Brain Lock: Twentieth Anniversary Edition (PDF)

Dedication This book is dedicated to the memory of my grandfather HARRY WEINSTEIN and to the memory of my father ISRAEL VICTOR SCHWARTZ and to the memory of my step-father GARY FLUMENBAUM Three men who deeply knew, each in his own unique way, that nothing makes sense without original sin. Contents C...

Dedication This book is dedicated to the memory of my grandfather HARRY WEINSTEIN and to the memory of my father ISRAEL VICTOR SCHWARTZ and to the memory of my step-father GARY FLUMENBAUM Three men who deeply knew, each in his own unique way, that nothing makes sense without original sin. Contents COVER TITLE PAGE DEDICATION ACKNOWLEDGMENTS FOREWORD PREFACE TO THE TWENTIETH ANNIVERSARY EDITION INTRODUCTION: Obsessions, Compulsions, and the Four-Step Self-Treatment Method PART I: The Four Steps 1: Step 1: Relabel: “It’s Not Me—It’s My OCD” 2: Step 2: Reattribute: “Unlocking Your Brain” 3: Step 3: Refocus: “Wishing Won’t Make It So” 4: Step 4: Revalue: “Lessons Learned from OCD” PART II: Applying the Four Steps to Your Life 5: The Four Steps and Personal Freedom 6: OCD as a Family Disorder 7: The Four Steps and Other Disorders: Overeating, Substance Abuse, Pathological Gambling, and Compulsive Sexual Behavior 8: The Four Steps and Traditional Approaches to Behavior Therapy 9: OCD and Medication 10: University of Hamburg Obsession-Compulsion Inventory Screening Form 11: An OCD Patient’s Diary of Four-Step Self-Treatment PART III: Self-Treatment Manual for the Four-Step Method ABOUT THE AUTHOR ALSO BY JEFFREY M. SCHWARTZ CREDITS COPYRIGHT ABOUT THE PUBLISHER Acknowledgments This book, and all that’s been learned in the twenty ensuing years about how to apply the Four Steps, has been made possible by the OCD sufferers with whom I have had the privilege of interacting in my work at UCLA and beyond. I would also like to give special thanks to Peter Whybrow, MD for his support of my appointment at UCLA, and to Beverly Beyette, who made a tremendous effort to help the book be as good and useful to as many people as we could make it. Foreword Howard Hughes was dining with actress Jane Greer at Ciro’s on the Sunset Strip in Los Angeles one evening in 1947. At one point in the meal, he excused himself to go to the rest room. To Greer’s amazement, he did not return for an hour and a half. When he finally reappeared, she was astonished to see that he was soaking wet from head to toe. “What on earth happened to you?” she asked. “Well,” Hughes said, “I spilled some catsup on my shirt and pants and had to wash them out in the sink.” He then let them dry for a while, hanging them over one of the toilet stalls. Once he put his clothes back on, he explained, “I couldn’t leave the bathroom because I couldn’t touch the door handle. I had to wait for someone to come in.” According to Peter H. Brown, coauthor with Pat Broeske of Howard Hughes: The Untold Story, Jane Greer never went out with Hughes again. Howard Hughes was eccentric, certainly, but he was not a freak. He was suffering from obsessive-compulsive disorder (OCD), a classic and severe case. By the end of his life, in 1976, he was overwhelmed by the disease. He spent his last days in isolation in his top-floor suite at the Princess Hotel in Acapulco, where he had sealed himself in a hospital-like atmosphere, terrified of germs. Blackout curtains at every window kept all sunlight out; the sun, he thought, might transmit the germs he so dreaded. Aides with facial tissues covering their hands brought him food, which had to be precisely cut and measured. Rumors abounded that he was this reclusive because of drug abuse, a syphilitic condition, or terminal dementia. Actually, all his strange behaviors are readily understandable as symptoms of a severe case of OCD. Sadly, there was no treatment for OCD in Howard Hughes’s lifetime. It would be another decade before the disease would be identified as a brainrelated disorder. I frequently cite the case of Howard Hughes to help my patients understand that this disease, OCD, is an insatiable monster. The more you give in, the hungrier it gets. Even Hughes, with all his millions—and a retinue of servants to perform the bizarre rituals his OCD told him to perform—could not buy his way out. Eventually, the false messages coming from his brain overwhelmed him. If you are one of many who suffer from OCD, whether it is a mild case or one as severe as Howard Hughes’s, this book will show you how to fight and beat it. OCD is a tenacious enemy, but a strong-willed, motivated person can overcome it. Along the way, you will also learn a good deal about your brain and how you can control it better. You will read the stories of courageous people who, by applying the Four-Step Method, learned how to overcome the dreaded feelings of “Brain Lock” that are caused by OCD. This method, which has been scientifically demonstrated to enable people to change their own brain function, will be described in such a way that you can readily apply it yourself. In the 2004 film The Aviator, Leonardo DiCaprio portrayed Howard Hughes. Dr. Jeffrey M. Schwartz was a consultant on the film, coaching the actor in OCD thought patterns and mannerisms. DiCaprio said he also read Brain Lock, so as to “truly understand the idea of the sticky gearshift” in Hughes’s brain. Preface to the Twentieth Anniversary Edition The core concept of Brain Lock—that people with OCD can defeat their disease through self-directed behavioral therapy that actually changes their brains—has withstood the test of time. Now, twenty years after this book was first published, it is accepted as a classic finding in the history of neuroscience. In scientific terms, this is neuroplasticity, a process resulting in changes to the brain’s structure, circuits, chemistry or functions in response to changes in its environment. And self-directed neuroplasticity, using the Four-Step program explained in this book, has empowered thousands of people with OCD to change their own brains. Brain scans have clearly shown that the brains of OCD sufferers literally flare up with over activity, sending terribly bothersome and intrusive false messages (see images on the back cover). In the last two decades, further brain studies have validated the finding that putting these troubling feelings in proper context, calling them what they are—symptoms of a disease—enables people to respond differently to their symptoms and, as a result, to regulate the structures of the emotional brain that play a key role in processing their feelings in reaction to the OCD-inducing stimuli. This milestone edition of Brain Lock is not a revision. It’s my sincere belief that there is no need to revise the Four-Step method. The cognitive-mindfulness treatment approach first presented in this book is now accepted as a standard outpatient OCD treatment. Now, twenty years later, I continue doing research and working to help OCD sufferers. I’ve concentrated also on further developing the Four-Step method to help people—not only those with neuropsychiatric problems like OCD, but those with no specifically diagnosed problem—to perform at a higher and more effective level. The method has proven very valuable, for example, in enhancing people’s capacities to develop their leadership abilities through use of the Wise Advocate concept, which you’ll read more about in these pages. In short, we’ve learned that the Four Steps can help anyone become more in touch with his or her True Self. Since Brain Lock was first published, I have lectured at conferences in major world cities, spoken before the United Nations and appeared on widely viewed television programs, including the Today show Good Morning America, and The Oprah Winfrey Show. This new peface serves to refine, and further clarify, the Four Steps to selfdirected therapy: Relabel, Reattribute, Refocus and Revalue. When OCD patients Relabel, they are calling their disturbing thoughts and urges what they really are: obsessions and compulsions. When they Reattribute, they recognize that the bothersome thoughts won’t go away because they are symptoms of a disease, OCD. When they Refocus, they work around the intrusive thoughts by doing a constructive, enjoyable behavior. When they Revalue, they learn to ignore those thoughts and view them as worthless distractions. Patients who have used this method have told courageous, though often heartbreaking, stories about their lives before the Four Steps. Happily, many stories have had inspiring outcomes. In sharing them, they have provided illuminating insights for all OCD sufferers. Anna, who related her story in Brain Lock, was once suicidal. For years, she had obsessed that her husband was unfaithful. She would bombard him relentlessly with questions: When had he last seen a former girlfriend? Did he read girlie magazines? Now married for twenty-five years and the mother of two adult daughters, Anna doesn’t consider herself cured—that isn’t realistic—but she has gained the insights necessary to manage her disease. Importantly, she also has a supportive partner. “If I have an urge, I might ask one question and my husband will say, ‘you know that’s an OCD question.’ You need a second party to cooperate and he usually isn’t cooperative because he knows it’s unhealthy.” Aware that “coping with OCD over a lifetime is a maintenance issue,” and that for her the Four Steps are essential tools, she still keeps in touch. Reed is an actor whose OCD caused such paralyzing stage fright that he abandoned acting for fifteen years. His was not garden variety stage fright, but a panic-inducing fear fueled by the thought that “everything I did had to be perfect.” At auditions, he was sure that “people could see that I was faking it and that I was imperfect.” Practicing the Four Steps has both diminished his stage fright and allowed him to Revalue how he approaches auditions: “I used to go in to get the job. I needed approval and validation” to combat low self-esteem. “Now I go in to give to the role what I have, knowing it may or may not be what will work for them. I don’t have to put on a show. I don’t have to be perfect.” He is able to separate his identity from the illness, to see himself as “a regular person dealing with a mechanical flaw. I’m not flawed any more so than if I was driving a car that wasn’t hitting on all cylinders.” Without this knowledge, he says trying to separate the disease from reality was “like looking for a polar bear in a snowstorm.” Reed has also applied the Four Steps successfully to quit smoking. Just as people with OCD do compulsions to avoid the pain caused by obsessions, he smoked to avoid the pain of not smoking. So he Relabeled his urge— “It’s not me. It’s a nicotine habit, a chemical addiction”. He Reattributed it—“Why is it bothering me? Because it’s a long-term habit that I once associated with pleasure.” He Refocused on being healthy. He Revalued: “I’ll be all right without a cigarette.” Jake and Carrie, a married couple, are both OCD sufferers. Carrie, who had unfounded fears about having committed violent acts, was first to seek help. Jake was in denial for years, even though Carrie recognized his symptoms as OCD. His obsession: That Carrie no longer loved him because she did not respond demonstratively to every hug or kiss. Then, reading her copy of Brain Lock, he saw himself in the book. He says, “I’d always thought these people (with their obsessions and compulsions) were really nuts, and I was normal.” Jake’s denial is not atypical. OCD is sneaky; it wants you to think that those obsessions and compulsions are real, rather than a chemical problem in your brain. When the OCD was at its worst, Jake tested Carrie forty or fifty times a day. A busy working mother, she would sometimes shrug him off—she had dishes to do, kids to get ready for school. After more than thirty years of marriage, she’d assure him, he needn’t doubt her love. For Jake, this wasn’t enough. He “would ruminate for days on end that I had nothing to look forward to, that our love was done. What really sent me over the edge was when she said she couldn’t live with me the way I was. She wanted a divorce.” Today their marriage is back on track. If Carrie says she’s busy, he accepts that. “I can feel the thoughts creep in and