Recently a man in his early 20’s named Allen came to see me. He was extremely upset and anxious and could hardly sit still. When questioned about why he had made the appointment he answered, “I have seen several therapists about problem thoughts I have, and as soon as I told them they suddenly treated me very differently, and as if they were really cautious and afraid to work with me. Some of them even suggested hospitalization. Some of the things they told me made me feel worse rather than better. Please listen and give me an honest opinion because I’m sick of people thinking I’m an unstable danger to myself and someone in need of supervision.”
“Okay,” I said.“ “Tell me what it is, and I promise to not make any judgements until I have all the facts.” Allen proceeded to explain that six months before, he had been streaming a movie in which one of the characters committed suicide. He explained that all of a sudden, the thought came to him, “Would I ever do something like that? If I did, how would I do it? What would it be like?” “From that point on,” he said, “I couldn’t get the thought out of my head and would curl up in bed when it got really bad. I couldn’t even look at or hear the word without breaking out in a sweat.” Allen went on to tell me how much this was limiting his life and how he had been avoiding his friends and family. Sometimes it kept him from going to work. The anxiety became so severe at times that it made him throw up. He said that he could no longer handle knives or sharp objects for fear that he might harm himself. He also hesitated to drive his car at times for fear of crashing it on purpose. He finished by explaining that deep down he was sure he really didn’t want to kill himself, never wanted or attempted to, and never had a plan. “The real torture,” he said, “is this constant question where I ask myself - why couldn’t I stop thinking about it if I didn’t want to do it? Was it really some kind of unconscious wish?”
I, of course, made sure to carefully assess Allen for depression and suicidal potential, as I do as a part of all my intakes. After much intensive questioning, I concluded that the real problem was OCD, which was causing constant, intrusive, doubtful thoughts about suicide. I explained this to him and tried to give him an idea of what OCD was and could do. I started by explaining that it was once known as “The Doubting Disease.” and told him that obsessions could be about virtually anything at all. In general, it can tell you all kinds of negative occurrences that can happen to you, those close to you, or even strangers. No one can really say why a person’s OCD picks a particular theme; only that it seems to have an insidious knack for picking out topics that will really get to you and give you doubts about them. Intrusive suicidal thoughts can take different forms, such as:
· “Do I really want to die?”
· “Why would I keep thinking about it if I really didn’t want to do it?”
· “Is my anxiety the only thing keeping me from carrying it out”
· “You’re depressed and will kill yourself.” Or “You’re depressed and don’t know it and will kill yourself.”
· “I’m a really bad person, I don’t deserve to live and must kill myself.”
· “What if I suddenly lose control, go crazy, and act on my thoughts?”
· “If I was going to do it, how would I make it happen?"
· “How do I know this isn’t some kind of an unconscious wish?”
· “Why don’t I just do it right now?”
· “What if I swerve my car into oncoming traffic, off a high point, or into a bridge abutment?”
Of all obsessive topics, one of the most misunderstood, and mistreated would be obsessions about suicide. It’s not only a topic that can really shake a person up, it also happens to be one that can give even experienced therapists sleepless nights. The problem is that suicidal obsessions can sound a lot like suicidal thoughts seen in those who are deeply depressed, desperate, and hopeless. It is all too easy for a therapist to diagnose someone with suicidal obsessions as suffering from depression. A therapist’s worst nightmare is losing a patient to suicide and something to be prevented at all costs. A therapist’s greatest responsibility is to protect their patients. Unfortunately, many therapists lack the training or experience to be able to tell the difference between genuine suicidal thoughts, and obsessions about suicide caused by OCD. In many cases, therapists will take some kind of action to protect their patient from what they believe is a real threat and not take any chances. This can include warning family members, having people placed under constant supervision, having them sign agreements that they will let the therapist know if and when they are feeling suicidal, and even hospitalizing them. In the case of OCD, this can obviously worsen someone’s symptoms.
It doesn’t just stop with the thoughts, however. It is human nature and seems instinctive to take obsessions seriously, to treat them as real thoughts, and to take action to prevent them and the anxiety they cause. Also, the thoughts can be almost constant and very ‘loud.’ The things that people do to try to stop these thoughts and the anxiety are what are known as compulsions. Unfortunately, they are also the opposite of what will solve the problem. If mental health professionals often misunderstand what the thoughts actually are, what chance does the ordinary person have? Some people wrongly believe that OCD makes them carry out compulsions. The reality is that they, themselves, are the ones who come up with them. They practice compulsions until they become almost automatic habits that are difficult to resist. This convinces them that OCD is stronger than they are. I tell my patients, “All OCD can do is tell you things but can’t make you actually do anything.
