Obsessive Compulsive Disorder Responds Well to Cognitive Behavioral Therapy by Lourdes Valdes, Ph.D.
For 17-year-old Samantha to study, her notebook must be exactly aligned with the edge of the desk. All of her subject books must be lined up on her desk in height order. Her pens and pencils must be lying down next to one another (in size order) and they must be aligned with the edges of the desk and with the notebook. Samantha knows this is silly, but she just can't seem to stop herself.
Each time Jenny (11) says goodbye to someone she loves, she must kiss them in the left cheek, then the forehead, and then she must say "See you later,alligator" (in that order), she worries that if she does not do that, something terrible will happen to them.
Every morning in the car, 13-year-old Preston must ask his mother three times if he is going to have an okay day at school and his mother must say "yes, of course" all three times; if his mother says anything else, he will become very upset, demand that she give the right response, cry, or refuse to get off at school.
Sarah, who is only four and very neat, will get very upset if her mother stirs her chocolate milk towards the right instead of the left.
Eight-year-old Michael must be perfect at school. He must make perfect letters, his coloring must not go outside the line (not even a little bit), his clip must stay in green at all times, and he will become very upset if he makes a grade other than "A" in any assignment or test. If he is not perfect, he must do it (for example, his writing) over and over again until he gets it perfect. The helpful and unavoidable errors and mistakes that we all make when learning something new make it very difficult for Michael to acquire new skills or learn new information.
Over one million children and adolescents in the United States have Obsessive Compulsive Disorder (OCD). Obsessions are thoughts that are irrational, intrusive, repetitive, and seemingly uncontrollable to the person who is experiencing them. Compulsions are actions; impulses to repeat an irrational act or behavior over and over again. Sometimes compulsions are developed to try to relieve obsessions. Jenny in the example above may have an obsession that something terrible is going to happen to someone she loves and her OCD has also developed a compulsion – her goodbye ritual that must be done each time to prevent the tragedy that she worries about. It is believed that OCD runs in families and may be rooted in communication disruptions between the front part of the brain and the deeper structures.
Children and adolescents with OCD may have diffi culty finishing homework, doing chores, or making friends because their disorder takes up so much of their time and energy. As in the examples above, those with OCD often engage family members as part of their rituals. Parents and teachers can become impatient with these children, who are sometimes seen as defiant or oppositional. When this happens, the difficulties inherent in the disorder itself are compounded by the interpersonal conflicts generated by those who have to deal with the child's OCD. Children with OCD can feel terribly ashamed; they are aware that what they do seems silly to others but they feel unable to stop.
Despite all its seeming intractability, OCD responds very well to treatment. OCD is particularly responsive to Cognitive Behavioral Therapy (CBT). In fact, this is the single most effective treatment for OCD. Cognitive Behavioral Therapy works by giving children effective tools to manage their anxiety while gradually and gently allowing exposure to the very things that make them anxious. Th ese tools might include relaxation, breathing training, positive self-talk, imagery, and habit reversal. Children and their families learn techniques such as "talking back to their OCD" and then practice their skills in a safe environment before they try them out at home or school.
As much as possible, clients guide the treatment: they set goals; they help determine which behaviors will be easier and harder to manage, they decide which are tackled first; and, with the therapist's guidance, they determine how far to push themselves. Feeling that they are in control of their treatment helps children (who often feel very out of control) feel comfortable and safe. Knowing that they had a key role in the development and implementation of their treatment plan enhances their feelings of accomplishment and mastery when they achieve success over OCD. Since families affect and are affected by OCD, the child's family is always an important part of the treatment.
Treatment is tailored to a child's developmental level, specific symptoms and needs. At the beginning of her treatment, Samantha, who needs her notebook and writing implements perfectly aligned, will learn what OCD is. Then, she will familiarize herself with some relaxation strategies and some distraction techniques. She may also learn to rate her perceived anxiety on a scale from 1 to 10. Treatment might begin by having Samantha imagine that she is doing a homework assignment and the notebook is almost perfectly aligned to the edge of the desk (but not quite). She may be asked to rate her anxiety and then engage in one the relaxation exercises that she has learned to try to bring that number down. Once her anxiety is very low and she can easily and repeatedly tolerate imagining the notebook where it is, she may decide to try bringing her actual homework to the therapy session and begin practicing tolerating having her actual notebook slightly inclined from the edge of the desk. After Samantha is comfortable with this, the next step may be to use strategies while imagining studying in her room with all the pens and pencils "out of place." Treatment will slowly and gently progress until Samantha is comfortably doing her homework with all the books, notebooks and pens at various angles from the edge of the table. Soon she finds that she can study without first organizing everything on her desk. In fact, she can study in the library and at friends' houses. At that time, the next compulsion or obsession is then tackled.
CBT is not the only treatment available for OCD, but recent studies have found that CBT alone meets and even exceeds the effects of medication alone. However, in combination, CBT and medicine provide a very powerful treatment approach to managing OCD. At the Tarnow Center we use the biopsychosocial approach in assessing and treating OCD. We treat the biochemistry that seems to cause the symptoms, the thoughts that maintain the obsessions, and the family who affects and is affected by the disorder. By learning specific tools that they can use to beat their OCD, children like Samantha, Jenny, Preston, Sarah, and Michael can and do become competent self-managers of their health.