The Essential Component of Treating Children with OCD

A Family Therapy Approach to Obsessive-Compulsive Disorder

Lynn Lyons • 7/15/2016 • Be the First to Comment

Seventeen-year-old David sat in my office and cried. “My friend has a four-year-old sister, and I had the thought that she was cute,” he whispered. “I keep thinking I might be a pedophile. Am I a pedophile?” David had spent hours on the computer researching pedophiles and refused to talk to his friend or parents about why he was so distressed. When his mother looked at his computer, she panicked. Was her son a child molester?

As 12-year-old Jade cleaned her newly pierced ears with hydrogen peroxide, she began to worry that she might pick up the bottle, guzzle it, and kill herself. When she told her mother of her thoughts, her mother hid all the chemicals in the house and slept in her daughter’s room, fearing she was suicidal. Dad was dealing with his own depression, so Mom wondered if her daughter was now following in his footsteps.

Both of these children have OCD, and they all finally found their way to my office, where, after months and sometimes years of confusion and family turmoil, the right questions led to an accurate diagnosis, followed by family intervention. David wasn’t a pedophile, nor was Jade at all suicidal.

The Cult Leader

In both of these cases, the diagnosis of OCD was a relief to the family, even though, of course, no family wants to hear that diagnosis. But once I explained how OCD works and assured them the symptom patterns were highly typical of what I see, the fear and confusion they’d been experiencing became more manageable. With families, I usually explain that OCD, like other anxiety disorders, is like a cult leader, demanding acceptance of a skewed view of reality. It shows up and makes an announcement that’s distressing (the obsessive thought): “You looked at the little girl and you were attracted to her!” “You might eat poison by mistake!”

It then posits a solution to the distress, some action, either internal or external, that offers temporary relief (the compulsion). But the thought inevitably returns, and to get rid of the associated anxiety or fear, the compulsion is repeated. If you don’t obey the cult leader, I tell the families, it becomes furious and even more demanding and irrational. When the cult leader is disobeyed, the price for the child and the rest of the family to pay is more and more worry and fear. So falling in line is the best strategy—except that it doesn’t work.

When I explain to families how OCD works, I usually see parents recognize this pattern of trying to placate the cult leader not only in themselves, but in their own families of origin. Sometimes one parent can now make sense of the marital struggles in a new way, understanding for the first time the controlling or “crazy” behavior of their spouse that’s made their relationship so challenging. Ideally, the parent acknowledges this recognition, a light bulb goes off, and they can see their own patterns in a new way. But even with their new understanding, the challenge of change can still be daunting.

Recognizing the Rules of OCD

The Howard family illustrates what can occur when the denial in a parent shifts to an embracing of a family perspective. Peter and Cathleen first came to see me six years ago for help with their seven-year-old son, Timothy, who’d been showing significant anxiety for about two years. His fears revolved for the most part, they told me, around the family car. He constantly needed to check the level of fuel in the gas tank, often unbuckling his seat belt to eyeball the dashboard gauge himself. He repeatedly asked for reassurance about the inflation of the tires and the safety of the air bags. “I’ve gotten into the habit of opening the hood of the car before we leave the house and showing him that the windshield wiper fluid is full,” Peter told me. “And even when I stop and get gas with him in the car, he starts asking if we have enough gas within a mile of leaving the station. We just can’t figure out why he feels so scared about the car. Nothing has ever happened. I don’t think we’ve even had a flat tire since he was born.”

I explained how Timothy’s behaviors were typical of OCD in children, and that seeing these patterns show up at around five or six years of age is also indicative of a family with a generational pattern of OCD. “Do either of you have OCD?” I asked. “Or do you know of family members that might have it? Your parents maybe?”

“I used to have it a little bit, I think, but I grew out of it,” Peter said, whereupon Cathleen snorted in clear disagreement.

“He vacuums the rug in a certain pattern, and flips out if we walk on it,” she interjected. “Then he has to do it again. That’s just one example. I don’t think you’ve grown out of it, Peter. You just don’t want to talk about it.”

“Keeping the house neat is not a mental illness,” Peter said. “It’s not at all like what Timothy does. Not at all. We need to deal with his issues.”

Cathleen locked eyes with me and shook her head slightly. I held her gaze for an important few seconds, recognizing how deeply stuck she felt. “Timothy definitely needs help understanding this, and you both need some support, too,” I said, knowing I had to tread lightly at this point. “This OCD thing can really take over, so I’m sure you’re both exhausted.” As the session ended, I hoped Peter would begin to make the connection between his patterns and his son’s.

When they returned the following week with Timothy, I explained to him that what he worries about is really of no importance. The content of his worries and the details of his rituals would probably change, just as they’d shifted already. So what we needed to focus on was the process of how to manage his OCD—which, I told him, was like a giant boss who made rules that felt real and important. “I hear your OCD makes rules about what you need to do at bedtime,” I said. “And if you don’t follow the rules, your OCD makes you feel scared or worried that something bad might happen, right?”

