November/December 2008 Issue

Therapist’s Notebook
Social Work Today
Vol. 8 No. 6 P. 18

Read about the presenting problem, history, and initial phase of treatment in the case of a woman with obsessive-compulsive disorder described by a therapist/presenter. How do your observations compare with those of the two therapists/discussants?

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

Case of Alana
By Constance Konikoff, MSW, LCSW

At her intake, Alana, a 39-year-old nurse manager, says in a pained voice, “I think it’s possible that I’ve killed someone. For the last week, when I’m driving those dark country roads home, I hear a thump and think I’ve run over someone.” Alana says she checks the road for up to three hours, reads the newspaper for reports of a found body, and asks her husband for reassurance several times a day. The precipitating event for treatment is the fear of having killed someone.

Other longer standing compulsions began after a bout of strep throat at the age of 33. Alana’s rituals occur in multiples of five (e.g., washing her hands five times to avoid contamination, checking the iron and door locks five times), fearing that if she doesn’t complete them in this way her mother, a healthy 61-year-old woman, will crash her car the next day.

Obsessive-compulsive disorder (OCD), the doubting disease, makes it difficult for Alana to live with uncertainty. She knows it is unlikely that she has run over someone or that her mother will crash, but the fear is real. In a shamed tone, she reveals that she obsesses about losing control and yelling a curse word in church, doing something sexually inappropriate during her dental checkups, or stabbing someone if she’s holding a knife in the kitchen.

Alana says she is exhausted at work and irritable with her coworkers. A few have asked her if she’s OK. She denies suicidal thinking, and her sleep is surprisingly undisturbed, though she naps for two hours daily saying, “It’s the only real relief from this worry.” She reports that her aunt and grandmother have “irrational fears.” She has no history of self-harm, impulsive violence, psychosis, or head injuries.

 I tell Alana that her symptoms are so common, they’re on a checklist to help identify OCD. I emphasize that people are more than their diagnosis, that she has many strengths and can face the challenges that life brings, so when she’s ready, I’d like to hear more about who she is.

Alana has been offered her dream job in Idaho, her vacation destination for the last 10 years. She and her husband are thrilled, though it means leaving good friends and family. Her psychosocial history reveals that although she and her mother are close now, during Alana’s childhood, her mother was overwhelmed caring for five children while her father worked long hours in the oil field.

Alana reports three years of therapy after nursing school that she found very helpful, using inner child work, boundaries education, and Eye Movement Desensitization and Reprocessing for her fear of anger. Her diagnosis at that time was generalized anxiety disorder. Mindfulness, relaxation training, and cognitive therapy in conjunction with a strong relationship with her therapist were very helpful. She has become puzzled as to why, with her extensive therapy and excellent results, she would still have periodic OCD symptoms.

I explain that OCD tends to wax and wane over the course of a lifetime, intensifying in times of stress, even positive stress, and that her strep throat may have chemically triggered this intensification. Strep can trigger OCD in people who never had it before, and OCD often targets causes close to the heart, so the obsession seems somewhat plausible. I validate that her effective past therapy helped her to individuate, build a mature sense of herself, and reduce generalized anxiety, and that we should consider adding a crucial component of exposure and response prevention training (E/RP) to manage the OCD specifically.

 I explain the protocol of E/RP, a form of cognitive behavioral therapy, shown in a number of long-term studies to stop OCD in its tracks for many people, keeping it managed over time and freeing energy for living. Alana is visibly calmer to hear that her past work was legitimate, and we just need to add a piece for the OCD.

Together, if she agrees, we will begin to treat the OCD in a systematic way after completing her psychosocial history to identify any other goals she may have. I expect that her depression will remit with the OCD. To lower overall stress, she will need to directly cope with the changes she is considering in her life (the job change and a move); however, it is the E/RP that will give her long-lasting skills to manage the OCD symptoms.