I Relabel them—‘It’s OCD. It’s OK’— and move on. It’s like that person’s just lying to me.” A full-time engineer and part-time teacher, Jake stays very busy, finding that keeping occupied helps him Refocus. “When I’m interacting with people, the thoughts are somewhat blocked and it gives me relief.” This is very positive. Just thinking a good thought is a bad Refocus strategy. For example, someone with a fear of dying might Refocus on assuring herself that she’s healthy. Why is that bad? Because it’s so easy for that thought to become an avoidance, merely a way of pushing aside the thought about death that is causing the OCD symptoms. It is an attempt to neutralize an obsessive thought, and that is a compulsion. Your Wise Advocate will tell you that the thought is just an obsessive thought; you then accept the thought and focus on a good behavior. In recent years we have placed increased emphasis on listening to the Impartial Spectator, a term we introduced in Brain Lock. The Impartial Spectator is simply the person within. Through self-directed therapy, patients learn to stand outside of themselves and, as it were, read their own minds. As Anna put it, this is “distancing yourself from your own brain. I do that all the time.” This is mindful awareness. Because the term mindfulness has been co-opted by the popular culture and has thus become less clearly defined, we use it less, or we tend to define it as progressive mindfulness. Just being in the present moment, in the zone, is not true mindfulness, nor is mindfulness about being non-judgmental per se. Whereas these are important aspects of mindfulness, in practicing mindfulness one needs to be making assessments and discernments. Mindfulness is an activity, not merely a state of mind or a way of being. You are not simply observing your thoughts; you are evaluating your choices and actions, letting thoughts in with an open mind, assessing them and then deciding what to do about them. For Reed, finding the Impartial Spectator was the key to removing himself from his illness, getting his identity back “totally clean of it.” He learned, “Nothing that ever happened to you changed what and who you are. OCD is not who you are. It’s just who you thought you were.” In using the Four-Step therapy, he says, “We learn not just how the OCD fools us, but how we fool ourselves” by clinging to false self-perceptions. “I came for the OCD. I stayed for the mindfulness.” Thinking himself a “total failure,” he gave up acting for fifteen years. With Four-Step therapy, he gained the self-confidence to return to acting. He is not totally free of OCD symptoms—including hoarding—but says, “It’s not MY OCD any longer. It’s just OCD. That’s part of getting it out of your psyche, dealing with it as a mechanical glitch.” We have begun also to use the term Wise Advocate, introduced in my 2012 book, You Are Not Your Brain, written with Rebecca Gladding, MD. The Wise Advocate is another way of viewing the Impartial Spectator, but you can literally talk to it, engage it in an inner dialogue. The Wise Advocate is your inner, loving guide that genuinely cares for you and is on your side. Your Wise Advocate sees the big picture, knows that the problem is your brain, not you or your mind. It knows what you’re thinking and feeling and keeps reminding you that those deceptive brain messages are not you, it’s just the OCD. The Wise Advocate guides and supports you in making rational decisions based on what is in your long-term best interests. It is the crux of the Four Steps. It enables you to face difficult situations and view them as events of the mind that will pass. Altering the brain’s circuits makes it possible to feel the bad thoughts, urges, and feelings as OCD, and to understand what is causing your pain. With your Wise Advocate and Impartial Spectator working together, you teach your body and brain to work for, rather than against, you. You Relabel the thoughts (Step One) and Reattribute them (Step Two). Relabeling answers the question, “What’s bothering me?” Just OCD symptoms, those deceptive brain messages. Reattributing tells you why the thoughts won’t go away. It reminds you that your gut-level anxiety is due to a medical condition caused by your brain. With your Wise Advocate’s help, you are able to Refocus (Step Three) on a healthy behavior, rather than giving in to the urges. Over time, the less attention you pay to the unpleasant sensations and actions, the weaker the brain circuits associated with them become. In that way you genuinely change how your brain works. That’s true self-directed neuroplasticity. Relabeling at first requires conscious effort—telling yourself that this is just an obsession or compulsion—however, the more you Relabel the more the process becomes automatic. Regular practice of the first three steps—Relabel, Reattribute and Refocus—leads to Step Four, Revaluing, recognizing that your OCD thoughts and compulsions are worthless. You have then strengthened your Impartial Spectator and formed a closer connection with your Wise Advocate. We recently added a sub-category to the Refocus step—Refocus with a Star, or progressive mindfulness. This means confronting the very thing that’s causing the symptoms. If dirt is your concern, you might Refocus on gardening. Doing so will surely make you anxious, but by Refocusing you are meeting the situation head-on, then focusing on a constructive activity that diverts attention from it and rewires your brain. Progressive mindfulness is more humane and less passive than classic exposure and response prevention, in which the patient is forced to confront those things that cause the OCD to flare up but is just told not to do the resulting compulsion. By contrast, progressive mindfulness allows OCD sufferers to truly understand what is happening to them and to know they don’t have to react to their symptoms. They are using the Refocus step with progressive mindfulness. Reed refers to this as “going right after the beast itself.” Carrie calls it “not giving the enemy ammunition.” We continue to learn from our patients how they adapt the Four Steps to their lives and become, in essence, lay therapists. One topic not addressed originally in Brain Lock is using the Four Steps in the workplace. The goal here is to do the doable and not get caught up in the OCD. Instead of giving in and becoming non-functioning, you might tell yourself, “OK, I can’t do this spreadsheet just now, but I can prepare for that meeting later this week.” Work activities become part of the Refocus step. Matt, a compulsive checker, once worked at a company that delivered medical supplies. His job was to do clients’ paperwork and, even though he knew intellectually that he was doing everything properly, he was driven crazy by the thought that he’d made an error. “It kept going around in my head,” he says, “did this guy get his oxygen?” Now 45 years old, Matt was a teenager in Great Britain when his checking obsessions started, not coincidentally with the stress of university entrance exams. Even after his disease caused him to drop out of college, he told almost no one about his problem, hoping it might just go away— “Twenty-five years ago in Britain, mental health wasn’t something we talked about”. A therapist failed to diagnose OCD. After moving to the United States, he saw a therapist who recommended Brain Lock. Learning the Four Steps was, he says, “like a breath of fresh air.” He still gets obsessive thoughts, still checks and double-checks door locks and light switches, but describes the OCD as “pretty well under control.” If intrusive thoughts interfere at his current job, in the field of medical insurance, he Refocuses on the task at hand. Now, he says, “When I get these thoughts, I Relabel them and Refocus on my work. The work is your therapy. Over time, it becomes automatic.” Some OCD sufferers also battle alcoholism. There are similarities between the Four Steps and the twelve-step Alcoholics Anonymous program. Sufferers of both diseases feel powerless to an urge. An alcoholic may think, “I don’t want to take that first drink because I know I can’t stop.” It’s the same for people with OCD. They know they’re hooked if they give into that obsession and compulsion. And, as one OCD sufferer observed wryly, “No one has really great weekend stories from OCD.” With therapy, we encourage people with OCD to see themselves as genuinely separate from their disease. Roger, a film maker and recovering alcoholic with OCD, has experienced the addictive cycles created by both diseases. He says, “With OCD, I’d have to do the compulsions to prevent myself from going crazy. You feel you’re going to jump out of your skin, a feeling similar to what people describe in AA meetings.” Doing the compulsions or taking a drink are both relief valves, and both are destructive behaviors. As with drinking, “With OCD, the more compulsions you do, the worse it gets,” Roger knows, and “I don’t get any pleasure out of doing compulsions, whereas I did get some pleasure out of drinking.” His obsessions and compulsions began in childhood. He recalls trying to walk the length of the garden hose on the lawn, certain that something terrible would happen if he fell off. Lying in bed, he’d count patterns on the wallpaper endlessly. As an adult, he developed a series of obsessions about harming others. One was that he’d hit someone while driving—“At first, I used to call police departments and ask if there had been any accidents in the area.” Because that carried a social stigma, he began instead to retrace his routes. When this started taking up to eight hours in one day, he stopped driving for several years. His “aha” moment in combating OCD was seeing the brain scans—“All I had done was light up my brain. Now I knew exactly what was happening.” He had a disease. He still retraces his driving routes, but on some days for only five minutes. He has learned to Refocus, perhaps by pulling over to the side of the road, waiting for his brain to “cool off.” And he has learned to Revalue the gut feeling that something is wrong as a seductive, but nevertheless false, symptom of OCD. Roger realized his driving obsession meant he wasn’t trusting his own senses. If he had passengers, he’d feel compelled to ask them for reassurance. Seeing a police car behind him was reassuring because he knew that, had he actually run over someone, the police would have stopped his car. “In effect, the police were overseeing me. I realized they were my Impartial Spectator.” He has since driven more than 150,000 miles by consciously applying the Four Steps—and installing his own electronic Impartial Spectators, front and rear recording dash cams. “This allows me to Refocus, knowing I can watch the recording later. It’s not a perfect solution, but it’s like training wheels, a nondrug crutch.” Roger’s goal is to strengthen his own Impartial Spectator and eliminate the cameras. Refocusing is not avoidance. The difference is huge, and important. When one avoids places, people or situations that cause OCD symptoms, the OCD becomes much worse. Avoidance itself is a compulsion. There is nothing you can do to just make the OCD feelings go away, but when you Refocus, you work around them. You do some healthy, adaptive behavior while reminding yourself, “This is just OCD.” You are using your Impartial Spectator, or Wise Advocate, to direct you to a behavior that is good for you. The key is to accept that the bad thought is just an obstacle to overcome. In treating brain disorders, which include OCD, professionals tend to think, “It’s just chemistry. Let’s treat it with chemicals.” Certainly, medication—most commonly serotonin uptake blockers—can ease the way into self-directed behavioral therapy and may well decrease the intensity and frequency of the compulsions, but we view that approach as perhaps a little too passive. Add an active component—the realization that “It’s just OCD”—and you can gradually decrease the dose. That’s medicine as water wings; in time most sufferers can go onto significantly lower doses. And patients using the Four Steps cherish their active role in their treatment. People tend to associate OCD with its most familiar symptoms, such as hoarding or compulsive hand-washing, but we see patients with many