Brain Lock: Free Yourself From Obsessive-Compulsive Behavior (31 page)

Once we begin to grasp how these emotional factors play a role in Reattributing inappropriate obsessive-compulsive urges to their true cause, we become more aware of the kind of mental processes that a person with impulse-control problems must learn to use. People with impulse-control problems must begin to get a good grasp of the difference between who they really are and who they really
want
to be and the urge to eat, get high, gamble, or have inappropriate sex. As they begin to see this relationship more clearly, which may in itself require traditional, emotionally related psychotherapy, they will then be able to effectively use the Four Steps and genuinely apply the OCD battle cry, “It’s not me—it’s just my inappropriate urge.” As their insight deepens, they will increasingly perceive the difference between who they are and what that urge to act in an impulsive manner is. From my perspective, although brain biochemistry plays a significant role in these inappropriate urges, it in no way decreases the amount of personal responsibility a person must take for how he or she responds to these inappropriate urges. This is just as true for impulse-control problems as it is for OCD. The fact that your brain may be sending you a painful message that’s difficult to deal with does not decrease your responsibility for coping with the problem in a healthy manner and performing functional, rather than destructive, behaviors. This is where the Refocus step is as genuinely applicable to people with impulse-control problems as it is to people with OCD.

LOOKING INSIDE OURSELVES

Ultimately, of course, the first two steps of the Four Steps are designed largely to enhance a person’s ability to perform the Refocus step under his or her own reconnaissance. This is what the Impartial Spectator is all about:
trying to observe your own behavior as if you were observing the behavior of another
. Once your ability
to do so increases, you are able to Refocus on new and more adaptive behaviors. Of course, it’s very important to remember that these two processes are interactive and reinforce one another. The more you Refocus your behaviors, the stronger your Impartial Spectator becomes. And the stronger your Impartial Spectator becomes, the more readily you are able to Refocus your attention and change your behaviors to something more functional and healthy. This truth is also as applicable to people with impulse-control problems as it is to people with OCD. The challenge for people with impulse-control problems who wish to begin the process of the Four Steps is to look honestly into their own motives and their own goals for the future and to do the work required to separate their emotional lives from compulsive eating, drinking, gambling, or whatever.

When people do that, they begin to be able to utilize the Relabel and Reattribute steps more effectively, and they are on their way to creating an adaptive armamentarium of healthy behaviors to Refocus on, just as a person with OCD does.

To summarize: People with OCD have an advantage in starting the Four Steps because they already know that they are different from their urge to wash or urge to check. People with impulse-control problems need to arrive at that same realization. Once they do, they can apply the Four Steps in a similar manner to the way people with OCD do.

A final word concerning urges to pull hair out, which is the cardinal symptom of the OCD-related condition, trichotillomania. There is one very practical piece of advice I can give: When doing the Refocus step and trying to switch gears away from hair pulling, it is particularly important to develop alternate behaviors that involve the use of the hands. Many people learn to knit, crochet, do needlepoint, make pottery, play a musical instrument, or perform any of a variety of activities that involve using the hands. You can even do things as simple as squeezing a rubber ball or, when things get really difficult, clasping your hands together. Dr. Don Jefferys of Melbourne, Australia, reports that wearing the type of rubber finger guards used by people who count money or sort paper can be very helpful. It makes the hair much more difficult to pull, leading to a decrease in the urge. Some people are even helped by sitting on
their hands for fifteen minutes. Again, as always with the Refocus step, you try to use greater delays and notice even subtle changes in the urge after fifteen minutes or so pass.

Another very important point for people who pull their hair out is to try to become aware as quickly as you can when your hands have moved into your hair because people with trichotillomania can start pulling their hair without realizing it, just like chain smokers can light a cigarette without even realizing that they’ve done it. (By the way, everything I’ve just said about drug abuse and the Four Steps applies to quitting smoking.) Sometimes, as a joke, I have told patients with trichotillomania to get into the habit of saying things like, “It’s ten o’clock. Do I know where my hands are?” It actually helps and is, in fact, another way in which the Impartial Spectator brings mindful awareness. Automatic behaviors can sneak up on you and very easily take control; mindful awareness is your best ally in fending off unwanted destructive behaviors.