Timothy nodded. To help him practice how to respond to the giant boss’s rules, we decided to name it Frank. When we drew a picture of Frank on my white board, he had a green face with bushy eyebrows and yellow teeth. Pretending to be Frank, I demanded that Timothy ask about the gas tank over and over. Then I modeled for Timothy how to roll his eyes and brush off Frank’s bossiness. Together, the four of us talked about how this change in reacting to Frank’s rules might at first feel scary, but coming up with a family plan to ride out the anxious feelings would help it get easier with practice. I stressed that getting rid of the OCD thoughts wasn’t the goal. “Frank won’t give up that easy,” I warned them. “He’ll be mad and bossy when you tell him he’s ridiculous, but I’ll help you learn as a family to respond to Frank in a different way.”

In our two-hour family session, we talked openly about OCD. For the first time, Peter talked to his children about his own OCD, acknowledging that his desire to keep the house perfect was because of his cult leader, not their laziness. They pointed out to him that he never wanted to play with them when they were visiting their grandparents on the lake because he spent all his time tidying up. In turn, he shared with them how his OCD made him feel like things were never quite right, and how he couldn’t fall asleep at night if he felt that something in the house or at work was out of place.

Together, they began to recognize the OCD patterns in Peter’s mother and aunt. The recognition resulted in laughter, as if they’d finally unlocked the secret of why holidays and visits felt so weird and tense. Cathleen told her kids how she’d tried for years to figure out how to manage all of these OCD rules, and that they needed to work together as a family to rise up against the cult leader, instead of feeling so anxious and mad at each other all the time.

After that, the Howards have come to see me as a family once a month. In one session, Timothy came up with a plan to spend 30 minutes on his math homework, more than enough to complete it when he reminds his OCD that it won’t be perfect. Rather than trying to avoid the anxiety and discomfort that his OCD triggers when he disobeys it, he tells his OCD that he’s supposed to feel anxious as he continues to step away from his compulsions. When he slips and asks his mom for reassurance about something he might’ve done wrong (his worries about lying have at times morphed into other imagined transgressions, like cheating or being mean to friends by mistake), Cathleen says hello to Frank, and reminds Timothy that he’s getting sucked into content by saying something like, “Oh, Frank, really? Are you trying to trick us with that again? Timothy, please let Frank know that we’re onto him.”

A few months after our family meetings began, the kids happily reported to me that a picture had fallen off the wall and left a big scratch in the paint. “And Dad is going to leave the picture leaning against the wall, and he’s not going to fix the scratch for now,” they said. To his credit, Peter actually left the “mess” in the hall for a few months, saying he’d fix it when he felt like it, not when OCD demanded it. Walking by the picture propped against the wall and the scratch in the paint, he said, felt like a victory.

Overcoming Denial

Not all families are as open and committed as the Howards were when dealing with the family impact of OCD. But family psychoeducation and involvement is a critical component of my approach. My policy when working with anxious children is that both parents must be involved in treatment when at all possible. While I understand some parents’ resistance to having their children labeled with OCD, I believe that they can benefit from seeing OCD symptoms demystified and being part of a family plan to deal with them.

Still OCD is a clever opportunist with the ability to pull children, families, schools, and therapists into the dizzying trap of decoding its meaningless content in a misguided effort at getting rid of symptoms, which often masquerade as something valuable. For instance, a physician I treat is admired professionally for his thoroughness, his long hours, and exactitude. His wife and children, however, talk about his paralyzing attention to detail and an inability to manage his time, which keeps him disconnected from his family. Another family told me of their son’s need to shoot 200 foul shots every single day during middle school, something his basketball coach regards as a model of discipline for the rest of the team.

Part of the goal of family treatment is to expand everyone’s view of the long-term emotional and relational cost of OCD, whatever its short-term payoffs in anxiety reduction may be. So I try to use humor and playfulness to help them grasp a larger story of their shared experience, which recasts the role of OCD in their lives and exposes the price family members pay for playing by its rules. When I succeed, that can be a first step toward enhancing the mental health of an entire family for generations to come.

This blog is excerpted from "OCD and Children" by Lynn Lyons. The full version is available in the July/August 2016 issue, OCD: Is There Any Way to Turn It Off?

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Illustration © Rob Colvin/Illustrationsource.com

Topic: Anxiety/Depression | Children/Adolescents | Parenting

Tags: Lynn Lyons | Anxiety | anxiety in children | Children | Children & Adolescents | children with ocd | compulsive disorder | Couples & Family | family counseling | family therapy | obsessive compulsive | obsessive compulsive disorder | ocd | ocd in children | ocd symptoms | Parenting | parenting issues | treatment of obsessive compulsive disorder

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