Obsessive Compulsive Disorders (OCD)
part 8

Since Kim was only 9, her parents and I thought exposure was pretty much out!  We came up with a counting exercise that she could use to prevent her from thinking of these things.  Every time she started thinking these things she would count backwards by 5s from 100 and take deep breaths. I also tried to get her to label these thoughts as bad thoughts that were from the OCD and thoughts which she didn't really want to think.  Kim loved dogs and so we got her to use the same analogy with the OCD.  The OCD was a big dog she was taking to obedience school.  We worked on her saying, "Down, OCD, "sit" to the "OCD" dog.  Well, her mom and I thought this all sounded pretty good.  She started counting and the obsessions disappeared.  Unless of course she thought she made a mistake counting, then they would come back!  So we had to change things around again.  Labeling the thoughts as not hers helped only a little.  In the end, we worked at this for about two months, but the obsessions kept changing and we weren't making any progress, so we decided to add medications to the treatment.

Although Richie loved to count, some things he had to count.  To start with, Richie went out with his dad on the wharf.  They counted the boards on the way out to the boat.  Richie counted them once, but wasn't sure.  He was able to then leave the wharf with his dad without counting and go home in the truck, having never properly counted the boards.  It made him nervous, but he was able to do it.  After a few tries at that, we picked something that was a little more difficult.  We picked steps in the house.  Richie was almost sure there were 40 steps, but never absolutely sure.  So, between Richie, his Dad , we started a little race.  Richie and his Dad would start at the bottom of the stairs each afternoon.  His Dad would say, "Go!" and they would both run up the stairs as fast as they could saying, "OCD can't get me" .  Who ever got to the kitchen counter first grabbed the loonie that was there.  If Richie did this every day, he could get 14 dollars by the time I saw him next.

That worked pretty good.  The confidence this gave him really helped when we took on some more of his counting problems at school.  There we had him go and do similar things with his Dad after school initially, and then eventually during school.  He would sing a song in his head the whole way down the hall instead of counting.  In class, every time he started to want to count, we worked out a little substitution game.  He would grind his foot into the floor as if he was grinding OCD into the floor.  These things worked well for Richie, and he never relapsed or got other symptoms of OCD.

When I discussed the idea of exposure and response prevention with Ashley and her mother, Ashley wouldn't do it.  She wondered how doing these things was going to make her think about AIDs less.  She was convinced it would make her think about AIDs more.  She also thought at times that we were just suggesting this because we didn't want her to know she really had AIDs.  Only sometimes did she see this as a goofy idea.  So, I gave up.  She agreed to take medications, because she thought maybe they were for AIDS and we just weren't telling her.

When Andrea and her dad came back for their appointment, they had already figured out a good program for treating this doubting.  The next day, Andrea and her Dad went out driving together.  Her father just rode along.  They drove to Yarmouth right at noon hour and went past kids, schools, and quite a few dogs.  Andrea would ask her Dad, "Do you think....?"  Her Dad just answered, "I don't know".  When she would pull over and want to turn around, then her Dad got more involved giving her a pep talk about beating OCD and not letting your nerves ruin you.  Well, that was one noisy car!  They did this every day for a week and by the end of the week, she pretty well had it.  She never pulled over any more but still had the thoughts to a certain degree.  The next assignment is she drives alone and her Dad times her, knowing that if she is late it means she is checking.  It will also mean she buys the gas for a week.

There is usually no way to do exposure when people have pure obsessions and mental acts.  We tried having Ann make the shapes she sees in her mind and then not cut them in half, but it didn't bother her at all; it was not at all close to the real thing.  We tried having her not do this obsessions for just a minute, but she just couldn't control it in the slightest.  We tried thought stopping and labeling this as OCD, as mentioned above.  It didn't work.  She went on medication and improved dramatically such that she never did have to use any of these techniques.

