Intensive vs. Self-Directed Treatment

There are currently two major models for how outpatient behavioral therapy for OCD is conducted. The first model, and perhaps the better known of the two, is Intensive or Therapist-Directed Treatment, and is taken from the original treatment that was conducted when behavioral therapy for OCD first began. It involves daily treatments of about ninety minutes in length for a period of three to four weeks. A therapist is present throughout the exposure, and directs and guides the patient through exposure exercises. There is about 30 years worth of scientific literature on the efficacy of this approach, and it has been an accepted means of treatment throughout that time. I was originally trained in the use of this model, and practiced it faithfully for a period of about 8 years in just about every home, office, and public setting there is.

The other model is known as Self-Directed or Home-Based Treatment, and has actually been around longer than many people realize. It first evolved in Europe in the 1970's, possibly as a response to the needs of socialized healthcare, where resources for each patient were more limited, and costs had to be contained (sort of like here, these days). According to this approach, patients are seen on a once-per-week basis at a therapist's office, and are sent home with homework assignments to carry out on their own. Their progress is monitored at their sessions, they are debriefed on what they accomplished the previous week, and given feedback, and new assignments, where appropriate. Sessions are also used to build motivation, discuss other life issues, and to do some cognitive therapy as well.

There are studies that also attest to the efficacy of this approach. In 1977, Drs. Paul Emmelkamp & Joost Kraanen published the first study that demonstrated its effectiveness. In this study, no difference was found between self-directed exposure and therapist-controlled exposure, and in fact, self-directed exposure was consistently superior to the therapist-controlled exposure at a one-month follow-up. In another study by Emmelkamp & De Lange (1983), self-directed exposure was tested against spouse-aided exposure, and both were found to be equally effective. Dr. Isaac Marks and others (1988) showed that self-directed exposure was as effective as therapist-controlled exposure, despite the fact that the therapist-directed treatment group received 5 times more treatment. Finally, in 1989, Dr. Paul Emmelkamp and colleagues showed again that self-directed exposure was as effective as therapist-controlled exposure.

Over the last 12 years, I have become an advocate for the self-directed approach to treatment. In 1990, while doing a literature search for a talk I was putting together, I ran across the studies by Dr. Paul Emmelkamp and others, and this coincided with the opening of my own OCD clinic. I had been finding it frustrating that the insurance companies were beginning to balk at paying for daily exposure treatments, and I was also finding it frustrating that I could only work with a small number of patients perhaps about 10 to 12 per week at any given time, although there were very large numbers of people in my area seeking treatment and not being able to find it. Using the European model, I could reach over 50 people per week. Having worked according to this model for the last decade, and having the experience of treating close to 400 cases in this way, I feel that it has some particular advantages as compared to therapist-directed treatment. The following is an outline comparing the advantages and the disadvantages of the two approaches.

The advantages of Therapist-Directed Intensive Treatment are that:

• It can lead to rapid change and get you off to a running start

• It is useful for the most severe cases to be in an environment that can be temporarily totally controlled to prevent relapse or non-adherence to instructions a kind of brief, total immersion.

• It can help in cases where you really want to recover, but just feel too anxious, demoralized or helpless to bring yourself to follow instructions on your own.

• It can be practical if you do not have any appropriate sources of therapy near where you live, and have no option except to travel to where an intensive program is located, for briefer, more concentrated treatment.

The disadvantages of Therapist-Directed Intensive Treatment are:

•  It is over after a few weeks, possibly leaving you without support or help with maintenance and open to relapse if you went to a program far from home and do not live near a source of post-discharge follow-up or booster therapy sessions. I have seen this happen to a number of people. If you are getting this treatment locally, this is obviously not a problem.

• It is too disruptive if you have a job and family and cannot easily take a month off from everything. If you are doing this locally, this may be less of a problem.

• In many cases, the three to four weeks are not sufficient, especially where there are dozens of compulsions and numerous obsessions to be dealt with. Insurance companies are not usually supportive of long courses of intensive treatment (if at all). 

• It rapidly uses up insurance coverage if you have yearly or lifetime limits, leaving you uncovered after discharge or even sometimes without enough time to carry out the full treatment.

• If conducted far from home, it can leave you unprepared to face symptoms that occur in your own real world environment, since the treatment is conducted in a safer, more controlled setting where many feared things from home cannot be brought or reproduced for exposure therapy purposes.

• The ever-present supervision may keep you from developing the feelings of self-efficacy and

• It may allow patients to avoid confronting the full range of the anxiety and feelings of responsibility and guilt that accompany their symptoms. It is easy to simply tell yourself that if anything bad does happen, it is the therapist's fault, and not yours, because they made you do whatever it was.

• If you have no insurance coverage, it is extremely expensive, requiring large sums to be paid in a short period of time (sometimes in advance) that may be out of the reach of many ordinary people.

• The three-or four-week time limit of many programs can put unnecessary pressure and stress on you, and may make you feel that you are a failure if you cannot recover sufficiently by the end of the set time period.

• Conversely, the time limit can also create unrealistic expectations on your part, or your friends and family members who believe that recovery will be complete by the end of your intensive treatment, when often it is not.

 The advantages of Self-Directed Treatment are:

•  It allows you to be treated in your own home setting, a place where symptoms have originated, and where the work of therapy really needs to take place, assuming help is nearby.

• Doing assignments on your own at home is a lot closer to what post-therapy self-maintenance will be like, and this teaches you how to be your own therapist and develop your own resources.

• It boosts personal feelings of effectiveness and self-control by allowing you to take your assignments home and be responsible for doing them without supervision. It is clearly much better for you to be able to say that you did an assignment because you made yourself do it, rather than because a psychologist or other staff person was standing over you. I believe that everyone has to essentially face their OCD themselves (with the exception of the most seriously ill) if they are to make the best recovery. No one can do your work for you. Along with behavioral change, it is vital that each sufferer be helped to develop the feeling that they are personally responsible for the management of their illness.

• It forces you to confront your own anxiety and feelings of hyperresponsibility, as you are not now in a position to blame anyone for making you do the homework. The therapist may have assigned it, but you had to make yourself do it.

• If you are submitting your therapy visits to a health insurance plan, they are more likely to pay for treatment. It is what they are familiar with, and they won't fight about it.

• Costs are spread over a much longer period which is somewhat easier if you are paying out of pocket.

• It allows sufficient time for those who have numerous compulsions and obsessions to have their symptoms treated in-depth and more completely when visits are spread over a longer time span. It allows more time for a greater variety of assignments to be carried out.

• It allows more between-visit time for assignments to be done a greater number of times, and for the development of greater tolerance of feared situations to occur.

• The lack of an exact short term time limit discourages you from perfectionistically pressuring yourself about recovering by a particular date, and also helps family and friends to be more patients and realistic about seeing the therapy as a process and not an event.

• It allows those who work outside the home or those who raise children to keep up their responsibilities while working on recovery, sparing the family added unnecessary stress and even further expense.

• It permits the therapist to observe and become acquainted without you, your world, and your symptoms over a longer period of time, allowing him or her to spot other problems that also need to be confronted in therapy, which could have a negative impact on your recovery if not treated. Some symptoms can be quite subtle, and may not be apparent at first.

• It allows more time for teaching maintenance and relapse prevention skills that will keep you well long after therapy has finished.

• There is sufficient time for spouses and other family members to attend sessions to be educated about the disorder, and to be given a role in treatment when necessary.

The disadvantages of Self-Directed Treatment are:

• It may not be suitable for the most seriously ill, who need constant supervision and structure in order to follow instructions.

• You may not have anyone nearby to see for outpatient therapy, making a visit to an intensive treatment program away from home necessary (although follow-up will still be a problem).

There are a fair number of therapists who routinely offer intensive daily treatment on an outpatient basis to every patient who comes their way. This seems to me to be impractical. Many individuals are functioning well enough to come to an office and take home assignments in the first place, and don't need to come for treatment five days per week. There would seem to be no allowance made for different levels of severity. Also, if a patient is so ill that they really need daily supervision in order to succeed, then they probably would be better off in an inpatient setting getting intensive treatment. One could make a valid case that intensive outpatient treatment is a less costly way for the seriously ill (who can make it to an office) to be treated. There is really no argument about this. Daily ninety-minute sessions are still very expensive, but certainly less so than inpatient treatment. The one exception to all of this is that insurance will sometimes cover inpatient treatment, but it will not always cover intensive outpatient treatment.

In my own practice, I routinely use self-directed treatment, and that seems to suit the needs of the majority of patients. I will see them at most two times per week (although even this is not usually necessary). When I do get patients whose symptoms are too severe for them to benefit from this approach, I refer them to more intensive inpatient programs.

Obviously, you may have to work with whatever is available locally; however, I am trying to make a case for adjusting the level of treatment to the needs of the patient, and against simply putting people into one-size-fits-all canned programs. I believe that by doing this, more OCD sufferers could be helped with the resources we currently have, and at lower cost.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com

Obsessive Love (When People Become "Obsessed" with Other People)

I recently visited my local library searching for current articles on OCD that might be of interest to my support group. The periodicals file is computerized so I conducted a search of articles on Obsessions, Compulsions and both together. I suppose a system is only as good as the knowledge of the person who programs and updates it. What I discovered under the topic headings was a mix of a few articles in the more well-known magazines, together with a group of writings which were shockingly out of place and so misleading that at first j. thought I had accessed the wrong topic. I came across such titles as "1 Love You To Death," "Crazy Love," "A Stranger Was Stalking Our Little Girl" and "Twisted Love: A Deadly Obsession."

To the uninformed reading these, it would appear that people with OCD are either a bunch of dangerous sweet-talkers, or delusional or violently jealous maniacs, posing a risk to anyone foolish enough to get into a relationship with them and who then want to break up. While I was aware that this misconception existed, it seemed to me to be more widespread than I had ever imagined. How could they be so ignorant? After all, these articles were from widely distributed popular magazines. There are those with OCD who actually have obsessions which involve others. I have met and treated quite a few over the years, but they are hardly dangerous, delusional or violent. These types of OCD seem to fall into the following categories:

1. Obsessions that one will have to break up with someone .they care about,

2. Obsessions that the person will want to break up with them,

3. Obsessive and doubtful questions about why one has broken up with someone,

4. Obsessive and doubtful questions about why the other person has broken up with them,

5. Obsessive doubts as to whether one has harmed, injured, insulted or embarrassed a particular person, often someone close,

6. Obsessive questions about the other person's past.

These types of obsessions are usually accompanied not only by compulsive rumination and analysis, but frequently by attempts to question the other person, either face-to-face, by phone, mail, or via a third party or parties. Here is where, I believe, the confusion about this type of OCD occurs. Generally, the OCD sufferer, when tortured by doubts, may repeatedly question or search for information. This may be the result of the individual with OCD being unable to process infor-mation on their particular obsessive topic, even though they might actually have enough to answer their question. Therefore they erroneously believe that more information will solve their problem. The more they question, the more the doubts increase. Gradually, this questioning strikes the other person as strange and begins to bother or annoy the other person who is being questioned inappropriately. They may respond with annoyance, graduating to hostility and in many cases, withdrawal from the rela-tionship and finally from all contact with the OCD sufferer. This withdrawal, of course, only serves to increase the sufferer's distress due both to rejection by the other person, and to their source of information being cut off. If, in addition, their obsession is about losing the other person, this can really drive anxiety and distress levels through the roof as the behavior paradoxically served to make the obsession come true.

This is where some of the really desperate behavior on the part of sufferers begins to be confused by many, with that of individuals who are delusional, pathologically jealous, or otherwise out of touch with reality. (None of which, by the way, have anything to do with OCD.) The person with OCD may go to great lengths to pursue the person to ask their relentless questions, and I have seen several cases where they would even manipulate to the point of threatening to harm themselves or do desperate things if their questions went unanswered. The other person may, at times, be driven to seek legal help, such as an order of protection, fearing harm from the person with OCD, not realizing the actual basis of the pursuit. The harassment here is unintentional on the OCD sufferer's part, but it does turn out this way, unfortunately. The disorder can become so all-consuming that they may overlook the needs of others without meaning to. I have never heard of anyone being harmed by a person with such an obsession,. nor can I imagine they would do more than simply be persistent and very frustrating to talk to or deal with, at times. Naturally, when they recover, they would never dream of behaving this way. Some have described it to me as feeling "like waking up from a nightmare" to find out that you have lost relationships with friends and loved ones, sometimes permanently. Fortunately, there are also cases where the sufferer has gone hack and explained what the problem was and was treated with understanding.

There is another type of non-OCD disorder called "erotomania" in which the sufferer has delusions that they have a relationship with another person, that the other person knows about, but is "keeping secret." Sometimes the other person can be someone famous. A good example is the woman who believes she is David Letterman's wife and keeps breaking into his house. Again, this is not OCD.

My hope is that as the facts of OCD become better known we will no longer see such articles listed under OCD as I saw in my town library. Perhaps some of you can help in this effort. Simply informing those close to you that you have a problem isn't enoughyou must make efforts to help yourself if you want others to be sympathetic. If you suffer from any of the obsessions mentioned earlier, you can get help and you can recover. Behavioral therapy and medication help a lot, but only if you utilize them. Don't wait until you have damaged an important relationship in your life.If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com

When Epidemics Collide: OCD and AIDS

Our planet is currently in the throes of a major health crisis. I am referring to AIDS. The average person's life has been influenced in a number of ways by this modem-day plague. Unlike previous decades, individuals no longer feel as free to have unprotected or casual sex. Medical and dental facilities have become far more careful about disease control. Blood supplies must be constantly screened. Police now wear gloves when searching certain suspects, as do food workers when serving meals.

There is also a place where this epidemic unfortunately crosses paths with another, less well-known epidemic: Obsessive-Compulsive Disorder. There are those with OCD who have obsessive thoughts about contracting AIDS, and the results can be extremely punishing. These fears are actually part of a larger group of obsessions about contamination. One of the main features of OCD is that sufferers have difficulty in determining just how risky certain things are. Sufferers often confuse possibility with probability: if something can happen, it will happen, no matter how unlikely. Unfortunately, for those with fears of AIDS, there happens to be a lot of media hysteria concerning the disease and how it can be contracted. As a result, it is not unusual for even the average individual to have unreasonable fears of people with AIDS. Even so, the average person's worries still do not tend to be as exaggerated or illogical as those of someone with OCD.

OCD sufferer's notions of how the disease can be contracted don't usually stop at the three most common ways: sharing infected needles, having unprotected sex, and receiving contaminated blood transfusions (which all happen to be direct blood-to-blood contacts). For the obsessively doubtful, almost anything that anyone else has touched can become a potential source of the disease.

The following situations are quite typical of this type of OCD, and are seen as high risks for contracting AIDS:

• Touching any red specks or spots anywhere, because they could be blood from an infected person

• Being near anyone who looks unwell or is very thin, or is disheveled or homeless, or who could be an addict

• Having blood drawn or having injec-tions, even with new, packaged needles

• Going to hospitals, doctors' offices, dentists, medical labs, or any place where ill persons gather or medical procedures are done

• Being near people who are, or who in the sufferer's mind, appear to possibly be, homosexual

• Being near health-care workers

• Touching doorknobs, light switches, or handrails in public places

• Getting cuts or scrapes where the virus could enter

• Fearing that they may be stabbed or struck by someone carrying an infected needle, or having thoughts that they may have stepped on a discarded syringe lying on the ground (they may even have false body sensations that this has happened)

This list is by no means complete.

A common variation on the fear of get-ting AIDS is the fear of contracting it, giving it to someone else, and then having to live with the guilt of having caused an innocent person's death. These sufferers may also have other problems with feeling overly responsible for others, another main theme among those with OCD. For these people, you could add this to the list above:

• Touching loved ones or touching anything else in public or in their homes (if giving AIDS to family members is the problem).

Getting and staying uncontaminated can be an excruciating 24-hour-a-day job. When sufferers are contaminated, they worry about getting perfectly clean. When clean, they worry about staying that way. They can only begin to feel comfortable when they are in control of everyone and everything around them. They wash and shower to excess when they believe they have touched something containing the AIDS virus, and they can often be spotted by their bright red, chapped hands. They will usually only touch feared things using barriers such as tissues, paper towels, or gloves. Every little cut or scratch may have to be covered with medication and a Band-Aid to keep the virus out. Anything possibly contaminated must be washed or disinfected, or else it must be thrown out. (Actually, most of these descriptions could be applied to the majority of people with contamination fears.)

To try to make this impossible task easier to manage, sufferers create "dirty" and "clean" worlds for themselves. They have places they can go and things they can do only when they are in a "contaminated state." The same is true for when they feel "clean." Certain rooms or locations can only be entered when sufferers themselves are "clean." One of my patients even had a "clean" car and a "dirty" car. When family members fall under a sufferer's control, they have to wash and change clothes whenever they enter the house, or else face a lot of upset or arguing.

Obviously, all this gets to be debilitating as the disorder takes over. Leaving the house can become extremely difficult. Some people stop socializing, or stop going to work or to school. In addition, sufferers tend to avoid or put off needed visits to physicians and dentists, and they may develop other health problems. In reality, all of the above are solutions designed to escape the doubt and anxiety, but they only end up helping in the short run. Unfor-tunately, in the long run, as sufferers use these methods, they only train themselves to be better avoiders who keep their fears going. Avoiding only convinces them that the fears are real, and it prevents them from actually seeing that the dreaded consequences never occur. Ironically, what starts out as a way to help control the anxiety ends up controlling and damaging their lives via a downward spiral of fear and avoidance. For those who do not suffer from these anxieties, it is difficult to appreciate just how gut-wrenching and debilitating they can be.

So, what do you do to get out of this kind of predicament? The answer (one that sufferers do not usually want to hear) is to learn to face the fearful obsessive thoughts while resisting the compulsions to escape and avoid. Behavior therapy is the key to accomplishing this. If you are a regular reader of this newsletter, you probably know that the type of behavioral therapy known as Exposure and Response Prevention (E&RP) is presently the best and most thoroughly proven way to do this. Success rates have been shown to be 75 percent or better.

E&RP is a retraining process. Basically, sufferers are encouraged to allow them-selves to be more and more unclean for longer periods of time as they try to carry out a growing number of average activities when they are "contaminated." By staying with what they fear, sufferers gradually become accustomed to acting in more normal ways in everyday situations, and they slowly begin to trust the idea that nothing catastrophic will happen. They learn that they can allow the fear to subside on its own, without taking any special actions, and that they can rely on this to happen. Double-checking, questioning, and asking others for reassurance or help in cleaning are discouraged and gradually eliminated. Friends and relatives are instructed to not participate or assist in these activities. They are shown that rather than helping or easing the suf-ferer's anxiety, they are only contributing to keeping that person in a helpless state.

The therapy process can sometimes be tricky as sufferers' obsessions work over-time to create more doubts about these issues. They ask, "How can doing the things I fear will give me AIDS help me to feel less anxious today, since it could take 10 years to find out if I will develop AIDS?" The answer, of course, is that the problem they are having doesn't really exist in the future, but within their own faulty judgment about taking risks in the present. OCD is not just a set of biological or behavioral problems, it is also a set of information-processing problems. Learning to challenge illogical thinking is another important part of the process. I like to ask patients if there is any scientific evidence to support their self-protective actions, or any reports of AIDS contracted according to their special theories. I also question why average persons don't live as self-destructively as the sufferer lives, yet manage to live just as long. Sometimes sufferers will answer: "Most people are ignorant. If they knew what I know, they would do as I do." When questioned as to where they get their unique information from, they of course cannot point to anything other than the same TV shows or news articles available to the rest of the population. When pressed, some severe sufferers will even admit that having AIDS couldn't be much worse than the personal hell they have created for themselves.