For E/RP, she will begin by rating her on the subjective units of distress scale (SUDS) from 0 to 100 for each obsession, and then she will choose one to challenge in the 40 to 50 SUDS range, since success at this difficult level is probable and gives hope to challenge tougher obsessions. We’ll do some imaginal E/RP in the office for teaching purposes, but follow-up homework is key. For the potential hit and run, she’ll choose not to check the roads or the newspaper, while expecting her anxiety to increase temporarily until it naturally drops. To make that tolerable, she will use mindfulness to observe her reactions without responding to them, supported by breathing, relaxation, and talking back to OCD to challenge the fears. As she tolerates the sensations of fear, she will use distraction by doing, in an OCD moment, what she’d prefer to do if she didn’t have OCD rather than allowing OCD to dominate her, thus breaking the chemical chain of the OCD moment.

 Challenging core beliefs about uncertainty, doubt, and assuming responsibility coupled with the changes that managing the OCD will bring to her life will enable Alana to face the exposures and minimize the OCD and even eliminate it in some cases. With her permission, Alana’s husband will be included as a trained ally to interrupt the reassurance seeking that reinforces the OCD. Alana must be careful about not using mental strategies of avoidance such as “I can check later.”

Alana is hesitant to try medication. Research shows that, for many, E/RP is as effective as medicine; however, medication helps to lower the decibels on the call to worry and takes the edge off the erroneous fear message her brain is sending that triggers terror when caution would do and worry when not even caution is warranted. Her courage combined with skills and a caring team will prevail.

— Constance Konikoff, MSW, LCSW, is in private practice in Lafayette, LA. She treats pediatric and adult OCD, inspired by the approaches of John March, MD, MPH, and Edna Foa, PhD. Marital therapy and trauma work are her special interests.

Discussion No. 1
By Jeannette Sinibaldi, LCSW

The diagnosis of OCD in this individual is evident in all the symptoms she describes. The work of helping a client who comes in with ritualistic behavior and intense fear and anxiety is a challenge for both the new and well-seasoned therapist. Above all, OCD must be recognized and understood as an intense anxiety disorder. The disorder must be discussed as an illness and a treatment plan agreed upon with the client from the start in order for any work to be successful.

I use mindfulness and meditation with clients confronting obsessive thinking and the compulsive undoing behaviors. As for Alana’s situation, the therapist should show compassion to her client’s daily suffering. Understand that the client’s life has become unmanageable due to rituals and the noise of relentless thoughts in the mind. Explain that treatment may require some discomfort, but life will become more manageable. A mantra of “I will give up control to gain control” is essential for the client.

The therapist may explain to Alana that she has created an illusionary house of mirrors to cope with anxieties and existential worries that we are born with. The metaphor is to help with anxiety that develops as she stops the compulsions associated with the obsessions. Alana’s thoughts are like the mirrors in a fun house. They are real mirrors, and they reflect an exaggerated image of her. Individuals with OCD keep trying to adjust themselves through compulsive behaviors to deal with those mirrors.

With meditation and guided imagery, clients learn mindfulness and to witness their own mind’s workings. They learn that they have created a house of mirrors of their mind’s distortions and have been unable to escape.

Examine the clients’ accomplishments. Find out if they can swim, drive a car, or ride a bicycle. If they have achieved any of the above, the prognosis is good for coaching them through this method of release from the imprisonment of OCD.

As with driving, swimming, bike riding, or any other accomplishment, they will depend on their teacher to train them to deal with life’s anxiety in a different way. At this point, clients should start journaling about their progress of not responding to their compulsions when obsessive thoughts arise.

The therapist may compare medication with any other aid for accomplishing the goal. If a student cannot read the blackboard or see street signs when driving, corrective eyeglasses are required. The therapist can help the client to understand that this illness is ingrained in brain pathways. Sharpening the brain may be needed to gain control, get out of the house of mirrors, and realize thoughts are created mirrors of the mind. If the brain’s “vision” is not sharp enough to realize this, frustration arises and the student feels stupid. Medication can assist with this situation.

Therapists should remain calm and firm throughout this part of the treatment. Clients’ fear of medication reflects the challenge in the mantra given to them—“I must give up control to gain control.” It is with this understanding that they progress. Bring clients back to focus on how out of control their lives are and keep them in that reality.

