PATIENT: I do not want you to call the police. I will bring shame on my family.
THERAPIST: Well that certainly sounds scary. Are these things you actually want to do?
PATIENT: Oh NO! Never! I would never want to hurt any living being.
THERAPIST: You can’t go to jail just for thoughts. Tell me what is going on so I can see if you need a hospital.
PATIENT: I keep thinking that I am going to lose control and shoot up a school or a movie theater or a mall.
THERAPIST: Do you have a gun?
PATIENT: I hate guns. I would have to buy one.
THERAPIST: Are you angry? Do you have a message or an agenda? Do you have any reason why you might do this?
PATIENT: No. It just keeps jumping into my head that I could.
THERAPIST: But why you?
PATIENT: Well I have these thoughts. They used to be about “what if I give someone AIDS?” but that went away. This is worse.
THERAPIST: Do you have AIDS or HIV?
PATIENT: Not that I know of. I have never done needles and only have sex with my wife.
This dialogue continued until it was very clear that the thoughts of shooting up a public venue constituted harmless unwanted intrusive thoughts and that the patient had a long series of harming obsessions whose topics morphed over his lifetime. This man—who turned out to be a kind and gentle soul—had a hypervigilant and over-controlling relationship with his mind. He was tortured by his mental OCD, and seeking the relief of someone else to contain him, as if it was only by his extreme effort that he had not succumbed to his horrible thoughts.
Another patient presented with the dilemma, as she described it, that her “unconscious was punishing her.” She was in a long-term committed relationship in which she and her partner had both stopped drinking in the past six months. Suddenly while they were making love, she had an intrusive image of strangling her partner, terrifying her. Now, every time they became amorous, she would have the same image pop into her head. And, even worse, she was starting to see pictures in her mind of poking in the eye, stabbing, and shooting her partner. The patient had profoundly non-violent values, and concluded that she must be angry and not know it; she was also worried that perhaps she was losing control now that she was not “numbed out” with alcohol.
Another presentation:
PATIENT: My wife said I have to see you.
THERAPIST: Why is that?
PATIENT: I am driving her crazy by talking about suicide. I have these thoughts. I feel as if I have to tell her about them so I won’t act on them. I am scaring both of us.
THERAPIST: What are these thoughts?
PATIENT: W ell, they are actually sort of fantasies or maybe images in my mind. I keep on seeing myself stepping into traffic or jumping off a building or buying a gun and shooting myself. I was on a cyanide kick for a while. When someone mentions something planned for next year, I quickly think “I won’t be here.” Then I have to tell her about it.
THERAPIST: Do you actually want to die? How is your life going?
PATIENT: T hat is what is so weird. I love my wife and my job is okay and I think I am healthy. I have no reason to commit suicide. But telling myself that does not stop it.
THERAPIST: So these are thoughts and images that seem ridiculous to you?
PATIENT: Yes, and also scary. But why can’t I stop them?
THERAPIST: Because the really good news here is that this is OCD, not suicidality, and it is really treatable!
This patient was attempting to cope with his unwanted intrusive thoughts by “confessing” them to his wife. These types of thoughts followed by a ritualized attempt to make them go away are signs of classic OCD: the thought (obsession) followed by the confession (compulsion) in an escalating cycle.
Issues for Therapists: Therapist Anxiety and a New Construct
This can be an extraordinarily difficult concept for traditionally trained therapists to accept, and it brings up two sets of issues. First, it generates therapist anxiety about the intent of these people. It is implicit in dynamic therapy that the wish is father to the fear (Freud, 1961). The theoretical assumption that a frightening intrusive thought refers to an impulse—even if unconscious—creates doubts about the safety of patients with violent and sexually charged mental images.