Working with a trained behavior therapist, either in an intensive daily program or in weekly sessions, you practice doing the things you fear to do. At the start of therapy, you work with the therapist to construct a list of all the places and activities that would give you difficulty if you stayed with them and didn't avoid. Each item is rated on a scale of 0 to 100. This list is known as a hierarchy. Next, a program of behavioral assignments is laid out for you, based upon the listing you have made. No one forces you to do things or surprises you. Typical homework assignments may include the following: (these are in no special order):

• Shaking hands with others

• Eating in a restaurant and not wiping or cleaning the silverware

• Touching light switches, door knobs, mailbox handles, etc.

• Sitting on public benches, using public phones or rest rooms, taking public transportation

• Bringing home items from stores and not washing or wiping them

• Visiting a local hospital and sitting in the waiting room, using water fountains, phones, or rest rooms, or eating in the coffee shop

• Bringing such things as brochures or napkins home from a hospital and touching them to your belongings

• Touching books about AIDS in a bookstore or library and even buying or borrowing them so they can be used to "contaminate" things at home

• Allowing yourself to be near, or to touch people who look as if they could possibly have, AIDS

• Not washing or changing clothes immediately upon coming home from being outside, and allowing family members to do the same

• Limiting hand-washing to just a few times per day and to only 10 seconds per time

• Limiting showering to only 10 minutes per time, and to no more than once per day (even less often if this has been a serious problem)

• Listening to audio tapes several times daily telling you that you have AIDS (or will give it to others)

• Resisting putting band-aids and disinfectants on every tiny cut or scrape

This last type of assignment is gradually made more anxiety-provoking, and is designed to increase your tolerance of your obsessive thoughts to the point where you can feel free to disregard them. Not washing, wiping, or otherwise undoing assignments after they are carried out is extremely important. To do so would be to cancel out any benefit they may have.

Medication can often be important to overcoming OCD. It should not be an end in itself, but should be seen as a tool to help you take part in therapy. It can provide a level of improvement from which to begin working. Not everyone requires it, but there are many who could not carry out behavioral assignments without the symptom relief it provides. It may also reduce feelings of depression, which can then result in a person feeling energetic and having a more posi-tive and motivated attitude about working toward a recovery. Antidepressant drugs such as Anafranil, Prozac, Paxil, Zoloft, Luvox, Celexa, Serzone, and Effexor are all currently being used to relieve the symptoms of OCD and depression. There is no best drug as everyone responds differently to them. Medication for OCD has been discussed in other articles in past issues, so I will not go into further detail here.

Recovery from this problem is possible. Many have already achieved it. Don't feel helpless or give up hope. Find your-self a behavior therapist trained in the use of E&RP, as well as an experienced psychiatrist if you need one. Don't assume that every practitioner is qualified to treat OCD. Be a good consumer and find out how many cases of OCD they have actually treated and if they use the most up-to-date approaches. Call the OC Foundation for names of practitioners in your area, or get names at a local OCD support group.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com

Very Superstitious (Magical and superstitious obsessions)

Together with morbid obsessions, magical and superstitious thinking makes up one of the stranger and more misunderstood aspects of OCD. When my patients try to describe their symptoms, they preface their explanation with, "I know this sounds crazy, but...." The presence of magical thinking is probably the main reason why many with OCD have been misdiagnosed over the years as schizophrenic. superstitious thinking makes strange and magical connections between things which logically don't seem to connect in the real worldthus the apparent 'craziness'. Some common examples, would be the idea that thinking of an unlucky number can ruin your day, that clothing you wore to a funeral can lead to more unhappiness if you wear it again, or that thinking of the name of a disease will cause you or someone else to get that disease.

Magic and superstition are as old as the human race. They have represented a way for us to try to explain the normally unexplainable, and to try to control the seemingly uncontrollable. They have therefore always held great allure and attraction. One might go as far as to say that there is a human tendency to think superstitiously. Just look, for example, at people playing their 'lucky' lottery numbers, or reading horoscopes to guide their lives. Clearly, OCD does not have a monopoly on such thinking.

There are limits, however. The average person can find a place for a little superstition without it taking over and causing them to be unable to function. Even members of primitive societies, where magic dominates most important decisions, can tolerate its presence without becoming paralyzed by it. It is used as a tool and a guide. In OCD, we see magical thinking run amok, and out of control. Once it establishes itself as a symptom, it can grow like a cancer, starting as a way to relieve anxiety, and expanding to become the sufferer's chief occupation and the cause of even greater anxieties than it was supposed to relieve.

There is currently no scientific explanation as to why some individuals tend to have these particular symptoms, compared to any others. Many of those with OCD are constantly bombarded with very strange and doubtful thoughts about harm coming to themselves and/or others. Sufferers thus may feel that they cannot resort to ordinary protective measures, because of these extraordinary threats. Their world seems out of the range of normal control. They therefore turn to magic as the only other viable alternative, as a way of restoring a feeling of control.

One other possible influence upon the development of magical thinking may be if an individual with OCD comes from a culture in which superstition plays a strong role. Coming from such a background cannot, of course, cause OCD, however, it can certainly help give someone at risk a push in the wrong direction if everyone at home is doing magical rituals.

As we know, an obsession is any thought that causes anxiety, and a compulsion can be any action, either mental or physical, which relieves it. Obsessive thoughts generally tell sufferers that something harmful is happening, or will happen to themselves or someone else. Magical thinkers generally obsess about many of the same types of threats that other sufferers do they, themselves, or others dying or becoming ill or disabled, being 'cursed', having bad luck, being blasphemous or sinful, going to hell, getting into trouble, or deliberately or accidentally harming others in some way, etc. The list could be much longer, if there were space. The thoughts don't simply stop with a bad consequence being revealed to the thinker. They would otherwise be no different from morbid obsessive thoughts. What distinguishes them, is that they are also (as mentioned earlier) connected with some type of magical cause or attribution. Whether magical thinkers make this attribution themselves, or whether it is part of the obsession itself, is unclear. They come to believe, for instance, that the harm can be brought about by unlucky numbers or their multi-ples, by simply hearing about bad things happening to others, by thinking about or seeing certain words or images, by carrying out (or forgetting) certain actions or behaviors, by unlucky colors, by being 'possessed', or by contact with places, objects, or people associated with unlucky or unhappy occasions. Contact in this last case can be purely mental or physical.

The most basic magical compulsions involve simple avoidance of the magically 'bad' words, numbers, objects, colors, persons, etc. We can call this avoidance magical because it is done in response to magical obsessions. Beyond avoidance is control. Perhaps because the harm is thought to have magical origins, the compulsions sufferers invent to control it are frequently also magical. There are more complex types of magical compulsions which resemble the practice of ancient magic and they tend to follow strict rules or precise steps, which if not performed perfectly, must be repeated. We commonly refer to these as 'rituals'. These types of magic rituals are also referred to as 'undoing rituals'. Magic, as we all know, must be kept 'pure' and perfect if it is to work. Because anxiety typically hampers most people's performances at anything, it is of course difficult for sufferers to get rituals to be perfect. They tend to get the steps wrong, forget something, or have some type of unpleasant obsession or image intrude, thereby 'contaminating' or ruining the magic. When this happens, very high anxiety and depression can result. Unless their obsession allows them to have another chance to make things right, a great deal of careful activity can be ruined in an instant. If it is a ritual that can only be done at a special time or on a special day, the sufferer might not get another chance for as much as a month to try again. I have seen individuals go into deep depressions because midnight rituals done badly on New Year's Eve have spoiled the entire New Year.

Because sufferers identify words, numbers, actions, etc., as having magical power to cause harm or bad luck, the magical compulsions which are supposed to undo them are frequently seen to involve the same elements. These rituals are generally used to cancel out or negate the 'bad' magical elements by employing their opposites, such as thinking of health promoting words in response to thoughts concerning the names of illnesses.

Examples of compulsive magical behaviors I have witnessed would include:

• Repetitive praying or crossing oneself

• Counting up to or beyond certain numbers

• Reciting or thinking of certain words, names, sounds, images, phrases, or numbers

• Moving one's body or gesturing in a special way

• Stepping in special ways or on special spots when walking

• Washing off bad ideas or thoughts

• Arranging objects or possessions in a special order

• Performing physical actions in reverse

• Thinking thoughts in reverse

• Repeating behaviors a special number of times, or an odd or even number of times

• Performing behaviors at special times or on particular dates

• Repeating one's own words, or the words of others

• Repetitively apologizing to another person, or to God

• Gazing at certain numbers or words to cancel others out

• Touching certain things in a special way or a particular number of times

In terms of what can be done to remedy magical obsessions and compulsions, I recommend, as usual, the two-pronged approach of medication plus behavioral therapy. Antidepressant medications (Anafranil, Prozac, Zoloft, Luvox, Paxil, or Celexa) can provide a degree of symptom relief, reducing the obsessive thoughts and the urge to do compulsions sufficiently to allow behavioral therapy to help the sufferer overcome the rest of the problem. This is not to say that one cannot be successful without medication, however, it does improve your chances quite a bit. On the other hand, medication alone usually isn't sufficient to do the job entirely.

By behavioral therapy, I mean specifically, Exposure and Response Prevention (E&RP). The person in treatment is gradually encouraged to put themselves in a position for the bad luck or harm to occur, and then is discouraged from carrying out the avoidance or the magical ritual. It is not that magical thinkers totally believe in their magic. They don't. They do, however, experience serious doubts and need encouragement to take the risks necessary to see that their beliefs aren't justified. These are beliefs that are never challenged. Most of those with OCD generally don't resist long enough to learn that their anxiety would pass even if they did nothing in response to the obsessions. In therapy, a listing, or hierarchy, is created in which all feared situations are ranked in order, usually on a one to ten or a zero to 100 scale. Patients work their way up the scale, gradually tackling more and more difficult items via homework assignments, or working with the therapist in the office or on field trips. No one is ever forced to do anything, and nothing is thrown at persons by surprise.

Additional exposure to obsessive thoughts is accomplished via taped presentations, writing assignments, or selected readings. I have found the taped presentations to be of particular value. They are used several times per day, and increased in difficulty as the listener's anxiety decreases with presentations. Despite what you may have heard, obsessions can be as effectively treated as compulsions. There are presently some small case studies from Britain which give evidence that this is so. Further scientific study will be needed to confirm this, once and for all, to convince the doubters. Some people require repeated exposures to feared situations, and some actually require only one. In this latter case, it is almost as if by facing something feared, the sufferer is breaking a 'spell'. This is not to suggest that therapy is in some way like magic; it isn't. Therapy requires persistent and consistent work.

In this way, confidence is progressively increased, and symptoms are systematically eliminated. The person becomes habituated to the fearful thoughts to the point of no longer having to react to them, even if they do not completely cease. In uncomplicated cases, the process described above should take anywhere from six to twelve months. With individuals who habituate after only one exposure to each feared situation, the process may even be quicker.

If you suffer from magical thoughts and compulsions, my message to you is don't continue suffering needlessly. Help is available. Call the Foundation for a referral in your area. If you live with a magical thinker, remember: they are not crazy, just doubtful and anxious, and in need of support and encouragement.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com

Living With Your Loved One's OCD: Some Advice For Significant Others

A frequent problem among those with obsessive-compulsive disorders is one involving the attitudes and behaviors of the significant others in their lives, i.e., husbands, wives, boyfriends, or girlfriends. You significant others can be of great help and support to the recovery process, or you can create many types of obstacles. Trying to recover from OCD is difficult enough in itself, and when relationship problems are added, it just makes things that much tougher.

Let us first examine some of the ways in which significant others can be a source of difficulty. Then, we will look at ways in which you can help, instead.

Probably the single greatest source of problems in any relationship is when one partner sets out to change the other. The most successful relationships are based upon unconditional acceptance. This is necessary because all human beings are naturally imperfect, so each partner must accept the other as they are, with all their strengths and weaknesses, if they are to get along. Please understand that unconditionally accepting one’s partner does not mean liking every single thing about them. It just means acknowledging that they are the way they are. Certainly we all have things we would like to change about our partners, but we learn to live with them because: 1) it is not within our power to make such changes in them; and 2) we hope that they will accept our own problems, weaknesses and deficiencies.

Truly loving someone doesn’t mean being merely in love with the image of the perfect partner you would like them to be. That ideal person doesn’t, and never will exist. Your partner is an ordinary fallible, mistake-making human being, just as you are. To set yourself up to judge them as if you, yourself, were some kind of superior being is to egotistically imagine you are god-like, and totally free of all faults. It is as if you sat there on your throne, and looking down, commanded “You should not be the way you are! You should be the way I say you must be!” All important undertakings in life are risky, and if you decide to enter into a relationship, you have to accept that you are in it for the whole package. You cannot simply filter out the parts you don’t like.

Throw away your blueprint! You may command that your partner not have OCD, however, whether you like it or not, it is a part of their life. They own it. It is chronic, and it is something they carry with them. It will not simply go away because you don’t like it. Many things that we do not like exist in life. In order to have a relationship with this person, you must accept that their disorder is a part of that total package. Your partner may attempt to change this behavior, or they may not. In the end, it is totally up to them. The only one who can change them, is them. In any case, you cannot change them. Period.

Please don’t misunderstand. Everyone with OCD would like to get rid of this problem, but not everyone is ready or able to do so at a particular time, for a wide variety of reasons. For example, proper help may simply not be available where they live. Don’t criticize them in their entirety as human beings. Those with OCD feel badly enough about themselves already without that. OCD is only one facet of who they are. It is not all there is to them. I have heard many sufferers describe themselves as “weirdos” and “freaks.” Imagine having to explain to the people in your life about the unusual thoughts you are having, or the strange behaviors you feel compelled to perform, despite being an intelligent person. Also, it is important to understand that the purpose compulsions serve is to relieve the anxiety and stress caused by obsessions. If you insult, threaten, or criticize, the stress you will be creating will only result in more obsessions, and thus more compulsions.

Look at it this way: this is the person you love and have joined your life to. As far as we know, the problem is biological in origin and probably genetic. It is not simply a bad habit or a vice. Don’t confuse yourself by believing the notion that having OCD was a deliberate act on their part. They didn’t ask for it, and are not to be blamed for having it in any way. On the other hand, it’s true that they are responsible for helping themselves, but even if they are not doing that at the moment, how can you justify making them feel badly about it, and what purpose do you think it will serve? What if they were afflicted by some other chronic illness such as lupus or diabetes. Would you still be as angry and upset with them?

It might help to examine the source of the difficulties you are having with your partner’s problem and look into yourself. Ask yourself these questions: could it be that rather than empathizing with your partner and feeling sympathy for what they are going through, you are only concerned in a self-centered way with what others will think of you, when you are with this person? Do you worry that you will be seen as responsible in some way, or that you will be considered abnormal by association? Do you feel that this kind of thinking or behavior has somehow magically made this person you may have spent years with, into someone that you suddenly don’t know and can’t tolerate being with any more? Is this person’s illness now all there is to them in your eyes?

Even if you are over the hurdle of acceptance, and can accept the disorder, there are still a number of difficulties you may encounter. First, if your partner is actively working on improving their self-control, openly expressing impatience with their rate of improvement will prove extremely destructive to their morale. Recovering from OCD takes a lot of work and effort, and can be a difficult task. It is a very stubborn set of habits. Unless you want to make a difficult job even more difficult, avoid pressure tactics, such as constant nagging. Simplistic statements such as “Why don’t you just stop,” or “Get a grip” are useless and meaningless for these disorders. Don’t try to punish them with your anger, silence, or absence at times when they have slips or setbacks. Don’t try to use guilt, with such statements as “Our relationship would be great if it weren’t for your OCD,” or, “I’m ashamed to be seen with you in public,” or, “You must really want to ruin our lives,” or, “If you really loved me, you’d stop.” As one of my patients told their impatient partner, “Do you actually think that I like doing these things, or thinking these miserable repetitive thoughts?”

No matter what the problem is, avoid the rather childish use of sarcasm and name-calling. It is an inappropriate and disrespectful way for one adult to treat another adult, and as a way to get someone to improve, it’s crude and simply won’t work. Finally, don’t continually threaten to leave them because they aren’t getting well quickly enough to suit you. If you really feel you absolutely can’t understand or accept it, and can’t control your frustration with them, then leave. It is probably kinder in the long run.

A second type of difficulty commonly seen is a situation in which the unafflicted partner is totally enmeshed in helping their ill companion by doing compulsions with them or for them. They may do this to keep the peace by avoiding angry scenes, or to spare their loved one upset, anxiety, or exhaustion from another bout of compulsions. They may actually believe that they are showing they care by doing these things. Understand that there are some types of help that simply don’t help. Washing or cleaning things for your partner, changing your clothes at their command, checking things for them, reassuring them, or doing tasks for them that their illness makes difficult to do does not truly represent caring. It only looks like it. These behaviors are short-term fixes designed to get you by for the moment. In the long-run, however, this so-called help is really helping to lock your partner more strongly into their illness, and you along with them. It may even help them to function just enough to feel that they really don’t have to change or get help at all. As you become more and more responsible for helping to get them through their day and meeting their needs, you gradually find that you are not really living your own life anymore, and that you are pursuing your own goals less and less. This can then only lead to increasing frustration, depression, and a sense of helplessness on your part.

A third major source of difficulty in these relationships is when one member is supportive of an ill partner in their treatment, but somehow becomes directly responsible for that other person’s recovery. You can’t want them to improve more than they do. If they can’t do it themselves, it is simply no good. They won’t learn if you try to do it for them. Even if you could get them to stop doing compulsions every time you caught them at it, what would happen when you weren’t around? You cannot stand guard over them twenty-four hours a day. Also, if you were to somehow take total responsibility for their problem, it would relieve them of ever having to take responsibility for it themselves, so they wouldn’t. If your partner actually prefers that you take control of their behavior because they imagine that they are too weak to learn to control themselves, resist the temptation. Otherwise, they will soon come to believe they are powerless. You’ll be doing them a big favor by allowing them to be fully responsible for themselves. Try to not get into the bad habit of calling their attention to their compulsive behaviors. Don’t waste your time whistling, snapping your fingers, waving, or otherwise signaling whenever you see them about to check, wash, or ritualize. Resist the urge to physically restrain them. Suppress your impulse to yell or call out. Developing self-awareness and control takes a lot of work, even when you’re motivated. If your partner isn’t motivated, rest assured that nothing you can do will make the slightest bit of difference.

So having said all this, how can you truly be of help? First, accept that the problem exists, and that it is not their fault that they have it. Read up on it, and educate yourself about it. Visit a support group meeting, if that is possible. Second, stay out of any involvement in their symptoms. If you are not yet very involved, keep it that way. If you have already fallen into the trap of participating in numerous compulsions, you will need to gradually withdraw. In many cases, this may require the help of a trained therapist who will explain to your ill partner why this is necessary for their recovery, and outline some gradual steps by which this can be accomplished. As they say, “don’t try this at home.” Third, understand that it is not your responsibility to get them recovered - it is entirely in their hands. It is completely up to them to change their behavior. Stay out of it and give them space to do what they need to do. Keeping their stress down will enable them to do a much better job. What you can do, is give unconditional support for their efforts to help themselves, and always be aware of how difficult it must be for them to live with this problem and fight it every day. Try to appreciate the courage it takes for them to face their worst fears, and to break years of solid habit. Accept their lapses, bad days, and slip-ups. There may be disappointing times when weeks of progress suddenly seem to vanish. This is not unusual, and must be viewed as one of the potholes in the road to recovery. No one learns a new skill without making mistakes. They may feel really discouraged at times, and believe that they cannot do it. Your belief in them can go a long way. If a pep talk is appropriate to the person and the situation, give one, by all means. Just be careful not to overdo it.

