by Ian Osborn
A 1584 case of apparent OCD in which the sufferer was almost burned at the stake is recorded by a justice of the peace of that time, Reginald Scott of Kent, England. Scott writes of Mrs. Davie, “a good wife,” who was brought before him after she admitted to having evil thoughts to harm her family. The prosecutors wanted her torched, but Scott ruled, “She hurt no one except, by her imagination, herself.… Anyone who looks closely at the thoughts, words, and actions of this woman will perceive that she is not a scheming witch, but a poor deceived, melancholy woman.… No one in his right wits would believe her.” Other OCDers were surely not so fortunate in those who would judge them.
But at least in some levels of the Christian church, progress continued to be made in understanding the peculiar tormenting thoughts we now know as obsessions and the strange repetitive actions called compulsions. Richard Baxter (1615–1691), an English minister very famous in his own time, offered advice for OCDers in his Christian Directory that is so good it can hardly be improved upon. Baxter suggests: (1) Take less notice of your troublesome thoughts. They are like troublesome scolds. If you answer them, they will never be done with you. But if you let them talk, and take no notice of them, they will become weary. (2) Trust not your own judgment, but commit yourself to the direction of an experienced guide. (3) Be sure that you keep yourself constantly employed as far as your strength will bear.
ENLIGHTENED SPIRITUAL DIRECTION
Perhaps the most insightful discussion of OCD from centuries past is that of John Baptist Scaramelli, a Jesuit who wrote in 1753 a popular instruction manual for spiritual directors, The Directorium Asceticum. Scaramelli devotes a hundred pages to obsessions, compulsions, and their treatment, anticipating modern concepts and approaches.
He first points out that certain temptations come into the mind that, unlike other temptations, are detestable to both the rational and the animal part of our being. These temptations, which include certain blasphemous and abominable thoughts, are not dangerous in themselves. They can, however, cause great turmoil and spiritual desolation. Scaramelli astutely notes that “the more these thoughts are driven away, the more they return to the mind, because resistance to them only stirs them up and imprints them more deeply.” As for how to deal with such thoughts, Scaramelli emphasizes:
The priest should tell the sufferer first that he does not commit a sin by having such thoughts. Then he should order the sufferer not to act against the thoughts, for it is unwise to struggle or to enter into hand-to-hand combat with these. The sufferer should allow them to pass through his mind, without giving ear to them. He should fix his attention on what he is doing—to go on praying if at prayer; talking if in conversation; working if occupied. In a word, the sufferer should deal with these temptations just as if an idiot were to whisper them in his ears: he should go on without giving notice to them.
Scaramelli gives an especially comprehensive account of scruples, obsessions that take the form of tormenting religious doubts. He likens scruples to “a kind of pitch—the more we handle them by thinking and talking about them, the more they stick.” He advises, therefore, “It is best to take no notice of them … and to keep fully occupied.” Aware of the shortcomings of many religious counselors, he wisely advises the scrupulous to “avoid people of narrow conscience; and seek out the advice of not just any priest, but of an experienced, spiritual master.”
Scaramelli deals at length with compulsions. He describes mental compulsions, which he refers to as “interior acts,” such as people repeating prayers and saying certain words over and over. He also describes behavioral compulsions, “exterior acts,” such as people shaking their heads, pressing their hands upon their bosoms, and rolling their eyes strangely. The result of all of these, Scaramelli notes, is that “the more the thoughts are driven away the more they return to the mind.” Scaramelli highlights the particular problems of endlessly repeated confessions and prayer rituals. Of the latter he notes: “Some persons are greatly distressed in reciting vocal prayers, fancying they have omitted portions, or not pronounced the words plainly, so that they repeat again and again the same words, without, of course, ever gaining any peace or satisfaction from so doing.” The advice he gives is to stop the rituals: “Such people should be commanded to go forward in their prayers, and they must be forbidden ever to repeat any portion.”
Scaramelli’s approach is distinctly psychological. Of obsessions and compulsions, he notes, “Their first cause is a melancholy, gloomy, timid, and anxious character.” This eighteenth-century spiritual master must have dealt with some tough cases. He reminds me of present-day psychiatrists commiserating with their colleagues over coffee when he describes the frustration of dealing with treatment-resistant OCDers:
They hold obstinately to their own opinions and after having consulted a multitude of advisers, end at length by doing what they themselves think to be best.
Their care is one of the most arduous tasks that can fall to the lot of a physician of souls. For even as these poor creatures are ever tormenting themselves with the self-same scruples, they fail not to torment their confessors with never-ending repetitions. It is arduous, because this malady is one from which few recover completely … if they go not mad themselves, they will at least make their confessors go mad.
Sound Advice from Saints Who Suffered OCD
Saint Ignatius of Loyola, Saint Therese of Lisieux, and John Bunyan are all celebrated for their unique spirituality. As discussed in Chapter 3, these three luminaries also suffered OCD early in their lives. Of special interest is the fact that Ignatius, Therese, and Bunyan incorporated into their writings what amounts to behaviorally sound advice for OCD: exposure to obsessions and prevention of compulsions.