other manifestations of the disease. One could not buy fruit at the supermarket because he imagined that it had been poisoned and his fingerprints would be found on it. He also developed a fear that a piece of paper left next to a telephone cord would catch fire and dozens of people would die in the inferno. OCD sufferers tell us of having tried for years to hide their symptoms. While the shame of acting out their compulsions remains very real, there is no longer shame in having the disease. Twenty years ago, OCD was a misunderstood affliction, even diagnosed as schizophrenia. A diagnosis of OCD—and the knowledge that it is caused by a chemical imbalance in the brain—comes as a great relief to sufferers. Both the medical community and the general population have become much more aware of OCD. Hollywood has played a part in this—think of Leonardo DiCaprio, as Howard Hughes in The Aviator, arranging his food just so on his plate, or creating a germ-free zone in his house. Many OCD symptoms are now so familiar that people who don’t have the disease will say, “Oh, I have that, too.” But as one of my patients observed, “If you think you have OCD, you probably don’t.” The intense pain and suffering caused by OCD is not something a sufferer with real OCD would ever speak of in a glib or casual manner. Indeed, it’s this suffering that has led some patients to find a potential for spiritual growth in having OCD—once they have identified their disease and learned coping strategies. Matt says, “OCD has actually made me a better, more rounded, person. All the things you go through, it makes you appreciate the good things.” Anna knows, “The lessons I’ve learned from dealing with OCD make me a much stronger person. I have a depth of understanding of my own thought processes that other people might not have. It makes me very compassionate.” She adds, “If I could choose, I would choose not to have it. But you gain a lot of mental strength by having to do these exercises, evaluating your thoughts in a mindful, and impartial, way. These are all very useful skills for life in general.” Patients ask me, “Is this OCD going to drive me crazy?” The answer is no— so long as you use your Wise Advocate to remind yourself that it doesn’t make sense, that it’s just deceptive brain messages. That doesn’t mean it goes away totally. But you can learn to deal with it. Your Wise advocate will be there to remind you, “My whole self-identity is not tied up in this. My brain is just playing cruel games with me.” Jeffrey M. Schwartz, MD (with Beverly Beyette) Los Angeles, California September 2016 Introduction Obsessions, Compulsions, and the Four-Step SelfTreatment Method We all have our little quirks—habits and behaviors—that we know we’d be better off without. We all wish we had more self-control. But when thoughts spin out of control, becoming so intense and intrusive that they take over against our will, when habits turn into all-consuming rituals that are performed to rid us of overwhelming feelings of fear and dread, something more serious is happening. THIS IS OBSESSIVE-COMPULSIVE DISORDER (OCD) The victims of OCD engage in bizarre and self-destructive behaviors to avert some imagined catastrophe. But there is no realistic connection between the behaviors and the catastrophes they so fear. For example, they may shower forty times a day to “ensure” that there will not be a death in the family. Or they may go to great lengths to avoid certain numbers so as to “prevent” a fatal airplane crash. Unlike compulsive shoppers or compulsive gamblers, people with OCD derive no pleasure from performing their rituals. They find them extremely painful. Almost certainly, OCD is related to a biochemical imbalance in the brain that we now know can be treated very effectively without drugs. We know, too, that the Four-Step Self-Treatment Method you will learn in this book enables people with OCD to change their own brain chemistry. Furthermore, this method can be applied effectively to take control over a wide variety of less serious, but troublesome and annoying, compulsive habits and behaviors. (If you think you may have OCD, the University of Hamburg Obsession-Compulsion Inventory Screening Form on page 198 may help you find out. If you don’t, the techniques you learn in this book may help you overcome other troubling and annoying habits and behaviors.) Simply defined, OCD is a lifelong disorder identified by two general groups of symptoms: obsessions and compulsions. Once thought of as a curious and rare disease, it, in fact, affects one person in forty in the general population, or more than five million Americans. A disorder that typically has its onset in adolescence or early adulthood, OCD is more common than asthma or diabetes. It is a devastating disease that often creates chaos in the lives of its victims—and those who love them. The preoccupation with repetitive behaviors, such as washing, cleaning, counting, or checking, causes trouble on the job and leads to marital strife and difficulty with social interaction. Family members may become impatient and angry, demanding, “Why don’t you just stop!” Or they may aid and abet the performance of the silly rituals to buy an hour’s peace (a very bad idea). WHAT ARE OBSESSIONS? Obsessions are intrusive, unwelcome, distressing thoughts and mental images. The word obsession comes from the Latin word meaning “to besiege.” And an obsessive thought is just that—a thought that besieges you and annoys the hell out of you. You pray for it to go away, but it won’t, at least not for long or in any controllable way. These thoughts always create distress and anxiety. Unlike other unpleasant thoughts, they do not fade away, but keep intruding into your mind over and over, against your will. These thoughts are, in fact, repugnant to you. Say that you’ve seen a beautiful woman and can’t get her out of your mind. That is not an obsession. That is a rumination, something not inappropriate, something quite normal and even pleasant. If Calvin Klein’s marketing department had really understood the word obsession properly, the perfume would have been called “Rumination.” GETTING THE (WRONG) MESSAGE Because these obsessions don’t go away, they are extremely difficult to ignore— difficult, but not impossible. We now know that OCD is related to a biochemical problem in the brain. We call this problem “Brain Lock” because four key structures of the brain become locked together, and the brain starts sending false messages that the person cannot readily recognize as false. One of the main signal-processing centers of the brain, made up of two structures called the caudate nucleus and the putamen, can be thought of as similar to a gearshift in a car. The caudate nucleus works like an automatic transmission for the front, or thinking part, of the brain. Working with the putamen, which is the automatic transmission for the part of the brain that controls body movements, the caudate nucleus allows for the extremely efficient coordination of thought and movement during everyday activities. In a person with OCD, however, the caudate nucleus is not shifting the gears properly, and messages from the front part of the brain get stuck there. In other words, the brain’s automatic transmission has a glitch. The brain gets “stuck in gear” and can’t shift to the next thought. When the brain gets stuck, it may tell you, “You must wash your hands again”—and you’ll wash, even though there is no real reason to do so. Or the brain may say, “You’d better check that lock again”—and you’ll check again and again, unable to shake off the gnawing feeling that the door may be unlocked. Or an intense urge to count things or to reread words may arise for no apparent reason. By applying behavior therapy techniques, you can change how you respond to these thoughts and urges, and you can physically change the way your brain works. The use of these techniques actually makes the automatic transmission in the brain shift more smoothly, so that over time the intrusive urges decrease. One patient at UCLA, Dottie, on being told that her problem was caused by a biochemical imbalance in her brain, immediately brightened and coined the catchphrase “It’s not me—it’s my OCD.” To most people with OCD, this realization alone comes as a great relief. Washing, checking, and other OCD rituals consume hours of time each day and make the lives of people with OCD miserable. People with OCD may even fear they are going crazy—they know that their behavior is not normal. Indeed, the behavior is apt to be foreign to their personalities or self-image. Yet until they learn the Four-Step Self-Treatment Method, they are unable to stop themselves from responding to the brain’s false alarms. WHAT ARE COMPULSIONS? Compulsions are the behaviors that people with OCD perform in a vain attempt to exorcise the fears and anxieties caused by their obsessions. Although a person with OCD usually recognizes that the urge to wash, check, or touch things or to repeat numbers is ridiculous and senseless, the feeling is so strong that the untrained mind becomes overwhelmed and the person with OCD gives in and performs the compulsive behavior. Unfortunately, performing the absurd behavior tends to set off a vicious cycle: It may bring momentary relief, but as more compulsive behaviors are performed, the obsessive thoughts and feelings become stronger, more demanding, and more tenacious. The afflicted person ends up with both an obsession and an often embarrassing compulsive ritual to go with it. It is not surprising that many people with OCD come to see themselves as doomed and may even have suicidal thoughts by the time they seek professional help. In addition, years of traditional psychotherapy may have served only to confuse them further. A Checklist of Common OCD Symptoms OBSESSIONS Obsessions about Dirt and Contamination Unfounded fears of contracting a dreadful illness Excessive concerns about dirt; germs (including the fear of spreading germs to others); and environmental contaminants, such as household cleaners Feelings of revulsion about bodily waste and secretions Obsessions about one’s body Abnormal concerns about sticky substances or residues Obsessive Need for Order or Symmetry An overwhelming need to align objects “just so” Abnormal concerns about the neatness of one’s personal appearance or one’s environment Obsessions about Hoarding or Saving Stashing away useless trash, such as old newspapers or items rescued from trash cans The inability to discard anything because it “may be needed sometime,” a fear of losing something or discarding something by mistake Obsessions with Sexual Content Sexual thoughts that one views as inappropriate and unacceptable Repetitive Rituals Repeating routine activities for no logical reason Repeating questions over and over Rereading or rewriting words or phrases Nonsensical Doubts Unfounded fears that one has failed to do some routine task, such as paying the mortgage or signing a check Religious Obsessions (Scrupulosity) Troublesome blasphemous or sacrilegious thoughts Excessive concerns about morality and right or wrong Obsessions with Aggressive Content The fear of having caused some terrible tragedy, such as a fatal fire Repeated intruding images of violence The fear of acting out a violent thought, such as stabbing or shooting someone The irrational fear of having hurt someone, for example, the fear of having hit someone while driving Superstitious Fears The belief that certain numbers or colors are “lucky” or “unlucky” COMPULSIONS Cleaning and Washing Compulsions Excessive, ritualized hand washing, showering, bathing, or tooth brushing The unshakable feeling that household items, such as dishes, are contaminated or cannot be washed enough to be “really clean” Compulsions about Having Things “Just Right” The need for symmetry and total order in one’s environment, for example, the need to line up canned goods in the pantry in alphabetical order, to hang clothes in exactly the same spot in the closet every day, or to wear certain clothes only on certain days The need to keep doing something until one gets it “just right” Hoarding or Collecting Compulsions Minutely inspecting household trash in case some “valuable” item has been thrown out Accumulating useless