It was a good time of year to try therapy with Darrel, as his dad was gone every day lobstering.  In co-operation with his mom and Darrel, we came up with a plan.  First we would try having him leave just one thing out of order and see if his Dad came home safely.  Then we would try another and another until he was leaving things quite out of order.  At the same time, his mom would limit the time he could spend in his room by 15 minutes every week.  That meant this week he could only spend two hours in his room.  So, off they went ready to do this.  By the time the next day rolled around, Darrel had changed his mind.  He did not want to co-operate.  He went in his room and refused to come out for three hours.  His mom was not big enough to force him to come out and no amount of rewards or punishments would either.  When they came back we agreed that even though we wanted Darrel to get better, Darrel didn't.  Darrel refused to see me again.  In the end, when faced with repeating a grade and being in the same class as his younger brother, he did do less ritual ordering, but not that much less.

After we had discussed what OCD was, Kelly, her mom, her boyfriend, and her boyfriend's mom all came in.  We decided that Kelly would be allowed a certain number of "doubts" a day.  If she went over that, no one would answer her.  Kelly picked the number to start with, 30.  So the first week she asked the above people about 35 times a day, but they didn't answer after the 30th.  Since they all lived on the same road in the same village, it was easy to coordinate.  Each week the number of "doubts" she could have went down.  At the same time, we worked on substituting.  When she was tempted to ask questions about whether or not he loved her, we trained her to either say, "I Love Gary" or, if he was there, say that to him and give him a kiss.  Three months later, she was completely better, but still had these thoughts occasionally.  She never told anyone, not even her boyfriend.

When Deb got to the hospital, she was very, very angry.  She did not believe this was something that was medical in nature.  This is between me and God, she would say.  Even in the hospital she spent hours praying and obsessing.  So we brought in her priest and talked to him about OCD.  He knew about it anyway.  So he tried to explain this to her and reluctantly, she agreed to treatment.  She refused any medications.  The treatment consisted of her initially playing ping pong on the ward with the priest for 15 minutes each day.  This was under the condition that she try not to pray at the same time.  Each day another activity was added.  If she was obviously obsessing, then the priest would not visit.  Things were not going great after a few days, but looking better.  That night Deb cut her wrists with a light bulb.  It was not serious.  She said she knew she would never be better and would be going to Hell anyway, so why not suicide?  Eventually, Deb agreed to take medications, which thankfully worked and she was discharged to home.  Deb still attended Mass almost daily, but she was able to function in other parts of her life without any problems.

Cleaning rituals are usually one of the easiest things to treat with behavior treatment.  Part of the treatment involved response prevention.  That is, we didn't want him to wash his hands so much.  But before we could do that, we had to get an accurate idea of how often he was cleaning his hands.  So, there was a sheet taped to the door where Sean could make a mark for each time he went in the bathroom.  Even Sean was surprised at the number of times he was there in a day - about 30.  Sean's mom bought a little timer for cooking which went off in 2 minutes.  When Sean went into the bathroom (his parents bathroom was now to be locked) his mom turned on the timer.  In 2 minutes, she called out, "2 minutes more!" and set it one more time.  Then she came in the bathroom, which now had no lock from the inside, thanks to Sean's Dad.  Then she would ask him to come out.  If he didn't come out, he went to bed early.  If he still didn't come out, no video games for the day.  If he still didn't come out, she would call her husband to bring him out.  It never came to that at all.  At the same time as this was going on, Sean worked with his Mom on not washing his hands after touching certain things that other people touched.  It started with chairs, but was eventually to move to toilet seats.  He was to first go one minute, then two minutes then more without washing.  This second part never happened.  The timer in the bathroom did the trick.  Over a month's time the hand washing went down to 6 times a day.  Now, six months later, when Sean starts to spend more time in the bathroom, all his mom has to say is, "Sean,. do I have to get that timer out again?" and it stops.

Rob was pretty motivated to stop checking.  The first thing we did was to come up with a list of his "top ten" checking.  It turned out that his fly was at the top of the list.  So we started with one that was not such a big deal, light switches.  The plan was that he would go out of a room with his older brother (20 y.o.) and Rob would turn off the lights once, and then the two of them would leave.  At first for a short time, then a longer time.  At first with his brother, and then alone.  Well, it was a breeze, because that compulsion was basically gone by the time we got things set up to get rid of it.  Same thing with checking his fly, by the time we set up a program, that checking compulsion was gone, too. Unfortunately, new obsessions and compulsions were coming up all the time and there was not a lot of stability to the symptoms.  After a month of chasing compulsions, we decided to try medications.