A young mother named Sherry presented to me for treatment in a panic because of violent fantasies of the worst types imaginable, including stabbing her daughter, slitting her own throat, and crashing her car. Compulsions were not the major problem; rather she was primarily disabled by the terror caused by her obsessions, and her avoidance of the many different situations that brought them on. She often could not cook because of her fear of using knives. Sometimes she could not bring herself to drive the car. Occasionally, she would stay in her bed almost all day long out of fear that she might act on one of her violent urges. A complete discussion of her case and treatment is contained in the book Tormenting Thoughts and Secret Rituals,
Sherry’s therapy included the following steps. The first couple of sessions were spent gathering history and educating her on the nature of OCD. After that, Sherry kept a diary of her symptoms as they occurred throughout the day. Once the obsessions had become clearly defined, she ranked them in a hierarchy according to the amount of anxiety each caused. She then began homework assignments geared first toward overcoming avoidance, and finally involving direct exposure in the imagination to her tormenting thoughts.
Here is a sample of her first week of journaling:
Tuesday. Woke up in the middle of night and again in the morning with the obsession of stabbing myself. Thought how I could walk down to the kitchen and get a knife and push it in my stomach. Saw blood everywhere. Bob wakes up and I’m dying, covered with blood. Avoidance: Stayed away from knives all day. Did go in the kitchen, but used “alternative cooking.” Wednesday. Obsessions while driving were constant: Crash into this car, swerve over and hit that little boy. I’m praying, “God, get me through this.” I must really be sick to have these thoughts. Helped to remember that the doctor said that everyone has crazy thoughts. Didn’t want to cook dinner, but I did and I forced myself to use knife (a dull one). Hurrah! Thursday. Awful day. Started with obsessions of slitting my throat while shaving my legs in the shower. Thoughts of knives all day long. Read magazines to get away from them. Watched TV. Tried to go to sleep as fast as possible. Avoidance: Spent a lot of time in bed today. Didn’t cook with knives.
Friday: Better than yesterday. 99% of obsessions today were knife thoughts. Was vacuuming the floor and had the thought to grab a knife and slit my throat. Or to stab myself in the belly. Same ones over and over. At dinner time the thought of knifing Bob. I kept telling myself: “This is gross. Stop it!” Saturday. Obsessions in and out of my mind all day long. Thought of stepping out in front of a truck. Then while I was driving I thought of running off the road. At Art Alliance, thought: “I could chop all their heads off.” Gross. At dinner time, thought of grabbing a knife and slitting Bob’s throat. The thoughts just pop in and out, but when they occur they’re so powerful. Avoidance: Some avoidance of knives and driving. Increased time in bed.
Based on her journal, Sherry and I constructed an OCD situations hierarchy.
OCD SITUATIONS RANKED ACCORDING TO ANXIETY LEVEL
Situations Causing Knife Obsessions
|1. In kitchen–slitting my throat or my wrists or stabbing myself in the stomach with the kitchen knife,
or else stabbing Megan or Bob
|2. In shower–slitting my throat or my wrists with a razor while shaving my legs||90|
|3. In bed–stabbing Bob in the stomach while he’s sleeping||50|
|4. In bed–slicing up Bob while we’re making love||30|
|5. Anywhere–slitting Megan’s or Bob’s throat or throat or stabbing them
|6. Meetings, malls–stabbing people, cutting their heads off, etc.||20|
Situations Causing Car Crash Obsessions
|1. In car, see little kids–swerving my car to hit them||70|
|2. In car, truck or overpass coming–pulling the wheel and swerving into it||60|
|3. Anytime in car–crashing it||30|
Our goal in behavior therapy was to expose Sherry to her obsessions, and to continue her exposure long enough for habituation to take place. Sherry began the active phase of behavior therapy with homework assignments directed toward confronting her avoidance. For two weeks she worked on forcing herself to get out of bed every morning, and not allowing herself to retreat to her room later in the day. After accomplishing these goals, she began taking long drives in her car. Later in treatment, she exposed herself to the more fearful task of using sharp knives while preparing dinner.
