Avoidance

Again, Fellow OCD Sufferer has some thoughts that have me thinking, in response to my Anxiety in Disguise post. She talked about the difficulty of response prevention, and the fear of endless rumination and unease. That is the irony of the compulsions we use in OCD to damp down the anxiety--they become odious and cause their own suffering, while stealthily encouraging us to think that we couldn't function without our rituals.

And my life history colludes with this version of reality, because from a young age I used perfectionism as a way to make things right with the world, and allow the possibility I could exist on this planet. I barely registered in my parents' world. I was the invisible girl who still felt she took up too much space. When I delay writing something, because I fear going over it in my mind repeatedly, I am fearing the triggering of this compulsion, and OCD is more than glad to praise me for this. But what is even scarier, is contemplating writing something and sending it out into the world without going over it, and living with the fear that I've done it wrong, that I am inadequate and will be haunted by this distress forever.

And yet, I still get an initial moment of hopefulness when I start my compulsive avoidance, by doing extra research for a post--"maybe this time I will find exactly the right thing." It's like a high, and full of expectation, which quickly crashes to the ground when the searching drags on, my body gets tired, and my mood falls into depression, and yet OCD still claims that it's not worth taking the chance to actually do the writing and purposely let it be imperfect.

Right now I am learning that OCD is on the side of whatever painful things I believe about myself. I do not want to collude with that perniciousness. It comes down to avoidance. OCD would have me avoid so many things, because of a fear of making mistakes, that I would end up avoiding my whole life, and I did this for many years. When I do Exposures, I have the chance to actually live my life. This isn't to say there's no pain in my life, but that there is a possibility of joy as well.

Anxiety in Disguise

Fellow OCD Sufferer, from OCD Reflections, had a comment on my recent post about the History of Exposure Therapy that has me thinking. She talks about the possibility of habituation to anxiety when it seems "more like a biological reaction - when I can feel my heart beat faster, butterflies in my stomach. . .my OCD fears don't bring about that sort of visceral 'anxiety'." Instead it is rumination, in her head.

I've noticed this in my own OCD experience, that in a lot of my wanting to be "complete" or have something feel "right" doesn't register on my radar as "anxiety." Sometimes I feel like all the stuff going on in my head is sealed in a black box, and I can't get a good look. I know I do feel uncomfortable and uneasy if I contemplate moving on from a task if I don't feel finished(and yet, I rarely feel finished, so I'm waiting for something illusory), and this results in a dialog with myself about why I'm not moving on, when I don't feel severely anxious in a stereotypical way, and then my mood deteriorates as I get more self-critical.

A question that helps me identify what is going on in the black box:

What is my feared consequence if I don't do something the "right" way?
My therapist emphasizes that if someone had my fears of what would happen, they wouldn't want to do things either. I fear if I make a mistake, I will be a failure, worthless, and my defectiveness will haunt me forever. So yeah, that might make avoiding doing anything somewhat appealing!

He was telling me about some recent research showing some people are exquisitely sensitive to anxiety, and will search for ways to avoid feeling it. The vague tightness in my chest, the heat in my face, the heaviness in my muscles, the diffuse sense of being off kilter--not exactly a panic attack, not classically "anxious" with a capital A--but I quickly go into avoidance when I feel this way--avoid doing anything that makes me feel this way, like living my life, with the possibility of making mistakes, leaving things out, being incomplete.

Things like taking a shower even if I feel a resistance, a nagging fear that it's the wrong task at that moment, or leaving the house early enough to meet a friend, rather than getting on the computer and reading every single email message in my inbox before I leave. All the unfinished tasks call to me as I get ready to leave--the dining room table is "clear me, clear me!" and the sweater on the chair says "take me upstairs" and the email that I've ignored for a week suddenly clamor to be read. As Fellow Sufferer continues:

I know that exposure should also work for this type of "anxiety," but sometimes it's hard to conceptualize how changing my behavior will change my opinion about the way something "has to" be done.

I've been here! Many times. For me, it is sometimes a stalling tactic on the part of my OCD--"get it all worked out before you even start"--"know everything in advance, before you begin." When my OCD says, "Do it this way. Do it perfectly. Or don't do it at all" I divert into distraction so quickly I often don't notice I've done it, and go into avoidance mode, which ultimately comes back to haunt me when I snap out if it hours later, and I haven't done the things I really value in my life, like make art, or be with friends, or write this blog. My "regular" anxiety is probably a fraction of the intensity of all the anxiety I fear is waiting for me if I stop ruminating or compulsing or distracting myself.