Couples encounter many obstacles in their lives together. This will just be another. Whether we like them or not, we are forced to accept such obstacles. Life is not like a card game where you can always throw down your cards and simply ask to be dealt a new hand. Remember that to get through this, or any difficulty, it must be the both of you combining your efforts against the problem, rather than each other.

Dr. Fred Penzel is a licensed psychologist, and executive director of Western Suffolk Psychological Services, located in Huntington, New York (631-351-1729). He has been involved in the treatment of obsessive compulsive disorders since 1982, and is a frequent contributor to the IOCDF newsletter. Dr. Penzel sits on the science advisory boards of both the IOCDF and the Trichotillomania Learning Center.

25 Tips For Succeeding In Your OCD Therapy

1. Always expect the unexpected - you can have an obsessive thought any time or any place. Don’t be surprised when old or even new ones occur. Don‘t let it throw you. Be prepared to use your therapy tools at any time, and in any place. Also, if new thoughts appear, be sure to tell your therapist, to keep them informed.

2. Be willing to accept risk. All life is risky business. Risk is an integral part of life, and as such, it cannot be separated out. Remember that not recovering is the biggest risk of all.

3. Never seek reassurance from yourself or others.  Instead, tell yourself the worst will happen, is happening, or has already happened. Reassurance will cancel out the effects of any homework you use it on and prevent you from improving. Reassurance-seeking is a compulsion, no matter how you may try to justify it.

4. Always try hard to agree with all obsessive thoughts - never analyze, question, or argue with them. The questions they raise are not real questions, and there are no real answers to them. Try not to get too elaborate when agreeing – simply say the thoughts are true and real.

5. Don’t waste time trying to prevent or not think your thoughts. This will only have the opposite effect and lead to thinking more thoughts. Studies have shown that you cannot effectively suppress particular thoughts. Your motto should be, “If you want to think about them less, think about them more.”

6. If you slip and do a compulsion, you can always turn it around and do something to cancel it. Try to not be a black-and-white all-or-nothing thinker who tells themselves that they are now a total failure. The good news is that you are in this for the long haul, and you always get another chance. It is normal to make mistakes when learning new skills, especially in therapy. It happens to everyone now and then. Accept it. Even if you have a good sized setback, don’t let it throw you. Remember the saying, “A lapse is not a relapse.” This means that you never really go back to square one. To do that, you would have to forget everything you have learned up to that point, and that really isn’t possible. Also remember the sayings, “Never confuse a single defeat with a final defeat,” (F. Scott Fitzgerald) and as they say in AA, “You can always start your day over.”

7. Remember that dealing with your symptoms is your responsibility alone.  Don't involve others in your homework (unless specifically told to) or expect them to push you or to provide the motivation. They won’t always be there when you need them, but you are always with you.

8. Don’t get too impatient with your rate of progress or compare yourself to someone else. Everyone progresses at their own particular rate. Try, instead, to simply focus on carrying out each day’s homework, one day at a time.

9. When you have a choice, always go toward the anxiety, never away from it. The only way to overcome a fear is to face it. You can’t run away from your own thoughts, so you really have no choice but to face them. If you want to recover, you will have to do this eventually.

10. When faced with two possible choices of what to confront, always choose the more difficult of the two whenever possible.

11. Review your therapy homework assignments daily, even if you think you know all of them. It is easy to overlook them – especially the ones you don’t look forward to doing.

12. If your therapist gives you an assignment you don’t feel ready to do, don’t be shy about saying so. As half of the team, you should be able to have a say in your own therapy. The goal is for the homework to produce moderate anxiety you can get used to tolerating - not to overwhelm you with it and cause you a setback. On the other hand, don’t be afraid to stretch yourself a bit whenever you can.

13. Procrastination is a feature of many people’s OCD, so start your homework assignments the day you get them. Don’t wait for the perfect moment to start. The perfect moment is whenever you begin doing them.

14. Perfectionism can be another feature of OCD. You may find your OCD telling you that if you don’t do your homework perfectly, you won’t recover. If you do find yourself obsessing about having to do your homework perfectly, you risk turning it into another compulsion. Watch out for having to do your homework according to the same rigid rules each time you do it. Also, don’t do your homework so excessively that it takes up your whole day. Remember that you still have a life to live.

15. If OCD tries to confuse you in terms of how to handle a particular symptom, you can sidestep this by simply agreeing with the thought that you won’t know what to do, and therefore won’t recover.

16. Be careful when carrying out assignments to not undo them by telling yourself that “It’s only homework, and the things I’m saying and doing don’t count and aren’t real,” or “My therapist wouldn’t ask me to do something that would cause harm to me or others,” or “I’m only doing this because I was told to, so I’m not responsible for anything bad that happens.”

17. Try to not let yourself get distracted and tune out when doing certain assignments, so that you don’t have to feel the anxiety. People sometimes let the homework become routine and do it in a very automatic way as a kind of avoidance. Also, don’t do homework while you carry out other distracting activities. Give it your full attention, focus on what you are doing, and let yourself feel the anxiety. You are building tolerance to what you fear and for that to happen, you have to be in the moment with it.

18. When faced with a challenging assignment or an unexpected challenging situation, try to look on it as a positive, and as another opportunity to get better instead of saying, “Oh, no. Why do I have to do this?” Tell yourself, “This will be good for me – another chance to practice and get stronger.”

19. Try to not rush through your therapy homework so that you don’t have to feel as much anxiety. Take your time, and see if you can view it in terms of all the good it will do you. Getting it over with as quickly as possible is not the goal. Raising a moderate level of anxiety and staying with it, is.

20. If your homework doesn’t really produce any anxiety, tell your therapist about it. If your exposure homework doesn’t cause at least some anxiety, it isn’t going to be effective in helping you. On the other hand, try doing all new assignments for at least a week before deciding that they don’t make you anxious. Some assignments can cause delayed reactions and it may take doing them a few times before the anxiety occurs.

21. It is sometimes possible for OCD to try to make you doubtful about your homework. It may tell you that you are not in the right treatment, that your assignments cannot possibly make you better, or that you really don’t understand what you are doing and won’t be able to make it work. Remember that OCD was known as The Doubting Disease, and will try to cast doubt on anything that is important to you. To fight this, you may have to agree with it by saying, “Yes, that’s right. I really won’t get better.”

22. Never forget that you have OCD. This means that you will not always be able to trust your own reactions or sensations, especially if they seem to be telling you very negative and extreme things. If you are unsure if something is really a symptom, treat it as a symptom. Better to err on the side of doing a bit more exposure than not enough.

23. Remember that in OCD, the problem is not the anxiety - the problem is the compulsions. If you think the anxiety is the problem, you will only do more compulsions to get rid of it (which will only create more anxiety). If you recognize that the compulsions are the problem, stop doing them, and stay with the fearful situation, then the anxiety will eventually subside as you build up tolerance.

24. Always take a moment to endorse your own efforts and recognize your successes. It’s a good way to help keep up your motivation. Look back at earlier assignments that are no longer challenging if you believe you aren’t making progress.

25. Overall, never forget that OCD is very paradoxical. The things that you thought would make you better, only made you worse, and the things you thought would make you worse are the very things that will make you better.

Acceptance and OCD

Those of you reading this newsletter probably think a lot about "change." That is, changing your compulsive behaviors, changing your obsessive thinking, changing the way you live, etc. Change is a fact of life. We all are in some state of change at any given time, whether we realize it or not. In many treatments for OCD, there is also a constant emphasis upon change. With all this changing or thoughts about changing going on, it would be very easy to overlook something equally important and without which change would not and could not happen. This is something called acceptance.

Acceptance means agreeing to something, believing in it, and viewing it as true or real. Accepting something doesn't mean liking it or grudgingly giving in to it. There are many things whose existence we accept that we do not like. OCD is a good example. There are many out there who suffer with the disorder who simply cannot acknowledge or accept that they have it, or that it is really having a very negative impact on their lives. Typically, when it comes to their disorder, these people do not change very much. If they finally do go for therapy, they cannot seem to bring themselves to follow through with treatment. The psychoanalyst Carl Jung once said, "We cannot change anything unless we accept it."

Much of what you need to know about acceptance and change (and therapy in general) is summed up in the Serenity Prayer (familiar to those who go to AA meetings):

God grant me the serenity to

Accept the things I cannot change,

The courage to change the things I can,

And the wisdom to know the difference.

I sometimes think that the mental-health field has become obsessed with the idea of change. This would be fine if we care givers could change everything about the disorders of the people who come to see us for help. Actually, there is a whole list of things we cannot change or help you change. For instance, we cannot presently change the following facts:

• You have OCD.

• OCD is chronic - it won't simply go away on its own.

• You will have unpleasant obsessive thoughts and will sometimes respond to them using         misguided compulsive solutions.

• Others will have a right to live free of your symptoms, and do not have to participate in, or cooperate with them.

• No one can "make" you better. You have to learn to help yourself with informed guidance.

• You will never "perfect" your symptoms, that is, getting all your compulsions  "just right," and still being able to live like everyone else.

• As part of your illness, you may have problems figuring out how risky certain things are or how responsible you are for others.

• You had no choice in having OCD. It is neither fair nor unfair, it just happens to people according to the laws of chance.

• Getting well takes time and patience, and is hard work.

• In order to confront your disorder, you will experience anxiety and discomfort at times.

• Progress toward recovery doesn't always go smoothly.

• Being in recovery doesn't mean you will forever be 100 percent symptom-free. Once in recovery, you will continue to work on your OCD each day, although not as intensely as time goes on.

• You can slip sometimes and still keep your recovery.

• You may have lost some previous part of you life to the disorder and may not be able to get it back.

When you don't accept any or all of the above, what generally follows is some type of emotional disturbance such as anger, anxiety or depression. My own observation is that these disturbances then lead to bringing about the opposite of what you really want - you create a paradox. Some good examples of the kinds of paradoxes people create are seen among people who -

• are so angry and upset simply about having OCD that the stress they create makes their symptoms worse;

• want to get well through a quick fix without having to confront their symptoms, or feel anxious and so don't improve and end up feeling even more discomfort;

• want those close to them to help them feel less anxious by cooperating with compulsions, which ends up driving these people away, makes them upset and angry and causes  them to withhold their support for the sufferer;

• unrealistically expect that in recovery they will never have a lapse or symptom flare-up, and when they do, get so depressed and angry at themselves that they have an even worse setback; and

• are so upset about having lost part of their lives to OCD, and they lose even more time due to the depressed and angry mood they create within themselves.

In actuality, change and acceptance are not exclusive of each other. They are linked together. Acceptance can actually be one of the most effective ways of bringing about change. The biggest problems within OCD are the sufferer's misguided and illogical strategies for coping with obsessive thoughts - what we refer to as compulsions. Compulsions can only provide short-term relief from anxiety Over time, and through habit, they become the problem itself. Becoming a more accepting person would include letting go of the unwinnable struggle to control obsessions via compulsions, and turning to more effective solutions, such as behavior therapy and medication.

So how does one become more accepting? One way of achieving acceptance is to truly understand that many things in life cannot always be exactly the way we want. They may only be the way they are. We human being are very wishful creatures, and while there is nothing wrong with wanting things to be different, we are not in the Godlike position of being able to demand that things be as we say they must be. Resisting such demands is especially difficult for those with OCD, as they often have difficulty in the way they try to over-control themselves, people, and things in their lives. Remember that acceptance doesn't mean liking something, but just seeing it as what is real.

Another path to acceptance would be through living in the present. By this I mean not looking backward toward the past. Some insist that things shouldn't have happened the way they did. Other OCD sufferers often sit and continually obsess about past events, agonizing about what might or might not have happened, and whether or not they were responsible. You cannot change the past.

The other side of this is not living in the future. People with OCD tend to use the phrase "what if" a lot. They anxiously waste time trying to predict or control future events to prevent harm from coming to themselves or others. This, of course, is fruitless, as obviously no one can predict the future or prepare for every possible outcome.

All you can reasonably expect to do is to concentrate upon living in the present and do the best you can to fully involve your-self in whatever you need to accomplish at any given moment. The idea is to achieve a focus that enables you to let go of all other considerations and direct all your mental and physical energies toward your goal. If you don't think you can do this, consider that when you were wrestling with your symptoms at their worst and trying to control the uncontrollable, you were already doing this, but in a negative rather than a positive way.

Finally, it is vital to have an understanding of just what it is you need to specifically accept. I propose the following list, which I call "The Five Acceptances."

1.  Unconditional Self-Acceptance

Seeing yourself as an acceptable, ordinary mistake-making human being who cannot

be rated as a whole on the basis of a few selected characteristics or symptoms.

2.  Unconditional Acceptance of Others

Seeing them as ordinary imperfect beings also, and understanding that they don't have to do as you say, or support your efforts if they do not choose to.

3.  Accepting Your Illness and its Nature

Understanding that your symptoms are what they are; that they are chronic; that it isn't "unfair" that you have them; that as a result of them you may have poor judgement when it comes to risk and responsibility; and that they can be recovered from even if there is presently no cure.

4.  Accepting the Nature of the Task of Therapy

Knowing that you are responsible for your own recovery; that therapy is hard work, takes time, and may involve discomfort; and that obsessions must be confronted and compulsions resisted.

5.  Accepting the Nature of the Task of Ongoing Recovery

Learning that recovery is an active work-in-progress and something that must be practiced each day; that there may be lapses along the way; that you may have to take out time to grieve for what your illness has cost you; and that recovering means that you are now free to live in the same imperfect world facing the same problems as everyone else.

What I have outlined here may seem like a tall order, but it is achievable. Just talk with someone who has made a good recovery and you will see that they may have done most of these things without even being aware that they have names or descriptions. If you are working on the acceptance of change portion of your recovery, keep in mind the need to stubbornly refuse to quit. As the famous 18th century OCD and Tourette's sufferer Samuel Johnson said, "Great works are performed not by strength, but perseverance."

If you would like to find out more about what Dr. Penzel has to say about OCD and related disorders, take a look at his self-help book - "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000).  You can find out more about it at www.ocdbook.com

Behavioral Treatment of Body Dysmorphic Disorder

A particular disorder which is believed by many to be a member of the OC family, has been receiving a lot of media attention lately. This disorder is known as Body Dysmorphic Disorder (BDD), also called by some Dysmorphophobia, a term originated in the last century by Morselli. We call it BDD when an individual appears to be strongly obsessed with what they believe to be a defect in their appearance. They tend to believe that some part or area of their body is misshapen, asymmetrical, wrongly sized, or ugly. Typical BDD complaints can include preoccupations with the face (such as scars, spots, veins, discoloration, acne, or the shape or size of the nose, lips, mouth, eyes, etc.), the hair (fears of receding hairlines), or the size and shape of any other body part (such as the hips, abdomen, buttocks, legs, hands, etc.). In some cases more than one body part may be involved, or. the preoccupation can shift from one part to another over time. BDD should not be confused with the more common type of dissatisfaction that many people experience with themselves. Ordinarily, many individuals wish they were taller, that their nose was shaped differently, that their breasts were bigger or smaller, or that their thighs weren't so large. Often others will agree with them, and even suggest that. they do something abut it. In BDD, it is very difficult, if not impossible, to see things the way the sufferer does. BDD sufferers seem to be totally preoccupied with the imagined defect which can be something very specific, or very vague. Often, it may be a defect no one else can see, or it can be something so minor or microscopic that we would judge the person to be grossly exaggerating it. Frequently, the belief in the defect can be so strong it seems to border upon being a delusion.

Individuals with BDD tend to spend much time obsessing about their defect, questioning others, checking it directly or with mirrors, or having others check them. Frequent visits to physicians, surgeons and dentists for treatment or correction of the defect are not uncommon. Sufferers will often gather evidence to prove their ugliness. None of these professionals can help, even though they may be sympathetic and do their best. I know personally of several cases where plastic surgery was performed and BDD symptoms returned as soon as the surgery healed. One woman was completely preoccupied with the shape of her nose, had surgery to her specifications, and after six months returned to the same preoccupation when the swelling disappeared. As mentioned before, the degree of belief in the existence of the defect can be extremely high, almost total at times, and frequently higher than we generally see in OCD, although it can vary from person to person. In most of the cases I have seen, there is also a great deal of anxiety over the idea of having the 'deformity'. Many sufferers seem genuinely tortured. One patient found it so upsetting that it took several sessions and a lot of gradual preparation before we could even mention it in therapy. Individuals with BDD may be depressed because they can not convince others of the problem and not being able to change it no matter what they try. I have sometimes seen other typical CC symptoms along with BDD, many of which frequently include various types of perfectionism and double-checking. Social isolation is also common.

The two major modes of treatment which I normally recommend for BDD are the same as those for OCD medication and behavioral therapy. The fact that medication can help seems to point to a biological basis for BDD. As in OCD, success with medication varies from person to person and the same drugs that seem to help with OCD Anafranil, Prozac, and others, seem to help completely. For instance, it can reduce the thoughts of deformity, but not always completely eliminate them. Also, a lot of the checking and questioning habits can remain, even when thoughts are reduced.

Exposure and response prevention is the primary behavioral intervention. Despite their strong belief in the deformity, there is usually enough doubt that these beliefs can frequently be challenged in therapy. Talk therapy alone will not do the job though. In behavioral therapy, our aims are twofold. First, we aim to reduce anxiety about thoughts of deformity via repeated exposure to the thoughts. By doing this, we can bring about habituation to the thoughts as the person gradually exposes him or herself to the thoughts. Individuals purposefully experience the anxiety until it dissipates. Eventually the thoughts do not produce anxiety and interest in them decreases. This exposure can be done in a variety of ways, including using audio tapes containing the fearful thoughts, having the person wear clothes that remind them of the deformity, having them go into situations where the thoughts can occur, looking at pictures of 'perfect' body parts, reading articles that will bring on the thoughts, etc. Sufferers will frequently ask, "1 already think of it a lot and my anxiety isn't any less; how can this help me?" The answer is that they have not exposed themselves to it on purpose, or for very long, nor have they done it systematically and regularly. Also, when they have experienced the thoughts, they typically don't stay with the anxiety for long. Usually, they try to avoid it by checking themselves, asking others for reassurance, or escaping the situation; somehow this prevents habituation from ever occurring.

Our second aim is to prevent the behaviors just mentioned, that sufferers use to reassure themselves and terminate the anxiety. Homework for the response prevention part of the treatment can typically include such things as not inspecting body parts by eye or in mirrors, refraining from questioning others or seeking reassurance, wearing previously avoided clothes that remind the person of the deformity or accentuate what they imagine it is, not consulting physicians or surgeons, not running away from or avoiding situations where they imagine they are being scrutinized by others, etc.

A good example of a treatment situation was the case of a man who believed he had numerous spots, or marks on his face. Others could not see them. He did convince a reluctant dermatologist to try different therapies on him, including several laser treatments. This treatment never produced satisfactory resultsthe spots never seemed to go away. He finally sought therapy. His behavioral treatment involved listening to tapes telling him how ugly the marks made him, how because they would never go away, and that he would be deformed for life. Additionally, he was instructed to cease visiting the dermatologist, to stop spending hours stating at his face in the mirror and to not question friends or relatives about his appearance. He felt quite anxious and nervous at the start of treatment, but the above instructions, combined with antidepressant therapy, resulted in recovery over a three-month period.

