away; the struggle is not to give in to the feeling. Emotional understanding will not make the OCD symptoms magically disappear, but cognitive-biobehavioral therapy will help you manage your fears. If you can hang in through the first few weeks of self-directed therapy, you will have acquired the tools you need. You will have become stronger than your OCD. Mastering these therapy skills is like having exercise equipment in your head. It makes you strong. OCD is a chronic disease. You can’t run from it, and you can’t buy your way out of it, but you can fight back.
Patients often say to me, “Oh, if only I could have someone wash my clothes whenever I feel that they need to be washed over and over….” They think that would take care of the OCD. They’re dead wrong. Remember Howard Hughes? That’s precisely what he did—and look where he wound up. OCD is insatiable. You cannot do a compulsion enough times—or have someone else do it for you—to get a feeling of “That’s enough.” The more you do it, the worse it gets. It doesn’t matter whether you wash your clothes or hire someone to wash them. Giving in to OCD is giving in to OCD. It makes things worse!
In Howard Hughes: The Untold Story, Peter H. Brown and Pat Broeske provide more evidence that Hughes’s obsession about germs and contamination caused him to act in irrational ways. We now know that his actions only served to make his symptoms worse. For a period of time, Hughes weekly invited his friends, underworld figures Lucky Luciano and Bugsy Siegel, to dinner. Because he was obsessed with the idea that gangsters had germs, he kept in a cabinet a set of special china for these occasions. This china could be used only once. At one time, Hughes shared a house in Los Angeles with Katharine Hepburn and Gary Grant. One evening, having come upon the housekeeper smashing the dinner plates, Hepburn confronted Hughes: “This is stupid! People can’t spread germs like this.” Hughes was not convinced. Furthermore, he told Hepburn, “As a woman who takes eighteen showers a day, I don’t think you’re in a position to argue with me.”
It is possible that Hepburn, too, was afflicted with OCD. We do know that it is not unusual for people with OCD to be attracted to one another. First of all, it’s comforting to find another who understands the agony, who hears the inner voice asking, “Why do I do all these weird things?” People with OCD know that they do things that are a little strange. So, it can be comforting to know others who also do these things. At UCLA, we started the first OCD behavior therapy group in the country. This group still meets weekly at UCLA; it’s a place where people with OCD feel free to divulge their most bizarre thoughts and behaviors and to exchange self-therapy techniques they may have developed on their own. (The Four-Step Method allows for a lot of personal creativity.) At first, there was some concern that these sessions might prove counterproductive, since in some well-intentioned victim-support groups, participants get into a sort of sick competition about who has suffered the most. Also, several patients expressed to me their fear that, through the power of suggestion, they might develop new symptoms to pile onto their existing ones. Neither of these fears has proved true in the nearly ten years the group has been meeting.
One of the many success stories in the OCD group is Domingo, a onetime plumber who is now a self-taught art dealer. Domingo, who was diagnosed with OCD in his native Mexico, was “all the way at the bottom” of the OCD heap when he came to UCLA for treatment. Over a fifteen-year period, his symptoms have included showering five or more hours a day, the fear of showering, checking and eating rituals, and—what is the most bizarre—an obsession that he had razor blades attached to his fingernails. This last obsession led to his reluctance to wear certain clothes, including a favorite vintage motorcycle jacket, for fear that he would rip them to shreds with his imagined nail-blades. “I can’t touch babies,” he says. “They’re too delicate. My dog, I play with him but I cannot touch his face, his eyes, for fear I’ll cut him.” At times when Domingo and his wife made love, he drew back from touching her, especially her chest. As he said at the time, “I think I’m going to cut her. I keep thinking I’ve got blades on me, and my hand begins to shake, my muscles get real tight, and I have to pull back. My eyes see there are no blades, but my mind won’t believe. And I have to ask her, ‘Are you okay? Did I hurt you?’”
Through therapy, he has learned a basic truth: “You have to be stronger than OCD, physically and mentally. If you’re not, it will eat you alive. It will put you in bed, and you will rot like a vegetable.” Most days, when seized by a compulsion to wash or check, he is able to say to himself, “This is not real. You have to stop. You have things to do.”
Domingo makes himself choose: “Am I going to listen to this OCD or go and do my laundry? I tell myself, ‘It’s going to hurt really bad, but I have to go on.’ I close my eyes, take a deep breath, and just go through it—just push as hard as I can.”
Because he is capable of seeing quite clearly the difference between normal behavior and OCD behavior, he is able to bring himself around by zeroing in on reality. He reminds himself that a beautiful woman has chosen to be his wife and that she sees something special in him. “Look at all you’ve done,” he tells himself. “This is the reality you have to grab onto. You have to stop this thought right now. You must. If you don’t stop this, it will take over—and then what?” Domingo knows that if he gives in to the compulsion or the thought, it will keep going around and around in his brain, sapping his energy and wasting his time. He calls this “brain loop.”
