All this season, board-certified clinical psychologistDr. David Tolin will be checking in with this blog for episode-specific interviews on The OCD Project, which places six people living with obsessive-compulsive disorder in a house in an attempt to treat and control their disorder. Our chat on the fifth episode is below. In it, Dr. Tolin talks about Jerry’s withdrawal, the duration of Arine’s exposure, Kevin’s prayer and why he thinks this method of treatment might not be right for Kevin…
At the beginning of the episode, we discovered that Kevin seems to be regressing, per the Yale Brown Obsessive Compulsive Scale.
This is an issue that we had seen happen on a couple of occasions, if you remember when Kevin was watching his fear movie, and again when we were doing exposures trying to stop his father’s heart using his thoughts, and then again in the hospital. What we saw is that Kevin’s anxiety did not seem to reduce in the same manner that everybody else’s did. Kevin was having a very different emotional reaction to the exposure exercises. So when we administered the YBOCS after one week of treatment, what we see is that his condition wasn’t getting any better in fact, if anything he was looking a little bit worse.
Could the treatment have been damaging him?
Hard to tell. My guess is that it wasn’t necessarily worsening his OCD, but it might have been increasing his overall level of distress. It is important to recognize that even though exposure therapy is uncomfortable, we do it for a reason and you see it in the other five people. When they can face up to their fears and when they can tolerate some distress, their overall levels of distress and discomfort goes down. They start feeling better. That wasn’t happening with Kevin.
The institution exercise seemed pertinent to Jerry’s issues. However, when he arrived, he seemed angrier at the fact that he was being treated than the issues the treatment brought up. I wondered if that was as sign of progress.
Sometimes I think in order to beat OCD you’ve got to get mad at it. Sometimes people want to get mad at their therapist and that doesn’t really help that much. But when you get to a point where the person is so sick of OCD and so sick of what OCD has done to their life that they’re willing to do anything to beat it, that’s when the person is really starting to turn a corner and is ready to put in the hard work that it’s going to take.
I think Jerry really needed and benefitted from the support of the other five people. He needed people who were going to be there for him, who knew what he was going through, and were facing concerns of their own that were kind of similar. I think that ultimately helped to bring him out of his shell.
You ended up telling Jerry to “kill” Arine, fully aware that he wouldn’t. It seems like treating people whose fears are based internally (i.e. people who are afraid of themselves) is different than with those who are afraid of external factors: in the former group, you expect them not to be able to do what you’re telling them to do (like last week, when you told Traci and Kevin to stop hearts with their minds).
Everybody’s a little different, but last week I was saying to Traci, “Traci stop his heart.” Essentially I was telling Traci to kill her son with her thoughts. She learned through experience that she simply could not do that and that was a real turning point for her. In Jerry’s case, I wanted him to see that while he certainly could kill people, he is not going to. It is not in his nature. The mere opportunity to kill somebody does not mean that he is going to actually do it.
Both Traci and Arine surprised me this week with their extreme reactions to the exposures. It seemed like they had turned things around earlier, but now it seems that they have to go through their anxiety all over again.
In some sense they do. Beating OCD is a long and arduous process. It’s not like you do one good exposure and a light bulb goes off and the person is fine. The person really has to face a variety of fearful situations, usually done in an escalating manner until essentially they have faced all of their fears. Until they do that, you don’t really see that they’re truly better. So for example, last week when Arine and Traci had some really solid exposures, that’s great, but I also know that doesn’t mean they’re out of the woods. They’re still going to have some really hard things to do.
How do you measure progress then? Is it how quickly they calm down within any given exposure?
Not necessarily. Some people seem to calm down very quickly in the middle of an exposure. Some people seem to take a really long time. Either way is fine. What seems to be most critical is how they react to that situation the next time we approach it. So if we have the opportunity to repeat the exposure, to go back to something similar, do we find that they’re reacting differently to it, that they’re able to cope with it a little bit better or do we find that it’s like we hadn’t done anything and it’s back to square one? When we see that, I think that’s a bad sign. When it seems like we’re just at square one with every single exposure, that’s a sign of somebody who’s struggling.
Was it all a concern that Traci was still having trouble distinguishing reality from fantasy?
People with OCD have varying levels of insight into how irrational their obsessions are and Traci is a bit lower on that scale than some of the other people are. It’s important to recognize that doesn’t mean that Traci doesn’t have a good grip on reality. It doesn’t mean she is psychotic. It doesn’t mean she is delusional, but what it means is that she is not as good as detaching herself from her obsessions and recognizing them for the nonsense that they are.