Generally, by combining this type of treatment with an OCD drug approach suited to the individual, symptoms and anxiety can be greatly reduced, if not eliminated. Please note here that I am speaking from my own clinical experience; much more research needs to be carried out in the use of these treatments for BDD to judge their effectiveness. I can say though, that these are the only two approaches I have ever seen work for this disorder. When other OCD symptoms are present as well, they will also benefit from medication and behavioral therapy, sometimes responding even more so than the BDD symptoms.

Can everyone with BDD benefit from such treatment? Honestly, the answer is no. Some individuals with BDD have such an unshakable belief in their deformity that they either refuse to engage in the treatment at all, or else will do it, but only halfheartedly, as they believe that everyone else is wrong and they are right. What percentage of those with BDD falls into this category is not known. I would advise those with the disorder to give treatment a chance; sometimes those whose beliefs seem very strong can still be successful by first starting with medication which can weaken and reduce the thoughts, and then make them more receptive to the idea of therapy. Family counseling for those close to BDD sufferers can also be of great help. This is a very puzzling problem for those who are a part of a sufferer's everyday life and who are uninformed as to what is happening. With help, family members can learn to be supportive of efforts to seek treatment, and to not pressure, punish, or ridicule as a way of dealing with the sufferer.

The number of therapists who can treat BDD probably remains small at this time, but there are those familiar with OCD who should be able to adapt their methods. Just be sure they are qualified and if you don't immediately find one, keep looking. Persistence is the key to beating OCD and OC related problems.

If you would like to read more about what Dr. Penzel has to say about BDD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000).  You can learn more about it at www.ocdbook.com

Coming To Terms With The Lost Years

There is an important, if unspoken, issue among those who suffer from OCD. It affects both those who have recovered as well as those who are still in the throes of the disorder. It involves the irretrievable loss of that which is most precious to us all, something we all possess in limited quantities. I am referring to the loss of time.

One study done a number of years ago indicated that the average amount of elapsed time from the onset of OC symptoms until the time an individual went for treatment was approximately seven years. What studies don't detail for us is that these were years spent suffering, years of little or no productivity, years spent hiding symptoms from family and friends.

The question here is how may a person come to terms with the loss of a part of their lives, be it a few years or even decades? Obviously, for those who cannot come to terms with such a loss the outcome is depression and feelings of anger and resentment, not unlike reactions seen in grief for someone we have lost. It is bad enough to lose a part of one's life to a mistake or a decision made that you can at least feel responsible for or explain, but it is far worse to have been in the grip of microscopic flaws in your own brain chemistry, most likely inherited in the same manner as one's height or hair color. There is at least some comfort in knowing that your loss was due to something that you could have had a say in. A sufferer asking, "What did I do to deserve this?" will be hard put to come up with an answer that is consoling. We spend a lot of time in these articles discussing symptoms and how to get help for them, but not enough perhaps in understanding how this disorder impacts on people's lives and how sufferers can make sense of and go on living with these things.

To get some help in understanding these questions, I solicited information and reactions from attendees at an OCD support and education meeting I conduct monthly. A poll taken among the sixteen sufferers yielded the following information: by their own reckoning, they had lost an average of 13.7 years of their lives to OCD, ranging from 9 months to 45 years. The total lost time among these sixteen was 219 years, the equivalent of about three lifetimes! Not all were currently in treatment.

Much of what they had to say is probably typical of most OCD sufferers. At one end of the scale was extreme rage and anger; one person said that they still "hold a grudge." Another expressed anger and rage over having lost years to an incorrect diagnosis. The term "a living hell" was the way another characterized the lost years. Others expressed anger at themselves for having participated in the illness, even though they knew what it was doing to their lives. A comment relevant to this was made by one person who stated, "You regret it while you're going through it, but you don't care how much time you waste."

A bit further down the scale from anger was a feeling of extreme sadness and regret. This reaction seemed almost universal in our group: the feeling of having felt helpless then, as time went by, and knowing now that they are powerless to reclaim it. Some said that this sadness could escalate to depression if they concentrated on the subject enough.

Finally, at the other end of the scale was a feeling of current detachment and disconnectedness as a result of this past incapacitation. One individual stated that due to this lost time he now felt "like an alien." Similarly, another stated that "I feel total detachment now. My symptoms are less now, but I feel outside the everyday world." Rather than feeling strong emotion, some seem to have lost emotional contact with others, having drifted away during the period of their illness.

Clearly, we elicited a lot of unhappy reactions, having raised a rather sad topic. There was, however, one ray of hope. There was one woman who said she was now in recovery. Rather than concentrating on what was lost, she said "I feel fortunate at having found the right treatment." She further said that having escaped the illness, she was now able to live with "a sense of joy." While not wanting to seem like a Pollyanna, she added that "You never forget the time you wasted."

I believe there is something to be learned from this person. Looking for joy and purpose in the present, and trying to live each day thankfully and productively, while coming to terms with feelings about the past, is probably the wisest course of action. Looking back to a past that can never be retrieved is useless and paradoxical because in doing so, one runs the risk of losing even more time to feeling disturbed. Yesterday is beyond our control, just as the future is.

I believe that AA has it right with their motto"One day at a time." It can clearly be seen that all those who only look back on their lost years have merely achieved remorse, regret, bitterness and anger, rather than anything positive. Realistically, we know that being in recovery is no guarantee of a "perfect" life; there are no guarantees in this world. Recovering from OCD means overcoming perfectionism and the need for certainty. Medication is liberating, but it isn't perfect; nor is it free from troubling side effects. Everyday life, free of OC symptoms, will still contain its share of stress, responsibility and sadness. Some look at these realities and decide it isn't worth it, that it is more comfortable to cling to the discomforts they have grown familiar with, rather than risk trading them for the unknown. Some may even shortsightedly believe they have more to gain by remaining ill and settle for half-lives. Being in recovery means being free to participate, as everyone else, in the same imperfect world filled with fallible humans. However, it also means regaining the ability to be spontaneous, to strive, to be able to experience successes as well as failures, and to be able to take the credit or responsibility for either to be an actor, rather than a reactor. There may be dangers out there, but many are able to look past these and also see the opportunities. Suffice it to say that, despite whatever drawbacks some sufferers may perceive in recovery, no one I have ever known who has made it and put an end to the "lost years" has ever wanted to return to them.

Coming to terms with the "lost years" is a healing process. For those who cannot achieve an adjustment to the loss and find healing on their own, counseling will be of help - probably a type not unlike grief counseling. I say this because where there is great loss, mourning is important work necessary to coming to terms with it. In a book entitled "Grief Counseling and Grief Therapy," by J. William Worden, Ph.D., four goals of grief counseling are identified. They are, to paraphrase: 1) to accept the reality of the loss; 2) to identify, deal with, and express feelings (such as guilt, anger, anxiety, sadness, etc.); 3) to help the person to overcome various impediments to establishing a life after the loss; 4) to encourage the individual to make a healthy emotional withdrawal from the deceased and to feel comfortable reinvesting that emotion in another relationship (in our case, substitute "illness years" for "deceased", and "future life" for "relationship"). I believe that any counseling to help someone adjust to their lost years should work at these four tasks of mourning.

If your "lost years" are keeping you from moving ahead either with your therapy, or with your life post-recovery, consider getting help with this issue. It is real, it is legitimate, and it is worth resolving. 

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com

Do-it-Yourself Therapy: Self-Directed Treatment

Back in 1990, not long after I had started the Western Suffolk Psychological Services treatment group, I found myself facing a dilemma. We found ourselves with more patients than we could treat. This was a desirable situation for a practitioner, but a very undesirable situation for sufferers. We were using the traditional intensive outpatient 5-day-per-week model at that time, seeing patients for daily 90-minute treatment sessions supervised by a therapist. A full-time therapist could only have a caseload of perhaps six patients at a given time. Given that one-in-forty people is afflicted with OCD, this clearly left many sufferers in our immediate area out in the cold. Turning away these people plainly seemed wrong. In addition, there had always been things I disliked about intensive treatment.

Since an intensive program lasted three to four weeks, it was too disruptive if a patient had a job and family and could not easily time off from everything. In many cases, the three to four weeks were not sufficient, especially where there were dozens of compulsions and numerous obsessions. Also, insurance companies were not usually supportive of long courses of intensive treatment (if at all). It rapidly used up insurance coverage if there were yearly limits, and if a patient had no insurance coverage, it was extremely expensive, requiring large sums to be paid in a short period of time, putting it out of the reach of many people.

Another thing I disliked about intensive treatment was that the constant supervision could inhibit the development the feelings of self-efficacy and control that come with doing things on your own. Knowing that a therapist was constantly watching as patients did anxiety-provoking things could be reassuring in a way that slowed a patient's improvement. Patients could say to themselves, "There's nothing to worry about, because the therapist has to be responsible, and wouldn't really ask me to do an assignment that would harm me or someone else." Thinking this way, patients didn't feel as much anxiety, weren't really confronting their fears, and therefore weren't getting the full benefits of therapy. 

It also seemed to me that the three-or four-week time limit of intensive programs sometimes put pressure and stress on patients, and could make them feel that they were a failure if they could not fully recover by the end of the time period. Conversely, the time limit could also create unrealistic expectations on the patient's part, or on the part of their family members, who believed that recovery would be complete by the end of the intensive treatment period, when often it was not. I was certain there had to be a better way to treat OCD sufferers. A solution soon appeared in the form of several intriguing behavioral treatment studies I found when seeking other treatment models. In 1977, Drs. Paul Emmelkamp & Joost Kraanen (in Holland) published the first study that demonstrated the effectiveness of Self-directed Treatment (SDT). In this study, no difference was found between self-directed exposure and therapist-controlled exposure, and in fact, self-directed exposure was consistently superior to the therapist-controlled exposure at a one-month follow-up. In another study by Emmelkamp & De Lange (1983), self-directed exposure was tested against spouse-aided exposure, and both were found to be equally effective. Dr. Isaac Marks and others (1988) in England showed that self-directed exposure was as effective as therapist-controlled exposure, despite the fact that the therapist-directed treatment group received 5 times more treatment. Finally, in 1989, Dr. Paul Emmelkamp and colleagues showed again that self-directed exposure was as effective as therapist-controlled exposure.

In SDT, as we began to practice it, patients came to the office on a once-per-week basis for a 45-minute session. Their progress and what they had experienced the previous week was monitored at their sessions, and they were given feedback and new assignments where appropriate. Sessions were also used to build motivation, meet with family, discuss other life issues, and to do cognitive therapy.

I could quickly see that there were several clear advantages to SDT. To begin with, if patients depended upon an insurance plan, they were more likely to be reimbursed for treatment. Also, costs were spread over a much longer period easier if patients were paying out of pocket. On a more technical level, it allowed sufficient time for those who had numerous symptoms to have their symptoms treated in-depth and more completely when visits were spread over a longer period. It allowed more time for a greater variety of assignments to be carried out, and to be done a greater number of times, leading to the development of greater tolerance of feared situations. It permitted the therapist to become better acquainted with a patient, their world, and their symptoms over a longer period of time, and allowed the detection of other significant problems that also needed to be confronted in therapy. Some symptoms can be quite subtle, and may not be apparent at first. Further, there was more time for teaching maintenance and relapse prevention skills that kept patients well long after therapy had finished. There was also sufficient time for significant others to attend sessions to be educated about the disorder, and to be given more of a role in treatment when necessary. Finally, I found that the lack of an exact time limit discouraged patients from pressuring themselves about recovering by a particular date, and also helped family and friends to be more patient and realistic about seeing the therapy as a process and not an event. It allowed those who worked outside the home or who raised children time to fulfill their responsibilities while working on recovery, sparing the family added stress and further expense.

Another advantage of SDT was that it had patients doing assignments on their own at home which was a lot closer to real life, and more like what things would be like after treatment. This, I believe is crucial, as it instills a sense of personal responsibility, teaches patients how to be their own therapists, and to develop their own resources. Becoming your own therapist is, after all, the chief goal of treatment. In line with this, SDT boosted personal feelings of effectiveness and self-control by allowing patients to be responsible for doing assignments without supervision. It was clearly much better for them to be able to say that they did an assignment on their own, rather than due to a therapist supervising them. I believe that ultimately everyone has to essentially face their OCD themselves (with the exception of the most seriously ill) if they are to make the best recovery. No one can do your work for you. It is crucial that each sufferer be helped to develop the feeling that they are personally responsible for the management of their illness. In working on their own, SDT put patients in a position to confront their own anxiety and hyperresponsibility, as they could not now blame anyone for making them do their homework. The therapist may have assigned it, but they had to make themselves do it.

Convinced that this was what we had been looking for, we began by implementing the approach with our incoming patients. We found, was that in line with the European studies, our patients did every bit as well or better than those treated with the intensive approach. We could also deliver services to many more members of the OCD community, as a full-time therapist could see six times as many patients as before. 

Having worked according to this model for the last two decades, and having the experience of personally treating over 1000 cases in this way, I feel that it was clearly the right decision. Some claim that Intensive treatment works faster, but when you figure in all the follow-up sessions that are required, it really isn't. The only clear disadvantage I have discovered for SDT is that it may not be suitable for the most seriously ill, who need constant supervision and structure in order to follow instructions. When I do get patients whose symptoms are too severe for them to benefit from SDT, I refer them, without hesitation, to intensive inpatient programs. 

I would take issue with therapists who despite available evidence, still routinely offer intensive daily outpatient treatment to every patient. This is impractical. Many individuals are functioning well enough to come to an office and take home assignments and don't need to come for treatment five days per week. They seem to make no allowance for different levels of severity. Obviously, you may have to work with whatever is available locally; however, I advocate for adjusting the level of treatment to the needs of the patient, and against simply putting people into one-size-fits-all programs. I believe that by doing this, many more OCD sufferers can be helped with the resources we currently have, and at lower cost.

If you would like to hear more of what Dr. Fred Penzel has to say about OCD, you can take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can find out more about it at www.ocdbook.com .

Fight for Your Rights: Getting Insurance to Pay for Your Treatment

Over the years, I have written a number of articles about the treatment and acceptance of Body-focused Repetitive Behaviors (trich, skin picking, or nail biting), or BFRBs as they are known. These are all very practical issues, to be sure, however, another practical issue I would like to inform you about has to do with getting your insurance company to cover the cost of treatment. If you are lucky enough to be able to pay for your treatment out-of-pocket, then this article will probably not be of much interest to you. If, however, you rely on health insurance to pay for treatment, then read on.

There is a little secret that your insurance doesn't want you to know about. The rules say that your company is responsible for providing you with adequate treatment by properly trained practitioners. This is particularly so if you belong to an HMO, are required to see doctors who are a part of your plan, and are not covered for the services of professionals outside of your plan. BFRB specialists are, unfortunately, in short supply, and chances are good that you will not find one within your company's list of providers. The plain truth is that many specialists do not work for insurance plans. This is also true of most BFRB specialists. 

You will most likely start by calling your insurance company to ask someone in customer service whether or not they have any practitioners who treat BFRBs. Before you make this first call, there is one word of caution. Always be sure to take notes of every conversation you have with anyone there, and always get the full name of each person you talk to. Insurance companies have a nasty habit of forgetting things they have promised or information they have given out. When you call a customer service representative at your plan, and ask for the name of someone local who treats BFRBs such as trich or skin picking, you may be given several names. Find out where they are located, as there may be rules about how far your company can require you to travel to see someone. Usually, you cannot be required to see someone outside a certain radius. Alternatively, they may ask you such things as, "What is trichotillomania?" or "Is skin picking a real disorder?" 

In the former case, if you call the professionals whose names and numbers they give you, you will most likely find (unless you are particularly lucky) that they do not treat your problem and cannot fathom why the company gave you their name. If they say they do treat BFRBs, grill them on how many cases they've treated, what methods they use, and what kind of training they have to do this. In most cases, they will not have the right answers and will probably get a bit cagey with you. If none of their professionals pan out, you graduate to the next step, and are now in a position to make your plan give you permission to see the therapist of your choice. If they actually admit they have no one, this is even better, as you will certainly be able to force them to let you see whom you want, even if that therapist is not officially a part of your plan. 

What you do next, in either case, is to inform your insurance company that you have found someone who is considered competent to treat what you have. I should add, at this point, that to make all this work, you need find that competent professional before you set all of this in motion. Also, you need to make sure they are properly licensed, either as a psychologist or a social worker.

If your company admits that they have no one, they will go onto contact the practitioner and negotiate what is commonly known as an "ad hoc," out-of-network, or "single case agreement." This will enable the professional to be paid their full fee, without your having to pay more than your usual co-payment. In effect, you will be covered on an in-network basis, not out-of-network.

If they decide to put up a fight and get difficult about it, they will start by either telling you they simply do not cover out-of-network providers, or, if you have out-of-network coverage, that you are free to see someone outside their list, but that they will only pay out-of-network rates usually 50 percent of a fee that they think the practitioner should be charging (generally a lot lower than the going rate). At this point, you have to get more assertive and say something like, "I'm afraid you don't understand the situation. You have no one in your network who is qualified to treat me, and since you are obligated to provide me with care under the terms of my contract, you must now allow me to see someone out-of-network, but on an in-network basis, and you will have to negotiate a fee with them." If they now realize you know your rights, they will ask for the name and phone number of the practitioner, and will call him or her to negotiate a fee. 

Before you show up for your first visit, make sure the practitioner has received a contract or statement of agreement in writing from the company. The paperwork should state how many visits have been initially approved with the practitioner, and the rate your company has agreed to pay this professional for various services. The standard insurance service code for a first visit is 90801, and for regular office visits of 45 minutes is 90806, and the contract should clearly state how much will be paid for each. You will also need to know if you will be required to pay your standard copayment at each visit.

If the insurance company still resists, you must then ask to talk to a supervisor, and assertively explain the situation one more time. If they insist that they really do have a practitioner, ask for that person's name and credentials. Also ask if they are known specialists, and have specific training in treating TTM or other BFRBs. Also ask how many people with the disorder they have treated. Since you have already called a whole list of people, you may be able to inform them that the professional they have in mind for you, a) really isn't qualified, b) isn't taking new patients, or c) didn't know what TTM was, etc. Hopefully, at this point, they will recognize they are now in a no-win situation and will give in. Most companies do at this point. If you have an unusually stubborn company that can't tell when they have no case, you may have to contact the state agency that regulates insurance companies. As I mentioned earlier, always be sure to get the full names of everyone you speak to at the insurance company, as you may need them if you file a complaint.

The only exceptions that I have ever encountered to all of the above have been special contracts negotiated by employers with insurance companies. These agreements may forbid an insurance company from negotiating fees above set levels. In such a case, the employer has tied the insurance company's hands, and there is nothing they can do. Fortunately, these types of setups tend to be rare.

Overall, be assertive, speak firmly, don't lose your cool, and indicate that you know your rights as a consumer. If you get angry, you will be labeled as difficult, and will undercut your own position. Just remember that the insurance company isn't doing you a favor if they let you go out-of-network. You (and/or your employer) are paying good money for your benefits and you are entitled to them. Don't be bullied, put off, or take "no" for an answer. Persistence pays off; so don't let them double-talk you. Never forget that you are dealing with a profit-making business with stockholders, and not a humanitarian organization. They are dedicated to paying out as little as possible and will use every ploy they can in order to do this.

I have negotiated many out-of-network provider contracts over the years, and can tell you that this can be done, and is being done by savvy consumers all the time.

