Organized Chaos - Volume 4
But … They Seem So Real!
by Fred Penzel, Ph.D.
I was sitting in session with a patient, Jesse, a sixteen year-old boy who had started seeing me only three weeks before for a problem with thoughts that were very unpleasant. So far, we hadn't gotten very far, because he still couldn't seem to tell me anything about them. He sat there nervously, playing with his sneaker laces and looking at the floor. "I don't know if I can tell you about my thoughts yet," he said. "They're really bad, and if I tell you you'll probably think I'm crazy and won't want to work with me any more. I don't just mean 'bad' thoughts. These are the worst ever."
Jesse was an honor student and the captain of his school's Lacrosse Team. He was a tall dark-haired boy, with good looks, good grades in AP courses, and the appearance that everything in life was going his way. That was how it looked to the other people in his world. Jesse had been extremely anxious and depressed for the last four months since the thoughts had started. He had difficulty concentrating on his schoolwork, and his grades were starting to slip.
I looked back at Jesse for a moment. "And what if you don't tell me about your thoughts," I asked. "How will I be able to help you? It seems to me that if you really want to get control of them, you'll have to tell either me or someone else. I don't see how you can go on like this. I don't think you really have many other options. Besides with all the people I've seen over the years with thoughts like yours, I honestly don't think that you'll be able to tell me about anything I haven't heard many times over from other people. No matter how bad you think they are."
"Please understand that I'm not here to judge you or your thoughts," I told him. "I don't think you're crazy. I'm just here to help you recover from this problem and give you back control of your thinking and your behavior. I think we can do that if we work together. Wouldn't it be nice to have a quiet mind for a change?"
I didn't yet know the nature of Jesse's "bad" or morbid thoughts. But I imagined what they were like. Morbid thoughts come in a number of varieties and fall into two major categories. Something horrific or unpleasant happening to the thinker, or, the thinker is doing something horrific or unpleasant to someone else. Morbid thoughts are about sexual acts (hetero- or homosexual), about committing murderous or aggressive acts, about acting out in socially unacceptable or inappropriate ways in public, or blasphemous or irreligious behaviors (usually done in houses of worship or religious settings). If Jesse didn't share them with me, there would be little I could do to help. If I didn't pressure him, his desire to get control over the thoughts might overcome his feelings of shame and fear.
"I really hate having to think about these stupid things," Jesse offered. "They're so crazy and ugly that I can't even tell my best friends or my family what's happening to me. I couldn't tell my last doctor either." He had seen a female psychiatrist for several visits before coming to see me. (She meant well, but didn't have a lot of experience in treating OCD.) He gave a short bitter laugh and said, "Can you believe she actually told me to try and think 'good' thoughts instead? How dumb was that? If I could do that, I wouldn't be seeing her in the first place!"
I sat silently and looked at my patient, not saying anything, for what seemed like a very long time. Then suddenly, he spoke up. "I just don't know if I'm ready to tell anyone. Really. I'd like to, but I wouldn't even know how to start. I just know you'll think I'm some kind of sick pervert or psycho."
"Maybe you could start with one of the less horrible thoughts," I suggested.
"I don't know," he murmured, "It feels like someone else is living in my brain, making these things up. I'm really scared. It's like it will punish me for telling with even worse ideas."
"I know," I reassured him. "Everyone finds it hard at first, but it really does get easier. You just have to start somewhere. Anywhere. Give yourself a chance. If you want to overcome something fearful, you have to take risks sometimes. It's like jumping into space and trusting there will be a net to catch you. This therapy will be that net."
I sat and waited again. He had curled up in a ball in the large leather recliner chair with his face in his hands. He was really wrestling with himself. I wanted to give him the space he needed to think it over. Sometimes doing nothing is doing something.
After a few minutes, he began to speak with his hands still over his face. The words began to come out slowly. They picked up speed. It was as if someone had suddenly punched a hole in a dam.
"Okay, okay, okay. It's like I keep thinking in these crazy sexual ways about my parents and my dog and cat. Like touching them in bad ways or doing these things with them. Sometimes I get ideas about hurting or killing them. Like I would just do it. That I would like doing it. Like I'm going to do it. But I love them. I would never ever do these things. But when I'm thinking about them, they seem so real. How do I know I won't do the things I've thought about? There, I told you everything. That's it!"
