By Fred Penzel, Ph.D.
Recently, I was sitting in session with a patient, Jesse, a sixteen year-old boy who had started seeing me only three weeks before for a problem with thoughts that he said were very unpleasant. So far, we hadn’t gotten very far, as he still couldn’t seem to tell me anything about them yet. He sat there nervously, playing with his sneaker laces and looking at the floor. “I don’t know if I can tell you about my thoughts yet,” he said. “They’re really bad, and if I tell you you’ll probably think I’m crazy and won’t want to work with me any more. I don’t just mean ‘bad’ thoughts. These are the worst ever.”
Jesse was an honor student, and the captain of his school’s lacrosse team. He was a tall dark-haired boy, with good looks, good grades in AP courses, and the appearance that everything in life was going his way. At least that was how it looked to the other people in his world. The reality was that Jesse had been extremely anxious and depressed for the last four months since the thoughts had started. He was having difficulty concentrating on his schoolwork, and for the first time, his grades were starting to slip.
I looked back at Jesse for a moment, and didn’t say anything. “And what if you don’t tell me about your thoughts,” I answered. “How will I be able to help you? It seems to me that if you really want to get control of them, you’ll have to tell either me or someone else sooner or later. I don’t see how you can go on like this, and I don’t think you really have too many other options.” “Besides,” I added, “With all the people I’ve seen over the years with thoughts like yours, I honestly don’t think that you’ll be able to tell me about anything I haven’t heard many times over from other people, no matter how bad you think they are. Please understand that I’m not here to judge you or your thoughts,” I told him. “I don’t think you’re crazy. I’m just here to help you recover from this problem and give you back control of your thinking and your behavior. I really think we can do that if we work together. Wouldn’t it be nice to have a quiet mind for a change?”
I didn’t yet know the nature of Jesse’s “bad” or “morbid thoughts,” as we like to call them, but I could imagine what they were like. Morbid thoughts come in a number of varieties, and fall into either of two major categories–either something horrific or unpleasant happening to the thinker, or else the thinker doing something horrific or unpleasant to someone else. Morbid thoughts can be about sexual acts (hetero- or homosexual), about committing murderous or aggressive acts, about acting out in socially unacceptable or inappropriate ways in public, or blasphemous or irreligious behaviors (usually done in houses of worship or religious settings). If he didn’t share them with me, there would be little I could do to help. I felt that if I didn’t pressure him, his desire to get control over the thoughts might overcome his feelings of shame and fear.
“I really hate having to think about these stupid things,” Jesse answered. “They’re so crazy and ugly that I can’t even tell my best friends or my family what’s happening to me. I couldn’t tell my last doctor either.” He had seen a female psychiatrist for several visits before coming to see me. She meant well, but didn’t have a lot of experience in treating OCD. He gave a short bitter laugh and said, “Can you believe she actually told me to try and think ‘good’ thoughts instead? How dumb was that? If I could do that, I wouldn’t be seeing her in the first place!”
I sat silently and looked at my patient, not saying anything, for what seemed like a very long time. Then suddenly, he spoke up. “I just don’t know if I’m ready to tell anyone. Really. I’d like to, but I wouldn’t even know how to start. I just know you’ll think I’m some kind of sick pervert, or psycho.” “Maybe you could start with one of the less horrible ones,” I suggested. “I don’t know,” he murmured. “It feels like someone else is living in my brain making these things up. I’m really scared. Almost like it will punish me for telling, with even worse ideas.” “I know,” I reassured him. “Everyone finds it hard at first, but it really does get easier. You just have to make a start somewhere. Anywhere. Give yourself a chance. If you want to overcome something fearful, you have to take what look like risks sometimes. It’s like jumping off into space and trusting that there will be a net to catch you. This therapy will be that net.”
