“Winter Is Coming!”—Treatment of Obsessive-Compulsive Disorder Imagery After Viewing the Television Series Game of Thrones

EMDR History-Taking Phase: Sessions 1–2

During the history taking, Sam was asked about disturbing events in both the present and in the past, and a hierarchy of the disturbing images was built according to those events.

EMDR Preparation Phase: Sessions 2–3

The preparation phase included psychoeducation about OCD and an explanation about EMDR treatment. Sam was also taught a relaxation technique which he was asked to practice on a daily basis. For the BLS, Sam chose to use eye movements.

EMDR Reprocessing: Sessions 3–4

The first targeted memory was the fight at the age of 12 years (Table 1). Sam ranked this memory as SUD = 5, and the NC associated with this memory was “I’m afraid.” The PC was “I’m safe.” At the end of the desensitization phase, the levels of the distress had been reduced to SUDS = 1. Interestingly, the picture which had represented the hardest moment was the look in the attackers’ eyes, which Sam interpreted as contempt and as an indication of victory.

EMDR Reprocessing: Sessions 5–6

The second targeted memory was an invasive memory image which was bothering Sam on a daily basis. In that situation, Sam had sat across his girlfriend and saw her with hollowed-out eyes. During the desensitization phase, Sam described this image as becoming blurred and, at the end of this phase, he reported being surprised that he could no longer see the image. The work on this disturbing image continued in the next session according to the eight-phase protocol at the end of which he reported that it no longer disturbed him. During a follow-up phone call on the following day, Sam related that he woke up without any anxiety or any aggressive thoughts for the first time in many months. He noted that he had felt some anxiety when he passed near sharp objects but that the discomfort lasted for only a few minutes and not for hours as in the previous months.

EMDR Reprocessing: Sessions 7–8

At the next session, Sam reported that both the intrusive imagery of the TV scene and the aggressive thoughts had decreased during the last week. Interestingly, during the period between the two sessions that focused on eye removal, Sam reported that he had started dreaming “strange but normal dreams” again. He was quite surprised because he reported that he usually did not dream or occasionally had nightmares. Meantime, Sam and his girlfriend broke up for reasons unrelated to the OCD imagery. The next targeted memory was that of a vacation in which Sam experienced a panic attack after seeing an image of his girlfriend with no eyes. Sam’s NC was “I am afraid of myself” and the PC was “I can cope with it.” During the two sessions which focused on this event, the frightening image blurred until Sam reported that he can no longer see it in spite of his efforts to summon it. In the following week, he reported that he felt very calm, and his friends had told him that he “returned to himself” and said that he looked less stressed out. He explained that he participated more in conversations and that he started to be funny like the “old Sam.” Sam reported noticing that he coped better with stress at work and did not get annoyed from petty things as he did before. When asked about what happened when he now passed next to sharp objects, he said, “It does not bother me as before.”

EMDR Reprocessing: Sessions 9–10

According to the treatment plan, the next targeted memory should have been the Game of Thrones TV scene, but Sam reported that he recently had a dream and that he only remembered his father in the dream. He remembered that he woke up anxiously in the middle of the night with itching thumbs and sat on the bed for 5 minutes until he calmed down. The next two sessions were dedicated to that recent dream because it was related to the original traumatic memory from his childhood.

EMDR Reprocessing: Session 11

At the 11th session, the targeted memory was the Game of Thrones scene and the image which represented the worst part of the memory. The NC associated with this memory was “I’m helpless,” and he gave this memory a SUD score of 6 (in contrast to 10 SUD score at the beginning of the treatment). The PC was “I’m safe” and the VOC was 2. During the desensitization stage, Sam reported that as he visualized the scene, he was paying attention to other aspects in it that he had not thought about before. In a subsequent set of bilateral stimuli, Sam suddenly said, “I saw my father but as the smaller guy in the scene.” After the next set of bilateral stimuli, he said, “I see my father in the scene . . . he’s wounded . . . I’m afraid to continue.” The session was paused for a few minutes to let Sam practice a relaxation technique.

