Tormenting Thoughts and Secret Rituals Page 17

  In doing therapy with Darren, I took care to conceptualize OCD not as an embarrassing personal weakness but rather as a short circuit of the brain that was not his fault. I emphasized to him that if he didn’t actively resist this brain problem, it would only get worse. Darren, like most children, easily grasped this idea. Next, I encouraged Darren to look on this problem as a war and to pick suitable names for OCD and himself. The battle was soon joined between OCD, the “bad guy,” and himself, “a Texas Ranger.” Darren’s job was to fight the bad guy by not performing the rituals. A family meeting was held, with Darren present, to agree on how much help family members should give. His mother assisted by coaching him on his eating, timing him in the bathroom, and sitting with him while he gradually exposed himself to batteries.

  All that proved necessary was to meet with mother and child for a total of five sessions. Quick progress was made with the presenting rituals and also with two new obsessions that cropped up, a fear of guns and a fear of bees. Once they caught on to the behavior therapy strategy for combating OCD, mother and son carried it out in efficient, military fashion. By the end of the fifth session, Darren’s rituals were so diminished that they were in need of no further treatment. It never became necessary to use medications. Darren’s case is not unusual—such positive outcomes are more the rule.

  Dealing with OCD at Home

  Broadly speaking, OCD parents err in one of two ways: assisting with rituals or becoming angered by them. Both of these responses are completely understandable; indeed, they are the common and natural reactions to OCD. Yet, indulging a child’s rituals actually reinforces the habits, while taking a hard line on OCD increases stress, which also exacerbates the problem. Parents become drawn into a vicious cycle: Their natural responses to OCD symptoms—even if well intentioned—produce the contrary effect of making rituals worse.

  A student in my OCD group, Aileen, recalls the moment during her seventh-grade year when she woke late at night with a start, consumed by the thought that she could grab a knife and stab her parents while they slept. For a week, she fought to get the terrifying idea out of her mind, but it only got worse. Finally, she tearfully confessed it to her parents. “Don’t worry,” they reassured her. “You, of all people, would never do anything like that.” But the next night the obsession returned and she had to ask again. Reassurance quickly became a ritual, and soon Aileen was spending one full hour every day telling her mother her fears. When her mother tried to curtail the litany, Aileen would beg to be heard, and her mother would always give in. Severe reassurance rituals continued throughout junior and senior high school, greatly interfering in the lives of both Aileen and her mother.

  Another student, Danielle, remembers when at age twelve she started to scrub her skin raw in response to irrational fears of dirtiness. “It was like I was in another world when I was in the bathroom,” she recalls. “First I had to get every bit of dirt off, and then I had to get all the soap off, and I could never be sure if I got it all.” Every night she spent two hours in the bathtub. Her mother’s response was to yell, “Stop it! What’s the matter with you!” Danielle’s most painful memory of childhood was of lying in the bathtub and hearing her mother, in the next room, ridiculing her to others. “I can’t believe how long she takes in the bathroom!” her mother would laugh. Danielle soon developed severe problems with depression and self-esteem. Finding refuge with the drug crowd, she “outdid them all” with her use of alcohol and marijuana. Later she required extensive drug rehabilitation.

  The successful approach to OCD involves avoiding the extremes of indulgence and disapproval. Rather than reacting with anger, or worse yet ridicule, parents should take a sympathetic attitude and avoid any personal criticism of the child. They should encourage a discussion about worries. Parents can gently inquire, for instance, “You seem to be doing things over and over. Lots of people do this because they are afraid something bad will happen. Have you been worried about something?”

  Supporting the child, however, does not mean enabling rituals. The goal is for parents to completely stop participation in any of a child’s compulsions. A critical step in behavior therapy is establishing a mutually acceptable contract between child and parent regarding how to respond to rituals. It might be agreed, for instance, that when the child is involved in excessive hand washing, the parent should intervene and help the child to stop.

