Exposure and Response Prevention (ERP) Comes to Our Home

* Advisory:  This post has some photos of hands damaged from over-washing.  They may be difficult for some people to look at.

This is a nearly empty bottle of liquid soap.

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It looks pretty normal sitting on the bathroom counter until you take a closer look.  That brown ring around the bottom of the bottle is dirt from our backyard.

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The bottle of soap caught my eye several days ago and I snapped a few photos of it to remind myself of where we’ve been.  This bottle, with its dirt that is settled all around the bottom has been with us this entire summer – since before I even began this blog.  It is a remnant of one of Blake’s last OCD treatment sessions before we made the  heavy-hearted decision to stop therapy.  I am sharing it with you today, as a way to share what Exposure and Response Prevention (ERP) can look like.

What is ERP?

ERP is “the most important therapy in CBT for OCD,” according to the International OCD Foundation.  In a nutshell, ERP involves a conscious choice for a person with OCD to confront the items (thoughts, situations, etc.) that create discomfort and then not do the compulsions or rituals that would normally be provoked.   The idea is for the OCD sufferer to allow his or her anxiety and discomfort to abate naturally, without using rituals to cope and thereby creating healthier ways of coping.  This is commonly done with the help of a mental health therapist who is trained to do Cognitive Behavior Therapy (CBT) with OCD (for more information, Click Here.  Janet at OCDtalk has also written a thorough post on ERP.).

In our situation, Blake was really struggling with hand-washing compulsions (in addition to many others).  It was particularly bad at the time and he ran to the sink to wash anytime he felt the slightest bit “dirty.”  No amount of salves or special creams could heal the damage he was doing to his poor hands.  Below are some photos of how his hands looked around the time.  A reminder, these are 14-year-old hands.  They are painful for me to look at.  Anyone who pokes fun at compulsive hand-washing or thinks it is a joke has never lived with a family member who is suffering because of it.  The pain is real, intense and it interferes with day-to-day activities.

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While Blake’s treatment team had done ERP work with him on the hand-washing at the office (they would touch “dirty” things and then he would not wash), we were seeing little impact of the exposures.  We all agreed at the time that Blake was “white knuckling” it through the exposure and avoiding truly immersing himself in it by reminding himself that he could wash as soon as he got home.  He never gave himself the opportunity to allow his anxiety to come down to a manageable level.  So, it was decided that one of his therapists would make the trip to our home.  The plan was for Blake and the therapist to “contaminate” our entire house so that Blake would not have a place of safety to run to in order to avoid his discomfort.

The Day Arrives…

Blake was in agreement with the plan, until the actual day arrived.  He was tired of painful hands and was hopeful that this exposure would finally put his hand-washing to rest.  He greeted his therapist, happily, at the door.  As they began to prepare for the actual exposure, he began to change his tune.

“I don’t remember actually agreeing to do this,” he told the therapist.  His anxiety was already on the rise, and he was trying to thwart the exposure from going any further.  His therapist and I reminded him of his desire to get better and advised him how important a step this was toward breaking free from the grip OCD had on his life.

Begrudgingly, he followed his therapist into the backyard where both dug into the dirt and began to put handfuls of it into a squirt bottle.  Then they returned to the house where they filled the bottle with tap water and shook it vigorously.  It looked like a muddy mess.  I silently gulped when I saw it.

Are you really going to spray that mess all over my house?

This was not going to be easy – and I really have no problems with dirt.  I can sit in it, get it under my nails, whatever…  But this – even I wasn’t relishing the idea of my house being sprayed with a bottle of dirty water.  The thing is, that was just the point.  Yes, it is uncomfortable to have dirt sprayed in your house.  It’s even kind of over the top.  BUT, it’s not going to kill anyone.  It is survivable – you can even thrive with dirt on your belongings.  The point for the OCD sufferer is to stick with the discomfort long enough to recognize that it abates and that they can have a good life without having to give in to their compulsions.

Reticent as I felt, Blake’s anxiety was rising through the roof.  He now wanted no part of this exposure.