He also knows that even if his OCD is never cured, he now has the upper hand. “Before, I couldn’t count the compulsions. One would go, and another would take its place. Now I know how many I’m fighting. Before, they were coming from right and left. I was overwhelmed. Now I know where it’s going to get me. I’m ready. I don’t listen to my OCD because I know it’s fake. I let it go quickly.”
TELL IT TO YOUR TAPE RECORDER
Another regular in the OCD group is Christopher, a devout young Roman Catholic who for more than five years has been battling OCD-induced blasphemous thoughts. Christopher’s disease reached a crisis point during a pilgrimage to a European shrine well known as a site where numerous apparitions of the Virgin Mary have been reported. Though he had gone seeking spiritual enrichment, to his horror, he found himself in the little church one day thinking, “The Virgin Mary is a bitch.” Profoundly sad and ashamed, he broke down and cried. Back home, these blasphemous thoughts piled one on another. He began having thoughts that the holy water is “shit water,” the Bible a “shit book,” the churches “shit houses.” In Mass, he would imagine the holy statues naked. In his OCD-invaded brain, priests had become “scoundrels.” The mere sight of a church made him cringe.
In desperation, Christopher checked himself into a psychiatric hospital, where he was diagnosed as paranoid psychotic and questioned about being “demonically possessed.” It would be two years before he was correctly diagnosed as having OCD.
Christopher is one of the patients who has found the use of taperecorded loops a useful tool in performing the Relabel step. This simple and effective technique was developed by Dr. Paul Salkovskis and Dr. Isaac Marks in England. Anyone can practice it at home. All you need are answering machine tape loops—thirty seconds, sixty seconds, and three minutes—a cassette player, and headphones. The idea is to record the obsession, repeating the thought over and over, and then to listen to it repeatedly, perhaps forty-five minutes at a time. The tape will keep relooping over itself, so there is no need to rewind.
Christopher suggests writing complex obsessions down in shortstory form before taping, creating a scenario in which the dreaded consequences actually come true. For example, “If you have scrupulosity and religious obsessions, have God strike you dead and throw you into the fire at the end. If you obsess about committing a crime, have the police arrest you and make you spend the rest of your life in jail. If you fear dirt and germs, make yourself look like you fell in a pool of mud or came down with a deadly germ-spread disease and died. The important thing is to make the obsession look as stupid and ridiculous as possible.” On a scale of one to ten, playing the tapes should cause anxiety in the five or six range at the beginning of a forty-five-minute session.
Another tip from Christopher: “I prefer using one of those big boom boxes. I found that, with the small players, I would often be tempted to get up and do things because it’s very easy to carry those things around. That’s not very effective for behavior therapy. A big boom box kind of makes you sit there.” When privacy is important, of course, you can use headphones.
The idea of the tape loops is to create anxiety that will peak and then ebb. The person listens to the tape perhaps twice a day for several days, perhaps as long as a week. “Eventually,” Christopher promises, “you’ll get to the point where you can’t stand even listening to it, not because it’s too anxiety-provoking but because it’s too boring. That’s why it works.” It’s also helpful, he believes, to keep a chart of your anxiety levels at ten-or fifteen-minute intervals. After some days have passed and the anxiety level is at zero, it’s time to rerecord the tape, this time in more anxiety-provoking language, and then do another tape, working toward recording the most anxiety-provoking aspects of the obsession.
Christopher cautions, “Don’t expect that after these sessions you will no longer have the obsessive thought. It’s just that you will more easily dismiss it from your mind and, eventually, it should decrease.”
Before behavior therapy, Christopher had literally dozens of obsessions, including violent thoughts about flying knives. “I used to have these horrible, wild fits where I would take a pillow and hit my face into it really hard and scream at the top of my lungs, punching the pillow or punching the couch. The OCD was so bad. It was terrible.” At first, working out his anxieties with the tape loop was no picnic. “There were times when the anxiety shot through my body so bad that I felt like a woman giving birth…that much pain. I would be sweating, and my arms and hands would be tingling. That doesn’t happen anymore.”
“DEAR DIARY”
As part of cognitive-biobehavioral self-treatment, I urge patients to keep a journal of their progress. Christopher, a faithful journal keeper, says, “I’ve found that whenever I recover from an OCD symptom, the natural tendency is for that symptom to become relegated to the back of my mind or forgotten. That’s the goal, of course, but as you forget each symptom, you tend to forget your progress.” Without this written record, he believes, the road to recovery is “like taking a journey across a desert and only walking backwards, while wiping away your footprints with your hand. It looks like you’re always at the starting point.” The critical point is to chart your progress, to keep a record of your behavior therapy efforts. It can be short and simple. It doesn’t have to be fancy or complicated.
