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How I Treat OCD: Using a Strategic Pressure Approach by Lee Fitzgibbons, PhD, of Anxiety Solutions and Lori Kasmen, PsyD, and Jonathan Grayson, PhD, of the Anxiety and Agoraphobia Treatment Center, Bala Cynwyd, PA from OCD Newsletter, Spring 2004, Volume 18, Number 3 - If you would like learn more about the OCD Newsletter and/or read more of its articles, click here. When we think about treating OCD, we generally think of hope. We can think of no other disorder that can be so devastating and yet at the same time so treatable. At our centers, we often say that designing an exposure and response prevention (E&RP) treatment program is easy; obtaining compliance is an art. The first part of an ideal treatment plan is obtaining compliance, i.e., convincing the sufferer to work at her treatment. This means deciding to learn to accept uncertainty that the feared consequences, no matter how unlikely, are possible. This acceptance is a prerequisite to following through with E&RP. If the sufferer doesn't want to learn to accept uncertainty, then s/he may be engaging in behavioral and/or mental rituals to "undo" the effect of the E&RP. This is not treatment. We spend a great deal of time preparing sufferers for treatment, because pressuring or forcing someone through a program who has not really agreed to do it is generally not helpful. But what happens when the OCD sufferer cannot be convinced? If we cannot persuade the sufferer to participate, then both the therapist and the family concerned are helpless. What do we do about treatment refusers? There are a few options: Option 1: Continue to attempt to persuade the individual with OCD to engage in therapy. This approach usually fails because we have already tried to persuade her and usually others have tried to persuade her, but with no success. Option 2: Consider inpatient treatment. Option 3: If someone continues to refuse treatment after we have spent a significant amount of time educating and persuading and if inpatient treatment is not an option or has failed, then the answer for the majority of the people in this group is to stop treatment and tell them to come back when they are ready. This is better than allowing them to go through treatment reluctantly or letting them undermine their own treatment. The result of such an outcome is that they leave therapy thinking, "I did the therapy and it didn't work," without them realizing that they didn't really do treatment. That message can be very damaging to a person. So we send many people away and hope that another therapist will be able persuade them to really engage themselves in the therapy. Alternatively, we hope that the client's own suffering will eventually persuade her to participate in treatment at a later time. Sometimes, to send these people away feels very WRONG. It feels wrong when the person is not functioning and the extent of her suffering suggests that this situation will just continue indefinitely and possibly worsen. It feels wrong when a 13-year-old child cannot leave her home, is missing her childhood and she tells us that she will be housebound forever! It feels wrong when a person's rituals are causing severe medical problems that are potentially life threatening. It feels wrong when the person is 27 years old, has been housebound for 13 years because of his OCD, and, without intervention, there is no reason he won't sacrifice the rest of his life to OCD. In such cases, the sufferer is so caught up in the anxiety of OCD that he is too afraid to confront his fears, even though this is the only path to the different life he so desperately wants. Somehow, their horrible situation is just tolerable enough to make it seem easier than treatment. The reluctant sufferer's feeling is often that he has no choice - that his only option is to continue living with his obsessions and compulsions. This brings us to an assumption that we make in the approach that we are advocating. Many people who are initially reluctant to participate in treatment will choose it when they realize they need to change to have the life they want. They go into treatment when they have hit "rock bottom." In other words, people typically choose to change when they have no choice but to change. But with the sufferers that we are referring to in this article, it is as if there is NO ROCK BOTTOM. Their OCD keeps getting worse and interfering more in their lives; and, yet they continue to refuse treatment. Our goal in this situation is to define a "rock bottom" for these people, rather than waiting for the OCD to totally disable them and reduce their lives to an endless cycle of nothing but obsessions and rituals before they agree to be treated. This is where Strategic Pressure is applied. The consideration of using Strategic Pressure with the family comes long after repeated failed attempts at individual treatment. If the therapist is the sufferer's first stop for seeking therapeutic treatment and she refuses to engage in treatment, the therapist should initially try to persuade the patient to give the therapy a chance. If the client cannot be persuaded, then the therapist refers the individual to another therapist to see if she can be successfully treated elsewhere. Obviously, psychiatric evaluation and medication should be a part of the treatment. But if the individual is not progressing after repeated failed attempts or after a repeated series of partially successful attempts followed by profound relapse, at some point the question becomes: How many years will we do this before we need to try something else? It is at this juncture that family therapy utilizing Strategic Pressure becomes a consideration. There are a few caveats to using this type of treatment. The first is that this type of treatment has not yet been empirically researched. The treatment successes we have seen have been with a small sample of clients at our clinic in Bala Cynwyd, PA. The sample is small because it is a LAST RESORT treatment. We are in the process of starting a three-year project to evaluate Strategic Pressure; but, at this point, our program is based upon our clinical observations, not data. This treatment is akin to what would be done with an alcoholic or drug-addicted adolescent who is on a self-destructive course and cannot help him or herself. It should ONLY be utilized when the other options discussed above have been exhausted and when the individual's symptoms are severe and impairing or medically dangerous. This treatment does exactly what the therapeutic community typically says not to do. So, we are going against the popular wisdom. Strategic Pressure is difficult. Although there are often challenges during the course of standard therapy, it is generally a positive experience because we are helping people who want change. In this approach, we are strategically pushing people to do what they do not want to do, with the ultimate goal of helping them. There are a few rules before beginning this type of therapy: 1. This therapy can only be used with a child or adult/ child who lives at home. It cannot be done with a spouse or an adult child who pays rent. 2. It is a variant of "tough love," but we think this approach is easier to do because it is not as severe. 