There are many types of compulsions that people invent to avoid obsessions and deal with anxiety caused by them. These could typically include such things as:
· Avoiding seeing, hearing, or saying the word ‘suicide’ or related words
· Not wanting to be left alone
· Checking for the presence of suicidal thoughts
· Checking and monitoring your own reactions to thoughts of suicide to determine if the idea is repulsive to you or not (if it isn’t, it supposedly means you will kill yourself)
· Avoiding contact with knives or other sharp objects
· Avoiding high places, busy intersections, railroad platforms, or bridges you could jump from or run into
· Not watching any videos, websites, movies, or TV shows having to do with suicide
· Saying special words or phrases or visualizing special images to cancel or reverse thoughts of suicide
· Repeatedly asking others for reassurance about the possibility you will not commit suicide
· Doing mental rituals to cancel images of people who have committed suicide
· Avoiding driving potentially tempting routes for crashing or driving alone
The leading and best researched treatment for OCD is Exposure & Response Prevention (E&RP) which has been around for over half a century. This is what I explained to Allen and proposed that we do. I told him that since we are simply unable to remove thoughts from the mind, our next best goal is to build up tolerance to them to the point where they no longer have any impact. Essentially, we would try to make him ‘obsession-proof’ by learning to face and stay with his thoughts while learning to let go of his compulsions. I like to tell my patients, “You can’t be bored and scared at the same time.” The real problem, I told Allen, is the compulsions and not the anxiety. “My favorite Zen saying, I told him was, “Facing what you fear is a way of getting closer to the truth.” Avoidance would only lead him to more avoidance. As nasty a topic as suicide was, if he wanted to overcome it, he would have to face it sooner or later. He agreed that although he didn’t look forward to facing his suicidal thoughts, he’d had enough and just wanted to get his everyday life back. He guessed that anything he would have to do in therapy couldn’t be worse than what he went through daily.
At the same time, I also referred him for medication; an SSRI-type antidepressant, as his symptoms were fairly severe. It lowered his anxiety and the intensity of his thoughts enough that it gave him an edge in facing both of these things.
We set up a program for him beginning with a listing of all his feared situations, thoughts, and activities and rated each one from 0 to 100. Then we began to assign structured homework he would carry out on his own, beginning with things rated at about 20 to 30. I’m a big believer in self-directed treatment. It teaches people to be their own therapists and is closer to what real life will be like once therapy ends.
It is important to understand that OCD treatment can be very paradoxical. That is, the things that people do to make themselves better only seem to make them worse, and many of the things they believe will make them worse actually end up making them better. While I think that treatment must be tailored to each person, I start most patients with what I call my Three Permanent Assignments. I tell them that these are always in effect no matter what else changes about their homework. These are:
1. Try to agree with your obsessions and let them be there. Say they are true.
2. Do not try to study or analyze your thoughts. Only agree.
3. Avoid all forms of reassurance from both yourself and others – go for the worst scenario
In the case of suicidal obsessions (after fully establishing that they are obsessions) this means simply saying, “It’s true” or “It will happen” when they occur and leaving it at that. The goal is to keep things simple and to not try to analyze one’s thoughts to see if they actually are obsessions or what they really mean. This kind of analyzing is a compulsion and must be extinguished. In addition, they have to resist reassuring themselves with statements like, “It’s just my OCD,” or “This thought is stupid,” or “I would never do anything like this.” This is a trap, as this would then be a compulsion, which again, must not be performed if recovery is the goal.
We built up further homework using these three assignments as a foundation. Each week we reviewed his work and continued and modified items on his list. Allen learned to gradually agree with his thoughts, and to resist the things he did to escape and avoid the resulting anxiety. He found that although it wasn’t easy, it wasn’t too hard either. He started to realize that if he just stayed with what he feared long enough, his anxiety would gradually decrease. He began to trust that this would happen and was able to face increasingly more difficult things as we continuously upgraded his homework. This didn’t happen overnight, but after a number of months of work he became compulsion-free and found that the obsessions no longer had any impact on him. He realized that even though he would still get some thoughts, he now had tools to manage how he dealt with them. He finally concluded, I’m just not interested in this topic anymore.”