  “OCD and Parenting,” a pamphlet available through the OC Foundation, makes the following general suggestions for dealing with OCD children.

  • Create an atmosphere in which the child is comfortable talking about feelings, especially worries.

  • Don’t give in to demands to provide unnecessary reassurance or to cooperate with other rituals.

  • Encourage the child to take reasonable risks.

  • Demonstrate, by example, that anxiety is “no big deal.”

  • Work on co-parenting; don’t allow the child to “divide and conquer.”

  What About Siblings?

  The truth is that brothers and sisters are seldom sympathetic toward OCD. A nine-year-old girl teased her twin brother about his counting rituals: “Why do you do that? That’s really weird!” A female college student who suffered reassurance rituals in junior high school recalls, “My brothers and sisters were terrible. They were flat-out mean. I would ask my sister if the house was safe, and all she would say was, ‘Won’t you ever shut up and stop bothering me?’ ”

  In cases of severe childhood OCD, siblings must be brought into treatment, educated about the nature of OCD, and coached on helpful ways to respond. In cases of milder OCD, when the sufferer has been successfully hiding his or her symptoms, it may be best to leave siblings out.

  THE SPOUSE WITH OCD

  I first met Matt when he accompanied his wife, Tina, to her third visit with me, on an evening in March. A big, slow-moving twenty-five-year-old dressed in work clothes and rugged boots, Matt had just finished up another twelve-hour day as a self-employed trucker in the logging business—one of the few booming industries in the Appalachian mountains of central Pennsylvania. It was a new job for Matt, a bold step to have taken with a pregnant wife at home, but it was turning out well. His income was already double what it had been working at WalMart.

  I asked Matt to tell me about Tina’s problem: what he had observed, what he thought was causing it, and how he dealt with it. Matt spoke in a careful and deliberate manner, pausing frequently to look at the floor while he searched for the exact words to express himself.

  The major difficulties had begun six months ago, right after the birth of their first child. Before that, during two years of dating and another of marriage, Matt had recognized that Tina worried excessively, fussed abnormally about small details, and was overly concerned about cleanliness. He had concluded, in fact, that she was “basically lazy” because of her inability to keep to an orderly work schedule. Yet he had adjusted to these shortcomings. He badgered Tina, reasoned with her, and, when all else failed, put up with her. This, he figured, was all part of being married. But now the situation had worsened immensely. Now, he could no longer deal with it. “I want to be honest with you, Doc,” Matt said. “I’m a decently patient person, but I’m ready to leave.”

  Matt told me of the expectations he had held. He and Tina agreed they would have a “traditional marriage”: She would stay home with the children; he would be the breadwinner. When he arrived from work, she would have supper ready. But it wasn’t working out that way. She was worrying all day long, doing “next to nothing,” and nothing he said made any difference. Not only that, but her worries no longer made any sense. “I want a normal marriage,” Matt lamented, “where people fight about money, not about crazy stuff.”

  Worst of all were Tina’s almost constant fears of contaminating the baby. What if she changed his diapers incorrectly? What if she cleaned his crib insufficiently? What if rust from the can opener poisoned the formula, or if, when screwing on the cap of the baby bottle,
she pushed too hard and caused pieces of glass to land inside? To make sure the baby bottle nipples were clean, Tina would stand over a pan of boiling water, repeatedly dunking the nipples down into the water for a half an hour or more, until they were, as Matt put it, “gummy and half decomposed.” Then, after taking them out, she would fear that the paper towel she set them on had in the meantime become dirty, necessitating that she put the nipples back into the boiling water and start over. Sometimes, Tina brought Matt into this ritual, insisting that he do the boiling. Her fear of spreading germs caused her to wash her hands many times an hour, and her skin was now chapped and red. The hot water, Matt complained, was almost constantly in use. He knew this for sure because it immediately came out scalding whenever he turned on a spigot.