objects Checking Compulsions Repeatedly checking to see if a door is locked or an appliance is turned off Checking to make certain one has not harmed someone, for example, driving around and around the block to see if anyone has been run over Checking and rechecking for mistakes, such as when balancing a checkbook Checking associated with bodily obsessions, such as repeatedly checking oneself for signs of a catastrophic disease Other Compulsions Pathological slowness in carrying out even the most routine activities Blinking or staring rituals Asking over and over for reassurance Behaviors based on superstitious beliefs, such as fixed bedtime rituals to “ward off” evil or the need to avoid stepping on cracks in the sidewalk A feeling of dread if some arbitrary act is not performed The overpowering need to tell someone something or to ask someone something or to confess something The need to touch, tap, or rub certain objects repeatedly Counting compulsions: counting panes in windows or billboards along a highway, for example Mental rituals, such as reciting silent prayers in an effort to make a bad thought go away Excessive list making THE FOUR STEPS In recent years, there have been major advances in treating this condition. More than two decades of research by behavior therapists have documented the effectiveness of a technique called exposure and response prevention. The use of this technique involves systematic exposure to stimuli that bring on OCD symptoms, such as having a person with OCD touch a toilet seat or other objects that he or she fears are contaminated, and cause the person to have obsessions and compulsions. The therapist then enforces extended periods during which the person agrees not to respond with compulsive behaviors. These periods, in turn, cause tremendous amounts of anxiety that last an hour or more and call for a significant amount of assistance by a trained therapist. As the therapy progresses, the intensity of the anxiety decreases, and the person gains much better control over the OCD symptoms. At UCLA School of Medicine, where we have been studying OCD for more than a decade, we have developed a simple self-directed cognitive-behavioral therapy to supplement and enhance this process. We call it the Four-Step SelfTreatment Method. It is a technique that does not require expensive professional therapy or the use of medications. By teaching people how to recognize the link between OCD symptoms and a biochemical imbalance in the brain, we were able to develop this method that very effectively treats persons with OCD solely with behavior therapy. In this book I will teach you how you can effectively become your own behavior therapist by practicing the Four Steps. This method can be used with or without a professional therapist. You will learn to fight off those urges and redirect your mind to other, more constructive behaviors. For the first time ever for any psychiatric condition or any psychotherapy technique, we have scientific evidence that cognitive-behavioral therapy alone actually causes chemical changes in the brains of people with OCD. We have demonstrated that by changing your behavior, you can free yourself from Brain Lock, change your brain chemistry, and get relief from OCD’s terrible symptoms. The end result: increased self-control and enhanced selfcommand, resulting in heightened self-esteem. Knowledge, as they say, is power. There is a huge difference in the impact an obsessive thought or urge has on a trained mind compared to what it has on an untrained mind. Using the knowledge that you will gain by learning the Four Steps, you will not only have a powerful weapon in your battle against your unwanted thoughts and urges, but you will empower yourself in a much broader sense. You will take a big step toward strengthening your ability to attain your goals and improve the quality of your day-to-day life. You will develop a stronger, more stable, more insightful, calmer, and more powerful mind. If people with OCD can do so, it is highly probable that those with a wide variety of other problems of different degrees of severity can, too. Other disorders include: uncontrolled eating or drinking nail biting hair pulling compulsive shopping and gambling substance abuse impulsive sexual behaviors excessive ruminating about relationships, self-image, and self-esteem The Four Steps can be used to help you control almost any intrusive thought or behavior that you decide you want to change. The Four-Step Self-Treatment Method is a way of organizing your mental and behavioral responses to your internal thought processes. Rather than just acting impulsively or reflexively, like a puppet, when unwanted thoughts or urges intrude, you can train yourself to respond in a goal-oriented manner and can refuse to be sidetracked by self-destructive thoughts and urges. We call these steps the four R’s: Step 1. RELABEL Step 2. REATTRIBUTE Step 3. REFOCUS Step 4. REVALUE In Step 1: Relabel, you call the intrusive thought or urge to do a troublesome compulsive behavior exactly what it is: an obsessive thought or a compulsive urge. In this step, you are learning to clearly recognize the reality of the situation and not be tricked by the unpleasant feelings OCD symptoms cause. You develop the ability to clearly see the difference between what’s OCD and whats reality. Instead of saying, “I feel like I need to wash my hands again, even though I know it doesn’t make any sense,” you start saying, “I am having a compulsive urge. That compulsion is bothering me. That obsessive thought is hounding me.” The question then arises, “Why does this keep bothering me?” In Step 2: Reattribute, you answer that question. You say, “It keeps bothering me because I have a medical condition called OCD. I am having the symptoms of a medical problem. My obsessions and compulsions are related to a biochemical imbalance in my brain.” Once you realize this fact, you begin to ask yourself, “What can I do about it?” In Step 3: Refocus, you turn your attention to more constructive behaviors. By refusing to take the obsessions and compulsions at face value—by keeping in mind that they are not what they say they are, that they are false messages—you can learn to ignore or to work around them by Refocusing your attention on another behavior and doing something useful and positive. This is what I call “shifting gears.” By performing an alternative, wholesome behavior, you can actually repair the gearbox in your brain. Once you learn how to Refocus in a consistent way, you will quickly come to the next step. In Step 4: Revalue, you revalue those thoughts and urges when they arise. You will learn to devalue unwanted obsessive thoughts and compulsive urges as soon as they intrude. You will come to see intrusive OCD symptoms as the useless garbage they really are. The Four Steps work together. First, you RELABEL: You train yourself to identify what’s real and what isn’t and refuse to be misled by intrusive destructive thoughts and urges. Second, you REATTRIBUTE: You understand that those thoughts and urges are merely mental noise, false signals being sent from your brain. Third, you REFOCUS: You learn to respond to those false signals in a new and much more constructive way, working around the false signals by refocusing your attention on more constructive behavior to the best of your ability at that moment. This is where the hardest work is done and where the change in brain chemistry takes place. By expending the effort it takes to Refocus, you will actually be changing how your brain works in an extremely healthy and wholesome way. Finally, the real beauty of the Four-Step Method is seen in the REVALUE step, when the whole process becomes smooth and efficient, and the desire to act on unwanted thoughts and urges has been overcome to a significant degree. You will have learned to view those troublesome thoughts and urges as having little or no value and, therefore, your obsessions and compulsions will have much less impact on you. Things come together very quickly, resulting in an almost automatic response: “That’s just a senseless obsession. It’s a false message. I’m going to focus my attention on something else.” At this point, the automatic transmission in your brain begins to start working properly again. Once people learn to perform the Four Steps on a regular basis, two very positive things happen. First, they gain better control over their behavioral responses to their thoughts and feelings, which, in turn, makes day-to-day living much happier and healthier. Second, by altering their behavioral responses, they change the faulty brain chemistry that was causing the intense discomfort of their OCD symptoms. Since it has been scientifically demonstrated that the brain chemistry in this serious psychiatric condition is changed through the practice of the Four Steps, it is likely that one could also change one’s brain chemistry by altering responses to any number of other behaviors or bad habits through using the Four Steps. The result could be a lessening of the intensity and intrusiveness of these unwanted habits and behaviors, making them easier to break. WHAT’S OCD, WHAT ISN’T? Because of the similarity in names, people tend to confuse the term obsessivecompulsive disorder with the far less disabling obsessive-compulsive personality disorder (OCPD). What sets them apart? Simply stated, when your obsessions and compulsions are bad enough to cause significant functional impairment, you have OCD. In OCPD, these “obsessions” and “compulsions” are more like personality quirks or idiosyncrasies, however unpleasant. For example, a man with OCPD may hang on to some object because he believes he may need it someday. But a man with an OCD hoarding compulsion may fill every square foot of his house with worthless trash he knows he’ll never need. People with OCPD tend to have trouble “seeing the forest for the trees.” Typically, they are list makers who get so hung up on details that they never get around to seeing the big picture. Their quest for perfection interferes with their getting things done. OCPD is a classic case of the “best” being the “enemy of the good.” People with OCPD tend to mess up things that are good enough in their quest to make everything “perfect in every detail.” They are often totally inflexible, unable to compromise. In their view, if a job is to be done right, it must be done their way They are unwilling to delegate. It is interesting that this personality type is twice as common in males, whereas OCD does not discriminate between sexes. The other crucial difference between OCD and OCPD is that although people with OCPD are rigid and stubborn and let their ideas run their lives, they have no real desire to change their ways. Either they are not aware that their behavior annoys others or they simply don’t care. The person with OCD washes and washes, even though it causes him great pain and gives him no pleasure. The person with OCPD enjoys washing and cleaning and thinks, “If everyone cleaned as much as I do, everything would be fine. The problem is that my family is a bunch of slobs.” The person with OCPD may look forward to going home at night and lining up all her pencils on her desktop like little soldiers. The person with OCD dreads going home, knowing she will give in to that false message telling her to vacuum twenty times. Unlike people with OCPD, those with OCD realize how inappropriate their behavior is, are ashamed and embarrassed by it, and are in the truest sense desperate to change their behavior. In the words of two people with OCD, “My brain had become an indescribable hell from which I could not escape,” and “It’s a good thing the windows in the hospital were bolted because I was ready to take the short way out.” This book is mainly about people with OCD. Most of the stories are about their struggles to overcome their disease. But millions of people with less crippling problems can take inspiration from these stories and learn a selftreatment method that can be applied to a wide variety of troublesome behaviors. Those who shared their stories are people who overcame a medical illness. The method they used can be learned and can benefit almost anyone. This book is for all those who want to change their