The treatment then continued, and the associations which came up were related to various childhood fears that his father would be killed in various ways, including a memory from age 17 years in which Sam imagined that his father was shot by an arrow. The associations went on to different scenes from various movies or series which included brutal killings and body mutilations. In one of them, Sam remembered a specific scene from a movie in which a man was being threatened that he would be castrated. Sam reported that he was too afraid to continue watching the scene and turned off the television.

Provision of Psychodynamic Psychotherapy: Sessions 12–14

The therapist asked Sam to describe his relations with his father throughout the years, and Sam described a strict father who always wanted his children to succeed in life but who did not attend to their emotional needs. During his childhood, Sam used to pull pranks on other children whose parents did not approve, and they reported Sam to his father who punished him. In addition, Sam reported that the father placed harsh limitations on Sam hanging out with his friends during puberty so that any attempts toward rebellion during this period were quickly ended. The father also insisted that Sam study engineering although Sam was reluctant to do so.

When asked if he felt anger toward his father, Sam first answered in the negative, but after a few moments of silence, he said that he did. The therapist explained to Sam that he thought that the next sessions should be dedicated to a joint investigation of his relations with his father, and Sam agreed. Sam and the therapist chose major incidents in which Sam felt anger toward the father but did not express it. Sam was encouraged to talk openly about those incidents with his father and to explain to his father the different emotions he had felt toward him during different periods of his life.

At the 14th session, after three-and-a-half sessions dedicated to focused dynamic treatment, Sam reported that during the previous week, he had talked to his father as the therapist had recommended and that he now saw his father in a completely different light. The father explained that the family had financial difficulties during most of Sam’s childhood and that those problems had constantly worried him. The father also said that he was a war veteran who did not receive any treatment, and he now believed that much of his harsh behavior toward Sam and the other family members stemmed from unresolved memories of horrific war experiences. The father said that he was sorry for what Sam felt, but, at that time, he believed that he was doing his best. He added that he saw Sam as the most talented of his children. Sam reported to his therapist that he had never heard his father talk in such emotional manner and that although he still felt considerable anger toward his father, he now was also compassionate toward and more understanding of the father’s intentions.

Reprocessing: Session 15

In the subsequent session, the work on the Game of Thrones TV scene was continued with EMDR as Sam rated the horrifying image with an SUD score of 3. The NC was “I’m shocked” and the PC was “I can cope with it,” and the VOC of this cognition was 4. At the end of the session, the SUD ratings had decreased to 1, and the VOC was 7. Sam reported that he no longer suffered from intrusive imagery and said that the aggressive thoughts “come and go sometimes” but they do not disturb him as they had before treatment.

Psychodynamic Psychotherapy: Sessions 16–17

The treatment now focused on Sam’s current relationship. He made numerous efforts to keep his girlfriend happy and wanted her to think that he was “perfect.” A discussion about his efforts to portray an image of being flawless elicited thoughts about his behavior with different people during his life. In the same session, he added that during the past week, he had felt pervasive anxiety when he passed next to sharp objects, such as knives and scissors, and he feared that those objects would hurt his colleagues. He feared to admit that he had obsessive thoughts about causing possible harm to others. Sam’s anxiety was conceptualized by the therapist as indicative of an additional unconscious conflict—the wish to be loved by everyone versus the fear of rejection. An earlier example of this was his many efforts to please his girlfriends and his constant worry that if he did not do enough, his girlfriends might leave him.

In addition, Sam had decided to tell his girlfriend that he suffered from obsessive thoughts with aggressive contents, without specifying the contents. Sam was at the beginning of the relationship with the current girlfriend and this decision heightened his anxiety because Sam was afraid that his girlfriend would decide to end their relationship. Another source of growing anxiety was intrusive thoughts of knives and scissors being stuck in his colleagues’ bodies that bothered him during the last week. Every lunch with his coworkers or any exposure to scissors and pencils turned to dreadful experience that made him fear his own potential aggression.

Exposure Response Prevention for Obsessive Thoughts: Session 18

ERP is a form of behavioral therapy that involves repeated exposure to disturbing situations or cues, such as objects perceived to be contaminated, while preventing rituals or repetitive behaviors, such as hand washing that are used to dissipate the anxiety related to the obsessive preoccupation (Abramowitz, Deacon, & Whiteside, 2011). ERP has received significant empirical support from numerous studies, and the American Psychiatric Association recommends this treatment for OCD (Koran, Hanna, Hollander, Nestadt, & Simpson, 2007).