I leaned forward in my chair and looked directly at him. "Jesse," I said, "I know that was really hard for you to do; but you've just taken the first and most important step toward getting control of the situation. Now, something can happen."
A phrase he used struck me as familiar: They seem so real.
It seemed strange to me how so many of the obsessive morbid thinkers use that exact same phrase to describe their recurrent thoughts. I cannot count the number of times I have heard it from people who I never met or spoken to before. This is one of the great mysteries of OCD. How thoughts about things that a person would never normally think, and would never do, seem "so real." It is one of the great tortures. The vivid and convincing way the thoughts hit an OC sufferer always seems to convince him that he might do the horrible things he is thinking about.
The first question that occurs to most sufferers is: "Why would I be thinking these things unless I were a psychopath or an evil person?" Since the thoughts won't quit and are striking, it seems like a reasonable question for a person to ask themselves. The more fortunate human beings can find a way to "change the channel" when we are having unpleasant thoughts. We don't appreciate what it is like to be in control of our own thinking. We take that ability for granted. That's why it is easy for people like Jesse's previous doctor to simply say, "Just think good thoughts."
We don't really understand why people with OCD think any of the particular thoughts that they do. There are many different varieties of obsessions. Morbid thoughts is only one category. Many thoughts go through a sufferer's mind, but only the ones that they think are repugnant, morally reprehensible or frightening are the ones that stick. No one knows. It is one of the special tortures that OCD reserves for those that have it. These obsessions may involve the people or things they love or prize the most. Beloved family members or pets are frequently the subjects of these obsessions. Sometimes they attach themselves to strangers as well. The thoughts don't just stop at ideas of bad things happening to the ones doing the harmful thing.
The good news is that there to help for those who suffer from morbid thoughts.
I wanted to communicate this to Jesse. "I really don't think you're crazy," I said. "It's just that OCD is putting these thoughts in your head and the techniques you are using to escape them is only making things worse. I can teach you how to take the fear out of your thoughts by confronting and challenging them."
My patient looked exhausted as if he'd just run a marathon.
"I believe that when we work together, you will one day be able to say, "Okay, so I can think these things, but now they don't scare me. I don't have to do anything about them. Also, if we decide to bring medication into the picture, we may be able to lower the level of these thoughts. What do you think?"
"Sounds good to me," he replied, "but you have got really your work cut out for you. I don't see how you can do it."
"I won't be doing it alone," I said. "Think of me as your advisor or your Lacrosse coach. I can show you the right moves and plays, but you have to get out on the field and perform. I design a program tailored to you and your particular thoughts. It will be up to you to carry it out step-by-step. My goal is to help you to become your own psychologist, so you won't need to see me any more. I'm going to refer you to a medical doctor to see if medication would be a good option."
"You make it sound so easy," he muttered skeptically.
My immediate answer was: "Absolutely not! No way! You never hear me use that word in this office. It is very hard at times. It may be the hardest thing you have ever done. If you're having doubts about what I suggest, I think you should ask yourself this question. How hard is it for you now? What do you have to lose by trying it?"
"Well, if I do what you want me to do, I could become more anxious," he offered.
"I don't see how you could get more anxious than you already are," I replied. "Anyway, the anxiety the therapy causes you will only last for a while. Later you will be in control of it. The anxiety you feel now from your symptoms doesn't look like it's going to let up any time soon." He nodded silently.
I knew we soon would make progress. There was one more thing I needed to say to him. "I have something important to tell you this one time," I said very seriously, "because I have a strict policy of not reassuring my patients just to make them feel better. People with morbid obsessive thoughts never act on them. They only fear that they will."
"I hope you're right," he said quietly.
We went after the morbid thoughts together. Jesse and I spent the next two sessions making up a list of all the situations and thoughts that made him anxious. I had him rate the different things on the list from "0" to "100," with "100" being the thing that made him most anxious. Once we finished this, I create homework assignments for him to do each day. These involved going places, being around people, and doing things that set off his thoughts.
