OCD is tricky because obsessive compulsive behavior is itself a kind of treatment. People engage in ritual to prevent what they fear is worse.
Take Contamination OCD.
Contamination OCD: Is when people, terrified they might become contaminated (with germs) or that they might contaminate someone, engage in ritual to prevent contamination (washing hands).
John can’t use the bathroom without washing his hands afterwards. This seems reasonable hygiene, but John washes for at least 10 minutes. He MUST wash his hands in hot water and scrub under his fingernails. This is painstaking enough, but he has also cut his fingerails very short. This, he reasons, is to eliminate the surface area to be cleaned, but it also diminishes protection of his top finger undersurface which starts to bleed and gets infected by his incessant picking and washing.
When he leaves the bathroom he must have a paper towel that he pours rubbing alcohol on (from a small bottle he carries with him at all times) and he cleans off the knob with the alcohol and the towel (if a knob exists). If it does not and there is a push door, to exit, he pushes it open with his elbow.
Why is John putting himself through this ritualistic ordeal every time he uses the bathroom? Because he “fears” contaminating himself or others. So, John is treating his “fear”
This is washing is a clue to the origin of OCD. The fear and the washing is a response to internal anxiety.
In concept, if you can lower John’s anxiety, he won’t need to take these steps.
Where does John’s anxiety come from?
It comes from “conflict.” Most OCD behaviors emanate from anxiety and the anxiety is a psychological state that emerges from “conflict.”
And, where does conflict come from? Conflict emergence from intra-psychic turbulence.
Below is a raging river. Note the rock in the middle. The water hits the rock and a massive disturbance is created, the water can’t go through the rock, it can only go around it. The rock blocks the flow, the water smashes into the rock and water goes in every direction including up, all with the goal of getting around the rock. It can engulf the rock, it can even, at times, move the rock, but it cannot (in this example) displace the rock.
The jagged white lines in this picture depict this turbulence. The smooth flow of water is impacted by conflict (the rock). Remove the rock and you still have the water flowing, but the rock creates the turbulence.
In Contamination OCD, the focus is not the turbulence (anxiety), the energy or behavior (the water), it is the rock (conflict). To treat OCD, it is essential to find and remove the rock.
MARY AND THE UNWANTED POODLE
Mary is a divorced 37 year old professional nurse with three children. She shares custody of the children with her ex-husband who is an investment banker. The children are 7, 10, and 13 years old. The ex-husband adores the children, he left Mary because he was having an affair with his administrative assistant. He has substantial resources, and the divorce was difficult. Mary got a house, joint custody of the kids, child support (partial), and alimony. The husband has a good relationship with the children. Mary knew the marriage was difficult from the get-go, but she stuck with it and hoped it would improve. The husband, Carl, had a pleasant personality, was an attentive father, and a fairly good spouse, but he was a liar and he was capable of lying about his situation for years.
Mary finds herself competing with Carl for the children’s attention. She calls Carl the “Disneyland Dad.” The children are showered with gifts, and trips, Carl is particularly found of the 10 year old daughter, and favors her. This also causes, Mary grief, because this daughter will often pit Mary against Carl using her affection.
The children want a pet, and this is one thing Carl has indicated he will not do. He doesn’t want the hassle of taking care of a dog or a cat, managing the animal in his house, training the animal, and being the caretaker when the children are not present. Mary, seeing an opportunity to get the upper hand agrees to getting a dog. She goes all out, taking the children to look at dogs, ultimately buying a pure breed toy poodle and paying a healthy sum for it.
This is a big price for Mary to pay for the children’s extra attention because she recalls as a child never wanting a dog, being afraid of dogs, and she recalls her parents regularly cleaning dog waste off their new carpet. Mary recalls the smell of dog urine. All this is highly distasteful, and probably contributed to Mary’s developed childhood fear of dogs. In Mary’s view, the dog is dirty, difficult, a constant effort. The children love the dog. Mary wants to keep the dog in the back yard, but somehow it finds a place in the house. The children begin by enjoying the dog, they prefer to play with the dog at Mary’s rather than go to Carl’s downtown apartment.