Dr. Fred Penzel is a licensed psychologist who has specialized in the treatment of TTM and OCD since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, New York, and is a founding member of the TLC Science Advisory Board. Dr. Penzel is the author of "The Hair-Pulling Problem," (Oxford University Press, 2003), a self-help book for those suffering from TTM. You can view more information about it at www.trichbook.com. Dr. Penzel can be reached at (631) 351-1729 or at penzel@attglobal.net.

How I Treat Violent Obsessions

There are dozens of categories of different obsessions and compulsions that make up the disorder known as OCD, and while these cover a wide range of differing themes, they all share many characteristics in common. These would include intrusive, unpleasant thoughts, unceasing doubt, guilt, fears of being insane, and crushing anxiety. While all forms of OCD can be painful, paralyzing, repulsive, and debilitating, one of the nastier and more startling is the type known as morbid obsessions. This is particularly true of those obsessions in this category that are violent in nature, and include thoughts of killing or injuring others or oneself, or of acting sexually in ways that are against society's norms. I include thoughts of acting out sexually in this category, as they really represent a form of violence, and have little to do with sex.

Violent thoughts may involve both mental images and impulses to act. These can include those in which people see themselves hitting, stabbing, strangling, mutilating or otherwise injuring their children, family members, strangers, pets, or even themselves. They may envision themselves using sharp or pointed objects, such as knives, forks, scissors, pencils, pens, broken bottles, letter openers, ice picks, power tools, poison, their bare hands, or even their cars. The urges they experience may involve pushing or throwing themselves or others into the paths of trains or cars, out of windows, or off balconies, buildings, or other high places. Some report thoughts of hitting pedestrians, ramming their cars into bridge abutments on the highway, or steering into the path of oncoming traffic. Others fear snapping or going berserk in public and harming people. One patient of mine would have thoughts of opening one of the exit doors aboard an airliner. In reaction, sufferers tend to fear being alone with anyone smaller and weaker they feel they could easily overpower, such as children and elderly people. They often avoid going to such places as train platforms, pedestrian-filled street corners, or being in crowded public places. Mothers may experience repeated thoughts of acting violently towards their infants or small children. Sexual thoughts in this category usually involve raping or sexually abusing children or other adults. Fears of acting out other sexually inappropriate behaviors may also occur.

Although the number of people who suffer from this type of OCD is still not exactly clear, it is probably more common than most people think. I would estimate that about a third of my patients suffer from some form of them. When most of my patients begin treatment, they believe that they may be insane, and that no one else could think as crazily as they do. I am usually able to convince them that neither of these things is true, and this is further confirmed for them when they attend a support group and hear others report the same types of thoughts. Another problem these sufferers seem to be burdened with is a nagging doubt that causes them to ask themselves," What kind of person am I that could think such thoughts? Why would I think these things if I didn't really want to do them. I must be a psychopath or a pervert." Not being able to resolve this doubt obviously results in a lot of anxiety. In years past, OCD sufferers who went for treatment via psychoanalysis were mistakenly informed that their thoughts actually represented repressed anger and that they unconsciously wished to do the things they were obsessing about. This only worsened the symptoms for these unfortunate people. Sad to say, treatment of this type still continues in many places. In one case I know of, a woman confessed her obsessive thoughts of hurting her child to a psychiatrist. She was rewarded by this professional reporting her to state protective services, who then promptly investigated her with an eye to removing her child from her home.

It is important for sufferers to understand that the thoughts are just thoughts, and do not cause anxiety, but rather the anxiety is caused by the views sufferers take of the thoughts. They need to overcome the idea that, "If I think it, it must be real." It should be noted that people who suffer from these thoughts have no history of violence, nor do they ever act out on their ideas or urges. Although OCD can project extreme and bizarre thoughts into people's minds, it is not the thoughts or the anxiety, as much as people's solutions to having the thoughts that represents the real heart of the problem. It is the compulsive acts that people perform to relieve their anxiety that cause the paralysis that they experience. Compulsions are seductive, in that they offer the illusion of immediate relief from anxiety, even if it only lasts a brief time. Compulsions paradoxically, start out as solutions, but eventually become the problem itself. They may grow from taking only a few minutes per day, to taking up hours at a time. Instinct tells people with OCD to avoid or run away from the things they fear, and they erroneously believe that this is possible. Unfortunately, the opposite proves to be true, and the avoidance only worsens the problem and increases the fear. A person's whole life may become oriented around never coming into contact with the things that make them anxious. In actuality, you cannot run from what you fear. It must be faced. People with OCD do not remain in the presence of what they fear long enough to learn the truth of things, which is that nothing would happen even if they did no compulsions. Regardless of the type of obsessions, treatment for OCD is all about getting sufferers to accept that their solutions do not work, and will never work, and that they have to finally face their obsessive thoughts while resisting their urges to do compulsions. Anything short of this will not be powerful enough to get the job done.

These principles are put into action in a treatment known as Exposure and Response Prevention (E&RP). This is a systematic way of confronting the violent (or any other) thoughts in a step-by-step manner. The actual exposure itself is very straightforward. Sufferers can be exposed to violent thoughts in a number of ways. These may involve assignments carried out under a therapist's direction in an office, or on one's own, at home. What all these methods have in common is that they don't reassure. Instead they are designed to provoke anxiety by essentially saying that the thoughts are true, that the feared consequences will really happen, and that nothing can be done to prevent them. Ideally, exposure should be done whenever and wherever the thoughts occur. Those who suffer from violent obsessions have various types of scripts they write for themselves, and it is important to understand these scripts in order to be able to use them in designing homework assignments. A typical script for violent thinkers runs something like, " I must be having these thoughts because I'm really psycho and want to do these things. Maybe I'll lose control and really do them. If I do act on my thoughts, they'll lock me up forever. That will be horrible for my family and me; they will suffer because of what I did, and I will suffer knowing what I did to them and to my victim. I won't be able to live with the guilt. I'll either die in prison, or kill myself." Scripts such as these are worked into a series of graduated assignments. 

I usually prescribe assignments based on a hierarchy we create, which rates all of the person's feared thoughts and situations in terms of the strength of the anxiety they cause. We begin with only those items lowest on the fear scale, and gradually work our way up, going at the patient's own pace. No one is forced to do anything they are not ready to tackle. If a particular assignment cannot be done in a whole step, it may be broken down into smaller steps. Each hierarchy and group of assignments is tailored to each person's symptoms. Treatment is home-based (also known as self-directed treatment) and outpatient. Homework is given weekly in written form, and done outside the office, with instructions to call if necessary. Most people have between 4 and 12 different assignments per week. In the majority of cases, treatment is on a once per week basis, requiring one 45-minute session to debrief the past week's homework, to give the next series of assignments, and discuss other ongoing issues in the person's life that may need attention.

The assignments usually begin with things that are more general, and only provoke a moderate amount of anxiety. Over time, they gradually become more specific, and get people to expose themselves to more and more challenging things. It is here that therapists are called upon to show their flexibility and creativity. We go wherever we have to go, and do whatever it takes to create therapeutic situations that will help the person to confront their thoughts. Behavioral therapy cannot be done in cookbook fashion. It is usually suggested to the patient at first, that there are people out there who are capable of violent acts, and who may lose control and act without warning. The exposure then moves on to suggest that the patient, themselves, just might be capable of the sorts of things they may be thinking about. From there, we move on to confronting the idea that there is a real possibility that they will snap, and commit a violent act. Following this, the next step has the patient expose themselves to the thought that they will definitely do whatever it is they are obsessing about, and that it may happen at any time without warning. At this stage, if the patient is particularly doubtful, it may also be appropriate to suggest that they have even done the feared thing recently, or in the past. Moving through these various stages can span a period of months, and the whole process can take approximately 6 to 9 months overall. Those with the more serious and debilitating problems may need to come more than once a week or for a longer period. A few of the most serious cases may even need to work within a hospital setting, if they are unable to follow treatment on their own, although this is much less common and rarely necessary.

One good exposure technique is via audiotaped presentations of these feared ideas that run several minutes in length, and are used several times a day. Other methods could include reading books or news articles that provoke the violent thoughts, writing brief essays on why the thoughts represent true desires, visiting websites related to violent or sexual offenders, hanging up signs with phrases that evoke anxiety, writing feared words or phrases repeatedly, or voluntarily seeking out real-life situations likely to bring the thoughts on. With regard to this last technique, it can be quite helpful to set up little plays to help the person confront a feared situation in a somewhat realistic way. One example of this would be the case of a young man who had thoughts that he would stab his father. We set up a nightly exercise where he would sit next to his father on a sofa watching TV together, as the patient held a large kitchen knife in his hand. Periodically, his father would turn to him and say seriously, "Please don't kill me, son." An important factor to also build into these techniques is repeatedly exposing the person to the idea that the escape or avoidance maneuvers they typically use, cannot and will not work. Probably the most important assignment I ever give patients is for them to agree with each violent thought as it occurs, rather than trying to argue with or analyze them. They probably get more opportunities to do this assignment than any other.

When first considering E&RP, people tend to ask, "Won't this treatment make me feel worse?" The answer is that it may, at least to start. By staying with what you fear, you may feel more anxious at first, but you will gradually build up a tolerance to the feared thing. I like to tell my patients, "You can't be bored and scared at the same time." The ultimate goal is total immersion, so that exposure takes place in a variety of ways throughout the day. The more total it is, the quicker you will get used to what you have feared, and the sooner the fear will subside. This may not be as easy as it sounds, especially in the face of really repulsive, violent thoughts. Obviously, the real art of doing therapy involves getting people to trust what the therapist is telling them, and that the method will work for them. By the time we get to the end of a person's hierarchy, there is little left in it that can bring on anxiety. They can think the worst of their thoughts, but not feel that they have to react to them.

The following list is included to show what some typical behavioral assignments might look like. No list can be complete for all people, so this is just a sampling. Understand that some of these are advanced assignments presented in no particular order, and you would work up to doing them over time. Note that no one does assignments such as these until they are ready for them.

Thoughts of running into people with your car:

• Reading news articles about hit-and-run accidents

• Driving down crowded streets or around shopping malls

• Driving down dark roads at night

• Thoughts of stabbing people:

• Gesturing at others with utensils, while eating

• Sitting close to others at home holding a large knife

Thoughts of hitting people:

• Walking down a crowded street and brushing against people

• Patting people firmly on the back

• Gesturing toward people while standing close to them

• Watching stabbing scenes in movies

Thoughts of molesting children:

• Reading about child molesters who got caught

• Standing close to children in public

• Holding one's own children or cuddling them (young children)

Thoughts of harming your infant:

•  Looking at articles about child abuse

• Holding your infant standing near an open window

• Reading about parents who killed or injured their children

Thoughts of stabbing yourself:

• Writing a composition on how you will lose control and harm yourself

• Sitting with a knife or pointed object in front of you on a table

• Holding a knife or sharp object pointed at yourself

• Fear of going berserk in public:

• Walking around in public with a knife in your pocket

• Walking with a knife in your pocket listening to a tape telling you that you will lose control

• Standing behind people on a crowded train platform

• Reading news articles about people who lost control in public

I like to make patients aware that many people they may encounter will not be particularly sophisticated or familiar with behavioral therapy or the purpose of its homework assignments that don't sound like your typical talk therapy. In discussing it with others, including family members or even physicians, they may get negative reactions. One psychiatrist gravely informed one of my patients that the therapy sounded very extreme and risky to him, and that he had his doubts about it. This obviously did little for my patient's motivation, and it took a bit of doing to get him to get back to work, while accepting that his physician just wasn't well acquainted with E&RP, and was commenting on something he knew little about.

Finally, I would like to share some rules that my patients find helpful in dealing with violent thoughts and other forms of OCD:

1. Expect the unexpected you can have an obsessive thought any time or any place.

2. Never seek reassurance. Instead, tell yourself the worst will happen, or has happened

3. Always agree with all obsessive thoughts never analyze or argue with them.

4. If you slip and do a compulsion, you can always mess it up and cancel it out.

5. Remember that dealing with your symptoms is your responsibility alone. Don't involve others

6. When you have a choice, always go toward the anxiety, never away from it.

There is a common myth that violent obsessions (and even obsessions in general) are harder to treat than other types of symptoms. This is absolutely false. Regardless of your symptoms, you can be successfully treated if the correct techniques are used, if you accept that you cannot go on as you have, and if you are prepared to do whatever it takes to recover and regain control of your life.

You can contact Dr. Penzel at 631-351-1729, or e-mail him at penzel85@yahoo.com

Obsessive Compulsive Disorder (General information)

Obsessive-Compulsive Disorder (OCD) is a problem that affects one out of every forty people. This works out roughly, to between five and seven million Americans. Studies have shown similar rates of occurrence in other countries as well. It affects one out of every 200 school-age children, and 21% of OC sufferers begin to experience symptoms by the time they are fifteen.

Obsessions are thoughts that are intrusive, unwanted, repetitive, inappropriate, and often doubtful. They frequently center around harm or bad luck happening to either the thinker, those close to him or her, or strangers. This harm may involve past, present, or future events. Anxiety, guilt, and depression frequently accompany these thoughts. Typical obsessions will generally fall into one of the following groups:

1. Morbid thoughts about having sex with, or harming others

2. Contamination via such things as dirt, germs, chemicals, radioactivity, or another person

3. Religious obsessions

4. Obsessions about harm, danger, loss or embarrassment happening to oneself or others

5. Superstitious or magical thoughts

6. Obsessions about one's own body

7. Perfectionistic obsessions

Compulsions are any physical or mental actions or activities that are performed for the purpose of relieving the anxiety, doubt, and guilt caused by a sufferer's obsessions. Compulsions may vary with different obsessions, or may be repetitive and ritualistic that is, having to be performed the same way every time. At the beginning, compulsions may only be performed occasionally, however, as time passes, they can expand to fill hours of a sufferer's day. Typical compulsions will generally fall into one of the following groups:

1. Decontamination

2. Hoarding

3. Double-checking

4. Magical/undoing rituals

5. Perfectionism

6. Counting

7. Special types of touching or movements

8. Mental Compulsions

It can be rather difficult for those who do not suffer from the disorder to appreciate just how tortuous the cycle of intrusive, unpleasant thoughts and repetitive actions can be. Those with OCD can generally see how illogical the thoughts are, and how destructive compulsions can be, but remain trapped by them anyway. OCD can take over a person's, as well as a family's entire life.

It is only in recent years that treatment for OCD has become better known and available. There are currently two modes of treatment for OCD that have been shown to be effective. They are antidepressant medication and behavioral therapy. Medications used to treat OCD include Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Serzone, Effexor, and Anafranil. The type of behavioral therapy used to treat OCD is known as Exposure and Response Prevention. While in treatment, sufferers are taught how to gradually confront their obsessive thoughts, while progressively resisting their compulsions. By doing this, they build up a tolerance to the thoughts and also learn that even if they don't perform compulsions, nothing can or will happen. By the end of treatment, even if the sufferer has an obsessive thought, they can accept it, acknowledge it, and feel that they do not have to act on it in any way. At this point, we may say that they are "recovered." We do not use the word "cured" because OCD is a chronic disorder, much the same as diabetes or asthma. In uncomplicated cases of OCD, time to recovery averages between six and twelve months. In cases where other disorders are also present, or a sufferer has been disabled for an extended period, recovery may take longer.

OCD was once thought to be strictly a psychological problem a type of defense mechanism and a reaction to one's early upbringing. Modem scientific findings of the last thirty years have revealed instead that OCD is a neurobiological brain disorder, most likely a disturbance involving the action of a brain transmitter chemical known as serotonin. There is also some recent evidence that OCD may have genetic origins. It is not unusual to see OCD in several members of the same family, spanning a number of generations. Further research will hopefully shed more light on this in the near future. If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com

In Search of the Elusive Behavior Therapist

A question I am frequently asked by those who suffer from OCD and Trich is, "How can I find a behavior therapist near where I live?." It must seem to many people that therapists with this specialty tend to be rather rare and exotic creatures. In truth, there really aren't all that many behavior therapists here in the U.S.. Also, they generally tend to congregate around certain regions and usually near major metropolitan cities. This is, after all, where the greatest number of patients are, and let's face it, behavior therapists have to make a living like anyone else. Don't get too discouraged. There are still a fair number of them scattered around, and graduate programs are turning out more all the time. My purpose in writing this article is threefold: first, to help you locate a therapist of the behavioral persuasion; second, to show you how to question them about their qualifications and services; and third, to give you at least some information so that you will be able to evaluate what they have to offer you.

Where and how to look:

There are several sources of referral information that you will find helpful in your quest, and I will give them to you here.

• The Trichotillomania Learning Center (TLC): the obvious place to start. They are the premier organization for those with this disorder. You can call them at (831) 457-1004 for the names of practitioners they know of in your area. Their web address is www.trich.org . and their website is quite helpful and informational.

• The International Obsessive Compulsive Foundation (IOCDF): They maintain a large national referral list organized by states, and you can call them to request their listing for yours at (203) 878-5669. There is no guarantee that the OCD specialists they list will also specialize in trich, but they may, or else those whose names they give you may know of other practitioners in your area. Their web address is www.ocfoundation.org

• The Association for the Advancement of Behavior Therapy (AABT): A professional organization whose members practice behavioral therapies. While they do not maintain a listing of inch specialists, they do have a list of specialists in OCD which is organized geographically. Again, these specialists are worth calling for the reasons mentioned above. Once again, even if some of these practitioners don not treat trich themselves, they may know other specialists who do. Their website can be found at www.aabt.org

• Your local trich or OCD support group (assuming you have one): Attendees are often a valuable source of information, because members may have already seen many of the local practitioners.

• University hospital centers that have OCD clinics: There are very few trich treatment centers, and you are better off asking to speak to someone in their OCD program. They may have a trich specialist.

• Your county psychological society: This may be a bit of a long shot, depending upon how many members they have, but you never know. They usually list their members by specialties, and may know of a local inch specialist. Sometimes the secretaries at these offices are extremely knowledgeable.

People who staff the organizations listed above are quite helpful and will certainly do their best to help you. Don't be shy about calling them, as they get such calls all the time. As you begin your search, there is one very important point to keep in mind. There is no such thing as the "perfect" therapist. A particular therapist may or may not be the best match for a particular patient depending upon the therapist's style, and the personalities of both individuals. If you are fortunate to live in a location where behavior therapists who specialize in trich are plentiful (Is there such a place?), you will have the luxury of being able to choose from several. My hunch, however, is that you will probably be lucky to have even one such specialist in your area, so you may have to work with them and make the best of it. Hopefully, this person will have the training and be someone you can work with in a therapeutic relationship. If not, you may have to be flexible and try to work with whoever is there. Even if they don't fit your ideal, it still doesn't mean you cannot be helped by this person.

What to ask: 

When you finally locate a practitioner, you would do well to ask them the following questions before making an appointment:

1. What degrees do you have, and are you licensed in this state? (Stay away from the unlicensed. No one regulates them, and you will have no protection if you are improperly treated. In most places, anyone can call themselves a "psychotherapist", whether they've had any training or not).

2. Do you specialize in treating OCD or trichotillomania (depending upon your diagnosis)? What are your qualifications for this? (Have they had some type of supervised training).