I made some audiotapes that talked about things his thoughts were telling him. He seemed nervous about the tapes. But I explained to him that the purpose of the homework was to give him practice staying with the things he feared It was to help him get used to facing them without trying to turn them off or escape. I made it clear that the reason his anxiety never seemed to go away, was because he never stayed with the thoughts long enough to see what would really happen.
I added that the goal was to become so bored with his thoughts that he would no longer react to them. I explained this approach was known as Exposure and Response Prevention. I told him the two mottoes were: "If you want to think about it less, think about it more" and "You can't be bored and scared at the same time." He didn't seem too certain about all this. But he was willing to try it, since it seemed to make sense.
We started off with easy things, low on the scale, most of which really didn't bother Jesse very much. He started taking antidepressant medication (which also happens to help reduce the symptoms of OCD). His mood improved; and he began to think that he could get through all this. He gradually worked his way up the ladder, taking on more and more difficult homework. We dared the thoughts to do their worst. we looked at them closely to see if anything about them made sense.
Because some thoughts involved his parents, we had to bring them into the picture. It was difficult for him to do this because he feared that they wouldn't understand. He didn't have to worry about that. We were able to explain what he was going through and how they could help. Fortunately, his parents did understand and had read some books about OCD. They said that was because he was their son and they loved him. They would do anything it took to help. We then had them take part in some of the assignments.
A later session, Jesse was able to describe the results of his therapy. "You know, I think I'm really starting to beat these thoughts. I keep facing them and thinking about them on purpose; but nothing they tell me ever happens. I think I'm even starting to get bored with some of them. They seem so stupid now. There are times, when I don't find myself thinking about them at all. I think I can do this."
He seemed able to push the thoughts away at times. I began to put more of the responsibility for the therapy on him. He had to create his own tapes and homework assignments. At later sessions, he dared me to do my worst and give him the hardest things I could think of.
"I can tell you are recovering," I told him. "You're really making me work. I think I'm running out of things to throw at you. It's getting harder and harder to make you anxious. When I really do run out, I guess we can say you are finished." This brought a smile to his face.
Not long after, we did finish. It took ten months in all. I looked at him with a serious expression on my face. "Well, Jesse at this point, our job is only half finished."
He looked at me, surprised. "Doc, what do you mean? I thought we ran out of assignments. What's left?"
"What I mean," I answered, "is that you've come a long way, but now that you are recovered, you have to stay that way." We talked about something known as relapse prevention. This meant he could expect to get an obsessive thought or two from time-to-time. He would have to be his own therapist and immediately give himself an assignment to do. I reminded him that it was unrealistic to think that he would never get an unpleasant thought. That even people who didn't have OCD had occasional unpleasant thoughts. If he slipped and did the wrong thing, he would just have to forgive himself ... let it go ... and, then get right back to doing the thing he knew was correct.
I said, "Just remember that many of the people I have seen relapse over the years were those who thought they were cured. When you get your symptoms under control, they must be kept that way. It takes ongoing work. It does get easier the longer you do it."
"Don't worry, Doc, " he reassured me. "I worked too hard to get to this point. I won't forget. There are a lot of things I want to do in life. I'm not going to let OCD stop me."
I hoped he was right. My parting words at the end of our last session were, "My best hope for you is to never see me again, unless we bump into each other on the street in town."
"I'll do my best to keep things boring," he replied with a laugh.
Only time would tell if this would be so.
I still heard from Jesse occasionally. He likes to e-mail me every so often. It has been eight months; and he is continuing to do well. He's applying to colleges now. I look forward to seeing him do well at one in the near future.
Fred Penzel, Ph.D. is a licensed psychologist who has been involved in the treatment of OCD and related disorders since 1982. Dr. Penzel is the author of the self-help book 1"Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well" (Oxford University Press, 2000). He is the executive director of Western Suffolk Psychological Services, in Huntington, Long Island, New York, and is a frequent contributor to the OCF Newsletter and this Organized Chaos Webzine. He sits on the science advisory boards of both the Obsessive-Compulsive Foundation and the Trichotillomania Learning Center, and can be e-mailed at penzel@attglobal.net
