AN EXAMPLE OF BEHAVIOR THERAPY FOR OCD: THE CASE OF RAYMOND
Raymond’s case is instructive because he responded well to a very simple behavior therapy program. All that was necessary for marked improvement was for Raymond to systematically expose himself to his everyday obsessions while doing his level best to prevent compulsions.When Raymond first came to me, he was in the midst of a severe OCD crisis. He was unable to work. His days were filled with obsessions of poisonous spills, and he performed hours of checking rituals in order to prevent imagined catastrophes. Raymond thought that he had lost control of his mind, that his life was ruined. He fully expected to be hospitalized.Instead what happened was that Raymond worked hard at behavior therapy for six months, seeing me every one to two weeks for consultation. By the end of that time, his symptoms were more under control than they had been since he was a teenager. Antiobsessional medications were also quire helpful in Raymond’s treatment, especially in the beginning. Group therapy was very beneficial, too. But Raymond and I both believe that behavior therapy was the critical factor in his striking improvement.Raymond’s behavior therapy was divided into three stages. Our first four sessions together were educational. He learned the nature of OCD and how to clearly recognize his obsessions and compulsions. Sessions five through seven were concerned with assessment; here, we identified all of Raymond’s symptoms and ranked them by severity. Our last nine sessions formed the active behavioral therapy phase, during which exposure and response was accomplished.As is often the case, Raymond was greatly comforted right at the beginning of treatment when he learned that obsessions and compulsions are caused by a physical, chemical disorder. Like most OCD sufferers, he had never carefully considered the root of his symptoms but rather had blindly assumed what, somehow, he was to blame for them because of some mental weakness. Learning the truth about OCD began a revolution in the way he looked at himself. For twenty years, although he had been an excellent worker, citizen, and family man, he had thought himself mentally inadequate and half crazy. That he is neither of these things but instead the sufferer of a specific brain disorder continues to surprise him even now.Identifying obsessions and compulsions—the critical step in the early part of therapy upon which all further progress depends— presented no special problems for Raymond. His intrusive thoughts of vile and dangerous spills were classic, easily recognizable obsessions. Carefully looking for spills, feeling carpets, checking hallways, and conjuring up visions of vacuum cleaners while making “whooshing” sounds were obvious compulsions. With Raymond as with all OCDers, however, identifying obsessions and compulsions was easier when he was sitting in the office calmly discussing his symptoms than when he was in the heat of an OCD attack.In the assessment stage of therapy, the important work is to take a comprehensive inventory of obsessions and compulsions and then to rank them according to their severity. In order to accomplish this, I first asked Raymond to keep a daily diary of compulsions for three consecutive days. Here is a typical day of entries:Even though Raymond’s symptoms were significantly improved by the fifth visit, his daily diary shows that compulsions were still taking up almost three hours a day. Obsessions, Raymond told me, were on his mind virtually every minute, except at work, when perhaps a half an hour would go by when he was completely free of them. The diary demonstrated that his obsessions were of two types: “spill fantasies,” in which he vividly imagined a container full of a deadly liquid ready to tip over and cause a disaster; and “poison fantasies,” in which he conjured up the image of a poison or diseased substance either accidentally present or deliberately planted in the food or drink of family members.Using his daily diaries as a starting point, Raymond then constructed a list of all the various situations in which compulsions commonly arose and ranked these situations according to the degree of anxiety he experienced when the obsession struck. His anxiety ratings were purely subjective—estimates of his level of anxiety during certain situations relative to others. To rate the anxiety, he used an “anxiety thermometer,” on which “o” represented no anxiety at all and “100″ was the most anxious that it was possible for him to feel. We divided the OCD situations into those involving “spill” and those involving “poison” obsessions.*25/338/2*