behaviors and are seeking the tools that will help them do so. OCD: A “DEVILISH” DISORDER “Damned if you do. Damned if you don’t.” This is exactly how people with OCD feel before they learn the Four Steps for fighting back against its overpowering symptoms. They have urges to do things that lead them to act in ways that only lessen the amount of control they have over their lives. With that loss of control comes a decreased ability to manage their responses to those destructive urges, which get more and more powerful and intense as time goes by. So if they perform a compulsive behavior, they are damned in the sense that their painful feelings get worse and worse. At the same time, without proper mental training (the Four Steps), they lack the skills they need to change their disordered brain chemistry through constructive action. Furthermore, before they learn the Four Steps, very uncomfortable and anxiety-ridden feelings arise when they don’t act on the compulsive urges. Thus, they are trapped in the “damned if you don’t” part of this dilemma. THE FAR SIDE © Farworks, Inc./Dist. by Universal Press Syndicate. Reprinted with permission. All rights reserved. OCD is the devil with his pitchfork at their backs. This devil knows that he has the upper hand. If people with OCD listen to him—and perform the silly rituals that the demon OCD commands them to perform—they will truly be damned because, in the long run, it will lead only to even more intense urges to perform more and more rituals. Their lives will become a living hell. But if they ignore the devil OCD’s awful urges, if they refuse to perform the compulsions right now, the devil will seize the opportunity to jab them with his pitchfork over and over again, causing them great pain. There is, however, another choice, a third door that the devil will never tell them about and, in fact, will try to hide from them. By choosing to go through this door, they can outsmart the devil. Behind this door lies the Four-Step program of self-directed behavior therapy that will enable them to change their brains, overcome these devilish urges, and free themselves from obsessivecompulsive behavior. THE WAY WE WERE: SIX CASE STUDIES Here are the stories of some who walked through that third door—people who were totally overwhelmed by OCD when we first met them, but have managed to beat the devil. The symptoms they describe are not rare and obscure; they are extremely common symptoms of this disease. JACK Jack, a 43-year-old insurance examiner, washed his hands at least fifty times a day—a hundred or more times on a bad-hands day. There was so much soap embedded in his skin that he could lather up just by wetting his hands. He knew his hands weren’t dirty, just as he knew that everything he touched wasn’t then magically contaminated. If there were some kind of mass contamination, he reasoned, “People would be dropping like flies.” But he just couldn’t get over the feeling that his hands were dirty, so he washed and washed, constantly worrying, “Did I really wash my hands? Did I wash them right?” His hands became so raw and red that big cracks opened between his fingers. Just a splash of water on his skin was like pouring salt in an open wound. But Jack kept on washing. He couldn’t stop himself. It was his terrible secret, one he covered up with ploys that a secret agent would admire. BARBARA Barbara, a 33-year-old honors graduate of a prestigious Ivy League university, knew that she was an underachiever, working for a temporary agency. She was intelligent and articulate, but was plagued by intrusive thoughts that told her to check and recheck things. Had she unplugged the appliances? Locked the door? Often, she would leave early for her job, knowing she would have to turn around and come back home once or twice to check. One really bad day, she tucked the coffee machine and the iron in her book bag and took them to work. She felt very ashamed. “If you start doing these things,” Barbara told herself, “you’re going to lose whatever self-respect you have left.” So she developed new strategies for coping with her nagging and nonsensical thoughts: Before she left for work each day, she put the coffee machine on top of the refrigerator, far from any electrical outlet, and said out loud—and very tongue in cheek—“Goodbye, Mr. Coffee!” She had come up with a mnemonic device to help her remember that she had unplugged it. She would also press the prongs of the plug on her iron into her palm, leaving deep marks that she could still see thirty minutes later to reassure herself that she had unplugged the iron. BRIAN Brian, a 46-year-old car salesman, lay awake in bed every night, listening for the wail of sirens. If he heard both a fire engine and a police car, he knew there’d been a traffic accident nearby. Whatever the hour, he would get up, dress, and drive around until he found the accident scene. As soon as the police had left, he’d take a bucket of water, a brush, and baking soda from his car and start scrubbing down the asphalt. He had to. Battery acid might have spilled in the collision, and Brian, who had to drive these streets every day, had a morbid fear of being contaminated by battery acid. Once he’d finished scrubbing—it might be 3 A.M.—he’d drive home, shower, put his tennis shoes in a plastic bag, and toss the bag into the trash can. He bought his shoes on sale, a dozen or more pairs at a time, knowing he could wear them only one night. DOTTIE Dottie, aged 52, had been battling obsessions since she was 5. One obsession was a fear of any number that included a five or a six. If, while driving with a friend, she spotted a car with a five or six on its license plate, she would have to pull over and wait for a car with a “lucky” number to pass. “We could sit there for hours,” she remembers. But she just knew that otherwise something terrible was going to happen to her mother. When Dottie became a mother herself, her obsessions shifted to her son and became even more bizarre. “It was eyes,” she said. “All of a sudden I got it into my head that if I did everything right, my son’s eyes would be all right and mine would be all right.” Neither Dottie nor her son had eye problems; still, she couldn’t bear to be around anyone who did. “Just the word ophthalmologist would bring in very bad thoughts. I could never step where a person who couldn’t see properly had walked. I’d have to throw away my shoes.” As Dottie and I talked, I noticed that she had written the word vision four times in the palm of one hand. She explained that while watching TV that afternoon, she’d had a bad thought about eyes and had tried to exorcise it. LARA Lara described her obsessions this way: “They tear at my soul. One little thought, and the obsessions explode into a fireball, a monster that is out of control.” It was knives that made her life hell. “It could be a butter knife, but when I picked it up I wanted to stab someone, especially someone who was close to me. It was horrible. God, I would never hurt anyone! The scariest for me was when I had these obsessions toward my husband.” ROBERTA Roberta would drive over a bump or a pothole and suddenly panic, imagining that she’d hit someone. Once, pulling out of a shopping mall, she spotted a plastic bag in the parking lot. “In a flash, something was telling me it was a body. I stopped and stared at it. knowing that it was just a plastic bag. But the fear and panic began. I drove around to look at it again....” Wherever she went, she would look in the rearview mirror, her stomach in knots. Was that just a newspaper at the side of the road? Or was it a body? Terrified to drive, she became a prisoner in her own house. THE BALKY BRAIN As a research psychiatrist at UCLA School of Medicine, I have treated more than one thousand people with OCD in the past decade, both one-on-one and in a unique weekly OCD therapy group. The vast majority of them are much more functional and more comfortable as a result of practicing the Four-Step SelfTreatment Method. Some of them also take modest amounts of medication, finding it improves their ability to do the work required in therapy. Our UCLA team came to the study of OCD as an offshoot of studying depression. We had noted specific brain changes in depressed patients, and, knowing that many people with OCD also suffer from depression, we wondered if OCD patients also undergo brain changes. So, we placed an ad in a local newspaper asking, “Do you have repetitive thoughts, rituals you can’t control?” We hoped to find a handful of respondents who would be willing to come to the UCLA Neuropsychiatric Institute to have a positron emission tomography (PET) scan, which measures the metabolic activity of the brain. To our astonishment, the response was overwhelming. Clearly, OCD was more prevalent than we thought. And when we did PET scans of these people’s brains, we could actually see changes related to their OCD. Over ten years, I’ve learned a great deal about people, their courage, their will to survive and improve, and their ability to change and control their responses to the false messages that come from their brains as a result of OCD. Until relatively recently, there was little that doctors could do for people with OCD. Sigmund Freud and his followers believed that these obsessions and compulsions are caused by deep-seated, emotional conflicts. Patients often tell us about years of misdiagnosis by well-meaning therapists. Brian recalled one psychotherapist telling him that his fear of battery acid had sexual implications and suggesting that perhaps he had been molested by his father. That was when Brian sought help at UCLA. WORRYING ABOUT WORRYING From a doctor’s perspective, the biggest problem that people with OCD face is how much they worry about how worried they are. What really troubles them is how anxious they get about things they realize aren’t worth worrying about. When we begin to understand the extent of this mental anguish, we can begin to understand some deep truths about the relationship between a person and his or her brain. One way to understand this relationship is to know the difference between the form of obsessive-compulsive disorder and its content. When a doctor first asks, “What exactly is bothering you?” most people with OCD say something like “I can’t stop worrying about my hands being dirty.” But a doctor who’s treated a number of persons with OCD knows that this is not the real problem. The real problem is that no matter what they do in response to what’s worrying them, the urge to check or to wash will not go away. This is what is meant by the form of OCD: Thoughts and urges that don’t really make sense keep intruding into a person’s mind in an unrelenting barrage. Together with many other brain scientists, our UCLA team believes that OCD is a brain disease, in essence a neurological problem. The thought does not go away because the brain is not working properly. So OCD is primarily a biological problem, tied to faulty chemical wiring in the brain. The form of OCD—the unrelenting intrusiveness and the fact that these thoughts keep reoccurring—is caused by a biochemical imbalance in the brain that may be genetically inherited. The content—why one person feels something is dirty while another can’t stop worrying that the door is unlocked—may well be attributable to emotional factors in a person’s background and family circumstances, as traditionally understood by Freudian psychiatry. Whatever the reason, there is no biological explanation for why one person washes and another checks, but OCD is truly a neuropsychiatric disease: Its hallmark symptom—intrusive thoughts and worries —is almost certainly caused by a problem in the brain. But. of course, having a problem like that brings with it significant emotional upset and personal insecurity. And the stresses of these emotional responses can actually intensify the brain-related difficulty. In this book you’ll learn to deal with both sets of problems. TAKING CHARGE So you have OCD. What can you and your doctor do to make those awful urges and compulsions go away? The core message in treating OCD is this: Do not make the mistake of waiting passively for the ideas and urges to go away. A psychological understanding of the emotional content of the thoughts