“I changed my mind.  I don’t want to do it,” he stated.

His therapist reminded him that this exercise, as uncomfortable as it felt right now, was going to help put his OCD in its place.  She asked me to bring her all the bottles of liquid soap that were in the house.  I complied and sought them out.  Within a few minutes, I was back.  Blake was not in a good place.

The Battle Begins

While I’d been on my mission, Blake’s therapist had opened my bottle of dish soap (which Blake uses all the time to wash his hands) and poured a good amount of that muddy water right into it.  Blake was going to have none of that and before anybody could convince him otherwise, he’d dumped the entire contents of the bottle down the drain and placed the empty container in the recycle bin.

“Blake,” she reminded him, “we need to contaminate all the things you use to relieve your anxiety.  You remember; we talked about this.”

“No,” he said firmly.  “I don’t want to do it.”

She continued with her task and began to pour muddy water into the liquid soap bottles I had brought to her.  Blake’s face grew red.

“I said, ‘No’,” he stated.  “LEAVE.”

The therapist continued.  She was finished contaminating his sources of washing.  She took a rag and sprayed it with the dirty water.

“Come on, Blake.  Help me.  Let’s contaminate the house together. It’s better if you’re a part of this.”

NO! LEAVE!”  His voice was powerful.  Anxiety was making way for fury.

“Remember?  You wanted to get better.  I’m not going to stop because I care about you.  I care about your hands and I don’t want you to have to keep living with OCD bossing you around and controlling your life,” she told him.

THERE’S NOTHING WRONG WITH ME!!!!  I’M TIRED OF THIS!!! I’M TIRED OF BEING TOLD THAT I’M SICK!!!  SICK! SICK! SICK! LEAVE!!! GET OUT OF MY HOUSE!!!!”

Blake was absolutely getting out of control at this point.  He’d never said an angry word to his therapist before.  Now, he was screaming at the top of his voice and looking like a maniac. My heart was breaking for him.  I didn’t know whether to cry or burst out into giggles at the sheer anxiety the whole thing was creating in me.

His therapist continued with her quest.  She carefully wiped the dirty cloth over all the furniture, the walls and our personal belongings.  Our entire family was going to be in on this exposure.  But was Blake going to buy into it?

Blake Hits His Breaking Point

“I TOLD YOU TO LEAVE!!!  I CAN’T TAKE THIS ANYMORE!!  I’M JUST GONNA…”

Blake lunged for the pencil cup on top of the cabinet near him.  In one swift move, he pulled out the sharpest pair of fabric shears in the house and raised it up over his head, as if he were about to plunge it into someone.  But it wasn’t clear to me if he was going for his therapist or himself.

“Put it down, Blake!” I commanded, but my words weren’t necessary.  Blake’s hand hesitated in the air and his expression turned to horror and he began to tremble.

“What am I doing?  What am I doing?”

He ran down the hallway to the living room where he started sobbing.

“I’m sorry.  I’m sorry.  I’m sorry,” he repeated.

The therapist stepped outside to call her supervisor.  Blake looked at me through his tear-filled eyes.

“I wouldn’t have hurt myself,” he said.  “I just wanted her to stop.  I can’t believe how far I went to protect my OCD.”  He cried quietly for a few minutes until his therapist stepped back into the room.

“Do you want to talk?” she asked him.

“I’m so sorry,” he said.  “I wouldn’t have done anything.  I know what I need to do now.”

He walked down the hallway with a half-smile on his face and picked up the abandoned squirt bottle.

“May I?” he asked.

“Of course,” she answered.

He began to make his way through the house, squirting that dirty water on the walls and the countertops.  He covered his game consoles in it and his favorite sitting areas.  Tears streamed down his face, but now they were tears of relief.  He knew this was what he needed to be doing.  Then, he directed the therapist to his room.

“We need to do my room,” he told her and he contaminated his entire room with that water, making sure he didn’t miss a thing.