When you were on the floor with Arine, exposing her to what might have been blood or red jelly or whatever, how long did that exposure take? The editing suggested you were sitting there for a while.
It was all pretty long processes. Each of those exposures was about an hour. I was doing those individual exposures for about six hours that night. I actually ended up giving myself an upper respiratory infection because of the bad air in the basement of that hospital.
Again and again, I’m reminded of the patience your job requires.
It’s a very slow, repetitive, gradual, step-by-step process. What you see on the show tends to be the peak moments and most outrageous aspects of the exposure but in reality, exposure therapy is very repetitive, somewhat plotting, and is just done baby step by baby step.
After Kevin’s exposure, he admitted that he had said a prayer to undo it. I thought it was kind of strange that he admitted that, when it was a secret to begin with.
I don’t know if he thought it wasn’t something not to tell me or if he just didn’t get that this is how it goes, that you don’t do rituals. When we did that exercise I was down in that room with Kevin for about an hour and his anxiety did start to go down and I was starting to feel encouraged. I was starting to think, “Wow, maybe we are getting to Kevin. Maybe Kevin is starting to turn a corner. Maybe he’s starting to benefit from these exposures.” Then when he told he had said this undoing prayer, this ritual, I realized that his anxiety level hadn’t gone down because he was habituating. It hadn’t gone down because he was benefitting from the exposure. It had gone down because he had given into the urge to do more compulsions. That he seemed to admit that so readily and freely that it struck me that he didn’t even get it. So I’m thinking, “Man we’ve been at this for a week now and you still don’t get it. What’s going on with this guy?”
I would never want to attack anyone’s religion. Some people have compulsions that take the form of prayers, but understand that there is a real difference between a true prayer and a compulsive prayer. A true prayer is somebody being spiritual, getting in touch with God or whatever superior being they worship. It’s a way for them to express themselves. It’s a way to ask for strength and so on. Compulsive praying is none of these things. There’s nothing spiritual about it. It doesn’t bring peace to a person. It doesn’t put them in touch with God. It’s not a way for them to mediate. It’s not a way for them to pray for strength. All it is, is a crutch that they use to try to prevent bad things from happening and in that sense compulsive praying is really no different from things like compulsive hand washing. They serve the exact same function. I tell people to stop doing compulsions. It’s important to stop doing compulsions, but it’s also important to recognize there is a distinction between compulsions and the real thing. Me asking Kristen to stop washing her hands doesn’t mean I hate cleanliness and me asking Kevin to stop doing these compulsive prayers doesn’t mean I hate religion and me asking Arne to run over a dummy doesn’t mean I hate safe driving.
It seems like compulsive prayers are something that show up in many people’s day-to-day lives — people who don’t necessarily suffer from OCD. It’s a very human thing to get in trouble and you start praying even when you’re not religious.
Even when we don’t mean it in a spiritual way, like, “God please let me pass this exam” or something. Sure, I get it. I think lots of us have been in the position of perhaps using prayer for the wrong purposes, but I think when you get into OCD, that’s taken to such extreme that you really need to tell that person to put a stop to it. Praying that your thoughts won’t kill people is a compulsion. We need to recognize that there is nothing spiritual about that. Just the fact that you’re calling it a prayer, doesn’t make it something special. It is essentially a mental ritual and a person needs to learn how not to do that.
Kevin revealing his prayer seems like the final straw for you, as far as treating him is concerned.
I think it was just one more piece of evidence that this treatment was simply not working out for Kevin. When he did his fear movie, it resulted in a panic attack. When we did the exposure with his dad, he didn’t quite seem to grasp it. We looked at his YBOCS score, it was going up not down. We took him to the hospital and did the exposure there and he controlled his anxiety by using rituals and seemed not to grasp that that was the wrong thing to do. I think it was just one thing after another that was telling me that we were just not reaching this guy.
Terribly disappointing. I want nothing more than for all six of these people to come away from the program happy and healthy. Otherwise, what’s the point? Honestly, I’m not here for the ratings. I’m not a TV guy. I’m a psychologist. I treat people. That’s how I make my living. I am in this business because I want people to get better and stop suffering. I brought Kevin into the program because I truly believed that I could help him to stop suffering and it was very disappointing to me to have to face the idea that maybe I couldn’t.