Christopher also uses the Impartial Spectator in Relabeling. He prefers to call it “my rational mind,” as in, “My rational mind says this isn’t true. This is reality. This isn’t. I’m going to follow the advice of my rational mind.” This is a perfectly legitimate and accurate alternative term. It’s the action of making mental notes that’s important, not what you call the process of mental observation.
Think of the Impartial Spectator as a vehicle for distancing your will from your OCD. In other words, create a safety zone between your internal spirit and the unwanted compulsive urge. Rather than respond to the urge in a mechanical, unthinking fashion, you present yourself with alternatives. As you’ll learn later, it’s good to have some alternative behaviors up your sleeve, so you’ll be ready when the intense pain occurs. As Domingo said, “This thing, OCD, is damned clever. You have to keep your wits about you to beat it.”
Frequently, patients find that one symptom disappears, only to be supplanted by another. However, a new symptom is always easier to control than one that has been long entrenched. Without treatment, OCD will just beat you into submission. Anticipate—be ready to resist this thing early on—and it will be far less painful.
HUGHES: BEYOND BIZARRE
This disease, OCD, manifests itself in ways that give new meaning to the word bizarre. Consider, once again, Howard Hughes. He went so far as to come up with a theory he called the “backflow of germs.” When his closest friend died of the complications of hepatitis, Hughes could not bring himself to send flowers to the funeral, fearing in his OCD-controlled mind that if he did, the hepatitis germs would somehow find their way back to him. Hughes was also a compulsive toilet sitter, once sitting for forty-two hours, unable to convince himself that he had finished the business at hand. This is not a rare OCD symptom, and I’ve treated a number of people for it. When they’re ready to get better, they’ll say, “I’d rather soil my trousers than sit here another minute.” Of course, no one has ever soiled his or her clothing.
Senseless repetition was another common symptom that Hughes was observed to have. Hughes, a cross-country pilot, once called an assistant to get the Kansas City weather tables before he took off. He didn’t ask for those tables just once. Although he got the information he needed for his flight the first time, he asked thirty-three times, repeating the same question. He then denied having repeated himself.
Interviewing me for his book on Hughes, Peter Brown asked, “Why couldn’t he stop it, someone as brilliant as he was?” Brilliance has nothing to do with it. Hughes had the feeling that something really bad was going to happen if he didn’t repeat that question 33 times. In this case, the catastrophic thought may have been that the plane would crash. Maybe he’d planned to ask the question only 3 times—to quell his OCD-induced anxiety—but didn’t put the accent on the right syllable, or something equally ludicrous, the third time, and thus felt compelled to ask it 33 times. Had he not gotten it right then, he might have had to ask it 333 times. These kinds of symptoms are common with severe OCD. The fact that he denied repeating himself indicates that he felt humiliated by having done the compulsion.
While testing an amphibian plane, Hughes insisted on landing in choppy water 5,116 times, although the aircraft had long since proved its seaworthiness. He just kept on and on, and no one could stop him. When this incident was reported in earlier biographies of Hughes, it was explained by Hughes’s need to be in control. Other things in his life were slipping out of control at that time, among them his fortune. That may be part of the explanation for his behavior, but I believe that the answer is less related to deep emotional factors and that Hughes wouldn’t have behaved this way had he not had OCD.
THE CASE OF THE FLYING PAPER CLIPS
Josh had a whole range of bizarre OCD symptoms. One was a fear that he had brushed against someone’s desk at the office, thus causing a paper clip to flip into that hapless person’s coffee cup. In Josh’s worst-case scenario, the person would then drink the coffee and choke on the paper clip. Now, Josh knew there was a one-in-a-million chance that a paper clip would flip into someone’s coffee cup, yet he couldn’t get the idea out of his mind.
Josh then developed an obsession that he had grazed a parked car while driving and, in doing so, had knocked loose the hood ornament or a chrome strip. Then he imagined, “That guy’s driving along the freeway, and the part falls off and kills six people.” Josh went so far as to memorize the license plates of all the cars that regularly parked on the street where he lived so he could check each day to make certain they were there, intact, and everything was fine. But he was constantly plagued by worry about cars that he might have come in contact with during the day and would not be able to trace. Once, he drove two hours in a vain effort to track down a car on which he had inflicted imaginary damage.
Another time, Josh flew to St. Louis on business, flew home to Los Angeles, then turned right around and flew back to St. Louis, intent on finding the car on which he imagined he had loosened the hood ornament.
