Maria was 9 years old when she heard a TV news item about an outbreak of hepatitis that originated at a local bakery. Long after the alarm had subsided, she couldn't stop worrying about it. At first, she feared that she might have contracted hepatitis and began washing her hands with increasing frequency. Then she began to worry that she herself could spread hepatitis and be responsible for the deaths of others. Maria began wiping herself clean to the point that she was chafed and bleeding. By the time she came in for treatment a year later, she was spending 45 minutes in the shower, 30 minutes at the sink each time she washed her hands, and 45 minutes cleaning up after each time she used the toilet. She barely made it to school most days.
Maria has obsessive-compulsive disorder (OCD), an often debilitating condition that affects from one to three percent of children in the U.S. A growing body of evidence suggests that neuropsychiatric, genetic, immunologic, behavioral and cognitive factors may all play a role in the development and maintenance of OCD. Over the past 15 years, the literature has repeatedly shown that OCD in children can be successfully treated with cognitive-behavioral therapy (CBT)---specifically, exposure and ritual prevention (ERP).
But while CBT is widely considered the treatment of choice for children with OCD, effectiveness is contingent on overcoming a formidable obstacle: children's reluctance to engage in ERP because they think that facing their fears without performing rituals will be too scary and impossible. The therapist and the children's families must find a way to help the children get past the discomfort of giving up rituals that seem to protect them against overwhelming fears. To do that, I've devised a CBT treatment approach tailored to the special needs and cognitive capabilities of children. It's aimed at thoughtfully cultivating treatment readiness before embarking on ERP.
Building Treatment Readiness
comes first. When I met Maria, she was shy and embarrassed as her parents described her symptoms and their futile struggle to get her to see reason. Her parents, like most parents seeking help for their child's OCD, expressed a sense of urgency. They asked if they should be actively fighting the OCD by "getting tough" with their daughter and refusing to give in to her rituals. I said that our first focus was on stabilization and that it wasn't the right time to withdraw support for Maria, who was already overwhelmed and struggling to function each day.
To alleviate blame and shame and build an alliance with the family, I then discussed the current understanding of OCD as a neurobehavioral disorder. "Having OCD isn't your fault. It's not your parents' fault either. It's like having allergies or asthma---it happens to you because you're more sensitive to it.” Maria glanced at her parents with a "See, I told you!" look, as her mother tearfully acknowledged having had such reactions.
is key. Most children and families aren't aware that the body is designed to habituate naturally to anxiety. I developed the Worry Hill metaphor to make CBT more child-friendly and prepare children for treatment, by helping them understand how exposure leads to habituation. It's a drawing of a bell-shaped curve that graphically illustrates how anxiety rises with exposure until it reaches a peak, and then, if the child persists in resisting the urge to employ the usual anxiety-avoidance tactics, automatically begins to decline.
"Maria, you may not like the dirty feeling," I explained, "but by touching things and not washing your hands, you'll get used to the feeling. It's just like the cold water in a swimming pool---you don't like it at first, but you get used to it when you stay in it for a while. You'll also learn that your fear of getting hepatitis won't come true." Maria listened thoughtfully, cringing at the mention of not washing her hands, but then nodded to indicate she understood.
involves helping children see the necessity for change, the possibility for change, and their innate power to change. Understanding both the costs of OCD to themselves and the benefits of overcoming it convinces children that change is necessary. When I tell stories of other youngsters who've successfully overcome OCD, children begin to believe that they have the power to do the same thing.
In this way, I help the child understand that she has the power to take charge and take control of OCD---a liberating experience---instead of letting it control her.
makes the child a key partner in treatment. The child and family need to know that the therapist isn't the one who'll "fix" the child's OCD: only the child has the power to do that. "I won't force you to face your fears," I assured Maria. "You and I will discuss together what you'll do when you're ready. But no one can ride a bicycle for you, so you'll have to do it for yourself. We'll take one step at a time, so that it'll never be too scary."
Rather than slow treatment and recovery down, building treatment readiness makes the entire process go faster. After a few sessions of readiness-building, children with moderate to severe symptoms can often begin to master OCD within 4 to 8 sessions of ERP---for a total treatment duration of 12 to 20 sessions.
Children who aren't properly prepared for how ERP works and what it entails are more likely to become ambivalent or afraid, withdraw from exposures, and refuse to do practice exercises. When they understand how exposure and habituation work, they're more willing to tolerate the initial anxiety experienced during ERP, because they know it'll increase and then subside.
This blog is excerpted from “The Worry Hill". Read the full article here. >>
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