The Aftermath

Blake adjusted relatively quickly to his contaminated surroundings (although I did put away all sharp objects, just in case).  He didn’t care that there were pieces of dirt in the soap bottles.  He relished it when I reminded him that our entire home was contaminated.  He’d won another battle in the war on his OCD.  His hands healed.

But the other areas his OCD affected were untouchable.  He wouldn’t budge on them; held onto them like a badge of courage and battled us to keep them.  Of course, this lead to us ultimately discontinuing treatment and to being in the limbo that we are in.

Today I still find remnants of that exposure, though it is about 3 months in the past.  There are still places that are too high for me to reach where he aimed that squirt bottle – and I kind of like the bits of dirt that remain anyway because they remind me that we still live with contamination to some extent.  They also remind me how far Blake was willing to up the ante to protect his OCD, how powerful the disorder can be in asserting itself.  And I wonder when Blake will grow in his own power and desire to take it on.  We can only wait and see.

In the Trash

Trash

Tonight as I’m preparing dinner, Blake pulls out the trash and begins searching through it.  He has both hands fully inside and is fumbling with the contents.

“What are you doing?” I ask.

“Oh nothing.”

No surprise at that answer.

“You’re not doing nothing.  You’re going through the trash.”

I sound like such a mom.  The thing is, I know exactly what he’s doing.  It’s all part of this dance that we do.  Moments before he had asked me what was for dinner.  I told him – and then I could hear him doing his quiet, anxious mumble.

“Ummm.  Hmmm.  Uh….”

It’s what he does when his OCD rules pop up.  He hedges.  He tries to be unobtrusive, but to get my attention at the same time.  Most of the time I don’t bite.  Tonight is no different.  He’s fully capable of stating the problem he’s having, so I don’t respond to this mumble.  I wait for him to say something.

Honestly, I’m pretty sure what the problem is.  He’s unhappy with the roast I’m serving.  It violates his eating rules.  Still, I wait for him to share the problem.  If he’s not going to speak up, I’m not going to do service to this.

Now he’s in the trash, searching for something to help his anxiety.  As I’m noting that he’s in the trash and asking him about it, he finds what he is looking for.  It’s the wrapper from the roast.  Still deep in the trash, he pulls it apart so he can get a good look at it.  I can see it doesn’t meet with his satisfaction.

“Blake, if you have a question about the meal, ask.  Stop hiding and pretending and saying it’s nothing.”

“Umm…okay.”  He walks away.  But then he starts again, quietly, at first.  “I don’t know what to do.  I don’t know what to do.”

“Blake, are you asking for help or is there something you’d like from me?  Or do you just need to be talking about this to yourself?”

“Well, um, I’m kind of asking for help.  I just don’t know what to do.”

“Is it about the roast?  You don’t feel you can eat it?”

“I’m sorry, Mom.  I just believe I shouldn’t.  So I don’t know what to do.”

“Blake,” I answer “you know that we want you to eat healthy.  I prefer that you eat the meal I prepare, but if you aren’t going to, then you’ll need to prepare yourself something.”

“I know, Mom.”

“And also, please just come out and say what’s going on.  This hiding and pretending and mumbling doesn’t help.”

He puts together something to make a complete meal for himself and we all manage to eat a meal together.  Still, I’ve got a frustrated feeling inside me.  The fact that he won’t eat the meal I’ve prepared is less upsetting than the sneakiness, the hedging and the hiding.  If he would simply come out with the truth, at least we could discuss it openly – but OCD tells him to sidestep the truth, tell partial-truths or omit the truth entirely.

I don’t understand exactly  what it is about OCD that seems to cause so many sufferers to operate in the realm of not being honest. It’s almost as though OCD can justify taking whatever means are necessary to maintain itself. Perhaps it is that OCD thrives on secrecy, but is threatened when it is out in the open.  At any rate, the irony is not lost on me that a young man with contamination fears is willing to literally dig through the trash because he is afraid of  eating the “wrong” food.

I’m hoping that I handled it okay tonight.  I didn’t blow up or get into a big lecture.  I tried to simply let him know how I felt and what he needed to do if he wasn’t going to eat the meal I was making.  Maybe next time he can be a little more honest – hedge a little less.  For our family, that would be a step in the right direction.

