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 sixth episode is below. In it, Dr. Tolin talks about Kevin’s dismissal, Kristen’s improvement, Arine’s driving exposure and the fake funeral for Traci’s son…
Was it difficult to tell Kevin you couldn’t treat him in this format? He seemed to take it very hard.
Kevin wasn’t happy to hear that news and I wasn’t happy to have to give it to him. But when it comes down to it, I have an ethical and moral obligation to Kevin and part of that ethical and moral obligation is to do no harm, to not subject him to things that could be painful, or uncomfortable, or anxiety provoking unless there was a really good reason to do them. It was becoming clear that the things we were doing with Kevin were not paying off and therefore for me to continue along those lines with him would have been, in my view, unethical.
People with Asperger’s very often have trouble with emotional processing and emotional learning, which really is what we’re doing in this program. We’re teaching people a new emotional reaction to things besides fear. It’s not that Kevin is not capable of learning this new reaction, but it was becoming clear to me that he was not going to do it in this format. In this format, we had only 21 days to do our treatment and as a result we had to keep moving with these exposures and get them going fairly rapidly. I thought that if Kevin could have one-on-one attention from a doctor that could do the same kind of program, but take it at a much slower and more gradual pace and explain it to him in ways that would make sense to him, he could benefit.
During the Kristen face-touching, she was resistant the whole time, telling you to get off of her. You assuaged her anxiety by saying, “This is your fear.” At what point would you have actually yielded to her request for you to get off of her? Is there a line that you draw?
Absolutely, the patient needs to have control over the process. Exposure therapy should never be something that I’m doing to them. I don’t know if you heard it, but when Kristen said, “Get your hands off me,” I paused and asked her, “Do you want me to?” The response was, “No.” I made sure I had her ongoing consent and permission to do the exposure exercise. The moment a patient says, “I’m not doing it,” we’re done. It’s over. I can’t force people to do these exercises, even if I think they’re going to be helpful.
I would guess that my hands were on her face for anywhere between 10 and 15 minutes. It was a long time. It takes time for these fears to come down, to habituate.
I’m impressed that she was able to withstand that.
I came away from that exposure feeling a bit more hopeful about Kristen. I was glad to see that her fear level did in fact come down and I was glad to see that she didn’t immediately retreat to her shell or start fighting and arguing, which had been some of the patterns in the past.
It does seem that at this point she’s been making a turnaround, especially after the hospital last week.
We might have not been pushing her as much in the hospital. I think around this point in the program, Kristen seems like she’s starting to engage a little bit more. She seems like she’s exerting less energy fighting me and fighting the program and exerting more energy in working on beating her OCD and facing her fears. I think the concern I have at this point is that it’s getting pretty late in the program. I kind of wish she would’ve got into gear earlier. I’m glad to see that she’s getting there, I just hope there’s enough time remaining in the program for her to really get a lot of benefit.
One of the things that I noticed about Kristen right away is she has the tendency to focus in on all the things that were bad and all the things she thought she couldn’t do. She had the tendency to ignore the things that were good and to downplay the things that she could do. It was like she couldn’t accept her own ability to start to improve her life and I think we continue to see that. I think when you look at where Kristen is and what her mindset is, you see it’s rather different from what we’re seeing in some of the other patients. What you really want to be seeing and what we are seeing in some of patients is them taking the bull by the horns and saying, “I can do this. I can face these fears and I can beat OCD.” I’m not sure I’m hearing Kristen saying that. Instead what I can hear Kristen say is, “God this sucks,” and, “All these people are being so mean to me,” and I worry that that mindset is going to get in the way of her ability to really engage in the program and to really benefit the way she needs to.
Wade was really wonderful and he was very patient and very understanding. I think that both Wade and Arine did a great job at acknowledging some very tough issues. Arine and to a lesser extent Kristen have been so worried about things like HIV at a microscopic level and for Arine to recognize that HIV has a face is a little bit jarring. For her to start to put this into human term is a bit of a wake-up call. Initially, I asked Arine, “Why do you need to get over OCD? What is so important about beating this?” She told me she had this unfulfilled dream of working with people who are impoverished, who are sick, who are in need, and her fear of these microbes was preventing her from doing that. That to me is a very compelling reason to help Arine get past this and I think Wade was able to play a big role in helping her do that.
By this point, I think Jerry is really starting to do well. You can see that he doesn’t get nervous nearly as easily as he used to. I think he’s becoming increasingly aware of the fact that he’s not going to somehow snap and become a serial killer. Cody’s anxiety was a bit higher during that exercise and I think it paid off with him. I think that he was able to engage with it. He was able to face that fear. He really did come out of that jail looking very different. He was tired, yes. He was pretty exhausted from a long day of exposure, but I also got a sense that something had clicked in his head, the same way I saw in Jerry in the hospital. It had really started to sink in that I am who I am. I’m not going to turn into some despicable person and there’s no magic to it.
You sent Arine off to drive at night to confront that fear. But obviously car accidents are accidents for reasons and you can’t always predict them. What if she had gotten into an accident, even if it weren’t her fault? Could that have damaged her process and recovery?
Certainly, it would’ve been a setback if an accident had happened, but I think you can make that same argument about anything. What if we really had gotten sick from touching a toilet? What if Jerry really had slashed my arm? Clearly there are bad things that can happen and the consequences of those bad things can be pretty dire. For the most part however, these things are low risk. They are not impossible, but they are unlikely. Therefore when you hold the probability of damage up against the probability and the impact of the pay off, I think it’s a no-brainer. These are the things that we should do. If occasionally there’s an unfortunate incident, most of the time we can recover from that setback.
I wondered if you ever considered taking Traci’s funeral scenario one step further to put her actual son in the coffin during his staged funeral?
I think that would be a bad idea on a couple of fronts. I’m sure Traci could handle it although it would be awfully tough for her. My bigger concern would be traumatizing her son. You’ll notice that even though we did lots of exposures related to Shawn, Shawn had very little involvement in any of them and no awareness of the things we were doing. Even earlier on when I was encouraging Traci to try using her thoughts to see if she could stop Shawn’s heart, you’ll recall that Shawn was in another room [and she was] watching him by a video feed. There’s a reason for that. I didn’t want Shawn to be exposed to that.
That was exactly the eulogy that I had instructed her to write. At the very beginning we were doing those fear movies when I asked people to write down and then listen to and watch scenes around their worst-case scenario. The idea is: let’s take this obsession to its logical conclusion. If everything you worry about is absolutely true and you don’t do any compulsions or rituals what’s the outcome going to be? That’s the exposure we’re trying to get for Traci here. So in a way, she didn’t do her fear movie the very first time we did it. This is her opportunity to come back around and face that nightmare scenario. It is only in facing it that she starts to really understand how illogical it is.