and urges will rarely make them disappear. Succumbing to the notion that you can do nothing else until the thought or the urge passes is the road to hell. Your life will degenerate into one big compulsion. Think of the analogy of the insistent car alarm that annoys you while you are trying to read a novel or magazine. No matter how annoyed you are, you are not going to sit there and say to yourself, “I’m going to make that alarm turn off and I’m not even going to try to read this until it does.” Rather, you’re going to do your best to ignore it, work around it. You’re going to put your mind back where you want it and do your reading as well as you can. You’ll become so absorbed in what you’re doing that you hardly notice the alarm. So by focusing your attention on a new task, what would otherwise be extremely annoying and bothersome can be worked around and ignored. Because OCD is a medical condition—albeit a fascinating one—and is related to the inner workings of the brain, only a change in the brain itself, or at least in brain chemistry, will bring about lasting improvement. You can make these changes through behavior therapy alone or, in some cases, behavior therapy in combination with medication. However, medication is only a “waterwings” approach to OCD therapy; it will help you stay afloat while you learn to swim through the rough waters of OCD. At UCLA, medication is used only to help people help themselves. But the underlying principle is: The more behavior therapy you do and the more you apply the Four-Step Method the less medication you’ll need. This is especially true over the long haul. (Behavior therapy is discussed in detail in Chapter Eight and medication in Chapter Nine.) In developing a new approach to treating people with OCD, our research team thought that if we could make patients understand that a biochemical imbalance in the brain was causing their intrusive urges, they might take a different look at their need to act on those urges and strengthen their resolve to fight them. A new method of behavior therapy might result. To help patients understand this chemical imbalance, we showed them pictures of their brains at work. During a study of brain energy activity in people with OCD, my colleague, Dr. Lew Baxter, and I took some high-tech pictures using positron emission tomography, or PET scanning, in which a very small amount of a chemically labeled glucoselike substance is injected into a person and traced in the brain. The resulting pictures clearly indicated that in people with OCD, the use of energy is consistently higher than is normal in the orbital cortex—the underside of the front of the brain. Thus, the orbital cortex is, in essence, working overtime, literally heating up. (Figure 1, opposite, shows a PET scan—presented in color on the cover of this book—of a typical OCD patient. Note the high energy use in the orbital cortex, compared to that in a person who does not have OCD.) We already knew that by using behavior therapy we could make real and significant changes in how people cope with their urges. Perhaps, we reasoned, we could use these visually striking pictures of the brain to help inspire people with OCD. Since a brain problem appeared to be causing their intrusive urges, strengthening their will to resist the urges might actually change their brain chemistry, in addition to improving their clinical condition. Benjamin, a 41-year-old administrator in a large school district whose brain photos are pictured later, in Figure 3, suffered from a compulsive, timeconsuming need to have everything in his environment clean and orderly to an abnormal degree. He recalls vividly having his brain photographed and then being shown proof that it was overheating. “Boy, was that a real jolt!” he said. “It was very distressing to learn that I had a brain disorder, that I wasn’t perfect. Initially, it was very difficult to accept.” At the same time, seeing the picture was critical to his understanding that he had OCD, in his words, “incontrovertible evidence that I had a brain disorder.” In our program at UCLA, Benjamin mastered the Four Steps of cognitive-biobehavioral self-treatment, and today, six years later, his symptoms are largely under control and he is functioning well, both professionally and in his personal relationships. Copyright © 1987 American Medical Association, from Archives of General Psychiatry, March 1987, Volume 44, pages 211–218. Figure 1. PET scan showing increased energy use in the orbital cortex, the underside of the front of the brain, in a person with OCD. The drawings show where the orbital cortex is located inside the head. The arrows point at the orbital cortex. Understanding the difference between the form of OCD urges and their content is the first step toward understanding that brain malfunction is the main culprit in these urges. Remember Barbara and her obsessive worry about Mr. Coffee? She was being driven to distraction, worrying whether she’d turned off that machine. That was the content of her obsession. Superficially, that was her problem. But in treatment, it soon became obvious to her, and to us, that the real problem was that she couldn’t rid herself of the feeling that Mr. Coffee might still be on. That she was plagued by that worry hundreds, even thousands, of times a day gave us an important clue to the mystery of OCD: She could have that all-consuming worry even while holding the unplugged cord from Mr. Coffee in her hand! Likewise, Brian knew that a brand-new battery was not going to leak acid. Still, if someone placed a battery on his desk, he freaked out: “The kid who worked with me said he saw guys under fire in Vietnam who didn’t have the fear in their faces that I had.” And Dottie knew that her son was not going to go blind if she didn’t perform a certain compulsion. But if she happened to see a TV show about a person who was blind, she’d have to jump in the shower, clothes and all. What really worried Barbara, Brian, and Dottie was how they could be so worried about something so ridiculous. We will probably never know why Barbara became fixated on Mr. Coffee, Brian on battery acid, or Dottie on eyes. Freud’s theories may provide clues, yet Freud himself believed that these types of problems stem from “constitutional factors,” by which he meant biological causes. Today, most psychiatrists in the Freudian tradition acknowledge that understanding the psychological content of these symptoms—the deep inner conflicts that lead one person to worry about causing a fire and another to fear that he or she will do something violent to someone—will do little, if anything, to make the symptoms go away. Why not? Because the core of the problem in OCD lies in its form, in the fact that the worrisome feeling intrudes repeatedly into the mind and will not go away. The culprit is a neurological imbalance in the brain. Once people understand the nature of OCD, they are better armed to carry out the behavior therapy that leads to recovery. Just knowing, “It’s not me—it’s my OCD” is a stress reliever that enables them to focus more effectively on getting well. From time to time, we remind them that they are not just pushing a rock to the top of a hill only to have it roll back down again and again. They are actually changing the hill. They are changing their brains. IT’S WHAT YOU DO THAT COUNTS The brain is an incredibly complicated machine whose function is to generate feelings and sensations that help us communicate with the world. When it works correctly, it’s easy to assume that “it is me.” But when the brain starts sending false messages that you cannot readily recognize as false, as happens with OCD, havoc can ensue. This is where mindful awareness, the ability to recognize these messages as false, can help. We learned from OCD patients that everyone has the capacity to use the power of observation to make behavioral corrections in the face of the brain’s false and misleading messages. It’s like listening to a radio station that’s jammed with static. If you don’t listen closely, you may hear things that are misleading or make no sense. But if you make an effort to listen closely, you’ll hear things the casual listener misses entirely—especially if you’ve been trained to listen. Properly instructed in what to do in the face of confusing messages, you can find reality in the midst of chaos. I like to say, “It’s not how you feel, but what you do, that counts.” Because when you do the right things, feelings tend to improve as a matter of course. But spend too much time being overly concerned about uncomfortable feelings, and you may never get around to doing what it takes to actually improve. Focus your attention on the mental and physical actions that will improve your life—that’s the working philosophy of this book, and the path to overcoming Brain Lock. The Four Steps are not a magic formula. By calling an urge what it is—by Relabeling it—you cannot immediately make it go away. Excessive wishful thinking about immediate recovery is one of the biggest causes of failure, especially at the start of treatment. The goal here is not to make obsessive thoughts simply disappear—they won’t, in the short run—but, rather, to be in control of your responses to them. The behavior therapy guidelines you will learn while doing the Four Steps will help you remember this crucial principle. You will gain control and change your brain mainly by using your new knowledge to mentally organize your behavioral responses and by learning to say, “That’s not me—that’s my OCD.” The key to remember is this: Change the behavior, unlock your brain! KEY POINTS TO REMEMBER OCD is a medical condition that is related to a biochemical imbalance in the brain. Obsessions are intrusive, unwanted thoughts and urges that don’t go away. Compulsions are the repetitive behaviors that people perform in a vain attempt to rid themselves of the very uncomfortable feelings that the obsessions cause. Doing compulsions tends to make the obsessions worse, especially over the long run. The Four Steps teach a method of reorganizing your thinking in response to unwanted thoughts and urges: They help you to change your behavior to something useful and constructive. Changing your behavior changes your brain. When you change your behavior in constructive ways, the uncomfortable feelings your brain is sending you begin to fade over time. This makes your responses easier to manage and control. It’s not how you feel, but what you do that counts. PART I The Four Steps WORDS OF WISDOM TO GUIDE YOU ON YOUR JOURNEY (in chronological order) One who is slow to anger is better than a warrior, and one who rules his spirit is better than one who takes a city. —King Solomon, Proverbs 16:32 You yourself must do the strenuous work. Enlightened Ones can only show the way. —Gotama Buddha, Dhammapada 276 Be not deceived; God is not mocked: For whatever you may sow, that you will also reap. —St. Paul the Apostle, Galatians 6:7 God helps those who help themselves. —Benjamin Franklin, Poor Richard’s Almanac, 1736 1 Step 1: Relabel “It’s Not Me—It’s My OCD” Step 1. RELABEL Step 2. Reattribute Step 3. Refocus Step 4. Revalue Step 1: Relabel answers the question, “What are these bothersome, intrusive thoughts?” The important point to keep in mind is that you must Relabel these unwanted thoughts, urges, and behaviors. You must call them what they really are: They are obsessions and compulsions. You must make a conscious effort to keep firmly grounded in reality. You must strive to avoid being tricked into thinking that the feeling that you need to check or to count or to wash, for example, is a real need. It is not. Your thoughts and urges are symptoms of obsessive-compulsive disorder (OCD), a medical disease. THE FAR SIDE © Farworks, Inc./Dist. by Universal Press Syndicate. Reprinted with permission. All rights reserved. Professor Gallagher, as you see, has his own ideas about “curing” patients who suffer from frightening and intrusive thoughts or obsessions. He is actually performing a cartoon variation on what is known in the language of traditional behavior therapy as “flooding.” Unfortunately, this poor patient more than likely ended up crazed rather than cured. In working with patients with OCD, our UCLA team has had excellent