I sat and waited again. He had curled up in a ball in the large leather recliner chair with his face in his hands. I could see that he was really wrestling with himself, and I wanted to give him the space he needed to think it over. As I like to tell my patients, sometimes doing nothing is doing something. After a few minutes, he began to speak with his hands still over his face. The words began to come out slowly, and then picked up speed. It was almost as if someone had suddenly punched a hole in a dam.
“Okay, okay, okay. It’s like I keep thinking in these crazy sexual ways about my parents and my dog and cat. Like touching them in bad ways or doing these things with them. Sometimes I get ideas about hurting or killing them. Like I could just do it, that I would like doing it, like I’m going to do it. But I love them – I would never ever do these things, but when I’m thinking about them they seem so real. There, I told you everything. That’s it!!”
I leaned forward in my chair and looked directly at him. “Jesse,” I said, “I know that was really hard for you to do, but you’ve just taken the first and most important step toward getting recovered. Now, something can happen.”
A phrase he had used struck me as familiar, “they seem so real.” It has always seemed strange to me how so many of my obsessive morbid thinkers use that exact same phrase to describe their repetitive thoughts. I cannot begin to count the number of times I have heard it from people who have never met or spoken to each other. This is, for me, one of the great mysteries of OCD for me; how thoughts about things that a person would never normally think, and would never do could seem “so real.” It is also one of the great tortures. The vividness and the convincing way the thoughts hit an OC sufferer almost always seem to convince them that they just might actually do the horrible things they are thinking about. The first question that occurs to most sufferers is, “Why would I be thinking these things if I really weren’t a psychopath or an evil person?” Since the thoughts mostly won’t quit, and are so striking, it seems like a pretty reasonable question for a person to ask him or herself. The rest of us more fortunate human beings can always find a way to ‘change the channel’ when we are having unpleasant thoughts. We don’t often appreciate what it is like to be in control of our own thinking, and take it for granted. That’s why it is so easy for people like Jesse’s previous and rather ignorant doctor to simply say “Just think good thoughts.” As if.
The truth is, we don’t really understand why people with OCD happen to think any of the particular thoughts seen to afflict them. There are many different varieties, of which morbid thoughts is only one category. Perhaps many thoughts go through a sufferer’s mind, and only particular ones that happen to bother them the most are the ones that stick. No one knows. It is really one of the special tortures that OCD reserves for those have it — that the unpleasant things they think about can often be the very things that they will find the most frightening and repulsive. They may also involve the people or things they love or prize the most. Beloved family members or pets are frequently the subjects of the thoughts, although they can attach themselves to strangers as well. Worse yet, the thoughts don’t just stop at ideas of bad things happening to the ones we love. They may go on, as in Jesse’s case, to tell the person that they, themselves, will be the ones doing the harmful thing.
The good news is, however, that there is a lot that can be done to help those who suffer from morbid thoughts. I wanted to communicate this to Jesse. “I really don’t think you’re crazy,” I said. “It’s just that OCD is putting these thoughts in your head, and the ways you are trying to escape them is only making things worse. I think I can teach you how to take the fear out of your thoughts by confronting them, and by challenging them,” I told my patient, who now looked as exhausted as if he’d just run a marathon. “I believe that if we work together, you will one day be able to say, ‘Okay, so I can think these things, but now they don’t scare me, and I don’t have to do anything about them.’ Also, if we decide to bring medication into the picture, we may also be able to greatly lower the level of thoughts. What do you think?” “Sounds good to me,” he replied, “but you’ve got really your work cut out for you. I don’t see how you can do it.” “I won’t be doing it alone,” I told him. “Think of me as your advisor, or like your lacrosse coach. I can show you all the right moves and plays, but it is you who will have to get out on the field and perform. I will design a program tailored to you and your particular thoughts, but it will be up to you to carry it out, step-by-step. My goal is to help you to become your own psychologist, so you won’t need to see me any more. I’m also going to refer you to one of our M.D.s to see if medication will be a good option.” “You make it sound so easy,” he muttered skeptically. My immediate answer was, “Absolutely not! No way! You will never hear me use that word in this office. It will be very hard, at times. It may be the hardest thing you have ever had to do. If you’re still having doubts about what I’m suggesting, I think you should ask yourself, how hard is it for you now, and what you have to lose by trying it?” “Well, if I do what you want me to do, I could get more anxious,” he offered. “I don’t really see how you could get much more anxious than you already are,” I replied. “Anyway, the anxiety that the therapy will cause you will only last for a while, and then you will be in control of it. The anxiety you are feeling now from your symptoms doesn’t look like it’s going to let up any time soon.” He nodded silently. I knew we would soon be making progress.