“I’ve Hit a Wall”

Image courtesy of cjansuebsri at FreeDigitalPhotos.net

Image courtesy of cjansuebsri at FreeDigitalPhotos.net

I’m sitting at home catching up on some volunteer work for Blake’s school when my cell phone rings.  It’s Blake calling.  For a moment, I hesitate to answer as I wonder what it could possibly be.  It’s been less than two hours since I dropped him off at a thrill ride park that is not too far from our home.  This is the first time he’s ever gone without an adult; it’s just him and his friend.

“Hi Blake,” I answer.

“Mom, I’ve hit a wall,” he says.  “I need your advice.”

Blake and Kyle have been planning this trip to the amusement park since late last school year.  Kyle is terrified of roller coasters – so terrified, in fact, that he was one of the only kids in the entire 8th grade to miss out on the class trip before the school year ended.  Blake can smell anxiety from a mile away.  He took Kyle aside to get to the bottom of things.  He discovered that Kyle had never been on a roller coaster in his life and he was afraid of how he would look in front of his classmates.

While Blake has fought us in the last year or so over engaging in his own treatment for his OCD, he has been through enough treatment and had enough success in the past to know what it takes to get past a fear.  In fact, his own fears prevented him from riding even a kiddie ride until he was 10.  With concentrated effort and a lot of support from his therapists, Mom, Dad and big brother, he became a roller coaster riding machine.

He shared his own struggles with Kyle and promised him that he could help him get past his own fear.  The treatment?  Exposure with Response Prevention with Blake as the behavior therapist.  Kyle apparently bought into the treatment plan.  He even convinced his parents to set up the date and to purchase Blake’s ticket to the park.  Blake gave it a lot of thought and came up with what he thought was a good plan.  He even knew what order they would visit each ride in order to build up Kyle’s confidence and extinguish his fears.

Now, apparently, it wasn’t going quite according to his plan.

“What kind of advice do you need, honey?”

Image courtesy of anat_tikker at FreeDigitalPhotos.net

Image courtesy of anat_tikker at FreeDigitalPhotos.net

“Well, I got Kyle to go on the Fast Track, and I want him to go on the Looper, but he keeps saying he has to go to the bathroom, or he wants to get a snack or a drink.  I think he’s stalling and trying to avoid.  Sounds familiar, huh?”

I smile to myself because he’s referring to his own avoidance – both in his quest to become a roller coaster rider and in his OCD treatment before we stopped this past year.

“Yes, that does sound familiar,” I say.

“Now I understand better what it was like for you and Dad,” he tells me.  “So tell me,” he says. “What did you guys do when I did this?  What were the skills and tricks you used?”

We talk for a moment about some of the tools at his disposal.  Then he tells me that Kyle is asking to go on the Rocking Thunder.

“Maybe you should go on the Rocking Thunder with him, then,” I suggest.

But Blake sees a problem with this.

“It’s too similar to the other ride, Mom.  He’s trying to stay in his comfort zone and if he’s going to get over this he’s got to get outside of his comfort zone.”

I suggest to Blake that maybe Kyle isn’t ready to step it up yet.  Perhaps they need to stay in this zone.  As the day progresses, Blake can ask Kyle if he is ready to take it to the next level.  Blake accepts this as a possible road to take.

“Bye, Mom.  I love you.”

Hours later, as I walk Blake back to the car, he is wiped out.  He’s not as exhausted from being at the park as he is from playing amateur behavior therapist.

“We got on the Looper, finally, but it was sooooo….frustrating,” he says.  “I understand what I put you and Dad through.  Thank you.”

“Thank you?  What for?”

“For pushing me.”

“You’re welcome.  It’s hard work being a behavior therapist, isn’t it?”

“Yep.  Well, we didn’t make it to the toughest ride, but we made progress.  We’ll do it again,” he says as he tilts his head back in the back seat and closes his eyes.