Second, the idea that content can be irrelevant, and that these symptoms are just hiccups of the brain can seem shocking. It is helpful to realize that the content of the thoughts may be irrelevant but not random. Thoughts get stuck by virtue of how much energy is expended to get rid of them, so they are actually the exact opposite of a wish. One never sees an atheist horrified by the intrusive thought of standing up in church and cursing: it is always a religious person. Such thoughts matter to someone who is religious and the intrusion is given power and repetitiveness by the force used to resist it. Similarly, it is people who love their children for whom the thought of the worst possible thing they could do is to harm their child. This is anathema and thus they give it energy by trying to get it to go away. People who have ego-dystonic intrusive thoughts of suicide (“what if, against my wishes, I suddenly lose my mind and jump off this bridge impulsively?”) are people who love life and want more of it.
The assumption that a frightening intrusive thought refers to an unconscious impulse creates doubts about the safety of patients with violent or sexually charged images.
Thoughts get stuck by virtue of how much energy is expended to get rid of them.
Lots of well-meaning therapists find these particular symptoms ripe for analysis. Unfortunately, traditional psychotherapeutic uncovering of these particular images adds to their intensity, since analysis reinforces the idea that the thought means something important and forbidden (after all, why else would it be repressed?), and needs to be made understandable. It is just one more example of the paradoxical nature of anxiety.
The point to take away is that intrusive obsessive thoughts are thoughts, and not impulses or wishes. Incorrectly interpreting a harming obsession (e.g., the thought that one could poke a loved one in the eye during lovemaking) as anger is a huge clinical error that will escalate attempts to suppress the thoughts, resulting in more repetitive,
Intrusive obsessive thoughts are thoughts, not impulses or wishes.
Intrusive thoughts are not random, but are usually not meaningful or important. Exploration can dramatically increase symptoms and suffering.
louder, and more intense thoughts of the same variety. Similarly incorrectly interpreting a bizarre obsessive intrusive thought (e.g., the thought that one locked a child in the refrigerator, or that one’s mother is actually possessed by Satan)—which the patient knows is nuts but can’t help thinking it—as a psychotic process can lead to antipsychotic medication, hospitalization, and other radical changes to stave off decompensation. This will again provoke panic, increase resistance to the intrusive thoughts, and result in increased frequency and intensity.
We agree that what comes to mind is not necessarily random, but we also assert that much is not meaningful, important, or worth exploring. And there are times when exploration dramatically increases symptoms and suffering. Since unwanted intrusive thoughts gain power by the effort enjoined to uncover and resist them, traditional analysis provokes more persistent, frequent, and intense symptomatology. As Robbins has stated:
The art of therapy has a lot to do with knowing when to go into content, and when to step out of content. For example, it is almost never helpful to go into the content of an obsession when treating OCD. The same is often true with worry.
(C. Robbins, personal communication, June 21, 2013)
Exposure to Unwanted Intrusive Thoughts
Once the patient understands that these thoughts are neither messages, nor facts, nor meaningful outcroppings of the unconscious mind that must be suppressed, confessed or “dealt with,” exposure tasks can be undertaken. These will involve deliberately inducing the thoughts by means of writing, singing, watching vide
os, and making recordings of the thoughts and playing them back. They can be translated into other languages. They can be played with and exaggerated. Or record it onto Songify, the App that turns a sentence into a song and plays it back (Songify for iPhone and Android).
Here is an example of an exposure session with a patient who has unwanted intrusive thoughts concerning the safety of her children.
PATIENT: Whenever my kids are out of my sight, even if I am busy at work, I start imagining that they are in danger or already dead or injured. I try not to think about it but my imagination keeps zinging me.
THERAPIST: Are you clear that this is an intrusive thought and not a fact?
PATIENT: I know what you are saying but it feels so real at the time that I want to call and check on them to be sure.
THERAPIST: Would you be willing to write a sentence on a piece of paper right now? The sentence is “My daughter is injured and will die if I don’t do something right away.”
PATIENT: (upset) I just can’t do that. I can’t stand thinking that.
THERAPIST: Do these words become true if you write them down?
PATIENT: I guess they don’t but it makes me so scared, like I am tempting fate.