  Obsessions of harm were also severe for Tina. What if the light switch was not quite off and as a result a fire might start? Tina would compulsively turn the switch on and off until she had attained an adequate feeling of certainty, only then to think, What if she had by now played with it too long? She would call Matt to check—even in the middle of the night. “It drives me up the wall,” Matt said in exasperation. “I feel like garbage the next morning.” Another daily obsession: What if the stove wasn’t turned all the way off? “We’ll be in the car halfway to Altoona,” Matt explained, “and she’ll insist that we turn around and check the stove.” Yet even returning to check could not quench her uncertainty; she would continue to ask Matt repeatedly what would happen if the stove was not turned off.

  It was the endless requests for reassurance that bothered Matt the most. As soon as he pulled his car into the driveway, he was met with a barrage of confessions, concerns, and requests for reassurance. Tina would yell out, “Guess what happened to me today?” The baby had walked on the carpet where it was dirty, had come too close to an ant trap, or had touched the formula with his finger. She had turned the light on and off too many times, changed the diapers the wrong way, or contaminated the soup. She had to get these worries off her chest, they weighed her down so badly; and she wouldn’t quit until everything had been told. She would beg Matt to listen to her; and if he refused, she would yell at him: It was his baby and he needed to know!

  Overwhelmed, Matt responded in different ways, depending largely on his own mood. Sometimes he would hear her out, nodding, giving her the comfort she wanted. Sometimes he would attempt to demonstrate to her that there was no problem. “If the light switch were on fire, you’d see smoke coming out of it,” Matt would say. “Do you see any smoke? Okay, you’ve answered your own question.” Increasingly, though, Matt was blowing up in anger.

  A particular compulsion developed which crystallized Matt’s conviction that he could not stay married to Tina in her present condition. Tina would have the thought—even though she was on birth control and had not missed her period—that she was pregnant and that she was sitting in a posture—bent over too far, back not straight, or leaning to one side abnormally—that was harmful to the baby inside her. Tina knew full well that this was bizarre. Still, it seemed so real and her fear was so great that she would wiggle, stretch, move back and forth, and get up and down repeatedly so that no harm would come to the baby she feared was inside her. And she would have to tell Matt all about it.

  By the end of that session it was clear that Matt was very pessimistic about the situation. Tina was downcast. But I was quite hopeful. I explained to the two of them that Tina’s severe OCD symptoms had been triggered by the unique stresses of being a new mother and were being exacerbated by marital discord. There was every reason to believe that with behavior therapy, medications, family meetings, and time, her symptoms would greatly improve.

  Fortunately, in addition to being admirably honest and straightforward, Matt truly wanted to save the marriage. At my request, he accompanied Tina to several of our early sessions. I had two goals for Matt: to understand about OCD and to help with behavior therapy. Learning that Tina had a “chemical disorder” was a revelation to Matt. Finally, he could make some sense of it all. Yet he was still often critical. Tina wasn’t getting the meals ready in time, or keeping up with the checkbook, or getting the housework done. He would also complain that she was not putting enough effort into her behavioral assignments. “You have to get off your butt and try some things,” he would say. I tried to point out that although Tina might be lazy, it was not the cause of her rituals, and furthermore, anyone having OCD plus a new baby would be worn out. Matt never acknowledged the truth of that, but at least our sessions provided a place for Matt to vent his frustrations, and as therapy progressed he became more sympathetic.

  As for behavior therapy, like most OCD family members, Matt was delighted to learn that it is best not to participate in rituals. The three of us took a careful look at the situation and agreed on a realistic approach to limiting his involvement. In some instances Matt was able to cease participating immediately. He stopped washing the baby’s hands and turning the car around to check the home. For other rituals it was best to remove Tina from the situation. Matt took over making formula, and they bought a timer for the lights. Still other rituals had to be negotiated as therapy progressed. Tina’s reassurance compulsions were a special problem. We tried to set limits: Tina could have half an hour when Matt got home to vent her fears to him, or ten minutes every hour after dinner. Yet Tina, inevitably, would badger Matt for reassurance until he either became angry or gave in. Fortunately, however, her reassurance rituals gradually lessened to a degree that they were tolerable.

