What You Can Change _. And What You Can't - Martin E. Seligman [47]
A therapy follows directly: exposure and response prevention. If you expose the patient to the feared situation and then prevent her from engaging in her ritual, she should become very anxious at first. If she continues to refrain, however, and finds out that the expected harm does not befall her—that she does not become infected by germs, that a gas explosion does not occur—the thoughts should wane and the ritual should extinguish. Thousands of OCD patients have been helped by this therapy. Here is a dramatic instance:
Jackie had obsessions about broken glass cutting her vagina. She kept her panties in a separate, locked drawer. She searched minutely for glass around chairs before sitting down. She could not use public toilets, and she would never wear flared skirts. Her most awful thought was of having to wear a tampon.
She entered behavior therapy and agreed to a response-prevention treatment. With her therapist’s help, she sat down on unfamiliar chairs without checking. She used public toilets. After she was able to do these things with increasing comfort, she sat on the floor while bottles were broken around her. Finally, with her therapist’s encouragement, she was able to use a tampon. Her obsessions and compulsions disappeared and have not returned.10
Between half and two-thirds of patients improve markedly after exposure and response prevention, and for most of those who improve, relief is lasting. At the end of therapy, however, the patient is usually not completely normal: The thoughts still lurk. A clear minority, it must be said, fail to improve. OCD patients who are depressed, who have delusions, or who secretly perform their rituals usually will not improve.11
The Right Treatment
OBSESSIVE-COMPULSIVE DISORDER SUMMARY TABLE
People with OCD have worry and depression as the dominant emotions on their jingle channel. People with other emotional problems have a different dominant emotion on their channel. People with object phobias have terror accompanying horrific scenes of encounters with the feared object. People with panic attacks have recurrent images of heart attack, stroke, and death accompanied by incipient panic. People with agoraphobia feel panic and terror as they tune in on scenes of going outside, of getting sick and being helpless with no one coming to their aid.
That we have a jingle channel is a fact we cannot change. It is an aspect of mental life so important that evolution wants to make sure it goes on incessantly. It is too important to be left to any conscious decision of whether or not to tune in. But its content may be changeable, and its volume is surely changeable. Changing the content, or at least adjusting the volume, can relieve some of our emotional problems. Cognitive therapy for panic probably removes heart attacks and dying as content on the jingle channel. Extinction therapy for any phobia and antidepressant drug therapy for agoraphobia turn the volume from loud to soft on the feared encounters. Both Anafranil and response prevention turn the volume from very loud to moderate in OCD. Changing the volume of the channel, while not simple, can now be effectively done with all these problems. My best guess, however, is that after successful treatment for OCD—and probably for phobias, too—the old jingles are still there—quieter and less insistent perhaps, but still lurking.
8
Depression
WE LIVE in an age of depression. Compared with when our grandparents were young, depression is now ten times as widespread in the United States, and the rate is climbing. Nowadays, depression first strikes people ten years younger, on average, reaching into late childhood and early adolescence for its youngest victims. It has become the common cold of mental illness.
Every age has