3. How long have you been in practice? (If they are the only practitioner in your area, this may be less important.)

4. What is your orientation? (The answer should be cognitive/behavioral treatment)

5. What techniques do you use? (For behavioral therapy for OCD the answer would have to be Exposure and Response Prevention. For trich, the answer would have to be Habit Reversal Training and Stimulus Control- see below)

6. What is your fee? Are your services covered by insurance (assuming that the answer to this is an important factor in being able to afford treatment)? Make sure you check with your insurance plan before calling anyone to find out if you have coverage for outpatient mental health treatment. Also be sure to ask if you are only allowed to see practitioners who are members of your plan's network. Insurance companies try to keep this secret, but if they have no one within their network who specializes in your disorder, they have to let you go out of network, and they will even negotiate the specialist's fee, often paying what that specialist usually charges. Don't be afraid to press them on this.

7. How often would you have to see me? Once per week ought to be enough unless you are in crisis.

8. On the average, how long will it take for me to see some results with this treatment? You should expect to see at least some results within the first six months, assuming that you are cooperating with treatment instructions.

If you don't like some of the answers you are getting to the above questions, or the practitioner gets defensive about answering them, look elsewhere. A reputable therapist should have no problems answering such questions directly.

What you should know:

Once you have made your first appointment, but before you show up. try to educate yourself about behavioral therapy (BT). Just as you would before buying a large household item, it pays to know something about the product. It is important that you be clear about what is proper behavioral therapy for trich. Over the years, I have had many new patients tell me that they have already tried BT and that it didn't work for them. When questioned further, it would become clear that they hadn't had proper BT at all, but something their therapist told them was BT. Most often, they were taught a simple relaxation exercise which by itself, wasn't enough to do the job. Others have tried hypnosis, and although it usually isn't represented as BT, they mistakenly took it for that.

BT for OCD consists of an approach known as Exposure And Response Prevention. To begin, a careful analysis of all symptoms is made, and a rank ordering of all feared situations known as a hierarchy is established. Based upon this information, an individualized treatment program is created, and behavioral homework assignments are given on a regular basis. Patients are then gradually exposed to larger and larger doses of the thoughts and situations they fear, while resisting their compulsions and staying with the resulting anxiety until it subsides. The therapy may either be self-directed, or done under a therapist's direct supervision in the office or out in the community. I tend to favor self-directed treatment, as it encourages people to be more independent and to eventually become their own therapists. It is a lot closer to real life than having someone standing over you and telling you what to do.

At the present time, proper BT for trich consists of what is known as Habit Reversal Training (HRT), as well as Stimulus Control (SC). HRT is composed of four major parts, together with some extra bells and whistles thrown in to keep you motivated and on track. These extras may vary from therapist to therapist. The four parts of HRT are:

1. Keeping records of your pulling behaviors to increase your awareness of your own behavior.

2. Relaxation training to reduce tensions that lead to pulling, and to help you center yourself when you get the urge to pull.

3. Breathing exercises to be done along with the relaxation, to increase the relaxationand to further center yourself

4. A muscle tensing exercise performed with the hands and forearms that is incompatible with pulling.

HRT may be done on an individual basis, or as group treatment. While space does not permit me to give you a really complete rundown on HRT here, you can call or write to TLC to get reprints of previously published articles on behavioral therapy. My article in a previous issue of In Touch (#3 for 1992) gives you a rundown on HRT, and will help you to spot the genuine article when it is being offered.

Actually, good therapy for trich should really offer you more than just HRT and SC. It should take a close look at all aspects of your life: your past history, your working life, your relationships, your general health, your philosophy of life (yes, you have one, everyone does), your spiritual life, the ways in which trich has had an impact on your life, and especially your attitudes toward trich itself and how you view yourself in regard to the disorder. Some people have been so stigmatized by the disorder that this, in itself, needs to be treated before you can even begin doing the HRT. If some of these issues aren't looked into and dealt with, your treatment may never get off the ground due to a lack of motivation or belief in your ability to recover.

There are a number of things which you should look for in a therapist, and some you should beware of. Look for a therapist who:

• listens to you, answers your questions, and doesn't just talk at you.

• answers your calls in a timely way and is reasonably available to you.

• uses the latest accepted treatments that are recognized by leaders in the field.

• not only teaches you techniques to get recovered, but also those necessary to stay recovered. They will show you how to realistically accept the inevitable slip-up and still keep going.

• helps you to grow into the role of being your own therapist - that is, someone who is responsible for their own recovery and who ultimately learns to depend upon themselves.

• doesn't just plug you into a "one size fits all" treatment program, but instead treats you as an individual and tailors (as much as possible) the various techniques they have to fit your particular needs.

• if they are the only one in your area and do not have the training, are at least willing to learn about it on your behalf, and to give it try.

Beware of the therapist who:

• has you come for an excessive number of visits, or seems to keep you coming to them without any kind of endpoint to the treatment

• simply chats with you at every visit but never seems to really work on anything.

• keeps you dependent upon them rather than teaching you to depend upon yourself.

• is flatly opposed to the use of medication rather than having an open mind about it.

• guarantees you results or promises a 'cure' (if something sounds too good to be true, it probably is).

• uses methods that neither you nor anyone else has ever heard of

• uses methods for which there is no scientific evidence

• tells you that your hairpulling is really the result of some other deep unconscious psychological conflict, and that this other problem must be worked out first.

• assigns homework that you find really distasteful, humiliating, or degrading.

• makes comments or observations that you find embarrassing or humiliating.

• keeps telling you that they will eventually get around to the behavioral therapy, but never seems to do so.

Whatever it takes to find a recovery, never give up. In pursuing a recovery, persistence is everything. As long as you keep trying, there is always a good chance that you will succeed. I have rarely seen someone fail to succeed who has stubbornly kept at it. There really are resources out there if you look for them.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000) You can learn more about it at www.ocdbook.com .

If Trichotillomania is your problem, take a look at Dr. Penzel's other self-help book, "The Hair-Pulling Problem: A Complete Guide to Trichotillomania," (Oxford University Press, 2003). You can learn more about this book at www.trichbook.com

The Boy Who Didn’t Know Who He Was: A Teen With Sexual Identity Obsessions

When I first saw Michael, I couldn’t help but notice just how depressed he looked.  The red-haired strongly built seventeen year-old could hardly hold his head up.  His parents said that he had been really down for several weeks, but no one knew why, and he wasn’t helping either.  He couldn’t seem to come up with the energy to get to school, and preferred to stay in his room, alone.  He had been a good student, enjoyed playing on his school’s lacrosse team, and was heavily involved in student government.  At a time when he should have been thinking about choosing colleges to apply to, he seemed to have dropped out of life.  Some possible clues were his parents’ report that he had suddenly thrown away his prized collection of bodybuilding magazines, and the fact that he seemed to be avoiding all contact with his guy friends.  Another clue was that his father suffered from OCD, which was particularly interesting to me, as the disorder sometimes appears to run in some families.  Finding out what was going one here would be my first, and probably most difficult task, since he was the only one who could help solve this mystery. 

Michael and I sat across from each other, with him slumped forward in his chair, his head down, and his hands clasped together.  I tried to engage him in some small talk to break the ice.  All I got in return were some one-syllable answers.  “Is there anything you want to tell me?” I asked.  “Nope,” was the reply.  His whole manner seemed to say that he was also really anxious.  Maybe it was the way he chewed his lips and drummed his foot.

As we therapists sometimes do, I decided to take a chance and act on intuition – just take a shot in the dark based on what evidence I had.  I knew it was risky, because if I was wrong, he might refuse to talk with me any further.  I thought I had it right, though, based on the clues I had.  “Michael,” I said suddenly, “Are you worried that you might be gay?”  With that, he jumped back in his chair, his eyes wide.  It was as if someone had given him a jolt of electricity.  “What?  How did you know that?” he gasped.  “Nobody knows that.  Nobody!”  I went further.  “Is that why you threw out your magazines?” I asked.  He nodded at me.  I had seen many cases like this over the past twenty-odd years, so I decided to pull out all the stops and really get things moving, now that I had his attention.

“Let me guess,” I said, leaning forward.  “One day you were doing something you always do, and suddenly you started to pay attention to yourself in a different way.  As you focused on yourself, the thought suddenly came into your head, “Maybe this means I’m gay.  How do I really know I’m not?”  I kept on, “Since then, you keep checking yourself, you know, like looking at guys or girls and trying to see who you’re attracted to.  Maybe you watch the way you talk, or walk, or move your hands, to see if you do these things the way a gay or straight person would.  How am I doing so far, Mike?”  He stared at me and answered, “I feel creeped-out, like you’re reading my mind.”

I went on to explain that I definitely didn’t have ESP (as far as I knew), but that he was suffering from a very common form of Obsessive-Compulsive Disorder (also known by the abbreviation OCD); one that doesn’t get talked about very much, and certainly not a lot by people his age.  Many people with obsessive sexual identity thoughts shared the particular symptoms I had outlined, so they weren’t very hard to guess at.  I related to him that at one time, a few years ago, I actually found myself treating six different people at once for this type of OCD, and that we had even held a support group meeting just for this group.  I added that these thoughts weren’t confined to heterosexual people, and that I had even treated a gay patient who was troubled by obsessive thoughts that he might be straight.

Michael went on to confirm that his doubtful thoughts of being gay came on suddenly one day when he was looking through one of his bodybuilding magazines.  He remembered looking at one picture in particular and thinking, “I wonder if I find this guy attractive?”  With that, he suddenly became very anxious and horrified that he could have such a thought.  He also found that in the days following, he couldn’t get the thought out of his head.  What made things worse, was that the other guys in school had a habit of teasing each other about being gay, a not unusual occurrence.  Remarks that he used to shrug off now became very frightening.  “What if they really can tell?” he remembered asking himself.  He found himself avoiding his usual crowd.  He threw away the bodybuilding magazines.  He stopped going to school.  Nothing helped.  It seemed like the harder he worked to avoid thinking about whether or not he was gay, the more he would think about it.  “But I’m not gay,” he emphasized, “I’m not attracted to guys, so why am I thinking this?  I’ve never been attracted to guys!”  He paused for a moment.  “But the thoughts seem so real.”

I explained to Michael that these obsessive questions were not “real” questions, and the thoughts were not “real” thoughts.  These things that seemed so real were the result of problems with his brain chemistry, and that there were no real answers to his doubts, so no matter how hard he checked himself and his behaviors and thoughts, he would not be able to erase the doubt.  The OCD (once known as “The Doubting Disease”) would not let him.  I told him that the thoughts were, after all, just thoughts, no matter how creepy they were, and that they really had no power to make him anxious.  The truth was that he was actually making himself anxious.  The proof of this was that even people who recovered from OCD would still report unpleasant thoughts, but also add that the thoughts no longer made them anxious.  Why?  Because with the help of therapy, they had faced the thoughts and built up a tolerance for them, to the point where they no longer produced a reaction.  “The real problem is not the thoughts,” I said, “The problem is what your attempts to control your anxiety are doing to your life and your ability to live it.” Another thing I tried to emphasize to him was that it was not unusual for people to sometimes get doubtful thoughts about their sexuality, but that people without OCD were better able to decide how they really felt about these things, and could eventually put the thoughts aside.  “Our goal,” I told him, “will be to learn to gradually face the thoughts and resist doing compulsions long enough for you to learn the truth about all this.  You will have to face a lot of doubt and feel as if you are taking risks at times, but if you stick with it, you will gradually become desensitized to the thoughts, and they will no longer seem to have any power over you.”  This was clearly a lot to think about, and Michael would need the next few sessions to really digest all this.

One of the really maddening qualities of OCD is that it can make a person doubt the most basic things about themselves – things no one would ever normally doubt.  Even their sexual identity could be questioned.  Sufferers will go to great lengths to overcome this doubt – even ruining their lives through their desperate actions.  Doing compulsions, such as repeated questioning, avoiding things, looking for reassurance, and checking, can be rewarding in the short run, and this is what keeps the problem going.  By staying away from the things that make them anxious, sufferers only keep themselves sensitive to these things.  Also, this only helps for a little while, and before long, the doubt returns, as it always does.  Fortunately, this process also works in reverse, or as a favorite saying of mine goes, “If you want to think about it less, think about it more.”

Michael had been attempting to control his anxiety chiefly by avoiding – throwing out his magazines, avoiding his friends, and not going to school.  He also kept double-checking his own thoughts to see if he really believed them.  He eventually revealed that he also would alternately look at other boys and then at girls, trying to decide whom he was more attracted to.  He, himself, admitted that even when these things did work (and often they only raised more questions) the relief only lasted a short time.

After learning much more about Michael and his life, we began to prepare to do the behavioral therapy that would be the main part of our treatment.  The specific type of therapy we would be doing is known as “Exposure and Response Prevention.”  In this type of behavioral therapy, the person voluntarily and gradually exposes themselves to greater levels of the things that bother them, and at the same time, agrees to resist doing the compulsive activities that they have been using to make themselves less anxious.  The purpose of all this is for them to learn that if they just stay with what makes them anxious long enough, they will come to see the truth of things – that these are only meaningless thoughts, and that the anxiety will gradually diminish even if they do nothing.  The ultimate goal is for a person to be able to tell him or herself, “Okay, so I can think about these things, but I don’t have to do anything about them.”

As a first step in treatment, we identified all of Michael’s various obsessive thoughts concerning being gay, and then all the different compulsions he was using to try to control the anxiety that resulted from the thoughts.  Next, we listed all the situations we could think of that would make him anxious.  These included such things as being around his friends, having his friends joke about being gay, hugging another guy friend, going to a movie with just another guy, looking at pictures of attractive guys or girls, watching romantic scenes in movies, just hearing the word ‘gay’ or similar words, seeing gay characters on TV or in movies, looking at gay magazines, visiting gay websites, etc.  We then tried to assign number values, from 0 to 100 to each of these situations, to help us to see what was worse than what.  I told Michael that together, we would create a program especially for him, using the items on this list.  We would start with challenging situations that he rated at about a 20, and work upward from there.  I helped him pick several lower level items, and also recorded an audiotape for him to listen to several times per day.  I explained that this was an Exposure Tape, designed to raise his anxiety to a moderate level, and to get him to “Think about it more.”  He laughed a bit when I told him, “You can’t be bored and scared at the same time.”  The tape was a two-minute recording of me, talking in a general way about how some people couldn’t be sure of their sexual preferences, and turning out to be different than they thought they were.  He found this definitely caused some anxiety, but he believed he would be able to listen to it.  He would keep listening to it until it became boring. Later tapes would actually tell him that he possibly was gay, and even later ones would tell him he definitely was.  I planned for him to eventually record his own tapes, in which he would agree that he was gay, and would soon ‘come out’ and go public.  I also stressed that it would become increasingly important for him to agree with his thoughts.  This would probably be the single most important assignment we would do, and that we would be doing it all through the therapy.  As I sent him on his way with his first list of assignments, I told him that he would see that it wouldn’t be as bad as he feared.  I added that the worst day of the therapy was the day before you start.

Michael seemed truly surprised at the end of the first week when he came in and told me that the tape really had become boring, and that he was ready for a new one. He seemed somewhat less anxious overall, and proud that he had made it through the first round of homework.  Week by week, he worked his way through the list. He gradually became more able to say things he feared to say, to look at pictures he disliked looking at, to listen to words he feared to hear, and to imagine things he really didn’t want to imagine.  Some things were a struggle for him to stay with, as they represented his worst doubts.  To his credit, he stuck with them, and refused to give up, even when he didn’t get instant results.  He was developing trust in what he was doing.  I could tell that he was improving when he was finally able to joke about his thoughts.  At one session, he came wearing a pink shirt.  “Do you know why I’m wearing this?” he said, raising his eyebrows.  “Why?” I asked him.  “Because I’m gay,” he answered, with a grin. “Didn’t you know?”  I knew we were winning.

The day finally came when we had arrived at the end of Michael’s list.  He was no longer avoiding anything, and the worst things on his list no longer seemed to have any effect on him.  He could tolerate all of them, and didn’t feel the need to run away or avoid them.  I showed the list to him to remind him of where he had started out.  As he looked it over, he said, partly to himself, “I can’t believe these things made me nervous.”  He added, “I really didn’t enjoy doing some of the things you had me do, but I’m glad I did them.  I don’t have all that nasty stuff filling up my head.”  I told him that the job was only half done.  “What do you mean?” he asked, looking puzzled.  “Now you have to stay this way,” I answered.  “Consider yourself officially in recovery,” I announced.  “But your work isn’t over.  This means that you will have to do maintenance from this point on.  When thoughts on the topic of being gay come up (and they will), you will have to continue to agree with them, and not go back to doing any of the things you used to do before – the ones that only made things worse.  People who go back to those kinds of solutions wind up with a relapse.  Like the therapy, doing maintenance will get easier as time goes on.  It will become second nature.”  I tried to leave him with the idea that this next phase would be just as important as the first one was.  I stressed that OCD was a chronic problem, which means that even though you can recover, you are not “cured.”  In a way, it’s kind of like having asthma or diabetes. “The people who relapse,” I told him, “are the ones who think they are cured.”  “Don’t worry,” Michael replied, “I worked too hard to just give it up like that.”  He was as good as his word.  He went off to college not long after, and several e-mails he sent me indicated that he had learned his behavioral therapy well.  Even the pressures of school couldn’t get him to go back.  As of his last message, things were fine.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

Stronger Than Dirt - OCD and Contamination

Recently, while going through some back issues of the OCF newsletter, it struck me that unless I was mistaken, there had never really been any special articles written about contamination problem. Perhaps it's because it is so well known. On the surface, it's not a very complicated subject dirt, germs, washing - what could be simpler? Actually, when examined more closely, contamination is quite a bit more complicated than that.

First of all, what we are really talking about breaks down into two parts: contamination obsessions and decontamination compulsions. Let us first examine the nature of obsessive contamination fears. Contamination isn't simply limited to dirt, germs, and viruses. It can also include:

          bodily excretions (urine, feces, saliva, etc.)

        bodily secretions (sweat, saliva, mucus, tears, etc.)

        blood

        semen

          garbage

          household chemicals

          radioactivity

          broken glass

          greasy or sticky substances

          people who appear unwell, shabby, or unclean

          spoiled food

          soap (really!)

          lead

          asbestos

          pets

          birds

          dead animals

          newsprint

This list is by no means complete. There are practically no limits to the things that could be contaminating. From my own experience, I would guess that the fear of certain illnesses is still the leader. Many years ago, cancer was one of the more commonly feared illnesses. In the last decade or so, this seems to have been replaced by AIDS (see my previous OCF newsletter article, "OCD and AIDS  When Epidemics Collide").

One particularly unusual aspect of contaminating substances is the extent to which tiny amounts of them are often believed to cover very large areas. Some sufferers believe that a minute quantity of a contaminant (such as blood or urine, for example), can somehow be spread to coat entire rooms, or even everything they own.

There is also a whole category of fears of contamination of a stranger and more magical type, which could include:

          thoughts

          words

          names (of illnesses, disabilities, people who are ill or disabled, or who have died)

          places where bad things have happened

          mental images

          overweight or unattractive people

          colors

          bad luck

Obviously, logic has little to do with these fears. The belief here is that these names, images, concepts, or the characteristics of certain people, can be magically transferred simply by thinking about them or by coming into contact with them. They can be every bit as disabling as the items on the previous list.

There is a further category that includes things that are a bit more vague. For instance, there are some sufferers who fear to touch the floor, the ground outdoors, or any public objects. When questioned about what it is they fear they can only reply "I don't really know, it just feels dirty to me." There are also cases where a sufferer will get the idea that another person is contaminated in some way, although they cannot exactly say why. It may be a total stranger, or a member of their immediate family.