I feel a glimmer of hope inside that maybe Blake will apply this to his OCD.  At least now he recognizes what it is like to see what someone you care about is capable of achieving and to face the “wall” of  fear and resistance when they can’t find the strength or motivation to keep moving toward that potential.   For Blake, it is another step in the right direction.

As for Kyle, his mother is overcome with joy.  Today, with Blake’s support, he has accomplished something his parents have been trying to help him achieve for over a decade. He rode a roller coaster.  He rode three roller coasters!  She text messages me to declare her delight.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

I see career possibilities for Blake :)”

Indeed.

“OCD is Like Addiction”

Image courtesy of Naypong at FreeDigitalPhotos.net

Image courtesy of Naypong at FreeDigitalPhotos.net

Last night we were sitting around the dinner table discussing a family friend who has had a relapse in his attempt to become clean from drugs.  We talked about how difficult it is to stay clean, what the appeal of drugs is and how addiction happens. Blake listened and participated in the conversation.  Mostly, he had a lot of questions.

As the conversation winded down, the kids cleared the table.  They contemplated the pros and cons of legalizing certain drugs and asked about their grandfather’s long struggle with drugs.  How did it begin?  Why was it so difficult to stop?  Then,  as both boys made their way to the couch to relax, Blake suddenly had a comment.

“OCD is like addiction,” he stated.

“What do you mean?” we all asked.

“Well,” he said, “every time I do a ritual, it brings me relief – for a little while.  But it never lasts very long and then I have to do it again to get the relief again.”

“Wise observation,” someone commented.

Wise observation indeed, my son.  You’ve identified the problem.  Now, what will you do with it?    These thoughts all remained silent as we all watch and wait to see if Blake can commit himself to his mental health.  All the same, it was nice to see a glimmer of realization.  Just waiting for it to spark a fire in him.

What? OUR Family? Healthy?

Okay, so given that I write a blog about what it’s like to live in a family where a member has Obsessive-Compulsive Disorder AND given that I’m a psychologist, I have to share this here.  I’ve mentioned in an earlier post (4:35 am), that we have had a house guest this summer.  He  is a friend and local fitness trainer who needed the opportunity to get out from under some financial issues.  He has been living in our guest room for the last three months.

To be perfectly honest, I was not very keen on the idea when my husband presented it to me.  First of all, it was thought out in that hazy kind of way my hubby tends to  approach things like this (“Hey, wouldn’t it be great to help this guy out?!”).  Second, although my husband has known the guy for a few years, I didn’t know him well at all.  In addition, I like to get up on weekend mornings and hang out in my PJ’s (one of my little indulgences).  How could I do that with a guy in the house?

Still, I agreed and I let the hubster handle the details.  Despite a few minor mishaps (like the fact that there was no bed in the room our guest was to stay in), we settled into a nice routine with our new (albeit, temporary) housemate.  There were a few times I was actually grateful he was there.

When someone lives with you, at least in our family, you find yourself on your best behavior – initially.  I think our “best behavior” lasted a few days.  After that, we quickly settled back into our usual routine.  Our guest saw it all – the good, the bad and the ugly.  He saw our loving moments and our arguments.  And he saw Blake’s rituals.  He saw how we tried to manage living with OCD and he was present when we made the decision to take a break from treatment.

At the end of this past week, it was time for him to move out.  He spent the day moving out his belongings and transporting them to his new place.

“One more load,” he told me in the late afternoon.  “I’ll be back for that tonight.”

True to his word, he and his girlfriend came that evening for his last load of the day.  We said our goodbyes and waived as they went out the door.  As I stepped back in I saw a flowering plant on the kitchen counter with a card attached.

Thank You Card from our House Guest

Thank You Card from our House Guest

You can see the card here, but it was what it said inside that really caught my attention:

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In case you have trouble reading, it says:

Thank you for all the unconditional hospitality!! You guys have a rare and uniquely healthy/functional family…   Thanks again,”

My husband and I read it again and started to giggle.  This man, who barely knew our family 3 months ago and who had just had a front row seat to our family nuttiness, was telling us that we were healthy and functional.  Not “normal” mind you – healthy and functional.