My therapist says the ultimate goal is to do things in the wrong way, at the wrong time, that this is when I can make a break for freedom. The times I do something instead of avoiding, and see that I survive, even if it sucks at that moment, I am reaching into the black box and adding the possibility of light. The human desire to avoid feeling worthless or inadequate is powerful--and since so much of our selves are molded when we are young, and still thinking concretely it gets all tangled up in our nervous system--and by the time we can get some distance, we don't always realize that the concrete thinking isn't serving us well. Fleeing pain when you are 5, and have no income, no independence, no real options--that makes sense. Now I'm almost 45, and attempting to do things perfectly in hopes I will loved and valued creates even more pain.

Part 3 : The History of Exposure Therapy: Hans Eysenck and Learned Behavior

Hans Eysenck was yet another British psychologist who explored behavior therapy beginning in the 1950's, and who wrote a damning article in 1952 about the ineffectiveness of psychotherapy. As Freud envisioned it, a psychotherapist could take the process of psychotherapy and deduce the facts from it, rather than studying what the facts actually were. I am staggered by the traces of this that still affect the practice of therapy in the 21st century. I have vague memories of reading about behavior therapy in social studies class, and the fear that people would be reduced to laboratory rats conditioned to do tasks for food. But there is something immensely liberating in the idea that our symptoms are in part a "learned behavior" which is unadaptive, and which can be unlearned.

It's as if we are running our own little laboratory within our own mind every time we have an obsessive thought, feel intense anxiety, and then apply a compulsion that reduces the anxiety quickly, but then rebounds in the long term.

In 1960, his article, Personality and Behaviour Therapy(Proc R Soc Med. 1960 July; 53(7): 504–508), he explores the uses of BT in "neuroses," a term not as popular as it once was. He cites the study from 1920 about "little Albert," an 11 month old boy who was conditioned to fear rats because whenever he reached for the animal, the experimenter would make a loud noise. This of course is probably where my vague uneasiness comes from, since freaking out small children is not acceptable. These early studies may be the roots of the discomfort many current therapists have about Exposure and Response Therapy, but it is worth stepping back from the old history and consider the even older history of Freudian psychoanalysis which brought a whole tradition of showing patients ink blots, asking what they saw, and building elaborate theories of their personality based on a puddle of ink.

The point that really stuck with me was Eysenck's description of avoidance--if Albert could've been exposed to a white rat for a long period of time, without the loud noise, the fear could be undone, but as he ironically puts it, "Little Albert is a free agent," and is going to avoid even the chance of encountering a white rat, thereby never getting a chance to break free of the fear. If we are willing to risk feeling the initial fear liberty is possible. I know that it feels as if we face the fear every day, we do things we don't want to do, and yet the OCD persists.

This is a frustrating and painful place to be in. I make a phone call, and it actually goes ok, but by the next time I'm anxious again as if I'd never done it before. It's taken me a long time to comprehend that I've had much more practice avoiding phone calls than making them, and what we practice tends to get better. Slogging through the anxiousness of the initial surge of fear without my compulsions sucks, but persistence in practicing strengthens the possibility of getting better.

Part 2: The History of Exposure Therapy: Albert Bandura and Guided Mastery

As I contemplated what to write next in the series on the History of Exposure and Response Prevention Therapy(ERP), I decided to pick the first article in the pile of ones I had found, and came up with Swimming against the mainstream: the early years from chilly tributary to transformative mainstream, by Albert Bandura, Behavior and Research Therapy, 42(2004): 613-30.

I know Bandura's name from being a teaching assistant for a Health Behavior class(an ironic position for a woman with Health Anxiety), and the professor's discussion of Bandura's concept of Self Efficacy: the belief in our own capabilities to get things done. For myself, I had little belief that I could do anything to change my compulsive behaviors or deal with the obsessive thoughts, and this is truly disheartening.

ERP is a form of Behavior Therapy(BT), and Bandura traces his involvement in the history of BT, starting in the 1950's. The dominant form of treatment for psychological problems was Psychodynamic--the descendants of Freud, the heavy dependence on the therapist interpreting what the patient says in terms of things simmering in the unconscious, and searching for underlying meaning.

To directly deal with a behavior that causes suffering was considered superficial, inadequate, but Bandura noticed how people who modified their behavior(ie. stopping drinking) in one way, had changes throughout other aspects of their lives. He published an article in 1963 on psychotherapy as a learning process, and it generated huge interest--including from Victor Meyer, featured in my last post. The response from more traditional psychotherapists was resolutely negative--BT was dangerous! It would lead to "symptom substitutions" and all that unconscious stuff stewing would burst out.