Compulsions are the obvious responses of sufferers to these fears. They may involve any protective act that an individual carries out to avoid becoming contaminated or to remove contamination that has somehow already occurred. Compulsions of this type may include:

          -  excessive and sometimes ritualized hand washing

          -  disinfecting or sterilizing things

          -  throwing things away

          -  frequent clothes changes

          -  creating clean areas off-limits to others

          -  simple avoidance of going to certain places or touching things

Another form of compulsion can include double-checking by a sufferer to make sure that they have not become contaminated, or asking others for reassurance that this has not occurred. Sufferers will also, at times, repeatedly ask others to check parts of themselves they cannot reach or see, or things they cannot go near. Some will go as far as to make lists of things they believe may have happened in the past, so as not forget this vital information.

In an attempt to keep clean and minimize compulsions, some sufferers will create two different worlds for themselves  one clean, and one dirty. When contaminated, they can move freely about their dirty world and touch and do anything, since everything in it is already contaminated. Nothing in it has to be cleaned or avoided. Clothes that are considered contaminated must be worn when functioning in this zone. This dirty world usually takes in most of the outside world, and can also include portions of their home or work areas. It may even extend to having a dirty car, to be driven only when contaminated. They may also be able to function freely in their clean world, as long as they themselves are clean when they enter it, and also stay that way. The clean world is usually a much more restricted area than the dirty one, and is often limited to special places at home or at work. There may also be a clean car, which can only be driven when clean. The two worlds may exist side-by-side like parallel universes that are never allowed to meet.

For magical types of contamination the solution is often a magical decontamination ritual, designed to remove or cancel out the problem thought, name, image, or concept. Saying special words or prayers, thinking opposing or good thoughts to cancel out bad thoughts, and doing actions in reverse are just some of the compulsions that can be seen. Sometimes, the usual washing or showering may even be part of the magical ritual.

"Washers" as they are referred to, are probably the most visible among those with contamination obsessions. It is not unusual for them to wash their hands fifty or more times per day. In more extreme cases, hands may be washed up to 200 times per day. Showers can take an hour or longer, and in severe situations can last as long as eight hours.

Obviously, washers go through large amounts of soap and paper towels (used in preference to cloth towels, which can only be used once and create laundry). Alcohol preps and disinfectant hand wipes are also popular.  Their hands often become bright red and chapped with cracked and bleeding skin. Antibacterial soaps, peroxide, and disinfectants such as Lysol can be used to excess by some, causing further skin damage. I have even worked with several people who poured straight bleach on their hands and bodies, resulting in chemical burns.

Compulsive showering and washing are really quite futile, as the relief from anxiety only lasts until the washer contacts something else that is seen as contaminated. Washing may, in some cases, be very ritualized. It may have to be done according to exact rules, which, if not followed, force the sufferer to start all over again. Counting may also be part of a washing ritual, to ensure that it has been done for a long enough period of time, or a certain number of repetitions. In order to cut down on washing, sufferers sometimes resort to using paper towels, plastic bags, or disposable gloves to touch things.

In some cases, family members have been drawn into the sufferer's web of compulsions. They are made to reassure, to clean things that cannot be approached, to check the sufferer or the environment for cleanliness, or to touch or manipulate things that are supposed to be contaminated. This type of help, of course, doesn't really help, as it only locks the sufferer into the illness and increases helplessness. It also leads to resentment and fighting, as family members feel increasingly imposed upon, and their lives become limited. This is especially true when a family member is seen as the source of contamination.

To further complicate our contamination picture, there is a variant that veers off into what is known as "hyperresponsibility." This is where instead of being fearful of becoming contaminated, sufferers fear spreading contamination to others. The types of contamination that can be spread to others are about the same as those that trouble other sufferers. Generally speaking, so are the types of avoidance and decontamination compulsions. There is not only a fear of possibly harming others, but also a fear of having to live with the resulting guilt. There are also some that suffer from both types of fears of simultaneously.

Having briefly covered this very complex topic, the next question would be, what can be done about problems such as these? To those of you familiar with OCD, the answer should be obvious  behavioral therapy and possibly medication. Behavioral therapy would be in the form of Exposure and Response Prevention. This remains the most widely used and accepted form of behavioral treatment for OCD. This type of therapy encourages patients to gradually encounter increasing doses of that which is contaminated, while resisting washing, checking, avoiding or conducting magical rituals. By staying with the anxiety, sufferers come to learn the truth of the matter - that nothing really happens when they face their fears, and that their efforts at taking precautions therefore serve no purpose. Gradually, patients learn to merge their clean and dirty worlds as they cease to protect themselves. They also concentrate on learning to accept that there will always be a certain amount of risk in life that can never be eliminated, and that life can still be enjoyed and lived freely in spite of this fact. By trying to eliminate risk, they come to see that along with it, they will eliminate their ability to function. I like to tell my patients that "When everything is contaminated, nothing is contaminated."

Therapeutic encounters are like small experiments to test patients' theories about the dangers of their particular type of contamination. Treatment is tailored to each particular person's symptoms, and is conducted at their own pace. If a feared substance or situation is too difficult to confront in one whole step, it is approached more gradually. Some patients can only touch something that has touched a feared substance or object, and only later do they go on to touch directly what is feared. Family and friends are taught to not participate in rituals and to not give reassurance or answers to repetitive questions. No one is ever forced to do anything, nor is anything sprung upon them by surprise. It takes persistence and hard work but through steady week-by-week work, the disorder is chipped away, until recovery is eventually reached.

Because OCD is biochemical in origin, medication can often be of great assistance as well. I believe it should be regarded as a tool to assist in doing behavioral therapy. Both treatments together are often more effective than either one alone. The main family of medications used to treat OCD are known as SSRIs (Serotonin Specific Re-uptake Inhibitors). Basically, they enhance the activity of serotonin, the brain chemical implicated in this disorder. Members of this drug family include Prozac, Celexa, Lexapro, Paxil, Luvox, and Zoloft.

If you suffer from this, or any other type of OC disorder, my suggestion is that you seek help. OCD is chronic. This means that there is no cure. There is recovery, though, and many have achieved it. With the right treatment, you can hope to live a normal productive life, and go on to fully realize your potential as a human being.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

My Parents Don’t Believe I Have OCD

Living with OCD is never easy, and this can be especially true if you are a teenager. At a time when you’re trying hard to learn about who you are and how to find a place for yourself in the world, having a disorder like OCD can make you feel so different from everyone else.  And the thought of having to talk about the disorder with anyone, let alone your friends and classmates, can be very scary. School is a small world, and things have a way of getting around pretty quickly, or so it can seem.

But talking to people and asking for help are the best ways to improve your situation. Your schoolmates may surprise you with their capacity for understanding. We often fear what we don’t understand. And your parents can help you to get the help and resources you need to succeed in school and beyond.

But what happens when your parents, the very people who should be most concerned about your well-being, don’t understand OCD and don’t know how to help you? Or worse yet, don’t believe that you are suffering from a disorder at all? I get many emails from young people seeking advice and guidance, and occasionally these include messages like the following:

Dear Dr. Penzel,

I don’t know if you can help me, but I have a really serious problem and I don’t know how to handle it. I think I have OCD. I was in health class in school and we were doing a lesson on mental health. When the teacher started describing the signs of OCD, I realized that it sounded just like me. When I got home, I went online and looked it up, and again it sounded just like me. I have two different kinds of thoughts that just won’t go away. One kind tells me that I want to harm people, like stabbing them with a pencil in class, or pushing them down the stairs. I don’t just get them in school – I also get them at home and they can be about my family or my dog. I also get thoughts that I could be gay. Both of these thoughts really scared me and I feel like I’m not sure about myself any more. Some of the things I read online told me that these thoughts really aren’t things I want to do, and that you can get help. When I read these articles, it can help for a little while, but it doesn’t last.

I told my teacher that I think I have OCD, and he told me that I should talk to my parents so that I could get help for this. This is where the biggest problem comes in. I told my mom and dad about what was happening, and they acted like I was making all of it up. My dad said, “I don’t believe in things like that. It’s just your imagination, and if you’re trying to get attention, it’s not a very good way to do it.” My mom was nicer, but she said that when people hear about different symptoms in classes like the one I’m taking, they start imagining that they have them, too. They said that because I had friends and was doing well in sports (I play basketball), and my grades were okay, there couldn’t be anything wrong. They didn’t want to go on talking about it, and said it would go away after a while when I got busy with other things. I just couldn’t make them understand, and now I’m afraid I won’t be able to get any help for this.

I feel really hopeless and don’t know what to do. I want to beat this thing but I won’t be able to get help on my own. What should I do?

While I don’t believe that this happens in every home, I have a hunch that situations like this happen a lot more than we would like them to. Someone once said, “The only thing worse than having OCD is having OCD alone.” I think that e-mails like this prove it. It takes a lot of work to recover from this disorder, but it also shouldn’t be such hard work to get help from those close to you.

No one wants to think his or her child has a problem, much less a psychological one. It’s one thing if a child has had serous problems from an early age, but it is quite different if a child has always appeared to function well. In the former case, parents have many years to come to terms with it, get advice, and to seek help. This is not so in the latter case. Some parents find it so unthinkable that they resort to denial, figuring that if they act like they don’t see it, it doesn’t exist. Sometimes it can become even a bit more complicated, with one parent believing that their son or daughter has OCD, and the other one stubbornly refusing to see it, resulting in family disputes and an overall stressful family environment. As we know, this doesn’t turn out to be a very good strategy. It can set a teen against their parents, or it can set one parent against another, making one into a hero and the other a villain. I have also met some parents who are flatly opposed to the concept of mental illness altogether. They see it as some kind of myth. I have been told by parents on a few occasions that, “You guys [therapists] just like to make people believe they have problems so you can get them to come for treatments,” or “She’s just making this up, and if we just use some more discipline and don’t put up with it, she’ll stop doing these things.”

No one who truly understands OCD would dispute that such a thing exists, and fortunately, many parents are understanding, empathetic, and go out of their way to get their children the treatment they need. However, when a teen or child does encounter resistance from their parents, what options do they have?

“What Can I Do?”

• Talk to the in school, especially your health education teacher and the school psychologist. Both should have heard of OCD and can be good people to get on our side. Perhaps they can help set up a meeting with your parents to discuss the problem and possibly help them to understand what it is all about, and what you need.

• If you have a relative with OCD (we often see OCD run in families), he or she can sometimes be a good ally. This is especially true if this is a trusted individual your parents will listen to. It’s always a plus if they got help themselves, and are now doing better. Perhaps they can persuade your parents to take you for help.

• It is possible you also have a friend who happens to have OCD and has been through successful treatment. A conservative estimate is that one out of one hundred people has OCD, so the odds are good that you may know someone. You might see if your friend’s parents would be willing to talk to your parents and share what they have learned about the disorder and about how to get therapy for it. It will also be a big help if your parents already know these people.

• Read up on OCD and educate yourself about the disorder. You can start with articles here on the International OCD Foundation’s website and on OCDinKids.org, and also check your local library for books on the subject. There are many good books these days, and the more you know, the better you will be able to speak up for yourself. Whatever you do, always make sure you are getting your information from reliable sources. The IOCDF has a list of many book about OCD on the website at iocdf.org/books.

• If you find yourself getting angry with your parents for not understanding, be careful about fighting with them about this. This is one of the most unhelpful things you can do for yourself. When people are angry, they listen to you a lot less and become more stubborn about sticking to their ideas. To get their help and support, you need to win them over. Remember that they do care about you, but just don’t “get it” yet. It’s something they clearly don’t understand or have much information about. One helpful approach would be to get some good articles and books on the subject (again, check the IOCDF website at iocdf.org/expert-opinions and iocdf.org/books) and ask them if they will at least read them before deciding anything further. One book I’d suggest is, What To Do When Your Child Has Obsessive-Compulsive Disorder, by Dr. Aureen Pinto Wagner. You can also find some good personal videos or documentaries about OCD on YouTube they can watch (the IOCDF’s Youtube page is a good place to start). Just be sure that the videos aren’t too extreme and give good, clear information. Watch them yourself, first, just to make sure.

• If you are feeling really alone and just need a community to talk to, you may find an in-person or online OCD support group for teens helpful (click here for more information about available support groups). You might also be interested in accessing some of the online self help programs that are now available (click here for more information about these self help programs for OCD and related disorders).

• Finally, if you belong to a church, synagogue, or mosque, and have a good relationship with a leader in that community, you might be able to talk to them and ask them to speak to your parents. Parents will often listen to people in authority that they respect and who are seen as honest, caring, and helpful.

The main thing is to not get discouraged, and to not give up. If you continue looking for a way to get through to them, you will be more likely to find a solution than if you give in to your frustrations and quit. As we already said, don’t talk your parents about it in an angry or nagging way that might only get them annoyed at you. You want to win them over, and you want them to see that you are serious, and are really having difficulties that require special help.

Once you manage to convince them, the next step is finding the right kind of help that will get you well in the quickest and most effective way. OCD is not something that just any psychologist or social worker simply knows how to treat. It takes someone with special training. If you have done your research, you will have found out that what is known as cognitive behavioral therapy (CBT) is the way to go, and a specific type of CBT known as Exposure & Response Prevention (E&RP) is the type of treatment you want. It will help you to gradually learn to face and overcome your fearful thoughts, as well as teach you better ways to confront your anxiety without having to do compulsions. The IOCDF website can give you further reliable information about this. Medication is sometimes also used to help you do better with your therapy. Understand that medication is not something that is automatically used with everyone, and is something that is only used when someone is seen to be struggling with their therapy. Even then, it is a matter to be carefully discussed with your therapist and physician.

I did give the young person who wrote to me some of the above advice, but I never heard back from him. I’m hoping he showed his parents my reply, and that they chose to get him help. After all, everyone deserves a fair chance to get well. 

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

Morbid Obsessions: Thought Of Harming Others

"Doctor," began Alex, "1 don't know if anyone can help me. I think I must be some kind of incurable psychopath. You know, the kind you hear about on the news, who just goes berserk for no good reason and kills someone. Whenever I'm alone with someone older or smaller or weaker than me, I can't stop thinking about harming or even killing them... I mean, children, or some of my elderly estate planning clients, or even my wife, or other people who I don't even know!"

Staring at my office floor and speaking in a hushed voice, he went on to say, "1 get thoughts about putting my hands around their throats and choking them, or else I think about punching them in the face, or even pushing them out of windows. I go to work by rail and, when I stand on the platform, I think about pushing people in front of moving trains. I can't even eat in restaurants anymore. I can't stop thinking how easy it would be to stab the waitress with the knives or forks. I keep telling myself that I'm a good person who has never hurt anyone in his whole life. I don't want to think of doing these things, but I just can't block them out of my brain!"

What could possibly have induced this mild looking thirty-six year old financial planner to think this way?

"The first psychiatrist I went to said he thought I suffered from schizophrenia," Alex continued. "He gave me some anti-psychotic medication that made me feel so drugged that it was as if I was walking underwater all day. The last therapist I went to made things even worse. He told me that I must be holding in a lot of anger and that these thoughts were really my unconscious wishes. He said I would have to work out some early conflicts in my life to get rid of the anger, and that would take a long time. I asked him, 'In the meantime, how can I really be sure that I won't go berserk and do the things I'm thinking?' And he nodded at me and gave me nothing as an answer!"

I tried to assure Alex that, despite his fears and his past misdiagnoses, he was not a 'psycho-killer: but was suffering from Morbid Obsessions, one of the more misunderstood forms of the complex illness known as Obsessive-Compulsive Disorder, or OCD. Despite the fact that this illness afflicts at least one out of forty people, it is one of the more poorly diagnosed problems seen by clinicians. For those who are not personally acquainted with such obsessive thoughts, we must be careful here to define what they are. Simply put, obsessions are any thoughts which cause anxiety, which are intrusive and repetitive, and which the thinker believes to not be his or her own and which they attempt to resist. Unlike those persons afflicted with schizophrenia, OCD sufferers are not delusional or hallucinatory. Their thinking is not disorganized. One of my patients refers to them as " my synthetic thoughts."

It was clear that Alex did not wish to harm anyone. He was simply unable to screen out thoughts of doing so. Most people with OCD, like Alex, almost universally begin describing their symptoms with the phrase, "I know this sounds crazy, but They exist in an isolated world of silent anguish, fearful of exposing this other thought process existing in their minds. They live in dread that the label 'insane' or 'psychotic' will be attached to them, if they share their thoughts with anyone, even a professional.

One woman related to me that her psychologist, in his ignorance, had actually reported her to state protective child services when she revealed her morbid obsessions about harming her children.

Obsessions are frequently accompanied by compulsions, which are any mental or physical activities done to reduce anxiety caused by the obsessions. These can range from simple avoidance to complex rituals of a superstitious and magical nature, which can take hours to perform.

While OCD was once thought to be strictly psychological in origin a type of neurosis it is now being recognized as a neurobiological disorder with a possible genetic basis. OCD can enter a person's life at an early age. According to National Institute of Mental Health figures, nearly ten percent of those who ever have it are already showing signs between the ages of five and ten. By the age of twenty, this figure rises to over forty percent. Until symptoms begin to emerge, it exists as "a potential" people carry around with them an accident waiting to happen. There are quite a few different categories of obsessions. Most of them revolve around either the thinker's harming someone else, or having harm happen to themselves. Alex's category, which is not uncommon, includes thoughts of killing, mutilating and injuring others or himself. These others can be loved ones, acquaintances or merely strangers.

Alex's morbid thoughts appeared to have really begun affecting his life when he turned thirty, just around the time he began his new career. This was a stressful time for him, he acknowledges, and the point at which he believes his illness began. On close questioning about his early years, he remarked that, ". It's funny, but now that we're talking about it, I remember that I used to sit at my desk in high school and think that I could stick my pencil in my eye and blind myself. Sometimes when I was slicing food, in the kitchen at home, I would get these ideas about cutting up my parents. I guess the thoughts weren't very strong, at the time, because I was able to push them away."

The recent upsurge in the punishing thoughts afflicting Alex began one night when he and his wife were lying in bed. "Suddenly it came into my mind how easy it would be to put my hands around Jessica's throat and strangle her to death. She is a lot smaller and weaker than me, and I knew she couldn't stop me. I could see myself doing it, and I imagined how she would struggle and then go limp. I told myself that this was totally stupid and unreal, but the thoughts just wouldn't go away:' The thoughts came back the next night, and every night there-after for several weeks. Alex began to dread this time of day. "I tried lying there all night, clasping my hands, and praying to God not to lose control. Eventually I began sleeping in our spare room, and told my wife I was just having trouble sleeping and didn't want to wake her up. I mean, how could I tell her what was going on in my head? I kept hoping that the thoughts would just go away."

As time went on, the thoughts not only didn't cease, but began to spread to many other situations with his wife and, later, with others. "Whenever we rode in the car together it would start up again, with me thinking how easily I could just do all these horrible things to her. I would try to grip the steering wheel really tight and force myself to concentrate solely on the road. But the thoughts were increasingly sinister and would almost seem to talk back to me every time I told myself that they were ridiculous, they would come back even stronger. They would make me think, 'Yeah, but how do you know for sure that you really don't want to do this?' And I would ask myself, why else would I be thinking about it all the time?"

At the start of his treatment, Alex had been about ready to give up. He had begun seeing a new psychiatrist, on his own, several weeks before he first came to see me. He was taking an antidepressant, which lessened the thoughts somewhat, but still didn't take them away. Luckily his physician was aware of the value of behavioral treatment for OCD and urged him to take this next step, despite Alex's growing fear that nothing could help him.