The second emphasis in Sherry’s behavior therapy was exposure to imagined scenes. Here, the assignment was to hold an obsession, in its complete awfulness, in her mind’s eye for a sufficient length of time to allow anxiety to fade (usually 20 to 60 minutes) and habituation to take place. There are several ways to implement this technique. The most time-honored is for the therapist to talk a patient through an obsessional scene, using the most vivid imagery possible. The patient can tape the session and play it back for home work. Another method is for the patient herself to write down a written rendition of an obsession; and then to imagine it in great detail, bringing back the obsession every time it fades by rereading the script. Yet another method is for the patient to record an obsession on a loop cassette and play it over and over.
Sherry used exposure in the imagination to treat several of her obsessions. Toward the end of therapy she wrote a script of her number one worst fear.
“Here goes! It’s winter and it’s ugly outside. I have been feeling down and have been unable to shake it. I’ve tried all day to concentrate on other things. It’s 4:30 PM and I’ve been to the grocery store and am feeling nervous. Life is so painful; nothing will ever be right. I’m putting things away in the kitchen, and I spot the carving knife. Megan is sitting at the table. The urge hits to slash at her. I shake with anxiety. The urge takes over. I am unable to control it. I sneak up behind Megan, and I stab her in the back, over and over. I see the blood spurting out. I think that I am out of control; that it’s really happening this time. Megan flops onto the floor, dead, into a pool of blood. I vomit hysterically. I’ve killed my daughter!”
Sherry recorded this scene on a cassette “loop tape,” and played it back to herself every day for 20 to 30 minutes, long enough to allow her anxiety level drop significantly. She needed occasionally to step back from the scene and remind herself, “This is my OCD, it’s not me;” or, “This does not mean that I’m going to really do it, but I must learn to live with the idea of doing it if I want to overcome my OCD.” Such psychological distancing is usually necessary, but I encouraged her to minimize it, because the fuller the immersion in the frightful fantasy, the faster therapy proceeds.
After twelve weeks of active behavior therapy, Sherry had markedly improved. Her journal, in which she was now taking note of her attitudes as well as her obsessions, reflects her progress.
Monday: Very mild obsessions. Ideas of knifing myself. Passed easily.
Self-talk: “Oh, it’s a knife. I could hurt myself with that if I wanted to. Well, it’s dinner time. I could stab myself if I wanted to.” I took out knife and used it easily for cooking.
Tuesday: Rating: 8. Very mild obsessions. Was busy all day. Felt sad in the afternoon.
Self-talk: “What a nasty illness. Why did it have to happen to me? Why couldn’t I have gotten help sooner?”
Wednesday: Had obsessions off and on all day. Don’t know why. Got up in the morning and thought of knifing Bob in the stomach. Image first, then urge.
Self–talk: “Oh, not you again. Stop bugging me, jerk. You’re bothering me, but you’re just an obsession.” Went away after a while.
Thursday: Stayed busy all day. Some thoughts about hurting myself.
Self–talk: “It’s just OCD. These thoughts can’t harm me.”
Friday: Fleeting obsessions of knifing and running people over. Not bad.
Self–talk: “Obsessions, I’m not scared of you any more! If I bear the anxiety, I know you’ll go away.”
Saturday: Had two hours of a pretty bad obsession after an argument with Bob. Kept my anger in. Variety of thoughts. Knifing myself. Running car into overpass. Took a long time for them to go away. Crying. Why does this happen while I’m driving?
Self-talk: “Come on, Sherry, shape up!
Sunday: Good day with family. Only a few obsessions all day. Very mild. Life can be good.
Sherry’s most satisfying moment of all came a few months later. Not since age eleven had she carried a knife with the blade pointed outward when another person was in the kitchen. Instead, she always carried it pointed toward her belly, so that if she stabbed anyone, it would be herself. But one day while she was carving a roast, her daughter calmly munching snackfood nearby, Sherry slowly and purposefully grasped the knife, held it pointed outward, and walked carefully, as if on slick ice, across the kitchen. At the finish of her journey, she put down the knife and gave her startled daughter a joyous, gasping hug. Sounds simple, but Sherry said it was like winning an Olympic gold medal.