In meeting others with OCD in support groups or at the IOCDF conference, and reading the OCD-Support List, and comments from readers of this blog, I am taken aback by how, in mainstream treatment of OCD by therapists of a general psychodynamic bent, they still want to find the underlying cause of the obsessions and compulsions, to the exclusion of actually addressing the behavior itself. This can lead to OCD hell--especially for those of us with existential OCD questioning of everything we do anyway. And Cognitive Therapy can also fall into the same hell, with analyzing our thought distortions ad infinitum.

This is not to say that the content of our minds was not important: there were those who were also interested in thoughts and beliefs, within the context of BT, and argued that people are self-examiners of their own functioning, that they as self-aware beings, we can influence our own environment, hence adding the "C" to "CBT"--Cognitive Behavioral Therapy.

He worked with people who had phobias, and I recognized the core truth in what he says, "When people avoid what they dread, they lose touch with the reality of what they shun." If a person with agoraphobia can test their dread by leaving the house and surviving, then they can get better, but Bandura understood the reality that

Intractable phobics, of course, are not about to do what they dread.

Yeah. I see myself in this. Bandura endeavored to create an environment where people could move toward that experience of getting back in touch with the reality that they shun. Bandura developed a treatment he called Guided Mastery, which strikes me as having elements of ERP:

• Modeling of the behavior by the therapist or other support person
• Following a graduated set of subtasks from easiest to most difficult
• Joint performance with the therapist of the feared task
• Performing the feared activity for only a short time, and gradually extending the time
• Increasingly challenging oneself in order to reclaim life
  

And then we come back to self-efficacy, which I learned about so many years ago.

Unless people believe they can produce desired effects by their actions they have little incentive to act or to persevere in the face of difficulties. Whatever other factors serve as motivators, they are rooted in the core belief that one has the power to effect changes by ones actions.

He argues that a good therapist arranges things for others in such a way that allows for success and "avoids placing them prematurely in situations where they are likely to fail," and emphasizes that if one can learn to see failure as informative rather than demoralizing, one can become resilient.

What can you do to encourage your own successes?

Part 1: History of Exposure Therapy for OCD: Dr. Victor Meyer and Ritual Prevention

The first obstacle to writing about the history of Exposure Therapy is, of course, my rituals of researching things indefinitely in hopes of being absolutely certain I haven't missed anything, and a long pattern of information hoarding. But here I am, after realizing I need to construct this series of posts as an Exposure--ie. pick a place to start without exhaustive information or a PhD thesis.*

The history of Exposure and Response Prevention Therapy(ERP) is scattered in journal articles and introductory paragraphs in books about anxiety disorders. A site that gathers information together for a fascinating read is The History of Obsessive Compulsive Disorder, written by an anonymous historian who suffers from OCD.

A name that appears often is Victor Meyer, British psychologist, who published a key article, Modification of expectations in cases with obsessional rituals. (Behaviour and Research Therapy 1966 Nov;4(4):273-80) This article isn't available in free full text, but I found a subsequent article that caught my interest [There's a lot of OCD noise in my head right now, 'just one more search,' 'you aren't done.' Yeah, I know.] Ritual prevention in obsessional patients, by Meyer and Levy, Proceedings of the Royal Society of Medicine. 1971 Nov;64(11):1115-8.

I am sobered by the bleak picture painted in much of the early and mid 20th century writings on the treatment of severe OCD, and the 1971 article refers to repeated leucotomy(ie. a kind of lobotomy) in some cases. Levy and Meyer report on a follow-up study of patients treated by interruption of their rituals. The fear had been that if someone interrupted a ritual, the person with OCD would have overwhelming anxiety or aggressive outbursts. These therapists ventured forward, and named the treatment "apotrepic therapy" from the Greek word meaning to turn away, deter or dissuade.

The sufferers were inpatients, incapacitated by their OCD, and with whom other methods of treatment had failed. I am trying to imagine this pivotal moment, a kind of stepping into the fray to break up a fight and fearing getting punched in the process. At least the researchers knew these people had OCD and that interfering with their rituals could be difficult. A couple years ago, I met someone who as a child had aggressive outbursts when his rituals were prevented by parents or teachers, and no one knew he had OCD and he was sent away to a school for kids with severe behavior problems.

Meyer's treatment consisted of instructing nurses to continually supervise patients during waking hours and preventing them from carrying out any rituals, either through engaging in distraction, discussion, or mild physical restraint(only resorted to with the patient's agreement.) The prevention of rituals was maintained for 1-4 weeks, during which the patients were gradually exposed to situations that evoked the rituals in the first place, and then supervision was also gradually diminished.