"Don't bother trying to teach me to relax myself, or to snap a rubber band on my wrist when I get those thoughts;' he informed me, with what sounded like barely concealed sarcasm. "My first two doctors tried those already and they didn't even make a dent in all this." I explained to Alex that these were not currently considered to be useful treatments for this disorder. 'Actually," I told him, "We have a saying around here - "If you want to think about it less, think about it more." He looked a bit edgy, when I said this. "Were you ever successful at forcing yourself not to think the thoughts?" I asked.

"No;' he answered, "I just wound up thinking about them even more. I then asked him, "Have you ever stayed with the thoughts and remained in a fearful situation long enough to see what really happens?"

When he said he never had, I went on to describe a treatment known as Exposure and Response Prevention (E&RP). This has been in existence for over twenty years. People are helped, in a step-by-step manner, to gradually face stronger obsessive thoughts while resisting the urge to do anything compulsive to relieve the anxiety. In this way they begin to build up a tolerance for the thoughts and eventually no longer feel anxious when they occur. They can acknowledge the thoughts, but do not feel as if they must react to them.

Morbid obsessions (as well as other types) have long been mistakenly labeled as hard to treat by practitioners and this is attributable mainly to three reasons:

First, the practitioners often fail to distinguish between obsessions and compulsions. While both are mental events, they are quite different in their functional relationship to each other. Some practitioners believe that the thoughts must be resisted or blocked out, in the same way as compulsions. Paradoxically, they cannot be suppressed and must be confronted.

The second reason is that many practitioners fall into the trap of being distracted by the nasty content of the thoughts, failing to recognize them as obsessions rather than true desires. When the thoughts are treated as genuine impulses, the practitioner often tries to help the person control them, or else gets lost in endless discussions of what the thoughts really mean. The harm this approach can inflict is immense, because it only helps to convince the patient that the thoughts have validity and that they are right to be worried about carrying them out.

The third reason is that even when practitioners have some knowledge, they are not effectively utilizing existing techniques to their fullest. While many will try to help patients resist compulsions, they use ineffective or outmoded techniques for the obsessions, the way Alex's other doctor did. They may not even attempt to treat the obsessions at all, not realizing that the untouched obsessions will only go on to generate more compulsions.

The actual treatment is straightforward. Alex began to gradually expose himself to the thoughts, and to resist his accompanying compulsions. He learned that, instead of avoiding situations where he might harm others (such as when waiting for the train), he had to stand there and keep thinking about doing so, in order to see that his anxiety and preoccupation would truly subside. In this way, he would learn that he didn't have to escape or stay at home like a recluse. While he was told, only at the outset, that "people with morbid obsessions do not act them out," he was given no further reassurance of any kind. He was encouraged, instead, to stay with and feel the anxiety. Alex would attend weekly therapy sessions and, in between, carry out homework on his own at his own pace. The assignments were tailored just for him, and were based on a ranked listing of all the situations he feared.

One of our most important techniques was to use audio tapes, several minutes in length, several times a day. Other methods include reading books or articles that provoked his thoughts, writing essays on why the thoughts were really true, and putting himself in real-life situations among other people likely to bring the thoughts on.

In all, between the therapy and medication, it took Alex roughly nine months of daily hard work to reach a state of recovery. He had his good and bad days, but he persisted. He still experienced the occasional thought, but could now handle it as it was occurring. Towards the end of treatment, he shook his head, saying, "There were times when I thought you were the Stephen King of psychologists, making me face all of those creepy things. I guess I called you some pretty foul names, at times. I have to admit, though, that I really learned something. You genuinely gave me every opportunity to act on every horrible thing I thought of doing, and I didn't do any of them! I truly believe, now, that I won't do any of them, ever, and that I never really wanted to, either."

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

“Let He Who Is Without Sin …”: OCD And Religion

“If you had to sum up most of OCD in two words, they would be “pathological doubt.” – Fred Penzel, Ph..D.

OCD can cast doubt on almost any aspect of a person’s life and can force them to question almost anything they are, or anything they do.  OCD is also extremely insidious and can infiltrate anything that matters to you.  I have heard many of my patients state that “OCD seems to know how to pick on whatever will bother me the most.”

One particular area that is of great importance and sensitivity to many people is their religion and matters of religious practice.  It is something that they would like to feel is the most certain in their lives.  As you could guess, this turns out to be a prime target for obsessive thoughts.  Religious obsessions can take on any of the following forms: 

• That the person has sinned or broken a religious law, or displeased their god in some way, either in the past or present, and may therefore go to hell or receive some other punishment

• That prayers have been omitted or recited incorrectly

• Repetitive blasphemous thoughts

• Thoughts about impulsively saying blasphemous words or committing blasphemous acts while attending religious services

• That the person has lost touch with God or their beliefs in some way

• Thoughts of being “unworthy” of salvation in some way

• Intrusive sexual thoughts about God, saints, religious figures, etc.

• That the person, through negligence has broken religious laws concerning speech, dress, food reparation, modesty, etc.

• Intrusive “bad” thoughts or images that occur during prayer, meditation, or other observances that “contaminate” and ruin or cancel out the value of these activities

• Believing that one’s religious practice must be 100% perfect, or else it is worthless or worse

• Thoughts of being possessed

Naturally, the stronger a sufferer’s beliefs, or the more orthodox their sect, the more distressful and upsetting these symptoms can be.  There are many who, no doubt, suffer in silence, feeling too embarrassed or worried that they will be thought crazy or branded as religious outcasts.  When people do seek help, they often turn first to their religious leaders.  If they are fortunate, this person will have at least some understanding of problems of this type.  If not, their revelations may be met with skepticism, criticism, or passed off as “nothing to worry about.”  In the worst cases, individuals are treated harshly, and told that they really are sinful and that their religious practice needs to be improved.  They may even be instructed to do penance in some way, only worsening the belief that they have truly done something wrong.  Even where a religious leader is sympathetic, consistent compulsive questioning and phone calling for reassurance by a sufferer can wear them down to the point where they become angry or impatient.  After all, they are only human, and OCD, in truth, probably could try the patience of a saint.

If obsessions are intrusive, unpleasant thoughts, compulsions are the mental and physical activities that people with OCD come up with as a way of dealing with them.  Since doubt is what drives most OCD, the answer, as OC sufferers see it, is to do, know, and control everything in a compulsively perfect way.  When everything is perfect, there is no room for doubt.  Compulsions start out as solutions, but inevitably become a large part of the problem themselves.  On the surface, they may have some resemblance to religious practices, but are often exaggerated and extreme behaviors that are out of control.  Some typical compulsions that are used in response to religious obsessions might include:

• Saying prayers, or carrying out religious acts repetitively until they are done ‘perfectly (a process that can last for hours)

• Saying prayers or crossing oneself a special magical number of times

• Constantly asking for God’s forgiveness, or telling God that you didn’t mean what you said or did

• Rereading passages from holy books over and over to make sure nothing was misunderstood or missed

• Repeatedly asking religious leaders or authorities the same questions on religious practice to be sure of understanding the answer, or to get reassurance about specific acts or words being sinful

• Double-checking different religious acts or observances to be sure they were done correctly

• Repeatedly reviewing past thoughts or actions to determine if they were sinful or not

• Protecting religious symbols, ornaments, books, or pictures from “contamination”

• Constantly reviewing one’s own words or phrases for double meanings that might have been irreligious or blasphemous

• Trying to imagine special “good” religious images or thoughts to cancel out “bad” and irreligious images or thoughts

• When any activity was performed with a blasphemous thought in mind, having to redo it with a “good” thought

• Excessive confessing of religious misdeeds or sinful behaviors to obtain forgiveness or reassurance

• Having to carry out religious dietary, dress, or appearance codes perfectly

This list by no means exhausts the possibilities.  They are almost endless.

Treatment for religiously oriented OCD is in most ways, similar to that of any other form of the disorder – behavioral therapy in the form of Exposure and Response Prevention (E&RP) and possibly medication.  The general principles of behavioral treatment for OCD involve gradually confronting obsessions while resisting the doing of compulsions.  In this way, the sufferer slowly builds up tolerance to the thoughts and their anxiety as they retrain themselves to not respond compulsively.  Those with OCD typically make things worse for themselves by trying to follow their instincts in avoiding or trying to escape the things that make them anxious. In their zeal to eliminate all possibilities of doubt and risk, they do not stay with what they fear long enough to learn the truth.  Unlike other forms of OCD, the facing of religious obsessions has some particular problems that must be carefully addressed.  These issues would include the following:

• Religion involves intangible matters of faith that cannot be seen, touched, or discussed from a scientific or logical point of view, in the way many other OCD problems can

• In order to confront blasphemous thoughts and images, sufferers need to carry out behavioral homework assignments that superficially also look irreligious, but really aren’t.  Sufferers may be asked to agree with their unacceptable thoughts, or say or do things that bring on their anxieties, as they resist doing compulsions.  Religious leaders who are consulted but don’t understand may not be willing to give their approval for such an approach.  Fortunately, there is a growing body of these people who can make the distinction between a psychiatric illness and sinfulness

• The consequences of being sinful or blasphemous may not be immediate, but could occur after a person’s death far in the future

• Behavioral homework may not involve simply doing things the way that ordinary people do (using the stove normally, driving without double checking, etc.), as when facing other types of O-C fears, but may require the person to overcompensate somewhat in the opposite direction so that they can eventually find the middle ground

Getting people to engage in E&RP for their religious obsessions can be tricky, owing to some of the above issues.  Matters of faith can get involved here in ways that make the planning and doing of homework a delicate maneuver. 

In order to be able to get a perspective on these issues, so that treatment may proceed, there are a number of understandings that must be established between patient and therapist.  The most important one is that religious obsessions really have nothing to do with true religion as it is understood.  They are biochemical aberrations, and therefore not a person’s own real thoughts.  They are, as a patient of mine once said, “synthetic thoughts.”  While the problem may superficially appear to be a religious one, it could really be about anything that OCD chooses to pick on.  As said earlier, OCD has an uncanny way of picking on things that will bother a person the most.  When a person is in the midst of OCD, it can be quite difficult to be objective and to see that these are not one’s own real thoughts.  A phrase many of my patients use is, “But it seems so real.”

When a person is asked to confront their thoughts and actually confront their fears by allowing that they are true, it can sometimes be difficult for them to see that they are not doing this to mock, belittle, or speak badly of their own beliefs, but are instead engaging in treatment.  There are usually three points I like to make to patients before beginning therapy.  These are: 

• That if God or one’s particular deity sees and knows everything, then they would have to know that the person is doing these exercises as treatment, and not to be irreligious.  They would understand that the person is simply trying to break out of OCD in order to become closer to their God and more appropriate in their observance.

• That what they have been doing up until this time is not correct and appropriate religious observance, but is compulsive and outside the norm, and cannot continue if they wish to be appropriately observant according to the dictates of their faith.

• That they are being asked to do some things that on the surface may look religiously inappropriate in order to get them over their anxieties, so that they can return to what is considered appropriate religious practice.  What they have been doing up until this time in terms of compulsions would also have to be considered religiously inappropriate.  Unless they build some kind of tolerance to the thoughts and anxieties, they will remain prisoners of their OCD.  Recovering from OCD means taking risks, and this means letting go, not just in the sense of letting go of compulsions, but also in terms of letting go of that need for certainty in the face of obsessive doubt. Doing certain types of behavioral homework assignments for OCD may sometimes make a person feel as if they are jeopardizing their immortal soul, but there are times when in order to prevail over the illness, they have to take a leap of faith. There is a very good saying that is used by the members of Alcoholics Anonymous – “Let go, let God.”  My own interpretation of this for our purposes, is that if you have faith and truly believe, you sometimes have to put yourself into God’s hands and trust that you will be guided in the right direction.  It is also important for patients to understand that they will not have to go on doing these types of assignments indefinitely – only until they reach the point of recovery. 

Can everyone get past their obsessive religious fears in order to take what look like risks in the service of recovering?  The answer is that not everyone can.  Although I have seen quite a number of people recover from this particular type of OCD, not everyone is ready or able to recover at a given time, nor may they have the insight to see what is really happening.  Some people find their thoughts extremely believable, due to the magnitude of their biochemical problem.  Their fear of damnation or punishment at a particular time may override their desire to reach a recovery.  However, if an OCD sufferer can accept and understand the true nature of treatment, they stand a better chance of improving.  They need to accept that the subject matter of the thoughts involves the very aspects of their lives about which they want to be the most certain.  Faith has helped many individuals overcome great obstacles in life, and when correctly channeled, it can also help to overcome OCD.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

Postpartum OCD: Two Cautionary Tales

As much as we would like to think that information and understanding about OCD have improved over the years, the following two stories will indicate that we have much further to go.  They involve a type of OCD commonly referred to as “Post-partum OCD.”  This refers specifically to OCD that is worsened or brought on by the delivery of a baby and is most likely linked to post-partum depression.  I would actually see this as part of a larger category, where O-C symptoms can be touched off or worsened by pregnancy as well.  Some adult women who have previously had low level OCD or even no prior symptoms will suddenly, following delivery, find themselves faced with either strongly increased OC symptoms, or the sudden onset of symptoms where they previously had none. 

The form of OCD seen in these post-partum cases is not limited to any particular type.  However, there is one form that I have personally witnessed, that seems to cause some fairly serious problems for new mothers.  I am referring to what are known as morbid obsessive thoughts.  These thoughts generally center on the theme that the thinker will deliberately cause harm to themselves or others.  This harm can include violence, sexual abuse, poisoning, murder, mutilation, etc.  Why OCD picks up on these particular themes in certain people remains unknown, but it always seems to have an uncanny knack for picking on whatever will bother a person most.  Perhaps people obsess about many different subjects, and only those that seem most threatening actually get noticed and then persist. 

It should be mentioned here that OCD sufferers never act on morbid thoughts, and are as horrified by and startled at their presence as are some of the people they reveal them to.  Those with OCD, in fact, tend to be a lot more risk-avoidant than the average person, and would seem the least likely to ever do anything that would endanger themselves or others.  This is all well known to those who have expertise in diagnosing and treating OCD.  For an experienced clinician, hearing people’s revelations that they are thinking about doing grievous harm to themselves or others is generally all in a day’s work, and nothing to get terribly excited about.  Patients are often relieved and surprised when the clinician isn’t shocked or upset, and when they are informed that such thoughts are common to many OCD sufferers. 

Unfortunately, things do not play out this way when a sufferer falls into the hands of someone who is not familiar with the disorder or the different forms it can take.  Here are two examples of this type of sad situation.

The first, involves a woman, Sharon (whose name and facts have been changed to protect her identity), a 32 year-old fashion designer who had been previously treated by me for problems with obsessive guilt and scrupulosity.  She had done well in treatment via a combination of Exposure & Response Prevention and medication and had reached the point of recovery.  At the point where she phoned me, I had not seen her for about a year, during which time she had become pregnant with her first child.  She had just given birth to a healthy baby boy in a large Manhattan hospital the day before, and was on the phone in tears.  As she related it to me, her second day after delivering, she began to have intrusive and repetitive thoughts about harming her new infant.  These were a type of thought she had not experienced in the past, and even though she had had experience in dealing with OCD, was caught off-guard.  Not knowing what to do, she discussed her thoughts with one of the ward nurses.  This was where things started to go wrong.  The nurse, out of a sense of diligence and protectiveness toward the infant, immediately informed the head nurse, as well as my patient’s obstetrician.  Apparently, not knowing my patient’s history of OCD (which even if they did, probably wouldn’t have made any difference), they then took the thoughts at face value and informed her that they would absolutely not allow her to have any contact with her baby in order to protect it from her, and in addition, were ordering an immediate psychiatric consult.  Nothing Sharon could tell them seemed to make any difference.

She tearfully called me in a state of panic.  “I can’t believe what is happening,” she said.  “I tried to tell them that I would never hurt my baby, but they just wouldn’t listen to me.  No one believes it when I tell them I would never hurt him.  I think these thoughts could be a part of my OCD, but then I get more doubts about whether they are or not.  Is there anything you can do?”  Sharon couldn’t be certain about the nature of her thoughts, because on of the chief hallmarks of OCD is doubt, and so she even doubted that obvious obsessive thoughts were O-C symptoms.  One further irony in this whole situation was that the hospital actually had a large OCD treatment and research unit as part of the same complex, but whatever they were learning there had not been communicated to any of its other units.

Fortunately, the story had a happy ending.  I was able to phone someone I knew at the hospital’s OCD center and asked if one of their more senior people would drop by the obstetrics unit to visit Sharon.  They soon did this, and after talking with her, were satisfied that the thoughts were, in fact, just thoughts, and that Sharon had no bad intentions toward her child.  They then explained things to the staff there, and the situation was then resolved.  I wonder, however, what would have happened had there been no one at this hospital with the knowledge or authority to set things right.

The second story is somewhat less happy.  One evening I received a phone call at my office from a distraught young woman I will call Joanne.  She was calling me from a state in the Midwest.  What she had to relate was a genuine O-C parent’s nightmare.  Having given birth not long before, she had, as had Sharon, begun to experience thoughts about hurting her new son.  “I didn’t know why I was having these constant thoughts,” she told me.  “I would never want to hurt my son, no matter what.”  Prior to this time, Joanne had never had any symptoms of OCD or any other disorder, and so had no real idea of what was happening to her.  She then did what any concerned parent would do.  She got the name of a local psychiatrist (there weren’t too many to choose from in her area) and set up an appointment to find out if there was anything she could do about the thoughts.  As Joanne related, “The doctor was nice enough at first, but I began to feel that I had made a mistake as soon as I started to tell him about my thoughts.  He sat up in his chair and looked at me with his eyes very wide, shaking his head.”  She went on to say, “He told me that this was a very dangerous situation that could not be ignored, and that he intended to immediately report me to the state’s office of child protective services.  He said they would take custody of my baby and make sure that nothing happened to him.   He wanted to know where my baby was, and who was watching him.”  At this point, Joanne got up to leave, with the doctor now angrily demanding that she give him the information.  She quickly ran to her car in a state of fright and bewilderment, and went straight home.  Once there, she hastily packed a bag, grabbed her infant son, and drove to the home of relatives in a neighboring state.  While at their home, she had gone on the internet and done a bit of research about people who had thoughts of harming their children, and come across an article I had posted there, concerning morbid thoughts.  She saw herself in this article and had decided to call me.                 

There wasn’t much I could do about the situation in her home state at that point, as she had already decided to relocate to the state she had moved to.  I was able to tell her more about her post-partum OCD and about morbid thoughts in general.  I was also able to give her the name of a psychologist in her new location that had a lot of experience in the treatment of OCD, who I believed would be able to help her.  After I got off the phone, I wondered how many other new mothers had found themselves in such a predicament.

What bothers me the most about both of these stories is that they each involved professionals who were responsible for the well-being of others, but who lacked crucial information about OCD and were completely unequipped to recognize or deal with it.  One was even a mental health professional who really should have known better.  Rather than try to fix the blame on anyone or any institution in particular (although there is plenty of blame to go around) I think that the point of all this is that it highlights how much more work needs to be done in terms of getting the word out on OCD to the public and health professionals alike.  In Sharon’s case, if she had simply begun to show signs of severe depression after giving birth, the hospital staff would most likely have recognized what was happening and would have treated her with understanding.  The same would probably have been true in Joanne’s case.

I think that those of us who treat OCD need to continue to teach the public, the school systems, and other professionals to the utmost of our abilities via websites, publications, lectures, media appearances, etc.  I also think that those of you out there who suffer with OCD and the members of your families need to put your support behind the OC Foundation in their quest to educate society about this serious and often puzzling disorder.  It really isn’t all that hard to diagnose, and once diagnosed, there is much that can be done to help sufferers to recover.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).