  By the end of four months of behavior therapy, medications, and family meetings, Tina had progressed from full-time to part-time OCD. Since then she has continued to make further gains. The family is now stable.

  I asked Matt what was most beneficial to him in our treatment. “It was a big relief,” Matt said, “when I finally understood exactly what was going on. She couldn’t control her OCD, but we could treat it, and I could live with it in a normal way.”

  I then asked him the best methods he had found for handling Tina’s OCD.

  First of all, I keep straight the difference between her compulsions and her laziness. When she doesn’t do the housekeeping and bookkeeping, I can ride her about it. That’s laziness. But her fears about dirt, electricity, or germs are in another category—that’s the OCD. Then of the compulsions, there are certain ones I can buck her on, and others I can’t. For instance, I always make her turn off the lights and take care of the baby’s stuff—she’ll complain a little bit, but she’ll do it. But I still have to give reassurance sometimes. I’ve learned that it’s better for me to just say, “It’s okay,” than to cause a scene.

  What advice would Matt give a friend whose spouse had OCD? “I’d tell him to go and see a good doctor. Seriously, that would be the most important thing. Learn what OCD is. Get medications. After that, go along with the rituals to some extent in order to keep the peace. And don’t scream, that only makes it worse.”

  As can well be imagined, being married to an OCD sufferer can turn into an ordeal even worse than having a child with the disorder. A recent study published in the Journal of Sex and Marital Therapy reports that more than 60 percent of OCD marriages are significantly troubled. Another study finds that 80 percent of OCDers’ spouses become involved in their rituals. Interestingly, other studies, seemingly in contrast to these findings, indicate that OCD marriages are on the average just as happy as non-OCD unions. What this suggests is that the agreeable personality characteristics of OCDers often make up for the problems caused by their rituals.

  The most crucial factor in determining adjustment in OCD marriages is the severity of the sufferer’s obsessive-compulsive disorder. “Full-timers,” those who spend virtually every waking moment fighting obsessions or carrying out rituals, do poorly in marriage. Males who fall into this category, in fact, tend never to marry at all. Women full-timers usually do get married but then end up either divorced or in chronically maladjusted relationships. The strains of being marrie
d to a full-time OCDer can be almost unimaginable. A husband or wife can become a tyrant in the household, ruling family members according to the dictates of obsessions. I once treated a woman who prevented family members from using the bathrooms in their own house; they had to use a gas station’s, instead.

  “Part-timers,” on the other hand, usually have normal marriages. Mild to moderate OCD is no harder on a marriage than the same degree of depression, and is probably not as bad, because of the OCD sufferer’s special facility to hide rituals and function normally despite them. As for intimacy, it used to be thought, on the basis of Freudian theories, that OCD sufferers were almost always sexually maladjusted. Psychoanalysts contended that the obsessional’s excessive need for control caused avoidance of sexual contact because of fear of failure to perform. But two recent studies document that there is no particular problem with sexuality in OCD marriages.

  The distinction between full-time and part-time OCD points up the importance of therapy, because what effective treatment most often accomplishes is that very sort of partial reduction in symptoms, a change from overwhelming to manageable OCD.

  How a spouse deals with OCD can contribute greatly to whether therapy is successful; in particular, this often determines whether the gains of therapy continue after treatment. A 1993 study by Gail Stektee of the Boston University School of Social Work found that patients with severe OCD who benefited from treatment were significantly more likely to relapse when spouses were critical of their condition, taking the attitude that the suffer should be able to control rituals on his or her own. At the same time, the study showed that when spouses expressed support, initiated rational discussions about rituals, and urged confrontation with feared obsessional situations, OCD sufferers maintained treatment gains.