Obsessive Compulsive Disorder can be a crippling thing to have. OCD can consist of obsessive thoughts or compulsive behaviors, it is often both. When it is both, the behaviors are often designed to neutralize the intrusive thoughts. They are a form of a kind of magical thinking that will keep anxiety at bay. If I arrange the coins on my dresser at night in some form or pattern, then my intrusive thoughts of inappropriate pornographic mental imagery will stop. The problem with this way of thinking is that there is never a set pattern of coin arrangement that will magically “work.” I have to keep arranging them until I “feel” that they are right, and then the anxiety subsides…….. for awhile. Sometimes what happens is that the compulsion to arrange coins develops its own psychic energy and I am compelled to arrange them until somehow, magically the compulsion is satisfied. It is only when that magic happenstance occurs that I can leave the dresser and go to bed.
People who suffer from this disorder discover that the amount of time and energy they begin to consume intrudes into their daily lives until their lives are no longer their own. Their lives are “owned” by or controlled by the obsessive thinking or compulsive behaviors. An example is a client I once had who was a young man in junior high school. He was an athlete and was very bright. Anxiety was an issue for him, he felt constantly that he would not be good enough to make the team, score the winning points or be the star unless he magically followed his routine every day. This kind of thinking begins, especially for athletes, when they randomly associate some behavior with an outcome that was successful, or unsuccessful. One has “lucky” socks that he must wear, another has a lucky bat that she must use. I once knew a high school quarterback who insisted that his lucky game socks could not be laundered until the team lost. They had magical powers and the team kept on winning. The team had an undefeated season, but lost the State championship game. Then the spell was broken and the socks were thrown away. (Boy, did they stink by then!) This boy and his team all believed in the power of the magical socks. In this case it was not an obsession or a compulsion, merely magical thinking. But the boy who had a routine he had to follow in order to leave the house had moved beyond just magical thinking. He developed obsessive thoughts and compulsive routines that involved counting and repetitive behaviors, as well as an order or sequence of steps that must be followed.
These behavior patterns become so intrusive that they prohibit you from being able to have a “normal” life. The boy in my example developed a series of steps he needed to complete, places he must touch with his right hand in the proper order and in the proper number of times so that he could get out of the door and go to school each morning. Each day it took longer and longer because he kept having to start over when someone would interrupt him, or something that he needed to touch in the sequence had been moved. He became more and more anxious and stressed, and it raised the stress and intensity level for his mother and siblings because they had to deal with his bizarre demands and ritualized behaviors everyday. His grades began to suffer because his rituals took more and more time, and he began to miss school or be very late. Finally his parents brought him to me for help.
Another example is a client I had who was reclusive. She could never quite manage to leave her home. She spent hours and hours each day in her bathroom getting ready to leave but she would become preoccupied by her cuticles and spend time working on them. She had to get them just right in order to finish getting dressed to leave. Consequently, she was not able to hold a job and had no social relationships that she could maintain. My client was eventually brought to see me by her husband. He was becoming extremely frustrated because she had lost the ability to function. She could not grocery shop, cook meals, meet her mother for lunch, and eventually, she was unable to even get dressed because the entire day was spent in the bathroom getting ready. This woman completely lost track of time. Hours and hours would pass while she was focused on getting herself “just right.” What we discovered was that while she was “focused” on these physical steps for getting ready, she felt no anxiety. When she was doing anything else, or more importantly, not doing these “reassuring” behaviors, she was riddled with anxiety that she found debilitating. Eventually, she found a cure for the anxiety in her compulsion, but the compulsion itself became a worse issue in her life.
As we took steps to limit her compulsive behaviors, her anxieties skyrocketed. I anticipated this and was able to prepare her and her husband, who was very supportive, to expect this and to plan for ways to contain it. They received a referral to a physician for appropriate medications and the supervision of them. Then we worked on a series of behavioral interventions and thought stopping techniques for the woman and her husband to learn in order to disrupt the compulsive behaviors. She had to gradually learn to find other ways to neutralize both the compulsive behaviors and the underlying anxieties. She had to take anti-anxiety medicines to keep her calmer so that she had the “breathing” room to be able work on changing her behaviors. Fortunately she had a good support system and was a strong, stubborn woman who was determined to get better.
In some ways, she was like the mathematician in the movie “A Beautiful Mind” who learned that he could not trust his own sensory information because his mind was playing tricks on him. He knew that he was imagining people and conversations no matter how real they sounded, or seemed. He had to learn ways to limit the damage the hallucinations and delusions were causing in his life. Because he was so brilliant, he was able to do so. If you have not seen the movie, please give it a look. It may help you to understand.
When working clinically with people suffering from intrusive thoughts (obsessions) and the need to repeat behaviors (compulsions), the therapist must work on at least two levels. We have to get the obsessions and compulsions under some level of control and that may take medicines in addition to therapy to be successful. Also, you must never lose sight of the reality that these issues are stress related responses. Where is the source of the anxiety? What is causing them to be so upset? Is it reality based, or is it a deflection or a projection onto an object that is “more acceptable” to be worried about? Be aware that these behaviors will grow in complexity and intensity. Their intrusiveness, if left untreated, will take over the lives of your clients. The therapist must provide a safe holding environment and must present themselves with confidence and quietness. You must believe that you can help them, and you must radiate that belief. You cannot be afraid of the symptoms. You cannot communicate to the client that you think the case is hopeless or out of control. If you cannot do it by yourself, get yourself involved with a team of professionals, including a physician, who can work with you and the client to achieve results. Work with the families or support systems of the client to teach them how to be supportive and helpful. Of course, for this you need permission of the client, but having a functional and helpful support system is crucial for progress to be made.
Everyone has some little snippets of these behaviors. However, they rarely rise to the level of a disorder. When you are stressed out you may discover that a song gets stuck in your head. No matter what you are doing, you hear that song intruding on your thoughts. You feel like you can’t stop it from playing. It will usually not be the entire song, but it may just be a phrase or a jingle. It will play and play and play and play……… That is a very small example of what an obsessive thought can be. Magnify that a thousand times or more and you will get a sense of what is going on for the person you are treating. Almost everyone has some form of ritual behavior that comforts them, from a baby sucking a pacifier, to a man putting his wallet in the same pocket every day. We learn to ritualize our behaviors. Think about how you get dressed. Most of us do it in the same sequence every day. If we are required or asked to change the sequence, it will most likely make us uncomfortable. It may make us upset or anxious. In severe forms, you may call it OCD.
As do most complex disorders, this disorder set requires both medical and physical interventions. It usually needs some medicines to regulate anxiety and calm the client, then it needs behavior modification to learn how to control the physical demands of the thought processes or magical behaviors. It needs cognitive, rational discussions of how to understand what is going on. The clinician needs to be open to all these modes of intervention. If possible, the clinician needs to be skilled in each of them, or to have a support team that will compliment the treatment plan. Do not forget the importance of the relationship with the client. Be connected, be supportive. Be confident and recognize that this is a very resistant disorder. It takes time, understanding and creating a safe environment to treat.