THERAPIST: How about if I write them and just show them to you.
PATIENT: OK (cries but agrees, and does read the sentence). This is silly isn’t it? I know it is just a bunch of words. I can read them. It isn’t true.
THERAPIST: I hate to be contrary, but actually, we just don’t know with absolute certainty if it is true or not. You have to deal with that.
PATIENT: I am not good with not knowing for sure.
THERAPIST: Would you be willing to fold this piece of paper up and carry it in your purse all week?
PATIENT: As long as no one else sees it, I can do this.
References
Clark, D. A. and Rhyno, S. (2005) Unwanted intrusive thoughts in nonclinical individuals. In D. A. Clark (ed.) Intrusive thoughts in clinical disorders: Theory, research, and treatment. New York, NY: Guilford Press 1–29.
Clark, D. A. and Purdon, C. L. (1995) The assessment of unwanted intrusive thoughts: A review and critique of the literature. Behaviour Research and Therapy 33(8) 967–976.
Salkovskis, P.M. (1989) Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy 27(6) 677–682.
Tallis, F. and Eysenck, M. W. (1994) Worry: Mechanisms and modulating influences. Behavioural and Cognitive Psychotherapy 22(1) 37–56.
Purdon, C. (2005) Unwanted Intrusive thoughts: Present status and future directions. In D. A. Clark (ed.) Intrusive thoughts in clinical disorders: Theory, research and treatment. New York, NY: Guilford Press 226–245.
Taylor, S. (1999) Anxiety Sensitivity: Theory, research, and treatment of the fear of anxiety. Personality & Clinical Psychology. Mahwah, NJ: Lawrence Erlbaum.
Watkins, E. R. (2008) Constructive and unconstructive repetitive thought. Psychological Bulletin 13(2) 163–206.
Wegner, D. M. (1994) Ironic processes of mental control. Psychological Review 101(1) 34–52.
Freud, S. (1961) “Dostoevsky and parricide. The Standard edition of the complete psychological works of Sigmund Freud, Volume XXI (1927–1931). London: Hogarth Press 173–194.
Songify for iPhone by Smule (2013) Songify (Version 2.1.1) [Mobile Application Software] Retrieved from https://itunes.apple.com/us/app/songify/id438735719?mt=8
Songify for Android by Smule (2012) Songify (Version 1.0.9) [Mobile Application Software] Retrieved from https://play.google.com/store/apps/details?id=com.smule.songify&hl=en
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Classic Pitfalls
Common Mistakes Non-Specialists Make
Therapists with limited experience treating highly anxious patients can easily fall prey to a number of understandable pitfalls which are unproductive and even harmful. These fall into several categories. First, misdiagnoses can lead to unhelpful (although often quite interesting) exploration of “issues,” when the therapy work that needs to be done is at a meta-level involving the patient’s relationship to his own thoughts, sensations, memories, and imagination. Second, traditional concepts such as insight and catharsis can lead to causal explanations and interventions that are less than helpful with this group of patients. We provide a number of examples. Third, there are typical mistakes in the application of exposure-based practice that we illustrate.
Traditional concepts such as insight and catharsis can lead to causal explanations and interventions that are less than helpful with this group of patients.
Common “under-diagnosis” errors include recognizing general anxiety disorder (GAD) but missing the underlying obsessive-compulsive disorder (OCD), treating social anxiety disorder as “low self-esteem,” and conceptualizing a phobia as fear of the external trigger (e.g., claustrophobia) without treating the panic disorder (fear of fear, or anxiety sensitivity) component. “Over-diagnosis” includes being waylaid by the bizarre nature of some unwanted ego-dystonic intrusive thoughts into concluding they are psychotic or dangerous intrusion of impulses. This can be particularly problematic in postpartum OCD, for example. Over-diagnosis can also occur in readily diagnosing Axis II traits such as lying, controlling, dependency, and manipulation prior to treatment of the anxiety. Often, these supposedly enduring traits will abate or disappear when they are no longer needed in the service of avoiding anxiety symptoms.
