Brain Lock: Free Yourself From Obsessive-Compulsive Behavior (30 page)

Deep down, she knew that Guy was “a really steady, nice guy.” She’d never seen any untoward behavior; in all the time she’d known him, she’d never even seen him drink too much. Deep down, she understood that because of her own insecurities, she was trying to sabotage a wonderful relationship. What she did not know was that
she had OCD. That summer, when she was at her worst, Guy asked her to marry him. “Really crazy, huh?” he laughs now. Soon, however, both began having serious doubts about a future together. Anna remembers, “We had a number of confrontations where I was screaming at him, saying he’d lied to me because I’d asked him if something had happened on Wednesday or Thursday or whatever and he would have gotten it wrong. I’d think, ‘Okay. I’m going to have to break up with this guy. He’s lying.’” In reality, he was just trying to get her off his back. He wouldn’t remember each answer he’d given her, but she would.

Back in Los Angeles, they sought help for her and were referred to me at the UCLA Neuropsychiatric Institute. By this time, they were living together and were both in stressful periods of their lives. She was in graduate school, and he was starting a job in academia—a job to which he could not devote full attention. Guy looks back on this time as “sort of a daze. We were trying to get through this mess, and I wasn’t sure whether Anna was the problem or if I was totally incompetent as a teacher.”

I diagnosed a classic case of OCD. This was nine years ago, and Anna was one of the first patients to whom I was able to explain, with some certainty, that the problem was the chemical imbalance in her brain I call “Brain Lock.” Told that she had a brain disease, Anna was greatly relieved and anxious to begin treatment. The Four Steps of behavior therapy had not yet fully evolved, but for the first time I applied the fifteen-minute rule in a systematic fashion.

Whereas family members sometimes try to sabotage the treatment of a person with OCD because they are fearful that the person will change, will refuse to continue to be the family doormat, or whatever, Guy was eager to help Anna. He understood, “This was not the person I loved. This was not her doing these crazy things. It was
happening
to her, and she was in pain.” Early in treatment, there were many times when it would have been easier for him just to answer her questions, but he understood that doing so would not help her get well. So he set some ground rules: He would answer one question, not a long string of them, and then make her wait fifteen minutes before he would answer another. They would fight, and she would cry, but Guy had the insight to see that the fifteen-
minute rule was more than just a waiting period; it was an implicit recognition that her questions were ridiculous, that they weren’t her—they were her OCD.

He says, “It was hard for her to choose who to trust. When I said, ‘This is your OCD,’ she would demand to know if maybe it was just a question that I didn’t want to answer.” He constantly reassured her, “It’s just the OCD. Don’t worry about it.” Very calmly, he would tell her, “I can answer your questions if you really want me to,” but he would always remind her that the problem was not her need to know the answers. Her problem was OCD. “The first three months were just traumatic, the antagonism between her and me.” She would stalk out of the room, slamming the door, or just sit on the bed crying. Since they lived in a small apartment, each would give the other space, literally and figuratively. One would go into the kitchen and the other into the bedroom for fifteen minutes. Sometimes, Guy acknowledges, they were putting the fifteen-minute rule into play, but not in a constructive manner: “One of us would just go off and sulk for a while.”

As Anna’s treatment progressed, Guy was able to say to her, “Do you really want me to answer your question?” and she would say no. A big step forward. “On those occasions,” Guy says, “she was so happy. We both knew that there was no real point in my answering the question. She’d already asked the question in the past, and I’d already answered it, but she’d forgotten the answer. Therefore, by osmosis, there could be nothing to be worried about.”