This is how we did it. Jesse and I spent the next two sessions making up a listing of all the situations and thoughts that could cause him to get anxious. I had him rate all the different things on the list from 0 to 100, with 100 being the thing that could make him the most anxious. Once we finished this, I began to create homework assignments for him to do each day, in between visits to my office. These involved going places, being around people, and doing things that set off his thoughts. I also made some audiotapes that talked about the things his thoughts were telling him. He seemed kind of nervous about the tapes, but I explained to him that the overall purpose of the homework was to give him practice staying with the things he feared, to help him get used to facing them without trying to turn them off or escape. I made it clear to him that the reason his anxiety never seemed to go away, and why he was always so sensitive to his thoughts, was because he never stayed with them long enough to see what would really happen. I added that the goal was to actually become so bored with his thoughts that he would no longer react to them. I told him our motto was, “If you want to think about it less, think about it more.” He didn’t seem too certain about this, but was willing to give it a try, since it seemed to make sense.
We started off with pretty easy things, most of which really didn’t bother Jesse very much. He also started taking antidepressant medication (which also happens to help reduce the symptoms of OCD). His mood improved, and he began to think that he could get through all this. As the weeks went by, he gradually worked his way up the ladder, taking on more and more difficult homework. Basically, we dared the thoughts to do their worst, and also looked at them more closely, to see if anything about them made sense. Since some of the assignments involved his parents, we eventually had to bring them into the picture. It was difficult for him to do this, as he feared that they wouldn’t understand, but between Jesse and myself, we were able to explain what he had been going through and how they could help. Fortunately, his parents did understand, and had even read some books about OCD. They said that because he was their son, and because they loved him, they would do anything it took to help. We then had them take part in some of the assignments.
At one of our later sessions, three months later, Jesse had this to say, “You know, I think I’m really starting to beat these thoughts. I keep facing them, and thinking about them on purpose, but nothing they tell me ever happens. I think I’m even starting to get bored with some of them. They seem so stupid now. I think I can do this.” I began to put more of the responsibility for the therapy on him. He now had to create some of his own tapes and homework assignments for himself. At even later sessions, he actually dared me to do my worst, and give him the hardest things I could think of. “I can tell you are recovering,” I told him. “You’re really making me work. I think I’m actually running out of things to throw at you. When I really do run out, I guess we can say you are finished.” This brought a smile to his face.
Not long after, we did finish. It had taken ten months, in all. I spent some time explaining to Jesse that at this point, our job was only half done. He looked at me strangely. “Doc, what do you mean? I thought we ran out of assignments.” “What I mean,” I answered, “Is that you now have to stay this way.” We talked about something known as ‘relapse prevention.’ This would mean that he could still expect to get a thought or two from time to time, but would have to be his own therapist and immediately give himself an assignment to do. If he slipped and did the wrong thing, he would just have to forgive himself, and then get right back to doing the thing he knew was correct.
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 obsessive-compulsive related problems, and is a founding member of the OCF Science Advisory Board. More of Fred’s work can be found on his website. Dr. Penzel is the author of “Obsessive-Compulsive Disorders: A Complete Guide To Getting Well And Staying Well,” a self-help book covering OCD and other obsessive-compulsive spectrum disorders.