Josh knew that none of his actions made sense, but he also mentioned—and this shows a deep insight into OCD—that sometimes when dealing with a particularly vexing business problem, he found that his compulsions, unpleasant as they were, had the power to divert him. During a very stressful time, he would literally prefer to be doing the compulsion to thinking about what he was supposed to be doing at work. In the same way, Howard Hughes might have been using a compulsion as an outlet. First, there was just the thrill of that amphibious landing, but he soon developed a compulsion around it. Without behavior therapy, which teaches you how to resist those urges, the urges can escalate into an unstoppable cycle. The lesson is: If you let your emotions cling to an OCD behavior, the behavior can easily get out of control.
In a similar way, Josh tended to have relapses during treatment because, by his own admission, he would let his guard down when his OCD symptoms were, say, 80 percent gone. As a consequence, he’s been dealing with the same symptoms for a number of years, never quite dispatching this devil OCD, doing the Four-Step method just enough to give him a livable comfort level. Then, in times of stress, his OCD flares up badly. Josh had the insight to realize that, in effect, his brain was looking for something mischievous to do all the time he’d put it in neutral. Mentally, he was allowing the OCD to lie in wait and not attacking it aggressively enough.
What he should have been telling himself was that by doing the compulsion, he was only assuring himself that another compulsion would follow, that his ability to function effectively would decrease and his stress level would soar. He needed to be brave, to confront his OCD and work past it. It’s true, in this case, that a coward dies a thousand times before his death, but the valiant fight off OCD right now!
Howard Hughes’s germ-backflow theory is similar to an obsession described by Jenny, a professional woman in her early 30s with a longtime involvement in ecological and environmental issues. While working for a U.S. government agency in Moscow, she developed the obsession that radiation could spread and attach itself to things. This was only a few years after the Chernobyl nuclear disaster, so, as is true with many OCD thoughts, there was a small element of logic. However, Jenny’s reasoning was totally illogical. “When people would come in from Kiev or Chernobyl, I’d worry that radiation would just come off of them and contaminate my things. Any logic that I tried to infuse about the physics of radiation was not working. It was kind of a basic contamination fear.”
Always, what she really worried about was that she, in turn, was going to contaminate others. She began to keep separate in her closet those clothes that were still okay to wear when she was around friends. These were the clothes that she’d never worn when around someone who’d been near Chernobyl. Certain books and papers had to be disposed of. “I threw away perfectly good things because I thought they were contaminated. I didn’t want people getting them out of the trash, so I would rip them up to make them unusable.” She became afraid to phone home, in fear that the “radiation” would somehow travel over the telephone lines.
ONE HOARDS, ANOTHER SCRUBS
With regard to the form of OCD and the content of OCD, it is certainly possible that a person’s life experience plays a role, especially in the content of that person’s irrational fears. Many of my patients believe this. Jenny, for example, wonders whether she might have been subliminally affected by a film on the bombing of Hiroshima that she saw on television when she was 12. She still recalls it vividly: “I couldn’t sleep. I kept thinking of burnt hands reaching up from behind my pillow and of faces with burnt skin sagging, faces staring at me.”
Jenny’s first OCD thoughts—of feeling compelled to tell people inappropriate things—date from early childhood. By her teenage years, OCD was a monster that had a real stranglehold on her. This moving diary entry was written when she was 18:
You are the awful…the awful. It has gone too far. There is no message, no inspiration, just pain. So that all else that is so fine is dulled. You are the duller, the awful…what fault mine? Possibly that I let you do this to me? No, I had no control. You took power of me, the fear holds me. Take your awful fingers from my mind…you awful…you be damned in heaven, hell the better. I hate it. I hate it. I hate it. I want to be free.
Using Four-Step self-directed therapy in combination with Prozac to make it a little easier, Jenny is now able to control her OCD. She is no longer afraid to mail letters because of some wild idea that they are contaminated. She forces herself to wear all the clothes in her closet. She says she would have no qualms about driving past a nuclear power plant or working near a nuclear reactor. One day recently, while cleaning out her office at a medical complex, Jenny came across a box in which were stored old cardboard covers for lab slides. “I had an idea that there were diseases in there. Well, I brought them out and put them on my desk and touched them and said, ‘This is ridiculous. Pathogens die within seconds. It’s not me—it’s my OCD.’” She was able to put the absurd thought aside.
At UCLA, we have provided scientific evidence that OCD is related to a chemical imbalance in the brain, that critical parts of the brains of people with OCD use too much energy because the brain circuitry is out of whack. This is true across the spectrum of people with OCD. But OCD presents itself in a huge variety of ways, some outrageous, some ludicrous. In my behavior therapy group, patients sometimes can’t help but laugh at themselves, but the disease is so painful that I have long since learned never to make light of any symptoms.