Pitfall Number 1: Turning the Causation Arrow Around
Patients can have significant intrusive anxious thoughts from childhood, and many of them spend time in psychodynamic therapy before finding specialized help. Here are a few examples of turning the causation arrow around that created massive relief and helped to reframe problems that had plagued patients for years.
One patient believed that her lifelong struggle with anxiety was derived from irrational childhood guilt over having caused the premature death of her father. She had misbehaved when she was 10 years old, and on that very day he had died of a heart attack on the front lawn. The patient had worked in therapy trying to acknowledge that she had only been a child doing what children do, that her father had an undetected heart condition, that she needed to have more compassion for herself, as well as a variety of other means of assuaging the guilt that caused her anxiety. However, when the original events were examined more closely, it became apparent that she had exhibited OCD symptoms for several years prior to her father’s death and it was therefore not possible that the “cause” was her irrational guilt. The intrusive OCD thought “what if I caused his death?” had not emerged until several years after he died. Her “misbehavior” on the day of his death had been a refusal to wear a certain piece of clothing which had been “contaminated” by “icky thoughts.” So the intrusive guilty thought that she had caused her father’s death was “caused” by her pre-existing OCD and was yet another OCD symptom. The best ways to handle such a thought was not to refute it but to get it labeled properly and disengage from it. Her previous therapy had inadvertently maintained her “guilty” thoughts.
A second and very similar example: an elderly woman came to talk about her lifelong struggle with “infidelity” thoughts. She was still plagued by the belief that she had “lusted in her mind” for men other than her husband. She had been widowed many years earlier after what had seemed to the outside world an ideal marriage. During her 40s, she had gone to a therapist to try to banish these thoughts. What resulted was an escalation of doubting thoughts about her marriage, so she fled therapy and tried to get rid of the thoughts on her own. She remained convinced that she had deceived her husband by keeping these thoughts private and felt guilty about this to the present. She believed that her private struggles indicated that she must not have really loved him. In fact, when she understood that all that was happening was OCD obsessions—that these were ego-dystonic intrusive thoughts rather than secret wishes—she began sobbing in relief. What good news to understand she had OCD! She real
ized that her choice to spare her husband knowledge of her struggles with these thoughts was a true act of love—and sharing her thoughts would only have caused him pain and further energized her struggle. The thoughts were not caused by not loving her husband enough; they were “caused” by refusing to allow any doubts about loving him to pass through her mind.
A final illustration: a young woman came to therapy in acute distress after her family doctor had sent her to a therapist one month after giving birth to her first child. The therapist had listened to her confessions of having thoughts of harming her baby, sometimes a fear of suddenly dropping him, sometimes “unspeakable” thoughts while changing his diaper. She had employed a full-time baby nurse because she was afraid she would act on these thoughts. The initial diagnosis was “postpartum depression” but she did not seem depressed—she was eating and sleeping well, and when someone else was taking care of her son, she seemed far more relaxed. The therapist suggested that she might be ambivalent about having a child and began to explore this theme, including her fears of being trapped with this husband now that she had a child with him. Perhaps, the therapist suggested, she was also ambivalent about her husband, and this was the “cause” of such thoughts. She became upset and argued vehemently that this was not so. Then, fortunately, the therapist wondered if this was “postpartum OCD” and referred her to a specialist, feeling unequipped to diagnose and treat OCD. This young mother resumed care of her child within weeks of an accurate diagnosis and attitude towards these thoughts. The meaning of harming obsessions is that these are the most resisted thoughts; it is not strange that a hormonally challenged and stressed young mother with a genetic predisposition towards “stickiness of the mind” would find passing thoughts of hurting her baby disturbing and would launch an internal compulsive campaign to rid herself of these thoughts. The avoidance of caring for the child was due to loving and “protecting” him and not due to ambivalence.
What Every Therapist Needs to Know About Anxiety Disorders Page 27