Anna hated what OCD had done to her, and she was motivated to work hard to get well. For weeks at a time, she would be able to resist asking questions. He says, “Anna knew that she had to get on with her life and that if she could get rid of this thing, she could.” In the short term, the trade-off was not an easy one to make: fifteen minutes of waiting in very real anguish with the promise of long-term relief versus the very real and immediate relief she could get by asking her questions. Guy says, “Deep inside, Anna knew that it was just her brain doing this to her, so the value of carrying out the compulsion really fell when she identified it as OCD. Every week that goes by, every week that this thing preys on your life, the value of not succumbing to the negative impulse increases. Anna would
use words like, ‘I have to remain vigilant.’” Guy knew that she was in terrible pain because she would start frantically checking and rechecking things around the house. She would become moody and withdrawn. “If I’d come home half an hour late, she’d be very upset. I hadn’t done what I said I was going to do when I said I was going to do it.”

As the months went by, she became increasingly confident that she could control the symptoms of OCD. Guy was her partner in behavior therapy. He would say, “Look, you’re getting down because you’re feeling a little bit more of the OCD today. But over the last week, it really hasn’t been that bad.” Or, “It’s been pretty bad this week, I know that.”

Anna had eighteen months of weekly outpatient behavior therapy—with small dosages of medication as her waterwings. During this time, she says, “Guy learned a lot about how to handle me. Before, he used to just get mad and say, ‘You’re torturing me. Stop doing this.’ But once he realized what it was, he was very strong about saying to me, ‘I am not going to participate in this obsession. I am not going to answer your questions. You can do whatever you want, you won’t make me answer these questions. So take your fifteen minutes, come back in fifteen minutes, and we’ll talk.’ I credit him a lot for my recovery. So many family members are just not helpful at all, but he was really there for me, pointing out when it was OCD. Many times, of course, I didn’t believe him. I’d say, ‘Oh, no, it’s not. This is real. I really need some help.’ And I’d be desperate for him to answer one of my questions or to verify some fact—but he just wouldn’t do it. I got very mad at him sometimes, but it helped. It really helped. Before treatment, this would have infuriated me as a suspicious obstruction. Now, however, I could see it was a positive step for my own good.”

Guy is well aware of how much effort Anna—with his help—put into getting well. “In some ways,” he says, “we were lucky because I was implicated just by the very nature of her OCD. It’s not clear to me that if she’d had a serious hand-washing problem, I’d have been involved in quite the same way. It was easy for me to see that there was a problem and to participate in the therapy because I was so involved.”

Now and then, Anna still has one of her crazy thoughts. They tend to be “What if?” questions that are unanswerable. Lying in bed one night, she began obsessing, “What if my husband is gay?” But she quickly turned to Guy and told him she was having this crazy thought and that she knew it was OCD. He said, “Yeah, you’re right. It’s OCD. It’s ridiculous.” And he went back to sleep.

Anna completed a demanding doctoral program, and both she and Guy have rewarding teaching careers. They have been happily married for four years and have a baby.

Anna now describes her life as “normal.”

KEY POINTS TO REMEMBER

• OCD always involves the family.

• Be aware of how OCD symptoms affect your loved ones.

• Be aware of using OCD symptoms as a way of distancing yourself from the needs of your loved ones.

• Avoid at all costs using OCD symptoms as a way of demonstrating anger or annoyance at your loved ones.

• Help family members learn more about OCD and the Four Steps to help them avoid nonproductive criticism and facilitating your symptoms.

• Family members can make excellent cotherapists. Encourage them to help, not criticize.

• Mutual acceptance in the context of constructive interaction is very conducive to improved performance of the Four Steps.

7

The Four Steps and Other Disorders

Overeating, Substance Abuse, Pathological Gambling, and Compulsive Sexual Behavior

P
eople frequently ask what the difference is between treating obsessive-compulsive disorder (OCD) and other disorders, such as eating disorders. How does this Four-Step method apply to other common conditions that may also be related to OCD? As with OCD, the serotonin circuits seem to be involved in the treatment of eating disorders and other types of impulse-control disorders like pathological gambling, drug and alcohol abuse, and compulsive sexual behavior.

The major difference between treating OCD with the Four Steps and treating these other disorders is that with OCD, people always find the urge to do the compulsive behaviors unpleasant. They complain not only that they wash and check too much but that they feel totally besieged by urges to wash and check, which they themselves view as entirely inappropriate and want to get rid of once and for all.