Let me share a few more of our case histories from UCLA:
OLIVIA
Olivia, a middle-aged homemaker, developed an obsession soon after the 1994 Los Angeles earthquake that the water in her washing machine was contaminated. She even imagined that water from the toilet was somehow pouring into the washer.
LISA
Lisa, an X-ray technician, developed an irrational fear of lead. Because she worked around lead, it became a terrible problem. First, she imagined that her hands were contaminated, then her shoes, then anywhere that she had stepped. She began to designate “clean zones” in her home. She would warn people that she worked around lead, so they could get away from her. Washing became a time-consuming compulsion.
LYNN
Lynn, an attractive college student, became obsessed with picking at her face, trying to rid it of imaginary flaws. She had a condition called body dysmorphic disorder, which may be related to OCD. Ultimately, she had to lower all the lights in her apartment and tape sheets of paper over the mirrors. (A similar disorder, trichotillomania, or compulsive hair pulling, may also be related to OCD.)
KAREN
Far more typical is the case of Karen, a homemaker and former dental assistant in her early 50s. Karen is a hoarder. Her problem began as a harmless hobby early in her marriage, when she and her husband, Rob, would haunt yard sales for inexpensive treasures for their new home. Before long, Karen was bringing home useless curbside castoffs. In time, every room in their house was crammed so full of junk that it was impossible to open the doors. Even the bathtub became a dumping ground for this rubbish. So much stuff was heaped on the stove that only a single burner was usable. Only a narrow path was navigable through the living room, between trash bags and boxes stuffed to overflowing. With their sixteen cats and four dogs sometimes relieving themselves behind those piles of trash, the stench became gagging.
Karen recalls, “We were too embarrassed to invite anyone in.” There was no heat in the house because they were afraid that they would start a fire if they lit the pilot on the floor furnace. Throughout the house, there were only two sittable chairs. Appliances would break down, but Karen and Rob couldn’t get them fixed because they were terrified that a repairman might report them to the health department. They shuttered the bottoms of their windows and let the shrubs grow so no one could peek inside. Rob had lived with this mess for so long that he no longer viewed the situation as wildly bizarre. “Our home was no longer a refuge,” Karen says. “It had become a prison. We were foundering, like a sailing ship that is depending on winds that don’t come.”
For them, help came inadvertently from one of Karen’s former colleagues who dropped by unexpectedly. Karen was so humiliated that she gave up yard sales cold turkey, only to begin haunting book sales. Now Rob had to build library stacks to house all the books she brought home. Still, Karen did not seek help, fearing that she’d be committed to a psychiatric hospital. Finally, in desperation, she saw a psychiatrist who suggested that she just set up a dumpster in the driveway and purge the house. Karen wasn’t about to do that. “I could just see myself running out into the yard, screaming and throwing myself on the dumpster and being forcibly removed to a psychiatric hospital—all in full view of my neighbors.”
Finally, after ten years of hoarding, she joined Obsessive-Compulsives Anonymous, a twelve-step program based on Alcoholics Anonymous. There she met someone who persuaded her to begin the long, hard process of cleaning out that would take years.
“My big mistake,” Karen says, “was that I thought I had to fix my problem myself. I had false pride. I did not want anyone to see my shame.”
At UCLA, we taught Karen the Four Steps, which she keeps pasted on her bathroom mirror and consciously invokes whenever she spots a tempting yard sale or an attractive item poking from a trash can. When Karen Relabels an obsession and says to herself, “Let it go!” she means letting go of both the obsessive thought and the fleeting wish to hang onto another piece of junk. “If I make the right choice,” she says, “I get to feel good about myself. I get to be that much closer to a rubbish-free, hassle-free environment. I get to be healthy. I get to have friends. I get to have a life!” One technique she uses is to get angry at all that stuff and how it’s wrecked her life. “I don’t just toss things into garbage cans. I throw them in with a vengeance, as if to kill them, as if our lives depended on it, and—in a deep sense—they do.”
BLAME IT ON YOUR GENES?
In telling her story, Karen mentions that she grew up in a rigidly perfectionist household with an eccentric father who would rant constantly against waste. She wonders if this experience mandated the content of her OCD, which is possible, especially since as yet there is no biological explanation as to why one person washes, while another hoards.
Other patients also reflect on their childhoods and their genetic legacies in attempting to find answers to why they developed OCD. Certainly, genetics does seem to play a role. Again and again, patients have told me of mothers or sisters or grandparents who certainly had OCD tendencies long before the disease was given a label. Formal studies show the same thing: OCD tends to run in families. Frequently, parents of people with OCD were rigid and inflexible and became very uncomfortable if things weren’t done in a certain way. For example, at five on the dot each day, Howard Hughes’s grandparents went out on the porch of their summer house. As a child, Howard had to be there precisely at five, or there was hell to pay. One can think of this kind of rigidity as low-grade OCD. These traits can be highly advantageous if you are, say, a surgeon or an accountant, but they can become pathological if they are amplified. Thus, it’s not surprising to see that a precursor of an OCD biochemical imbalance is this much less disruptive habit-based brain function.