The therapist gave Sam a detailed explanation about ERP, and together they created a hierarchy of feared situations which triggered gradually increasing amounts of distress. Sam was presented with the following situations:

Sam was asked to imagine himself holding a utility knife in great detail. His homework assignment for the first day of the in vivo exposure was to hold the knife for only 10 minutes to provide an opportunity for habituation to occur (Osgood-Hynes, n.d.) and because the therapist wanted him to experience success on his first actual practice. After each home assignment, he was instructed to write his thoughts and feelings and to rate the difficulty of the daily home assignment. On the first day, he reported that during the assignment, he thought of the utility knife cutting a stomach and then this thought disappeared and returned. Then he remembered that he had played with such knife and cut himself when he was in the second grade. He was reluctant to continue the exposure, so it was decided to target that memory with EMDR in the following session.

Provision of EMDR Therapy: Session 19

The targeted memory for the EMDR work in the following session was the memory from the second grade. At the beginning of the session, Sam rated the image with 8 SUDS, and at the end of the session, the SUDS ratings had decreased to 1. Following the session, Sam was ready to continue with ERP.

ERP Treatment: Session 20

In the following days, he held the knife for 30–45 minutes and felt a significant reduction in the frequency and the intensity of the aggressive thoughts. Interestingly, an image of a knife cutting a penis had appeared on one of those days.

Sam felt successful after this week and wanted to continue to the next feared situation. The behavioral treatment was accompanied with major cognitive components because Sam suffered both from aggressive thoughts as well as pervasive thoughts about himself.

Cognitive Therapy and ERP: Sessions 21–24

The therapist provided psychoeducation about the “normality” of aggressive thoughts among large part of the population and explained the difference between assertiveness and aggression. Another cognitive intervention was to challenge cognitions associated with dangerousness by presenting arguments, such as “Many people have aggressive thoughts—does that make them dangerous?” Sam read about aggressive thoughts on the Internet and realized that this phenomenon is prevalent among nonclinical populations. He became even more convinced that if a person has an aggressive thought, it does not mean that he or she intends to perform a violent act. The cognitive interventions were integrated into the ERP treatment not only to challenge some of Sam’s cognitions but also to reduce the impact of the unproductive self-talk. The therapist presented him with questions, such as “Does merely holding a sharp object make you a dangerous man?” “Do you see yourself, a well-respected person, going on a killing spree?”

The ERP treatment continued for the second feared situation. When he held the knife during cooking, he felt anxious and had images of this knife cutting people. Sam was instructed to hold the knife for 40 minutes each day and then to rate how distressful those situations were and describe his feelings and thoughts in writing. On the first day of this home assignment, he reported a SUD score of 8 and a passing image of the knife making scratches on various body parts, including the penis. On the following day, he held the knife and reported that there were fewer frightening images and aggressive thoughts. On the next days, Sam felt quite bored and the SUD decreased to 2. At the next session, when he reported on boredom during the home assignment, the therapist asked him to look at the sentence “Holding a knife is dangerous,” and to comment on it. The next lines describe the conversation.

The aim of the cognitive intervention was to challenge cognitions associated with danger and to assist Sam in identifying the cognitive distortions typically related to a faulty assessment of danger (Foa, 2010). This provides an opportunity to create adaptive cognitions concerning the encounter with the sharp object. In addition, the frequent mentioning of words which elicit anxiety during the conversation helps in the desensitization of the distorted beliefs and teaches the patient that talking about sharp objects is not dangerous. Encouraged by his success, Sam approached the most feared situation—scissors. He reported that the sight of the scissors in his office triggered images and thoughts of their being stuck in his colleagues’ bodies. As such, he kept the scissors in a bottom draw of his desk and did not use them.

The instructions for this assignment were to put the scissors on his desktop for 30 minutes a day. At the subsequent session, Sam noted that he worked during the past few days without paying any attention to the scissors which had remained on his desk the entire day. His next assignment was to occasionally hold the scissors, leave them on the table, and to use them if necessary. Sam followed those instructions on the first day and did not find the assignment distressful. On the next day, he decided to place the scissors in front of him and to keep looking at them for an hour. During that week, Sam decided independently to hold the scissors for more than an hour each day.

