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Obsessive Compulsive Disorder

Obsessive Compulsive Disorder, also known as OCD, is a complex and difficult disorder to understand and to treat.  In order to deal effectively with it, it is important to understand what it is, why it occurs, to whom it occurs and, what can be done about it.

Most of what is being written about OCD I find to be partially helpful at best.  The experts who are writing about it mostly come from a biological, cognitive and behavioral perspective in terms of theory and therapy.  What this means is that they believe OCD needs to be mainly (and sometimes completely) treated with medication, by challenging a person’s thoughts and beliefs, and with a series of behavioral modification trials that reduces the person’s symptoms.  While there are reasonable successes with these treatments there is the problem, in my opinion and in the opinion of many other clinicians that these therapies never get to the bottom of “why” the person is suffering from this particular disorder.  Another way of saying this is that the cognitive/behavioral approach treats the symptoms not the causes. 

Some would argue that the cause of OCD is primarily or completely biological/physiological.  The theory is that since the disorder is genetic the person suffering from OCD is doing so because they have a chemical imbalance and that with medication this person can have a better, more normal balance to their body chemistry.  My intent here is not to discourage any patient from taking medication.  I believe medication to be an integral part of most patient’s treatment plan.  I would never want a person as a result of reading this article to stop taking the medication their doctor has prescribed.  These are highly important decisions to be made by the patient and their doctor. 

My purpose in writing this article is to raise what I believe to be extremely important issues related to OCD; issues that I don’t hear being discussed or written about.  I believe what you are about to read can make a significant difference in the relief that you are trying to achieve.

Let me begin by explaining what OCD is.  The word “Obsessive” in OCD represents unwanted and recurring “thoughts” that won’t go away.  The word “Compulsive” refers to repetitive actions that are also unwanted and that won’t go away.  For example, a person may be walking to school and the compulsive behavior may be to not step on any cracks and that if he does he will have to go back to the beginning and start the walk to school all over again.  The obsessive thought may be that if he doesn’t go back to the beginning of his walk that something horrible will happen to an important person in his life.

OCD also centers on a few different areas.  The most classic area is an obsessive fear of dirt, germs, or contamination, but equally distressing obsessions can involve such things as repeated doubts (e.g., did I lock the door?, did I shut off the gas oven?, did I run someone over on my way to work?), aggressive or horrifying impulses (e.g., to hurt someone like a child or to yell out obscenities in an inappropriate place such as church), an obsessive need for order (e.g., a person gets extremely upset if things are not in their place combined with a need for everything to be symmetrical.  This also includes the need to walk without touching a crack), and unwanted sexual imagery which may be pornographic in nature that causes the person great distress.  The final area that OCD can center around is hyper-religiosity and an over scrupulosity.  This person suffers from the intense fear that they will not go to heaven and that God will reject them for something they have done wrong.  They have a difficult time believing they are saved and will often respond to alter calls many needless times to assure themselves that their salvation is real. 

In order to better understand the disorder let me expand on two of them. 

The obsession of contamination often leads the sufferer to compulsively wash their hands, to avoid public restrooms where more germs are likely to be more prevalent, or to use tissues to avoid touching any surface that someone else has touched.  While it makes sense to be clean in your hygiene, the person who suffers from OCD takes this to an extreme level often resulting in dry and bleeding hands.  It becomes such an obsession that it becomes the primary thing the patient thinks about.  You only have to think about Howard Hughes and the movie “The Aviator” to get an extreme glimpse of this form of OCD.   

Another area that OCD centers on is morals, religiosity, what is right and wrong, and scruples.  In other words, an OCD sufferer with this form will constantly be scrutinizing their thoughts and behaviors.  A common name clinicians and theorists have used is the word “scrupulosity” to refer to this obsession.  With this form of OCD there is an extreme tendency toward self-condemnation.  This is especially common among those who consider themselves to be devout in their religious beliefs and rituals.  This has led many in the field of psychology to blame religion as a major contributor to OCD and many other mental health disorders.  Some want to abolish religion altogether and seem to be on a crusade to do so.  To these clinicians it makes no sense to integrate psychology and religion.  I have seen many OCD sufferers of this kind because my practice serves almost entirely the Christian community.  In my opinion this is a silent epidemic in the church because few people who suffer from this share it with anyone for fear of being thought of as crazy. 

Those with OCD also take on a certain profile.  They are usually highly intelligent, sensitive individuals.  People with OCD are some of the nicest people you will ever meet.  They are the kind of people who

tend to be people pleasers.  They also prefer to hurt themselves rather than other people. At the end of the day, they say to themselves, “if anyone is going to take the hit on this one it is going to be me.”  When they do this they usually don’t know that they are doing this to themselves.  They also tend to take on too much responsibility for what is going on around them.  They have an overly guilty conscience.  Their temperament is usually melancholy.  Because of this temperament type there is a hypersensitivity to the stimuli around them.   

To illustrate what I am saying let me cite a few examples.  When a person who has OCD hears instructions from an authority figure in their life they take these instructions to heart, 110%, and literally.  If the person is in church and they hear a teaching from their minister (an authority figure) on something from the Bible (an authoritative document), they will seek to live out this teaching 110%.  The question in their head would be, “if I’m not going to do my best then why do it at all?”  They also get irritated with others around them that do not take the teachings as seriously.  This is an illustration of the rigid type of thinking and the judgmental attitude that exists in an OCD mind. 