Childhood-onset illnesses have also been linked to OCD. Dr. Susan Swedo’s group at the National Institutes of Health has established a link between OCD and Sydenham’s chorea, a variant of rheumatic fever that involves an autoimmune attack on the brain. Her work implicated Sydenham’s chorea in both the onset and exacerbation of OCD. The fact that there is a strong relationship between Tourette’s syndrome, a motor tic disease, and OCD is also intriguing. The link between childhood psychological experiences, especially traumatic ones, and classic OCD is less clear, but some of my patients are convinced there is one.
Michael, a stenographer, feels strongly that his OCD stems from growing up in a household with a father who would dwell for days on minutiae and a mother he describes as an “anal-retentive” compulsive cleaner. He recalled: “My mother tended to be very overpossessive. But, though she smothered me, she didn’t nourish me in other ways. Which is the same thing my OCD does. You know, you have all this potential that is smothered. I remember other kids taking piano lessons, whatever, but she never allowed me to do those things. She just did the smothering. With OCD, you might have the potential, but it smothers you and does not allow you to get it out.”
Michael describes himself as having a “Dr. Jekyll and Mr. Hyde brain,” with a good side and a bad side—the OCD side. He has had counting and touching compulsions, compulsions about “good” numbers and “bad” numbers, and compulsions to repeat sentences over and over again in his head. But his most bizarre compulsion—one with which he still struggles—began in fifth grade. “I would be sitting in class and suddenly I would feel my pants were too tight.” He was unhappy in school, partly because his OCD made it difficult for him to concentrate, and he now wonders if this feeling of creeping pants was some sort of subconscious distraction technique.
Although Michael has overcome most of his other obsessions, he says his OCD “seems determined to dig in for all it’s worth and win the final battle,” the battle of the too-tight pants. Or, as Michael somewhat inelegantly puts it, the fear that “my jockey shorts are going up my butt and are going to come through my mouth, they’re shrinking so much.” Before behavior therapy, he would sometimes shed his clothes in an attempt to shed the feeling. Now, he realizes that giving in to a ridiculous thought is the worst thing he could do.
Michael finally overcame his obsession about pesticide contamination, an obsession so severe that “just seeing a can of Raid at the supermarket” traumatized him. “If I’d put my things down for the cashier and somebody ahead of me had a can of Raid, I’d have to take all my food, everything, and put it back on the shelves and restock my basket. I thought everything had been contaminated. Of course, I’d have to go to a different checker because I didn’t know if the conveyor belt was contaminated. Sometimes it would take so long that I would just have to forget about getting food.” If Michael saw an exterminator’s truck on the road, he would have to go home, wash his clothes, and shower. Always, he says, “I felt like this shroud of poison was kind of draped over me.”
The moment of truth came when he was informed that the apartment house where he was living had been sold and the building was to be tented for termite treatment. Michael panicked. Should he protest at city hall? Get a psychiatrist’s note saying that the exterminators couldn’t be allowed in because he was mentally ill? Then he got hold of himself. “I thought, ‘Wait a minute. Just let them do it because maybe I’ll get better.’ I had resolved that this had to be done and that I wasn’t going to die. This was a really big thing for me.” One moment of clarity, after twenty years of suffering from this obsession. The work of using mindful awareness to know what obsessions really are began to pay off for him in a big way. Michael then went one step further. When the exterminator came, Michael asked him for his business card. He took to carrying the card around as a reminder that he wasn’t going to die. By purposely exposing himself to what once had terrified him, he knew he was making himself better.
Through practicing the Four Steps, Michael has learned to think of OCD as “this bad guy in my brain that can’t fool me anymore. I know I’m not going to die from pesticides. I know I can touch a table twice without touching it a third time” and nothing disastrous is going to happen. But those creeping pants still nag at him. “That’s part of my body. They’re on my skin. They’re there all the time, something I can’t escape.” Although Michael still has a modest amount of residual OCD, he’s well aware of the tremendous amount of improvement he’s made and of how much he has increased his ability to function.
In the battle against OCD, he has learned, “You just do anything you can to sabotage yourself. It takes incredible drive, total effort, to resist it. It’s just intense pain, as bad as any physical pain.” He has learned, too, that robotlike performance of the Four Steps, without mindful awareness, does not work. This is Michael’s description of himself locked in combat with his OCD, practicing self-directed exposure therapy: “You’re thinking, ‘Well, if I touch this, my father’s going to die, but I’m going to do it anyway.’ So you touch it and you still feel your father’s going to die. You just have to say to yourself, ‘Okay, whatever happens, it’s better than living this life.’ Just do the Four Steps and keep the faith.” What a deep insight that is! Today, Michael says, he’s “down in the dirt with my OCD.” The smart money won’t bet against someone who can fight like that.
