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OCD - Overcoming the Fear-of-Being-Filthy with an 'Exposure Agreement'
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In the last section, we examined the various substances that panic disorder clients misuse most commonly, which are caffeine; illicit drugs; and alcohol.
Many times, a client’s own anxiety results from an underlying disorder which causes them to repeat or avoid situations or events. This disorder, as you know, is obsessive compulsive disorder, or OCD.
In this section, we will discuss three steps in treating OCD clients, which are identification; exposure; and self-talk.
Three Steps in Treating OCD clients
♦ Step 1: Identification
The first step in treating a client with OCD is identification of the client’s obsessions. There are numerous manifestations of the disorder that could range from very mild to extremely severe and debilitating. When a client feels that he or she has not completed the ritual or that something has not been done correctly, he or she becomes anxious.
According the Maudsley Hospital in London, compulsive rituals are distributed in the following percentages. Since some clients report more than one ritual, the following percentages will total more than 100:
♦ Technique: Obsessive Compulsive Checklist
Kelly was a 21 year old client of mine who reported having trouble with controlling her impulses. To get a better idea of the extent of her compulsions, I asked Kelly to complete the "Obsessive Compulsive Checklist".
I gave Kelly a list of activities and asked her to score them from 0 to 2. Zero indicated that she had no problem with the activity and that it took her the same amount of time as the average person with no avoidance or repeating. A one indicated that the activity took her twice as long as most people, or she has to repeat it twice or that she tends to avoid it. A two indicated that the activity takes her three or more times as long as most people, or that she had to repeat three or more times, or that she usually avoided the activity altogether.
The list of activities included but was not limited to the following:
-- Washing hands and face
-- Using toilet
-- Touching people or being touched
-- Bed Making
-- Turning lights and taps on or off
-- Locking or closing doors or windows
-- Form filling
-- Mailing letters
Some activities that Kelly rated with a two were: using toilet, washing hands and face, and touching people. As you can see, Kelly was concerned about cleanliness and her anxiety arose if she felt at all dirty or unclean.
♦ Step 2: Exposure
The second step in treating OCD is the start of exposure. As we discussed in section 6, exposure is a way to acclimate the client to the activities he or she avoids or repeats. Exposure, according to research, is one of the most effective and long term treatments of OCD. To help Kelly overcome her fear of being filthy, I asked her to sign an "Exposure Agreement".
Together, we made a list of activities that would otherwise cause Kelly to feel anxious or unclean. She then signed her name at the bottom of the agreement, assuring me that she would practice the following list of activities.
- "Contaminate" my hands by touching garbage can, toilet seat and brush, wheelbarrow with rubbish in it, bird aviary, bird droppings, raw meat. Touch laundry basket and clothes whenever I pass them. Hug my three sons regularly. Fill the dog’s water bowl then touch taps in kitchen with unwashed hands.
- "Contaminate" work surfaces, plates, cutlery, pots, and all food before eating.
- With unwashed hands, lie on couch, answer phone, and touch switches and door handles, television and curtains,
- After touching the garbage cans, tidy beds, lie on them, and handle items on the dressing table.
- Touch the toilet seat and thereafter towels, switches, medicine cabinet, and my own hair.
Through these simple activities, Kelly gradually became less and less anxious about germs and uncleanliness.
♦ Step 3: Self-Talk
In addition to identification and exposure, the third step in treating an OCD client is Self-Talk. Because Kelly could not do these activities without some form of anxiety, I also asked her to try "Self-Talk" whenever she began to feel the urge to clean herself or the other objects in her house. For each activity, Kelly wrote out phrases to say to help relieve some of her stress.
For touching garbage cans and other unclean objects, Kelly would say, "These things are not dirty. I will not die by touching these things. I am in no danger of infection from touching garbage or other things." When she hugged her sons, Kelly would say, "I love my sons, and because I love them, I must hug them. They are clean and would not do anything to hurt me. I need to show them my love." Think of your Kelly. Could he or she benefit from Exposure and Self-Talk?
In this section, we presented three steps in treating OCD clients, which were identification; exposure; and self-talk.
In the next section, we will examine three other social avoidant behaviors more extreme than agoraphobia. These three behaviors are social phobia; social skills deficit; and dysmorphophobia.
- Robin, M., Ph.D, & Balter, R., Ph.D. (1995). Performance Anxiety: Overcoming your Fear in the Workplace, Social Situations, Interpersonal Communications, and the Performing Arts. Holbrook, MA: Adams Media Corporation.
What are three steps to treating an OCD client?
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