Another example is if this person with the hypersensitive temperament hears from his mother that it is very important to wash his hands after going to the bathroom, he will take this to heart and wash his hands thoroughly every time.  He will then generalize this hand washing to other areas and places in life.  This happens because he will reason if it is that important to have clean hands, and that germs are that dangerous, it makes sense not to touch any more than he has to and to make sure he washes his hands if he does.  What originally was meant by his mother as a caring, parental act is turned into an obsessive/compulsive act by his temperament which takes all of life too seriously.  Parents need to be observant when they instruct or reprimand their children to notice if the child takes what they are

saying too seriously.  For these children, something as harmless as a stern look can be crippling.      

This is a great segue into parental responsibility and its relation to and with OCD.  Usually one or both of the parents are rigid and authoritarian in their style of parenting.  This parent may have OCD himself.  Either way, the way these parents approach life is with black and white thinking.  It would be disgusting to this parent not to wash one’s hands after going to the bathroom and before eating.  These beliefs would be the beginning of personal hygiene.  There is nothing wrong with good hygiene.  The problem is in how this message is communicated: rigidly.  Even though it has become politically incorrect to point the finger at parents and to hold them responsible, I must state that I believe the parents are always involved in the formation and the maintenance of OCD.   

The etiology of OCD therefore involves the unique collection and confluence of a variety of important factors.  It begins with an extremely sensitive child with parents who fail to recognize this hypersensitivity combined with rigid parental expectations.  Another important etiological factor is that the expression of emotions is not allowed or downplayed by the parents.  This holds true especially with the emotion of anger.  Anger plays an extremely strong role in the development and continuation of OCD.  What happens is the following:  1. a child is born with a hypersensitive temperament, 2. the parents raise him rigidly, 3. the child becomes distressed and angry at the parents for this rigidity, 4. the child is not allowed to express these emotions, 5. the child’s hypersensitive temperament internalizes this anger, 6. the power of the anger becomes displaced into the symptoms of OCD.  Therefore, OCD is the symptomatic expression of displaced anger. 

The theory behind all of this is that the repression of the extremely powerful emotion of anger has to show itself somewhere or

in some way.  If you picture yourself in a swimming pool and that you are pushing down (repression) a beach ball (the anger) you will soon realize how much energy it is taking to hold the ball down.  If the ball gets away from you it will resurface in a different spot (displacement).  When the ball comes to the surface in a different spot it will appear different only in the sense that it is in another place.  This difference is evidenced by the symptoms of OCD.  In other words, the symptoms of OCD replace the feelings of anger that are repressed.  This shows the enormous power of the feelings of anger and the threat they pose to the person with OCD.  In order to deal with the threat of the power of anger the person represses the anger and pays the price of having OCD instead.  It is as if the person with OCD is saying unconsciously to themselves, "As difficult and painful as the symptoms of OCD are, I would rather deal with them than have to face my anger."

When I am presented with a person who suffers from OCD, I know the person will be intelligent, nice (in fact too nice), angry and not know it, and that their symptoms are preferable over the expression of this repressed anger.  These clients are great to work with because they are motivated to reduce the pain of OCD and once they are let in on what is causing the symptoms they realize there is something they can do about it.  This creates much hope for both the client and the clinician.

Treatment should therefore be aimed at reversing the above pattern.  It is extremely important to help the client get in touch with just how angry he is. In addition it is important to educate him that his tendency is to blame himself instead of others.  He should be told that he takes too much responsibility for the various conflicts that arise in everyday life and his personal interactions.  He needs to be taught to become less passive and more assertive.  Assertiveness will teach him how to achieve conflict resolution without the fear that he or the other people involved are going to die if he presents his anger in a

healthy way.  There are many good books on assertiveness and the client should be encouraged to read in between counseling sessions.  Journaling is a good way to access repressed emotions and another good way to keep the client engaged in the growth process while not in session.  I also use a technique called “the empty chair” in which the client talks to an empty chair.  I ask them to envision and talk to, in a role play situation, a person sitting in this chair with which they have unresolved issues.     

In counseling someone with OCD I rarely talk about their symptoms.  To me this can be a waste of time unless it is done to educate the client about some issue related to OCD.  I think there is a benefit to cognitive/behavioral treatment modalities especially if insurance demands short-term therapy and to bring some relief in the early stages of treatment.  After that, I try to go as deep into repressed feelings as soon as possible.  Fundamentally what I am saying is that OCD results from faulty interactions within relationships resulting in powerfully repressed emotions that are then displaced into the symptoms of OCD.   

This method of treatment can be very relieving to the client for many reasons.  First, the displacement theory has always made sense to the clients that I have explained it to.  Second, this gives the client a framework from which to view their symptoms and, therefore, provides grounding.  Thirdly, the theory reduces the guilt the client has over the distress that their OCD has placed on themselves and others.  Paradoxically, it also causes the client to take responsibility for the anger they feel and repress.  The responsibility is reflected in the owning of their feelings and then the need to express their anger in a healthy and assertive way.  The reduction of displaced and repressed emotions brings the reduction of OCD symptoms. 

It is my hope that this article has shed light and insight into what OCD is, where it comes from, and how it can best be treated.  The good news to those who suffer from this disorder is that OCD responds very positively to treatment and is, at times, completely curable.  Because people with OCD take too much responsibility for what is going on with significant others with whom they are in relationship, it is an easier transition to make to reduce this tendency when compared to other disorders where the person takes too little responsibility.  I often find that when treatment is successful and terminated, the client has learned a great deal about themselves, about how to relate assertively, about their feelings, and even about God Himself.

Sincerely,

  Paul J. Staup, Ed.S.