Unfortunately, from the perspective of treatment, the desire for change is not so straightforward with the eating and substance-abuse disorders, compulsive gambling, and sexual behaviors. Clearly, people who have eating, drug, gambling, and sexually related behavioral problems find the excessive nature and the poor impulse control surrounding those behaviors problematic. Then again, people obviously don’t want to stop eating altogether, and many drug abusers
would prefer to be able to use drugs in a controlled fashion. The same is true for gambling and, even more strongly, for the sexual behaviors. So the key problem in treatment is, how much can people with these disorders make the excessive, problematic behaviors “genuinely ego-dystonic,” that is, how much can they come to find their behaviors genuinely foreign to their own notion of who they are and what they want, as people with OCD do with the urge to wash and check?

HIDDEN AGENDAS

Because of this difference, applying the Four Steps to the eating, drug, compulsive gambling, and sexual behaviors requires additional work. You can think of this work as the need for additional steps. People with the impulse-control problems have to do a lot more work than even an OCD person does to clarify the role that these behaviors play in their lives and how much they really want to stop doing them. People with OCD also have a lot of hidden reasons to cling to their own compulsive behaviors as an excuse for not fully dealing with some of the genuine difficulties that reality brings. These reasons are often related to their relationships with their families and their fear of taking on greater personal responsibility.

However, it is also true that people with OCD genuinely do not enjoy on almost any level washing things over and over again and checking things over and over again. They also quite clearly recognize these behaviors as foreign to them, so getting them to acknowledge, at least to some degree, that they may be using these behaviors to fend off dealing with other unpleasant or anxiety-provoking aspects of reality, especially those that involve interpersonal relationships, is often not that difficult. The other impulse-control problems are sometimes considerably more complex, primarily because many people with these problems genuinely enjoy certain aspects of the pathological behavior—whether it is eating, taking drugs, gambling, or sex. These behaviors have what’s called in classical behavioral therapy theory “primary-reinforcing properties.” In other words, people as well as animals can be induced to work and exert effort to attain food, sex, or drugs that cause pleasant feelings.

This fact is extremely well known by many people in addition to professional mental health workers. So, the key difficulty that we have to deal with before we can apply even the Relabel step to the general category of impulse-control problems is how much a person really wants to stop doing this behavior and how much he or she is willing to let go of the pleasure experienced by doing the behavior—especially when the problems are in their early stages, before the behaviors become totally pathological.

As you can see, there is more of a need for what is commonly called willpower in overcoming the urge to eat, to drink or take drugs, to gamble, or to engage in sexual activity than there is in getting a person to stop washing or checking. Therein lies the dilemma. When people say “That’s not me—that’s my OCD,” they almost immediately realize that they don’t want to check or don’t want to wash. Much of the effort involved in perfecting your performance of the Four Steps revolves around further deepening your insight into the fact that this urge is not really you and is just caused by a false message from your brain. But this job is considerably more straightforward than it is for those who have eating, drinking, drug, gambling, or sexual problems. The key factor that determines how applicable the Four Steps are to problems of impulse control is the degree to which the person with the problem is able to separate his or her own self-concept from the behavior that is causing the difficulties.

CALLING AN URGE AN URGE

Even for people with OCD, much effort is required, especially to become profoundly aware of the difference between them and the OCD. But OCD is genuinely ego-dystonic: People view the urge to wash and the urge to check as foreign to them. The degree to which a person with impulse-control problems can come to the realization that “It’s not me—it’s just my inappropriate urge to eat, drink, take drugs, gamble, or have sex” tells us the degree to which the Four Steps will be helpful to them as a means of doing cognitive-behavioral therapy. In this regard, you can also begin to get a deeper understanding of the meaning of the Reattribute step. Although the
Reattribute step helps you understand that the urge to wash and the urge to check are caused by false messages coming from the brain, many people come to understand that part of the urge is related to an emotional need to avoid intimate interpersonal relationships and unwanted personal responsibilities.