But, over time, the dog starts to create trouble. It is hard to train, Mary sees dirt everywhere with the dog, she smells dog urine frequently. She hates walking the dog when the children are not home. By de facto decree, the dog has become Mary’s dog, and it has attached itself to her. Fortunately it’s a poodle and doesn’t shed too much, but it is dark haired and her carpet is light gray. She starts seeing dog hair on her clothes, on her kitchen table. She buys a new. very powerful vacuum. The kids lose interest in the dog, it becomes a part of the family, and it is ignored. This becomes a vicious cycle as Mary gets angrier with the kids for not playing with the dog, not taking care of it when they are present, not walking the dog. The 10 year old daughter starts telling Mary that she hates her mother because she feels like her Mom is mean to the dog. The daughter wants to spend more time with Carl.
Mary has always been a clean person. She grew up in a large, very religious family and she had many duties around the house. Mary’s mother saw the home as a sacred place, she was a stay-at-home Mom, and Mary was the primary person who helped her mother clean the home. Mary was a highly intelligent child, likely the most academically gifted of the group of children, but her upbringing de-emphasized education for her. It was easy for Mary to be taken advantage of, mostly because she cared and felt very responsible for the family. It was when she became a nurse that she noticed an unusual propensity for cleanliness. This cleanliness got paired with being disease-free, ensuring a sterile environment, and other such things that fit for nursing. It was hard for her to deal with some patients with vomiting disorders, diarrhea, and other related issues, but she got used to it. Always meticulous with her own hygiene, Mary struggled with activities like sex, French kissing, oral sexual activity. She avoided most of it, and this was frequently an issue with Carl when they were married. He would call her a prude.
This background sets the stage for Mary’s contamination OCD. From her teenage years on, Mary began developing rules around cleanliness and hygiene. She feared occasionally that she could be the carrier of a disease, a virus, a fungus. She frequently inspected herself, worried about picking up herpes from drinking fountains. She learned about Venereal Disease (H2V2) and feared intimacy of any kind. In her early 20’s she started wiping door knobs to prevent contracting disease, anything dirty was suspicious. The bathroom was particularly problematic. Washing her hands before and after using the toilet, washing hands before doing the dishes, always before eating. In her 30’s she noticed her skin flaking and reddening. In her mid twenties she read about OCD and decided that she had this disorder. She contacted a psychologist, and started treatment for it. Treatment consisted of Cognitive Behavioral Treatment (re-framing her thought patterns that she “Must” wash hands compulsively to avoid spreading disease to simply rinsing her hands and noting that she wasn’t transmitting disease, that hand washing and transmitting disease was not absolutely necessary to preserve her health). When, she learned about Carl’s affair, her anger and sadness started to show in more frequent hand washing, and cleaning, the refrigerator.
Mary finds herself in a state of substantial conflict around the dog. The dog was clearly linked to her hand washing. She noted that when she looks at the dog, the first thing she sees is the dog’s anus and she assumes that when the dog sits on anything the dog is transmitting germs. She is not sleeping because her mind is focused on the dog as actively spreading disease. The dog has become attached to her, the children are attached to the dog although they mostly ignore it when they are home. The dog is incessantly barking because it wants out. It wants attention. It needs to eat and so she is feeding it. The dog smells. It has accidents on the floor, both urine and fecal matter. The backyard is beginning to fill with dog poop because neither she or the children enjoy cleaning up after the dog. One of the children was playing roughly with the dog and the dog bit the child on the arm. No blood was drawn, but it frightened the youngest child. Mary’s OCD behaviors are now out of control. She is washing her hands constantly, changing clothes constantly because she fears that a transmission feature is the dog hair. She hates the idea of the dog eating on any plates, and the children love to feed the dog scraps from the table, so the dog has taken to begging for food. Mary’s fingers are bleeding, her cuticles are super sensitive. The skin on her hands has developed a red rash. She can’t wear fingernail polish because she washes it off. She cries at night because she feels life is hopeless and there is no future. She feels immobilized. She has started missing work because her morale around the dog is low, but when she is home all she can see is this dog who now stays downstairs and barks constantly. Her peace of mind is gone and her world is out of control.
What is Mary to do?