The results showed not only that compulsive behavior decreased, but that instead of the emergence of overwhelming anxiety, there was usually a decrease in anxiety and depression. The study was preliminary, but very intriguing. Some of the factors the authors attributed to the success were:

• Incorporating ritual prevention into family life, since family members often get drawn into helping complete rituals.
• Modeling by the supervisor who would perform whatever action the person with OCD was avoiding, ie. if they wouldn't touch a doorknob, the nurse would repeatedly touch the knob.
• "Alteration in Expectancies"--Meyer's assertion that failure to perform the ritual does not necessarily lead to the feared consequence.

The frustrating part for the authors was the stressful and time consuming nature of the treatment for all involved. For Meyer and Levy, they were trying something novel and very different from leucotomy or psychoanalysis, and they saw great potential, but also were aware of the difficulties, which eerily foreshadow some of the moments on VH1's The OCD Project. I end with a quote from the end of the article about interruption of rituals:

. . .we urge that this should only be done where the staff concerned can have the closest supervision and the fullest support. The line between firm but sympathetic control and unpleasant and inhumane bullying is a thin one indeed and all too easy to cross when one has devoted a lot of time and energy to a patient who relentlessly and monotonously pursues an unchanging course.

*This is way shorter than it would've been in the past, before I got treatment for my OCD, but man, it does still seem somewhat thesis-like. . .

Why do Exposure Therapy?

So here's the thing. Exposure Therapy for OCD is asking you to do what you don't want to do. If it were in flow chart form it would be boiled down to "Don't want to do it? Do it." This can be a hard sell. I pity the poor Exposure Therapists who get to present this to someone suffering with obsessions and compulsions.

In my last post I wrote about delaying getting on the computer, and doing this as an Exposure. Why would I do this? I feel anxious when I don't turn the computer on. I have too much time to ruminate about my anxieties if I am not distracting myself. But there is part of me that has dreams, and wants to live my life, not live the life OCD chooses for me. OCD is all about getting the anxiety level down by doing a compulsion; the rest of your life be damned.

I am not talking about being abusive, or harsh or punishing. I may take infinitely small steps in my Exposures, but it's not a race, or a TV show, and doing what I don't want to do is scary and takes courage and I have people in my life who understand that and encourage me. Exposure Therapy isn't a religion that I must follow, but a treatment that many clinicians have worked on developing over the past 40 years or so, based on observing what works. They aren't just making this stuff up.

Now, there are still gaps and shortcomings in our current treatments for OCD, but I will be writing some future posts on the history of OCD treatment, highlighting the breakthroughs and evolution of Exposure and Response Prevention Therapy. 40 years ago many thought patients with OCD were hopeless, and I want to pay tribute to those who searched for an answer, who believed hope was possible.

Related:
Part 1: The History of Exposure Therapy: Dr. Victor Meyer and Ritual Prevention

Delaying Compulsive Internet Searching: Hard and Yet Rewarding

Thursday I didn't get on the computer until 10:30 am. It was one of my goals from my OCD support group to pick a day this week to delay sitting down in front of the computer. It was definitely an Exposure. When I start websearching, I am in a kind of groggy trance. Searching the internet distracts me from anxiety and fear and is a compulsion. Spending 3 hours on my own time was a challenge.

In the past, I've regarded any improvement in my OCD or a "good day" as a fluke, and have a desperate sense of wanting it to last, and fearing that it won't. It's as if I see OCD as the weather, a climate that can change capriciously. But if I turn on the computer, I am stepping into the storm. It feels like I'm in a calm place at first, but it's actually the eye of the hurricane, and deceptive in its stillness. I go into a zone of deeply ingrained habit and muscle memory, into stiffness in my back, shoulders, neck and hands, and by the time I get off the computer, I am sapped of energy and my anxiety level rebounds back up, as I see how much time I lost. Then it starts all over, getting back on the computer to numb myself again.

So Thursday it was me alone in the house, wanting to flee this Exposure, wanting to turn on the computer, and at the same time marveling at how much I can get done when I don't turn the computer on. The OCD wants to seize hold of this and berate me for not doing the Exposure sooner, or more often. It's amazing how contradictory my OCD is--advocating for both complete compulsive immersion online, and for perfectly doing my Exposures. If the OCD wasn't intertwined with the whole apparatus of my anxiety, I'd call it out right away, but it has a secret weapon, my nervous system, my feelings of dread, nausea, and panic, but I'm learning to question the OCD's credibility.