results using behavior therapy, sometimes in conjunction with medication. Ours is not Gallagher’s sink-or-swim approach but, rather, a long-term self-directed therapy we call cognitive-biobehavioral self-treatment. Typically, our first consultation with a person with OCD begins with the person explaining with a considerable amount of embarrassment, “Doctor, I know this sounds kind of crazy, but...” The person then describes one or more from a checklist of classic OCD symptoms: compulsive washing or checking, irrational violent or blasphemous thoughts, or feelings of impending doom or catastrophe unless some bizarre or senseless ritual is performed. These people usually know that no one is supposed to think such weird thoughts. As a consequence, they feel humiliated and at their wit’s end. Their self-esteem has plummeted, their OCD may well have affected their ability to perform on the job, and they may even have become socially dysfunctional, withdrawing from family and friends in an attempt to hide these awful behaviors. IT’S NOT INSANITY, IT’S BRAIN LOCK In treatment, the person is first assured that the diagnosis is just OCD. It is just the brain sending false messages. We show pictures of the brains of people with OCD that prove conclusively that OCD is associated with a biochemical problem that causes the underside of the front part of the brain to overheat. In short, the person is suffering from Brain Lock. The brain has become stuck in an inappropriate groove. The key to unlocking the brain is behavior therapy, and that begins with the Relabeling step. Relabeling simply means calling the unwanted thoughts and urges by their real names—obsessive thoughts and compulsive urges. These are not just uncomfortable feelings like “maybe it’s dirty,” but gnawing and unremitting obsessions. Not just bothersome urges to check for the fourth or the fifth time, but brutal, compulsive urges. This is war, and the enemy is OCD. In fighting back, it is critical to keep in mind what that enemy really is. The person with OCD has a powerful weapon: the knowledge that “It’s not me—it’s OCD.” He or she works constantly to prevent confusing the true self with the voice of OCD. All well and good, you may say, but OCD has a mind of its own. It won’t shut up. To this I reply, “Yes it will, but it takes time.” Praying for OCD to go away won’t instantly make it happen, nor will idle and futile cursing. If you wish to pray, what you should pray for is the strength to help yourself. God helps those who help themselves, and it’s only reasonable to believe that God would help someone engaged in such a worthwhile struggle. In this case, it means concentrating on doing the right thing, while letting go of an excessive concern with feelings and comfort level. This is, in the best sense, performing a good work! At the same time, it is medical self-treatment that begins with accepting what you cannot change—at least in the short term. Right off, it is vital to understand that the simple act of Relabeling will not make your OCD disappear. But when you see this enemy for what it is, OCD, you sap its strength and you, in turn, become stronger. In time, it won’t matter that much to you whether the bothersome thoughts totally go away because you are not going to act on them. Furthermore, the more you are able to dismiss the importance of your OCD, the more you will feel in control and the more it will go away. On the other hand, the more you focus on it, wishing and hoping and begging for it to leave you alone, the more intense and bothersome the feelings will become. TALKING BACK TO OCD Because OCD can be a fiendishly clever opponent and a demonically selfprotective one, it will deny that it is simply a false message from your brain. You may say, “A plane is not going to crash because I didn’t wash my hands again.” But OCD will say, “Oh, yes it will, and many people will die.” That’s the time to show some faith and strength because you know what the truth is. You can’t afford to listen. If you sit and fret about whether OCD is going to invade your life on a given day, you’re only assuring yourself more dread and pain. You must say, “Go ahead, make my day. Just try to make me wash my hands one more time.” Then you must deal with the ever-present uncertainty, “How can I be sure that this is not me, just my OCD?” Well, perhaps there are no metaphysical guarantees that there is no possible relationship between hand washing and a plane crash, but I can guarantee that if you give in and wash your hands again, things will only get worse and the OCD will only get stronger. On the other hand, within a few minutes of Refocusing on another behavior and not responding to the OCD, the fear of some dreadful consequence will begin to fade, and you will begin to see the OCD compulsion as the ridiculous nonsense it is. The decision is clear-cut: Listen to your OCD and have your life disrupted and ultimately destroyed, or fight back, secure in the knowledge that within a few minutes you will begin to feel more and more certain that planes aren’t going to fly into mountains and cars aren’t going to crash just because you didn’t wash your hands or check the lock again. It is a matter of exerting effort so that good triumphs over evil. IT’S JUST A CHEMICAL At UCLA, our patients have come up with amazingly creative ways of applying the Four Steps—Relabel, Reattribute, Refocus, Revalue. Chet, who has since successfully controlled his OCD through behavior therapy and is now in dental school, was obsessed by violent thoughts. If he saw a fire, he thought he had started it. If he heard that someone had been fatally shot across town, he obsessed that he had done it. He would walk around saying to himself, “Man, you’re just one messed-up guy. You’re a bad person.” He was in a dead-end job that he hated and was dealing with debt. These factors made his stress level escalate and his OCD symptoms worsen. Stress commonly heightens OCD anxieties. At first, when Chet began Relabeling, telling himself that his violent thoughts were just OCD, his OCD would talk back, “Oh, is this upsetting you? Why? Maybe because you really will do it.” By gaining the knowledge that OCD is a biochemical imbalance in the brain, Chet was eventually able to use this phrase with his OCD: “Don’t be polemical—it’s just a chemical.” Anticipation is an important substep in Relabeling, and Chet understood it perfectly. Watching a movie in which he knew a violent scene was coming, he would tell himself, “Okay, here comes my obsessive thought.” When he did that, it didn’t hurt as much. In combating his OCD, Chet was both pragmatic and philosophical. He had always wished that he were six inches taller, he reasoned, but he knew that wishing wasn’t going to make him grow and he could deal with being short. He realized it was the same with OCD: Wishing wouldn’t make it go away, but he could learn to deal with it. Chet found another way to best the OCD: Every time he had an OCD thought, he would do something nice for his fiancée—buy her roses, perhaps, or cook her dinner. Whenever the OCD wanted to make him miserable, he would make himself happy by making his fiancée happy. A deeply religious man, Chet also turned to the Scriptures for inspiration and found comfort in the passage “The Lord searcheth all hearts and He understands all the imaginations of the mind” (I Chronicles 28:9). Chet clearly understood how this passage applied to him: God understands my heart and knows that my mind is messed up. I must work to stop beating myself up over it. It’s interesting to note that there is a centuries-old precedent for this. John Bunyan, the seventeenth-century British author of The Pilgrim’s Progress, suffered from what we now know was OCD. Because Bunyan was an intensely religious man (an itinerant preacher who was imprisoned for preaching without a license), he agonized over his OCD-induced blasphemous thoughts. He dealt with his guilt—as does Chet—through a conviction that God would be upset with him for punishing himself for having false and meaningless thoughts. For this brilliant insight, I consider Bunyan the father of cognitive-behavior therapy for OCD. THE IMPARTIAL SPECTATOR In learning to Relabel, it is not enough to shrug and say, “It’s not me—it’s my OCD” in an automaton-like manner. Mindful awareness is essential. Mindful awareness differs from simple, superficial awareness in that it requires you to consciously recognize and make a mental note of that unpleasant feeling, Relabeling it as an OCD symptom caused by a false message from the brain. As the feeling sweeps over you, you must say to yourself, “I don’t think or feel that my hands are dirty; rather, I’m having an obsession that my hands are dirty.” “I don’t feel the need to check that lock; rather, I’m having a compulsive urge to check that lock.” This will not make the urge go away, but it will set the stage for actively resisting the OCD thoughts and urges. We can learn from the writings of the eighteenth-century Scottish philosopher Adam Smith, who developed the concept of “the impartial and wellinformed spectator,” which is nothing more or less than “the person within.” Each of us has access to this person inside us who, while fully aware of our feelings and circumstances, is nonetheless capable of taking on the role of spectator or impartial observer. This is simply another way of understanding mindful awareness: It enhances our ability to make mental notes, such as “That’s just OCD.” In Relabeling, you bring into play the Impartial Spectator, a concept that Adam Smith used as the central feature of his book The Theory of Moral Sentiments. He defined the Impartial Spectator as the capacity to stand outside yourself and watch yourself in action, which is essentially the same mental action as the ancient Buddhist concept of mindful awareness. People with OCD use the Impartial Spectator when they step back and say to themselves, “This is just my brain sending me a false message. If I change my behavior, I’ll actually be changing how my brain works.” It is inspirational to watch people with OCD shift from a superficial understanding of their disorder to a deep mindfulness that allows them to overcome their fears and anxieties, to mentally organize their responses, to shift gears, and to change their behavior. This process is the basis for overcoming OCD. Once a person with OCD learns behavior therapy and resolves to change his or her response to an intrusive, painful thought by not performing some pathological behavior, a willful resolve kicks in: “I’m not going to wash my hands. I’m going to practice the violin instead.” But, in the beginning, the person is beset with fear and dread and may very well have catastrophic thoughts, such as, “But then my violin will get contaminated....” Adam Smith understood that keeping the perspective of the Impartial Spectator under painful circumstances is hard work, requiring, in his words, the “utmost and most fatiguing exertions.” Why? Because focusing on a useful behavior when your brain is bombarding you with distracting doubts and disturbing mental aberrations takes a great deal of work. Of course, performing a compulsive behavior repetitively, ad nauseum, is also exhausting. But it is exhaustion with no positive payoff. When the Impartial Spectator is attended to, when an action is done mindfully, it makes a significant difference in how the brain functions. And that is the key to overcoming Brain Lock. This is what our scientific research at UCLA has shown. WHO’S IN CHARGE HERE? There will be times when the pain is too great and the effort required too debilitating, and you will give in and do a compulsion. Think of it as a tiny backward step. Tell yourself that you’ll win next time. As Jeremy, a man with OCD, put it, “Even when you fail, you succeed—so long as you persevere. So long as you take on this enemy, OCD, with mindful awareness.” Anna, a philosophy student, described how she used the Relabel step in battling an obsession that her boyfriend (now her husband) was unfaithful to her. Although she knew her fears had no basis in fact, she would bombard him with questions about past romances, about whether he had ever looked at pornographic magazines, about what he drank and how much, what he ate, and where he was every minute of the day. Her relentless interrogations almost led to the breakup of their relationship. Anna recalls, “The first step in beginning to conquer my OCD was to learn to Relabel my thoughts and urges. The second step was to Reattribute them to OCD. In my treatment, these went hand in hand. On an intellectual level, I knew that OCD was a chemical problem in my brain and that the sensations this problem produced were more or less meaningless side effects of the chemical problem. Still, it is one thing to know this intellectually and another to be able to say while in the midst of an OCD attack that what you are feeling really isn’t important per se. The irritating thing about OCD is that when you have it, your worries, urges, and obsessions seem like the most important things in the world. Stepping back from them long enough to identify them as OCD-generated is thus no mean feat.” In the early stages of Anna’s learning to Relabel, her boyfriend, Guy, kept reminding her that her obsessions were “just OCD,” but he could not always convince her. Over time—and with practice—she became, in her words, “pretty good at recognizing what is OCD and what is a ‘real’ worry or anxiety. As a result, I can frequently avoid buying into OCD when it strikes. I no longer become mentally distressed each and every time an obsessive-type thought enters my mind. Often, I can look beyond it and say to myself, ‘You know, it won’t do any good to get all upset about this thought. I’ve been through all this before, and it doesn’t accomplish anything to allow myself to be sucked into OCD’s tricks.’ Doing this allows a certain calm and satisfying detachment.” Anna found that the intrusive thought—or at least the intense anxiety surrounding it—dissipates, usually within fifteen to thirty minutes. For Dottie, who had the obsession about her son losing his eyesight and who coined the phrase “It’s not me—it’s my OCD,” Relabeling was the biggest help in combating her compulsion. “It was not dwelling on it, recognizing it, and saying, ‘It’s okay, it’s just a thought and that’s all it is.’ Most days, that works for me. Some days it’s a struggle. I say people with OCD will always have OCD unless they find some magical pill.” But, as you’ll learn from the stories throughout this book, the mental strength and power you gain while fighting OCD can never be gained from any “magic pill.” Jack, the hand washer, had been looking for that magical pill. “That’s America. You take a pill and your life will be wonderful; you’ll be a whole new person, more aggressive or nicer or thinner or whatever.” But when medication did not make his OCD symptoms abate and the side effects of medication grew too bothersome, he turned to cognitive-biobehavioral therapy. For him, the first step in Relabeling was to recognize the absurdity of his hand washing and to convince himself that it was not logical. When he was at home, he washed almost continuously, but when he was out, it didn’t seem so important to wash. “In behavior therapy, I thought, ‘Wait a minute. You go out to fast-food places and you don’t wash your hands, then you handle money or they handle money, and nothing bad has happened to you yet, you know. And even if you use their rest rooms to wash your hands, it’s hard to get out without touching a doorknob.” Jack didn’t have dirty hands; he had OCD, and he was beginning to use his rational mind to overcome it. Barbara, who had obsessions about Mr. Coffee, spoke of mindful awareness as a tool that helped her to Relabel. “By putting myself into a deliberately aware or conscious state when checking, I could walk away from the site of the compulsion with, if not the certainty that the appliance was off, at least with the real, firm knowledge that the check had been performed. I also learned to say to myself when feeling the horrible uncertainty that, say, the stove was not off, ‘This is not me—this is my OCD. It is the disease that is making me feel uncertain. Although I feel the stove is not off, I have checked it mindfully and should now walk away. The anxiety will lessen eventually, and fifteen minutes down the line I’ll feel even more certain that the stove is off.’” If you have problems with checking compulsions, take particular note of Barbara’s description. It’s excellent advice on how to perform checking behaviors in a way that prepares you to deal with compulsive urges. Lara, who has the terrifying obsession about knives, learned to tell herself, “Lara, it’s only an obsession. It’s not reality. You’re frightened because it seems so horrific and unbelievable. This is a disorder, just like any other disorder.” Understanding that OCD is a medical condition and that obsessions are false messages with no real power or meaning “lessens their power and punch,” Lara learned. Obsessions don’t take over your will. You can always control—or at least modify—your responses to them. Jenny developed a lingering obsession about nuclear contamination while working in the Soviet Union. Learning that she had a biochemical problem in her brain “lifted some of the burden,” she said. “I’d always been so angry with myself. ‘How can you be so strong and successful in so many areas of your life and still have this problem?’ I’d always felt that I was entirely at fault because I was not able to psychoanalyze myself. I could never get in there and find out what was bothering me or find the right mantra, the right shrink, whatever.” Now, when OCD attacks strike, she talks to herself, telling herself, “Well, I know what that is.” And, usually, she manages to move on. Roberta, who has the obsession that she has hit someone while driving, said, “I still have the unwanted thought, but it is now controllable. Now, when I go over a bump in the road, I tell myself that it is just a bump. The thought that I hit someone is just a wrong message. It’s OCD—not me! I try not to look back or to retrace my route. I force myself to keep going forward. I am no longer afraid to drive. I understand that if the obsessive thought comes, I know that I can deal with it. When I’m getting frustrated, I even say out loud, ‘It’s not me—it’s the OCD.’ And then I’ll say, ‘Okay, Roberta, just keep going straight ahead.’” Jeremy, an aspiring young screenwriter, is largely free of OCD after eight months of behavior therapy. Today, he says, “I still feel the anxiety of freedom. It hurts, but it is the price to pay to be a free man.” From childhood, Jeremy had been overwhelmed by touching and checking compulsions that he performed without fail, fearing that a family member would die “and God would damn me to hell for it.” Home became a “torture chamber” of rituals. By his teens, Jeremy was seeking escape in alcohol and drugs. As a young adult, he kicked his drinking habit with the help of Alcoholics Anonymous, but he began to obsess that something he had eaten contained alcohol. It could be Rice-a-Roni or something equally nonsensical. Logic played no role here. At his gym, Jeremy imagined that someone had used drugs or alcohol before touching the bars and weights and that he would somehow absorb it. In a public bathroom, he would be seized by the thought that a drunk had vomited in the toilet just before he used it and, through some kind of magical transference, the alcohol was going to get into his system. Mentally and emotionally, Jeremy was exhausted from dealing with his obsessions and compulsions. When he first came to UCLA seeking help, he said, “I feel like I have been through the jungle in Vietnam.” During treatment, Jeremy kept with him a small spiral notepad on which he’d written CAUDATE NUCLEUS. That’s the part of the brain that’s not filtering out the OCD thoughts properly. This was his constant reminder that he had a brain-wiring problem, that he had OCD. It helped him to be mindful that he had to screen the OCD thoughts through his own mental power. “Once the pain had a name,” he says, “the pain wasn’t as bad.” Making mental notes eventually made his brain’s filtering system begin to work better. Earlier, I mentioned the Relabeling substep, Anticipation. The other substep in Relabeling is Acceptance. Jeremy became adept at both. Before treatment, he had lived in fear of being caught in some imaginary dastardly act and being fired from his job as a night watchman. With behavior therapy, he was able to say, “Big deal. Nobody’s perfect. Let them fire me; I’ll get another job. Worst-case scenario? I’ll eat at soup kitchens. Hey, George Orwell did it and wrote a great book about it,” Down and Out in Paris and London. And if there really was forbidden alcohol in something he’d eaten, Jeremy would say, “Just a slip. Not intentional.” No guilt. No recriminations. Once free of OCD symptoms, Jeremy had a reaction that is not uncommon. “For years, OCD had run—and been—my life. I thought of little else. I actually mourned my OCD.” But this mourning period was short, and soon Jeremy began to fill the vacuum with positive, wholesome activities. RX: ACTION Learning to overcome OCD is like learning to ride a bicycle. Once you learn, you never forget, but getting good at it takes practice. You’ll fall off, but you must get back on. If you give up, you’ll never learn. Most patients find that it helps at first to have training wheels for the bike. That’s where the medication comes in. In combination with behavior therapy, medication has been shown to produce an 80 percent success rate. The vast majority of those who fail to respond to this treatment combination do so because they become demoralized and throw in the towel. It is essential that you never do the compulsion and tell yourself, “I can’t avoid doing it. It’s bigger than I am.” It’s okay to feel overwhelmed by the compulsion, and even to act on it if you must, as long as you remind yourself, “This is a compulsion. Next time, I’m going to fight it.” Passivity is your enemy. Activity is your friend. The biggest enemy is boredom. Having something else you really need to do—something much more important than that nonsensical ritual—is a great motivator. People with nothing to do may not develop the mental and emotional strength to shift those gears in the brain and move on to a positive behavior. If you have a job, you’re apt to lose it if you go home to check that lock once more, so you’ll be much more motivated to pull yourself away. When you pull yourself away, you’re treating your OCD. Idleness is indeed the devil’s workshop. If you’re not up to working, you can get a volunteer job, but the important thing is to stay busy. Make sure you have something useful to do. Being useful will increase your self-confidence and motivate you to get better because others need you. It’s also a tremendous aid to the Refocus step. Some people are too depressed to work. Depression often, but not always, goes hand in hand with OCD. If your sleep pattern is radically altered, with repeated waking during the night; if you’re not eating properly and are losing weight; if you have poor energy and serious suicidal thoughts, you may have a severe depression. If that is the case, you must see a doctor. As you have learned, acting on a compulsion brings only momentary relief, followed very quickly by an increased intensity in the intrusive urge or thought —a true vicious cycle. After treating about a thousand people with OCD, I find that one of the most amazing things about OCD is that people continue to be shocked by their internal feeling that something is dreadfully wrong—that the stove is not turned off, or whatever—no matter how many times a day that thought intrudes. They would get used to, say, an electric shock after a while, but they never seem to get used to these OCD fears and urges. That is why mindful awareness, mental note taking, is so important. In step one, Relabel, you increase your insight. You call an obsession an obsession and a compulsion a compulsion. HANGING TOUGH After Relabeling, many patients ask, “Why the hell does this thing keep bothering me?” It does so because of a brain-wiring problem. The struggle is not to make the feeling go away; the struggle is not to give in to the feeling. Emotional understanding will not make the OCD symptoms magically disappear, but cognitive-biobehavioral therapy will help you manage your fears. If you can h