KEY POINTS TO REMEMBER

• The Four Steps can be applied to almost any behavior you genuinely want to change.

• The key to Relabeling and Reattributing is clearly seeing the difference between you and the behavior you want to change.

• Learn to consult your Impartial Spectator as much as possible in moments of weakness—this is how you can determine your true goals and interests.

8

The Four Steps and Traditional Approaches to Behavior Therapy

(Prepared in collaboration with Paula W. Stoessel, Ph.D., and Karron Maidment, R.N., UCLA Department of Psychiatry)

T
he treatment of obsessive-compulsive disorder (OCD) was revolutionized in the 1970s and 1980s by the development of behavior therapy techniques called exposure and response prevention. Here, I will briefly describe further developments of these now classical techniques at UCLA in the 1990s in the context of our work with the Four Steps of cognitive-biobehavioral self-treatment.

PART I: THE CLASSICAL APPLICATION OF EXPOSURE AND RESPONSE PREVENTION FOR OCD

Let’s begin by presenting an overview of classical behavioral therapy techniques. Whether treatment is done in the UCLA hospital or at the UCLA OCD treatment center on an outpatient basis, all people with OCD progress through the following stages: (1) assessment, including education; (2) collaborative design of treatment by the behavior therapist and the person; (3) exposure and response prevention; and (4) post-treatment follow-up.

1. ASSESSMENT

After the diagnosis of OCD is established by a thorough evaluation, including a structured interview, the person is clearly taught the
proper meaning of the words
obsession
and
compulsion
, as explained in the Introduction.

Once the person is clear about the true nature of obsessions and compulsions, a complete profile of all the person’s obsessions and compulsions is established. Included in this list of obsessions are internal and external cues that cause obsessions to occur and those associated with physical or bodily complaints or ailments. Compulsions include things that are inappropriately avoided and all types of rituals, as well as more typical compulsive behaviors, such as washing and checking.

At this point, the therapist explains the treatment and presents the rationale for treatment in behavioral terms, as follows:

Exposure and response prevention is designed to break up two habitual associations: (1) the association between obsessions and anxiety and (2) the association between anxiety and the performance of compulsive behaviors in an attempt to get relief from anxiety.

In addition to presenting this classical behavioral approach to OCD treatment, the behavior therapist explains the neurobiology of OCD, as described in Chapter Two, which helps the person conceptualize this disorder as a medical problem. The medical model frees the person from self-blame, destigmatizes OCD, and helps the person overcome the shame of having this disorder. At UCLA, we emphasize that the biological aspects of this disorder may be influenced by genetics, but that genetics and biology in no way interfere with the response to behavior therapy. In fact, behavior therapy, as well as psychotropic medication (see Chapter Nine), has been found to be efficacious in the treatment of the underlying biology of OCD.

2. COLLABORATIVE DESIGN OF TREATMENT

The treatment design is a collaborative effort between the behavior therapist and the person with OCD. Each obsession and each compulsion are assigned a value that indicates subjective units of distress, or SUDS, on a scale of 0 to 100, in which the item at 100 is the most anxiety-provoking to confront. Obsessions and compulsions are then arranged in a behavioral hierarchy, with the least fear-provoking items at the bottom and the most at the top. (This is what Professor Gallagher, at the beginning of Chapter One, failed to do.)
Generally, 10 to 15 items are represented on a person’s hierarchy, and the treatment begins at a SUDS of about 50.