At first we wondered what planet he had been living on…but then we realized something.  Even with family disagreements and weird habits, and even with undeniable mental illness in our family, we can still function and we can still be healthy.  We don’t need to be some standard of perfection for a relative stranger to appreciate us and what we strive to offer to one another.  We may have OCD in the family and a whole host of other things, but that does not need to define our family – or any family.  We can keep loving each other and keep rising to the challenges that are a daily part of this life and do it in such a way that others can have an intimate view into our lives and actually appreciate it.  We do not have to be defined by what we think is our craziness.

I am definitely going to keep this card.  I will look at it on the low days and use it as a reminder not to obsess on the bad or the troubling, but to remind myself of the good that exists here.

“I Didn’t Understand”

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

The phone rings in the late morning as I’m sitting at the computer.  It’s my mother-in-law on the other end of the line.

“Oh honey.” she says to me “My heart goes out to you.  I didn’t understand.  Now I know what you go through.  How do you do it?  And how can we help?”

She has recently spent two days with Blake and she’s been dying to talk with me about the experience.  She pours her thoughts and emotions through the phone line as she describes how confusing this experience was for her.  She’s known for nearly seven years that her grandson has Obsessive-Compulsive Disorder and she has even read articles I’ve written about our experience.  However, it is not until now that she and my father-in-law have had Blake in their home without his big brother for a few days that she’s beginning to connect knowledge and experience.

“We had pizza planned for dinner because we know that it’s his favorite,” she says, “but then he asked us where we were getting it and that restaurant wasn’t okay with him.”

The restaurant he approved was clear across the valley from them and my father-in-law made the trip over and back to bring pizza that Blake would eat.

“We just weren’t sure what to do,” she continues.  “We wanted him to eat.  We wanted him to be happy, but we weren’t sure if we should have done it or not.”

I can hear the struggle in her voice. She never expected being a grandparent would put her in the position of wondering whether it was okay to make trip to a special pizza restaurant.  And then there was the praying.

My mother-in-law was raised in a religious home.  Saying evening prayers together was a special part of family togetherness.  It tickles her when her grandchildren want to do that with her.  This time, she didn’t have to ask.  Blake was all ready to go with prayers, but these confused her as well.  She didn’t know what to do about his stopping and re-starting again.  She didn’t recognize the strange rituals that went along with them.

“I don’t recognize this religion,” she tells me.  “I wanted to feel good and close to him when we did this, but it didn’t feel that way.”

I know she’s struggling.  How can something that’s has wonderful memories and feelings for her become something she wants to avoid doing with him?  How can feeding her grandchild his favorite food become something she has to question?  As she probes for how to deal with this, I am aware of how grateful I am to have her and my father-in-law in our lives – aware of how grateful I am for all of our extended family for that matter.  They seek to understand this situation, to understand OCD, and to support us.

We are among the lucky in terms of family support.  Many times, parents who have children with OCD face lack of understanding, criticism from family members and outright denial that there is a problem.  One of my own patient’s mothers was just told that she coddles her daughter too much.  She hears that she spoils and babies her child and that the only problems are the ones she is creating.  Another family was berated by the child’s grandparent for turning this into a big deal and getting treatment for the child.

I spend enough time in my professional work addressing and working to undo the things parents have been told by family members to appreciate what my mother-in-law is offering.  She’s been touched by her up-close-and-personal encounter during this visit and she is reaching out to join with us even more strongly than before. For that, I feel a surge of love and want to reach through the phone and hug her tightly.  Though he may not yet realize it, Blake has a loving team around him ready to provide support.

Naming Names

Just a quick note today.  As I’m learning about blogging, I was thinking that it is going to get really tiresome calling my son, “My Son” all the time.   So I’m going to give him a name – Blake.  Yes, I think that will work.  And I’m going to give myself a name today, too.  I’ll be Angie.  It hails back to a time when a friend and I wanted to send each other messages without people knowing who we were.  So…Blake and Angie it is!

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