At UCLA, we have many case histories of OCD-related contamination fears. In the case of Jack, a temporary worker, actual physical pain was the impetus for him to seek help for his compulsive hand washing. He couldn’t face another winter with red, raw, cracked hands. He washed his hands so much that his young daughter called them his “soap popsicles”—icy cold with the smell of embedded soap that he could never quite wash away. In treatment, he learned that when he refuses to give in to the urges to wash his hands, nothing catastrophic happens. “I know if I don’t do it that it’s not going to be the end of the world.” Before, he always felt as though “catastrophe was just around the corner. My safe places—my car, my home—were all going to be invaded if I didn’t do those compulsions.”
It is not vital that Jack, and other patients, successfully Relabel every time an urge to do a compulsion arises. But if they give in and perform the compulsion, it is vital that they recognize mindfully that it is a compulsion and that, this time, they were unable to resist it. This is much more useful than Relabeling in an offhanded automatic manner. When you Relabel automatically, it becomes a ritual in itself and has no meaning. There is nothing magical about saying to yourself, “Oh, that’s an obsession.” Following doctor’s orders in that fashion—mechanically, without thinking about what you are doing—is not helpful. Mindful awareness is. So you say, “The feeling is too strong. I don’t have the strength to fight it this time, so I’ll look to see if I locked the door.” Then, when you do check the door, do it carefully, with mindful awareness, so you’ll be ready to fend off the urge next time. You don’t say, “Let me just make sure the door is locked.” That’s a sure prescription for endless compulsive checking.
ASSERTIVE RELABELING
At UCLA, patients are asked to write essays in which they describe their symptoms and how they respond to them—another type of self-directed therapy. These essays have also provided us with an extraordinary library of knowledge on OCD. Since OCD patients tend to be bright, creative people, their ways of expressing what they go through in battling their disease make for fascinating reading.
Joanne, who’d suffered for years from a small voice in her head repeating negative thoughts over and over like a broken record, told of seeking a cure in a self-help book. The author suggested she snap a rubber band on her wrist as a distraction technique whenever her mind started playing its OCD tricks. Joanne wrote, “All I got was a sore wrist the first day.” What eventually made her better was not a rubber band, but the Four Steps. She first began to feel that she had some control over her life when she told herself, “If I don’t want to get hit by the train [the negative obsessive thoughts], I have to get off the track and let the train go by.” She was applying a technique we call “working around” her OCD. Today, with the help of behavioral therapy and medication, Joanne is able to say, “The sun shines on my soul.”
Mark, a young artist, described a true-life OCD experience that reads like a pilot for a horror film. His OCD started in childhood with prayer rituals and, by his early 20s, had shifted focus to a cleaning compulsion. He would have to clean his apartment twelve times (twelve was a “good” number) and then “find some girl and have sex in order to cosmically sort of switch the energies back the right way,” so a member of his family would not die. Using a woman in that way made him feel bad, so he would clean one more time as a sort of purification ritual. Then, one day, after the thirteenth cleaning of his apartment, he was walking down the street and “a pigeon literally dropped out of the sky, dead at my feet, with blood gurgling out of its beak.” Clearly, this was an evil omen. Thirteen was a bad number; he had to clean a few more times. Having done so, Mark went to a coffee shop for lunch but, as luck would have it, the man in the next booth was reading a newspaper with the headline WHERE PIGEONS GO TO DIE. Okay, he thought, let’s clean some more. Finally, after he had cleaned his apartment twenty-one times, he was able to rest easy.
For a time, Mark thought he could fool his OCD by turning the tables on it, saying that if he did his compulsions, a family member would die. “I thought, okay, Mr. Smarty Pants. I’ve solved this thing. There you go.” It didn’t work. New compulsions took over. “I hadn’t learned my lesson, which is that you can’t use this shortcut and get to the finish line. It doesn’t work, and it always backfires.” It would be years before he would rid himself of his cleaning compulsion: “There was actually one time when I had to clean my apartment 144 times. It took months.”
For Mark, the breakthrough during behavior therapy came when he found an apartment he wanted but was warned by his inner OCD voice, “No, you shouldn’t move in there.” The numbers in the address were not “good” numbers. Mark took a stand. “Damn it, I can’t believe I’m going to let a choice in my life that’s this major be dictated by OCD.” This is assertive Relabeling. Right after Mark moved in, his thoughts about “bad numbers” went away. He told himself, as he always does now when OCD thoughts intrude, “I don’t have to do it. I don’t have to do anything about it.”