A hypothetical hierarchy of a patient with contamination fears might be:

SUDS

100 urine

  95 toilet seats

  85 handle on toilet

  80 toilet paper roll

  75 bathroom doorknob

  70 faucet handles in bathroom

  50 sticky substances like jelly

An OCD patient with primarily checking concerns might construct the following hierarchy:

SUDS

100 stove burners

  95 light switches

  90 kitchen appliance plugs

  85 heater

  80 bathroom heater

  70 locks

  60 doors

  50 television

These hypothetical hierarchies are simplified for the purpose of clarity. It should be noted that many people with OCD have very
complex obsessions and compulsions. However, the goals of behavior therapy are the same, regardless of the complexity.

3. EXPOSURE AND RESPONSE PREVENTION

Once the hierarchy has been constructed, the person is ready to begin treatment. As with the design of the treatment plan, the person is encouraged to collaborate with the therapist to develop assignments.

Exposures are conducted during the therapy session and again at home. The first assignment begins at a SUDS of approximately 50, and then progressive assignments move up the hierarchy until all items on the hierarchy have been addressed. The person is anxious during exposures, but his or her anxiety decreases over the next ninety minutes or so. (Reminder: These are the classical behavior therapy techniques that are done with the therapist’s assistance. When the Four Steps are used in self-treatment, the tasks are broken down into smaller bits, and the fifteen-minute rule is used, as described in Chapter Three.) Each time the exposure is repeated, the anxiety level lessens. If there is no anxiety, the exposure is not difficult enough. If the anxiety is too overwhelming, the assignment must be adjusted so it is appropriate.

At UCLA, we ask people with OCD to do exposures at least twice a day and to refrain from responding with a compulsion until the anxiety level goes down. This exposure is repeated until the initial anxiety, or SUDS, of the exposure becomes manageable; then the next item in the hierarchy is confronted. An example of an initial exposure for the man with contamination fears would be to put jelly on his hand and to have him refrain from washing until his anxiety decreased. He might begin this exposure with a SUDS level of 90, indicating that the jelly made him extremely anxious, and then end it ninety minutes later with a SUDS of 30. The therapist would be present or easily reachable the entire time. The second time he did this exposure, the beginning SUDS would probably be around 75 or 80 and would decrease to less than 30. The SUDS will continue to decrease with each exposure. The woman who checks would be asked to leave home to come to the therapy session without check
ing the television and not to return to check until the session was completed. As with the man with contamination fears, the woman’s initial anxiety, or SUDS, would be high at the start, but would decrease over time within a given exposure. The intensity of symptoms tends to decrease with each subsequent exposure and response prevention. However, since the initial anxiety and resulting SUDS scores can be quite high as the hierarchy gets more difficult, more assistance from the therapist may be needed.

Through exposure to the obsession without responding with a compulsion, the person breaks the association between the obsession and anxiety, since the anxiety goes down each time the exposure to the obsession is repeated. In addition, the compulsion no longer serves the function of reducing anxiety. So, the loop between the obsession and compulsion that was once so demanding, fear-producing, and self-perpetuating is broken. In other words, the person must confront the obsessive fears generated by an obsession and not act on the compulsion in order to break the cycle of obsessions and compulsions. This change in thoughts (obsessions) and feelings (anxiety) is accomplished by changes in behavior (compulsions).

4. POST-TREATMENT FOLLOW-UP

The person with OCD who has completed every item on his or her hierarchy is encouraged to follow up as an outpatient, or at least to have telephone contact for the next six months. If a new symptom emerges, the person is taught to continue to do exposure and response prevention twice a day, as he or she did during treatment.

PART II: APPLYING THE FOUR STEPS

The Four Steps can be combined with these classical treatment techniques very effectively. By regularly using the Relabel step, people with OCD become increasingly aware of their more subtle symptoms and the things they avoid doing because of their fear of OCD symptoms. Relabeling helps them create a complete symptom profile when preparing a SUDS behavior therapy hierarchy. The regular use of the Relabel and Reattribute steps helps them manage their
responses to anxiety, which, in turn, enables them to do the exercises in exposure and response prevention. This process can lead them to work their way up the SUDS hierarchy more assertively.