3. Parents cannot do this on their own. There are many reasons for this. First, parents need to change how they react to their child. The old ways do not work. We are treating the family as much as we are treating the sufferer. They need to learn new ways to respond. Second, the approach requires a thorough knowledge of how to treat OCD in the subtlest of ways. Third, the approach requires an understanding of family systems and structures. Parents cannot tweak their own family structure or change their ways alone because they are in the middle of it. 4. As we stated before, this therapy is difficult. Therefore, before starting the treatment, the family must be ready to change. The goal of using a Strategic Pressure approach is to promote success. We want to help someone improve who is so restricted by anxiety that he or she is not willing to make this choice on his/her own. We are cornering the individual so that the path of least anxiety is to choose to do treatment. The strategic part of the therapy is to set things up to encourage the sufferer into a higher level of treatment, with the ultimate goal being his/her willing participation in CBT. When we are successful, family therapy using Strategic Pressure consists of four phases of treatment. In Phase One, the sufferer's family is the client and the OCD sufferer refuses to attend sessions. The reason for the family going into therapy is explained to the sufferer as follows: We are starting treatment whether or not you want to engage in treatment. You can choose to participate or not. If you choose to participate, then you will have some control over the treatment choices made and the steps of treatment. If you do not choose to participate, all choices will be made for you. By working with the family as the client, we are able to do what cannot be done when working directly with the sufferer. The crux of the treatment approach is creating a hierarchy of symptoms. Because the OCD sufferer is not initially a willing participant, the therapist, using reports from the family, creates an exposure hierarchy for the OCD sufferer. We try to make steps small enough so that they are doable. Movement occurs through use of forced choices. The sufferer will need to do something, or else something that is slightly more anxiety-producing will be done for him/her. We are using the sufferer's anxiety to motivate him/her. The ideal is to "pressure" the sufferer with exposure to items that are higher on his/her hierarchy to do a task that is lower on the hierarchal scale. For example, for a sufferer with contamination obsessions, a choice might be: "You have to touch all the doorknobs in the house; or this rag that has touched the floor will be spread throughout the house so that you cannot avoid the contamination." Although, as a first step, this would probably be too demanding. Phase Two is when the OCD sufferer joins the family in therapy and then is able to exert some influence over treatment steps. The nuts and bolts of the second phase are very similar to Phase One. What is different about Phase Two is that "family contracting" is introduced. That is, the situation becomes more flexible: there is room for negotiation as long as the negotiation occurs during a therapy session. If the sufferer objects to a step of treatment that is proposed during the session, then he is allowed to offer a reasonable alternative that will accomplish something of similar value. There is no negotiation or bargaining outside of session in order to keep things predictable for the sufferer and to help the family prevent enabling, which just feeds the OCD. Phases One and Two are often very difficult for everyone. Parents are having to hold the line more firmly than they might like. The consistent message to the sufferer is: we are committed to doing whatever is necessary to block and fight your OCD until you are able to fight for yourself. This sometimes means locks on doors or cabinets and other means of providing barriers to OCD rituals. During Phase Two the sufferer may express great dislike for the process. When this occurs, the therapist commiserates with the client. If only the sufferer would agree to do "ideal" individual treatment, then this process would not be necessary. If only he felt able to fight for himself, then the family would not have to block the rituals and compulsions for him. The sufferer is reminded that if s/he were to actually DO treatment independently of the family and the family were to see progress, then eventually, the family might be able to bow out of the process. In such a way, the bait for individual therapy and "ideal treatment" is laid. As the process of Phase Two continues, the frustration and lack of control the sufferer has over treatment encourages him to decide to enter individual treatment on his own. Phase Three of the treatment begins when the sufferer opts to work with his/her own therapist on the OCD and the family continues to work with the family therapist. The family therapist becomes the "Bad Cop," who sets deadlines for major improvements rather than determining weekly E&RP exercises. The family therapist also continues to use forced choices to determine the consequences if deadlines are not met. Deadlines are important to prevent individual therapy from degenerating into a process where the steps the individual therapist can achieve with the sufferer are so small that they are not meaningful. The "Good Cop" is the individual therapist who helps the sufferer establish weekly E&RP goals so that s/he can progress to the larger deadlines without suffering the anxiety that will be engendered by the designated consequence. The individual therapist provides the support, encouragement, guidance and exercises that the sufferer needs to do the work. The family therapist is keeping the pressure on while the individual therapist gets the work of E&RP done. Phase Four of treatment is usually a natural evolution from Phase Three. As the person begins to succeed, the pressure exerted by the family therapist can be slowly withdrawn while the influence of the sufferer's therapist increases. The sufferer has begun to do "ideal treatment" by becoming a willing participant in CBT. He or she is no longer a treatment refuser: the ultimate goal of the Strategic Pressure approach has been met. Family members may continue to work with the family therapist to ensure that they are appropriately supportive and encouraging without enabling the OCD. As we stated at the beginning of this article, we believe that treatment for OCD is about hope. OCD is a treatable disorder. Although it is a last resort approach and a difficult process, the family therapy approach utilizing Strategic Pressure is also about hope. It provides hope for therapists who previously had to turn treatment refusers away to suffer with OCD until they were "ready." It provides hope for the families by providing a way that families can take action and fight back against OCD for their loved one rather than standing back and watching their loved one continue to suffer. Finally, we believe this approach gives hope to sufferers, often considered "untreatable" or "not ready" for treatment, who otherwise might have chosen to live many more years bound by OCD. from OCD Newsletter, Spring 2004, Volume 18, Number 3 - If you would like learn more about the OCD Newsletter and/or read more of its articles, click here. |
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