 Alana has thoughts that she will stab someone when holding a knife. She can calm herself with the image of the house of mirrors and concentrate on making her mirror disappear with rhythmic breathing. She can witness her distortion. If anxiety rises, the use of highly mentholated cough drops may help the client to feel relief in breathing. She can understand that she is creating her mirrors and watch herself. She can time how long she can go before she needs an “undoing behavior,” if at all. Therapists can go on outings with clients to reinforce the use of this technique.

With a motivated client, compulsive behavior extinguishes in a short amount of time. The interesting factor is that the therapy often turns to the underlying anxiety that propels the OCD.

Treatment of clients with OCD is difficult and demanding at times but certainly rewarding when life opens up to entangled and trapped individuals.

— Jeannette Sinibaldi, LCSW, is in private practice in Queens and Long Island, NY.

Discussion No. 2
By Sheila Peck, MSW, LCSW

When I was quite young, I almost drowned. My mother, instead of panicking, insisted that I go back in the water and learn to swim. Someone taught me how to swim, and now when I’m in the water, I have a sense of control combined with prudent and organized decision making about what is and isn’t safe to do. Alana needs to work on a way to develop the emotional equivalent of this for her OCD symptoms. She and her therapist have worked hard on developing a number of ways to accomplish this. However, they may want to use some of the following recommendations in their work.

A sense of control and the fear of “losing it” are basic components of learning to live with OCD. I would advise the therapist to strongly recommend that Alana try medication to get through the difficult patches. Alana could access a variety of Web sites for knowledge and reassurance. When working with Alana on her need for control, the therapist may ask whether the hesitancy about medication is due to a fear that the medication could have too much control over her.

Because the anxiety generated from her fear of having killed someone could interfere with her driving ability and increase the possibility of having an actual accident, Alana should consider medication as soon as possible. This would also enhance the central idea that Alana is more than her OCD.

Alana and her therapist need to review what is controllable and decide on goals that Alana can achieve. They could make a list of what needs to be done and prioritize it.

Alana also needs self-talk to remind herself that anxiety is only anxiety and will pass. She and the therapist could construct a sentence that Alana can use in the midst of panic; since anxiety may cause her to forget, it should be written down on an always-available card.

They may also want to develop a list of caring friends and family who Alana can call just to tell them she’s having a panic attack. The effort of holding it in or hiding it, which many OCD patients do, often makes it worse. These people should be told that they’re just there to listen, not reassure.

The therapist’s suggestion of imaginal flooding could be another means of working with Alana. Because one needs an active imagination to think up the “awful possibilities” in OCD, the therapist should utilize this in the treatment. Fantasies may be especially useful to bring about this imaginal flooding, always reassuring Alana during such a session that the therapist is there, and the experience is imaginary. Alana also should be reminded that anxiety feels bad but will eventually pass and that it arises when she feels out of control.

The therapist may ask Alana to write down all her “worries” and then schedule (at her own convenience) a daily “worry session.” Thus, whenever she is discomfited, she can tell herself, “I’ll put that off until it’s worry time at 5” and try to overlook it until then. It may be hard for her to commit to following through on this. However, this methodology may help Alana learn the necessary skill of tolerating her anxiety.

From the case description, Alana has already tried and learned a number of techniques. There are so many possibilities from which to choose that it’s important that neither the patient nor the therapist become overwhelmed. The latter could become swamped in the whitewater of Alana’s symptoms, such as a kayaker trying to go upstream. The therapist must keep the process and the program focused in her own mind so that she can provide a life preserver should a dangerous flood of feelings arise.

Alana’s husband should certainly be included as a “coach,” but I suspect that the therapist will have a problem getting him to interrupt the reassurance seeking that reinforces the OCD. Most likely, his own anxiety rises quickly when Alana is in such a state. He must be convinced that reassuring her might actually be damaging to both of them. Other options that could be considered are family therapy and group therapy. OCD patients often do well in these milieus.

If Alana and her husband decide to move to Idaho, the therapist would need to find another clinician to continue therapy. With Alana’s permission, the therapist should take the time to thoroughly update the new clinician, and Alana should speak with the potential new therapist to put herself at ease.

I am hopeful about Alana and admire the work that she and her therapist are doing. If they remain sufficiently focused, I think Alana’s symptoms will diminish, and she will be comfortable enough to enjoy the move to Idaho and her life in general.