OCD: A TUMBLEWEED
Lara, who suffers from Tourette’s syndrome as well as classic OCD, describes a plethora of symptoms, ranging from violent thoughts about knives to compulsive shopping sprees. Once, she sought help at Shoppers Anonymous, but quickly learned a basic fact of OCD: Whereas the anonymous compulsive shoppers described getting a rush, a high, from shopping, Lara gains no pleasure from her repeated trips to the mall. She says, “My obsessions are painful. They’re not nice. I’ll buy something I don’t need, and then I’ll return it. I almost get more charge out of returning it than buying it.” Lara’s statement helps to clarify an important difference between OCD and problems with impulse control. As a behavior, OCD in itself is essentially never enjoyable.
Lara is also driven crazy by obsessions—the fear of harming herself or someone else, of doing something embarrassing, of planes crashing into her house, or of freeway overpasses toppling on her. “It’s like one obsession propels another that propels another. If you’ve seen the rat on the wheel, that’s what it’s like. Or the teacup ride at Disneyland that spins unforgivingly fast.”
Lara has never acted out a violent thought. People with OCD never do. Through behavior therapy, she has learned to Relabel her thoughts as irrational, to tell herself, “It’s not reality. You’re frightened because it seems so horrific and unbelievable.” She now knows that she can control those thoughts and urges, no matter how strong or disruptive they become. She still battles the obsessions, which she describes as her “added baggage” that she takes everywhere with her and cannot walk away from.
Carla, a beautician, became so obsessed with the idea that she was going to harm her infant daughter that she considered giving up for adoption this child she had wanted so much, for so long. (She was 40 and had been married for fourteen years when her daughter was born.) Carla, who was at first misdiagnosed as having severe postpartum depression, would suffer panic attacks—thoughts that she was going to kill the baby—that were so severe that she couldn’t look at a knife or a pair of scissors. “It was like watching a movie where you almost put yourself into that screen and you think, ‘Oh, God, am I capable of committing such an act?’ I was fighting this every day, all day.” Only her determination to take care of her baby’s needs kept her going. She would literally crawl on her hands and knees into the nursery to change the baby’s diapers.
Her daughter is now 6, and Carla thanks God every day that she is around to watch her grow up. There was a long time when her OCD thoughts were so bad that she wanted to be committed, so bad that she thought of taking her own life to spare her daughter’s life. Carla describes OCD as a “tumbleweed” that picks up more and more nonsensical thoughts as it rolls along. But in treatment, she has learned to separate herself from those thoughts. When an OCD thought intrudes, Carla says to herself, “First, my name is Carla and, second, I have OCD. My life is not OCD.” It’s so automatic now, she says, that it’s like writing her name or taking a drink of water. Click! A lightbulb goes off in her head. Her defenses are ready. Mindful awareness and the ability to Relabel arise in a flash to the prepared mind.
Although many people with OCD are loath to tell others they have this problem—either out of embarrassment or of fear of losing their jobs or perhaps because they’ve learned that people just don’t want to hear about it—Carla finds a great sense of relief in sharing her secret with others. She does a great deal of volunteer work, some of it helping people with physical problems. “For me to say, ‘Hey, I have OCD. How can I help you?’—it’s almost like coming out of the closet.” Training your mind to think, “How can I help you?”—that’s behavior therapy with a capital B.
“Of course,” Carla says, “I wish there were some super-remedy where I could commit myself to a hospital, have surgery, and come out healthy. But that’s not fact.” Behavior therapy is the next best option, and in some ways it’s even better when it results in a person’s development of mindful awareness.
Now that you have an understanding of Step 1: Relabeling—calling OCD what it really is—I will introduce you to the Reattributing step. In essence, Reattributing is nothing more than placing the blame for OCD symptoms squarely where it belongs—with your sticky brain.
Reattributing answers those nagging questions, “Why is this thing bothering me so much? Why doesn’t it go away?”
OCD doesn’t go away because it is a medical condition. Someone with Parkinson’s disease may decide, “Oh, I’m no damned good. Why can’t I move at the same speed as everybody else?” The person with Parkinson’s has to regroup, to say, “Because I have a medical condition. I must adjust to this condition.” You must adjust to the condition called OCD and maximize your function. You’re not a victim. You’re working on a problem.
KEY POINTS TO REMEMBER
• Step 1 is the Relabel step.
• Relabel means calling the intrusive unwanted thoughts and behaviors what they really are: obsessions and compulsions.
• Relabeling won’t make unwanted thoughts and urges go away immediately, but it will prepare you to change your behavioral responses.
• When you change your behavior, you change your brain.
• The key to success is to strengthen your Impartial Spectator, your ability to stand outside yourself and observe your actions with mindful awareness.