During Session 24, he explained his attempt to immerse himself into the feared situation and stay in it with curiosity and self-confidence. He said that the previous successes enhanced his self-confidence and he wanted to test whether he was strong enough to cope with the threatening situation. In essence, Sam had chosen to perform flooding and it led to significant symptom reduction. Since then, the scissors have remained on his desktop, and he reports that he does not feel uncomfortable as before, nor does he need to hide them. Sam was worried that those thoughts appear and asked to get rid of them, and the therapist told him that such thoughts are much like sneezing—something that one cannot predict but simply comes and goes (G. Agassi, personal communication, March 8, 2016).

The last session dealt with the end of the treatment and with Sam’s current relationship, because he and his new girlfriend decided to break up because of incompatibility. A major moment in those sessions was when the therapist said to Sam that despite his fear that his thoughts would cause the separation, the relationship ended because of a completely different reason. Sam was quite surprised by this comment and said that he had not thought of it in that way. This comment provided support for the idea that Sam had already read about—that people can and do live with aggressive thoughts. In other words, people can have serious relationships and work productively with aggressive thoughts that occasionally come and go.

Contribution of EMDR Therapy

The contribution of EMDR therapy to the patient’s subjective experience and life quality was enormous. First, the intrusive imagery stopped bothering him. Second, after the processing of the first memory, the SUD scores of the next memories dropped. For example, the TV scene was rated with an SUD score of 10 at the beginning of treatment; then, when EMDR therapy was first provided for this image (Session 11), the SUD score had already dropped to 6; and it had dropped again to a score of 3 at the last session dedicated for processing this disturbing image. Third, after the beginning of EMDR therapy, Sam reported a significant decrease in the distress level associated with intrusive thoughts, although these started to bother him again after 4 months in treatment (Sessions 16–17). Fourth, during the first 10 sessions of EMDR therapy, Sam’s interpersonal relations and his social and occupational functioning had improved significantly.

These promising results suggest that future EMDR therapy protocol for OCD should be based on the “three-pronged” (past, present, and future) approach (Shapiro, 2001) and include processing of past memories, present triggers, and future situations. In the case of OCD aggressive imagery, therapists could use the future template to help the patient visualize successful management of an anticipated future event, such as sitting in a family dinner with knives on the table or standing on the pavement next to another pedestrian and not pushing him toward the traffic.

Böhm and Voderholzer (2010) also reported on the efficacy of EMDR in the treatment of a patient who had suffered from aggressive and sexual obsessions since the age of 14 years. However, those authors did not elaborate on the patient’s aggressive thoughts or aggressive images or the thought that was the focus of treatment. Therefore, after a literature review that failed to yield comparable reports, this case appears to be the first description of EMDR treatment of OCD imagery in general and of OCD imagery focused specifically on aggression.

Contribution of Psychodynamic Psychotherapy

Psychodynamic psychotherapy was used when Sam feared to continue with EMDR treatment in the session that focused on the most disturbing image and in sessions that focused on his relationship with his girlfriend. Although it is difficult to measure the unique contribution of psychodynamic psychotherapy in this case, the sessions which focused on Sam’s relations with his father, and especially the covert talking about the aggression and the anger toward him, contributed to creating a more open dialogue and improved the father–son relations. In addition, the application of psychodynamic treatment led to the continuation of the EMDR work on the most disturbing memory.

Contribution of CBT Treatment

CBT was used for three main reasons. First, psychoeducation was provided to normalize Sam’s aggressive thoughts. Second, cognitive interventions were used to challenge Sam’s cognitions about his dangerousness or about any other possible hazards in any imagined or real encounter with sharp objects. Third, ERP was used to help the patient stay in contact with situations which trigger obsessive and aggressive thoughts. This intervention helped to change his maladaptive beliefs and from week to week, Sam’s avoidance was reduced and his sense of self-efficacy was enhanced. The accumulative successes of ERP treatment led to his independent attempt to perform flooding and to confront his fear.