The approach of Saint Ignatius (1491–1556), founder of the Jesuits, is strongly introspective and analytical. Ignatius emphasizes the cardinal importance of identifying the nature of the thought that one is experiencing. Some types of thoughts come from Satan, the traditional purveyor of all bad thoughts. One specific type is that which we now call obsessions. Once it is recognized that Satan is at work, and that obsessions are the problem, Ignatius recommends preserving peace in the mind by ignoring these particular thoughts. In a letter to a friend suffering apparent obsessions, Ignatius writes:
It is necessary therefore to ascertain the nature of the condition we experience.… If the enemy discovers a conscience that is overly tender, he endeavors to torment, suggesting sin where there is none, anything to be able to disturb and afflict us.… If it is [this kind of] temptation that besets us, we must bear up against it without any vexation, and await the consolation of the Lord with patience.… Pay no attention whatsoever to the bad, impure, and sensual thoughts.
This excellent advice is consistent with modern behavioral therapy: once it is recognized that an obsession is the problem, try to bear it with patience and avoid fighting it.
John Bunyan, whose Puritan spirituality influenced Protestantism, including modern-day Evangelicalism, to a degree that cannot be overestimated, wrote two pamphlets, The Doctrine of the Law and Grace Unfolded and Some Gospel Truths Opened, only a short time after recovering from his lengthy OCD crisis. In them he says:
Know it for a truth that the greater you see your sins to be, the more cause you have to believe.… You must come to Christ with the fire of hell in your conscience; come with your heart hard, dead, cold, full of wickedness and madness; come as a blood-red sinner. Throw yourself down at the foot of Christ and say, “Lord Jesus hear a sinner, a sinner that deserves to be damned.” Resolve never to give over crying until you find that he has washed your conscience with his blood.
The important point here is that Bunyan encourages maximum exposure to obsessions. In fact, putting a remarkable spin on tormenting thoughts, Bunyan suggests that having sinful obsessions is actually good for you, because “the greater you see your sins to be, the more cause you have to believe.” Bunyan’s advice is to keep coming to God with the full weight of your obsession
s until you feel peaceful, or, in behavioral terms, to keep exposing yourself maximally to obsessions until habituation takes place.
Bunyan also emphasizes response prevention. Having learned from painful personal experience that efforts to reform, performances of certain rituals, and reassurances gained from reading scripture were of no help for his OCD, he cautions against the use of compulsions.
Have care of putting off your trouble of spirit in the wrong way: by promising to reform yourself and lead a new life, by your performances or duties, [by being] content with any knowledge that you can attain to by yourself. They that are saved are saved by Grace through faith; not for anything they can do themselves.
Therese of Lisieux, called by a recent pope the greatest of modern-day saints, developed a spirituality centered on abandonment and trust. Like Bunyan, she discovered through personal experience that obsessions do not respond to acts of will. What worked was surrender to God. In Story of a Soul Therese writes: “Even though I have on my conscience all the sins that can be committed, I go, my heart broken with sorrow, and throw myself into Jesus’ arms.… What pleases God is the blind hope that I have in His mercy.”
Therese’s cousin, Marie Guerin, suffered sexual obsessions. In a letter to Therese, Marie admits her shameful thoughts and requests counsel. Therese responds affectionately with advice that is behaviorally sound.
I understand everything, everything, everything, everything! You haven’t committed the shadow of any evil; I know these kinds of temptations so well that I can assure you of this without any fear.… We must despise all these temptations and pay no attention whatsoever to them.… Don’t listen to the devil. Mock him.
MEDICINE FINALLY EMBRACES BEHAVIOR THERAPY
Despite the fact that exposure and response prevention had been used for many centuries to deal with obsessions and compulsions, these techniques were not adopted specifically as medical treatments until the turn of the twentieth century, when French psychiatrist Pierre Janet (1859–1947) wrote his monumental, two-volume work on OCD: Obsessions and Psychasthenia. Janet may have appreciated the techniques used by spiritual directors, since he cites the case of a soldier who was cured of OCD when he entered a monastery, and he also remarks on several obsessive-compulsive women who remained well only as long as they lived in convents. In any case, he spells out clearly many of the principles of behavior therapy. Here, for instance, he explains how the psychiatrist should direct the OCD sufferer to expose himself to fearful obsessions:
The therapist will specify the action as precisely as possible. He will analyze it into its elements if it should be necessary to give the patient’s mind an immediate and proximate aim. By continually repeating the order to perform the action, that is, exposure, he will help the patient greatly by words of encouragement at every sign of success, however insignificant, for encouragement will make the patient realize these little successes and will stimulate him with the hopes aroused by glimpses of greater successes in the future.
PSYCHOANALYSIS
Unfortunately for the development of behavior therapy, Janet’s contributions were soon overshadowed by those of Austrian psychiatrist Sigmund Freud, who explained his ideas on the cause and cure of OCD in a famous 1909 case study known as “Rat Man.” This case involved “a youngish man of university education” who was virtually incapacitated by multiple obsessions and compulsions, including blasphemous religious thoughts, repugnant sexual ideas, and gut-wretchingly terrifying images of rats eating him and his father. After relating the details of the case, Freud gives his theory:
All through the patient’s life, he was unmistakably victim to a conflict between love and hatred.… In the unconscious the hatred, safe from the danger of being destroyed by the operations of consciousness, was able to persist and even to grow.… We may regard the repression of his infantile hatred of his father as the event which brought his whole subsequent career under the dominion of the obsessional neurosis.
To cure such unconscious conflicts, Freud invented psychoanalysis, a technique in which the patient lies on a couch and says everything that comes into his mind. The hidden information in the unconscious gradually becomes known, often in the form of symbols, which must be interpreted by the physician. In the case of “Rat Man,” Freud assures us that psychoanalysis, lasting for about a year, resulted in “the complete restoration of the patient’s personality and to the removal of his inhibitions.”
Psychoanalysis soon became the treatment of choice for OCD among psychiatrists in America and Central Europe and remained so for the next sixty years. Case reports were frequently cited as proof of its efficacy, but no controlled studies were done until the 1960s. Research since then has conclusively demonstrated that psychoanalysis does not work as a specific treatment for OCD. Well-known psychiatric researchers Donald Goodwin and Samuel Guze, authors of the authoritative text Psychiatric Diagnosis, reviewed the treatment of OCD with psychoanalysis and related therapies and concluded that there was no evidence at all to support their value.
In comparing psychoanalysis and behavior therapy as treatments for OCD, it is important to note that the two are not only very different but opposite in crucial points of emphasis. Behavior therapy emphasizes action, psychoanalysis introspection; behavior therapy says you have the ability to control your behavior, psychoanalysis says much of it is out of your control; behavior therapy holds that obsessions are random thoughts without special meaning, psychoanalysis that obsessions conceal important aspects of yourself.
Psychoanalysis may well have much to offer certain patients, particularly those with traumatic childhoods who suffer from such disorders as multiple personality, amnesia, and dissociation. In the case of OCD, however, psychoanalysis and other “uncovering” therapies are not only ineffective, they can actually be harmful. A 1995 report from the University of Cincinnati, for instance, cited cases where OCD was exacerbated by therapy aimed at uncovering childhood abuse. My own experience, too, is that in the treatment of OCD, therapies that search for unconscious meanings do more harm than good.
MODERN BEHAVIOR THERAPY
Not until the 1960s, when psychoanalysis began to fall from favor as a treatment for OCD, was anything on behavior therapy published that went beyond the writings of Pierre Janet. Then British researcher Victor Meyer, building on the earlier work of Joseph Wolpe and others who had successfully used behavior therapy to treat simple phobias, reported on the successful treatment of fifteen hospitalized OCD patients. Meyer used a program of classic exposure and response prevention: Patients were systematically exposed to situations that elicited their obsessional fears, such as public restrooms, and then prevented from performing responsive rituals, such as showering. The results were striking: Ten of the fifteen patients improved markedly.
Since then, over seventy published studies have demonstrated that behavior therapy is an effective treatment for OCD. English researchers Isaac Marks and Stanley Rachman, along with America’s Edna Foa, have led the way in developing new behavior therapy techniques, such as using cassette loop tapes to facilitate exposure to obsessions and involving family members to aid in response prevention. Improvement in behavior therapy techniques has allowed greater numbers of patients to receive more benefit in a shorter length of time. In a widely reported 1994 study, three quarters of patients using behavior therapy two hours a day for a two-week period showed a drop in symptom scores of 30 percent or more.
MEDICATIONS
The use of medication for OCD also dates back many centuries, although the number of OCD cases described by physicians and treated with medication is far fewer than the number described by clergymen and treated with behavior therapy. The ancient Greeks, founders of scientific medicine, were the first to put forth completely naturalistic explanations for all diseases, including mental disorders. The father of medicine, Hippocrates (460–377 B.C.), wrote:
And men ought to know that from nothing else but thence [from the brain] come joys, delights, laughter, and sports, a
nd sorrows, griefs, despondency, and lamentations.… And by the same organ we become mad and delirious, and fears and terrors assail us, some by night, and some by day, and dreams and untimely wanderings, and cares that are not suitable, and ignorance of present circumstances, desuetude, and unskillfulness. All these things we endure from the brain, when it is not healthy, but is more hot, more cold, more moist, or more dry than natural.
Hippocrates founded the “humoral theory” of disease. The body had four humors, black bile, yellow bile, blood, and phlegm, each of which differed from the others in being either hot or cold, and either moist or dry. All diseases were due to excesses of one or more of the four humors, and all diseases could be cured by draining off the humors that were in excess. Purgatives could empty the body of black bile by inducing bowel movements; emetics could empty it of yellow bile by inducing vomiting; salivants and blood letting could likewise drain the body of phlegm and blood.
Later Greeks divided all mental illnesses into depression, mania, and delirium. OCD—at least in its severe form—was viewed as a type of depression, or melancholia, which means, literally, an excess of black bile. An account is given by Plutarch (A.D. 46–120) of a probable OCD sufferer with religious obsessions and compulsions to roll on the ground: