OCD requires ERP for effective uprooting of the compulsions, but as explained in the ERP blog, it requires back breaking effort from the sufferer. And the sufferer often finds himself less than adequately equipped to handle the pressure exerted by the response prevention. It prompts him to give up halfway; it forces him to learn to live with failure. Often, this leads to a disagreement with caregivers, who cannot understand this lack of will, and exert undue pressure on the sufferer to comply.
One of the biggest inhibitors to progress in an OCD sufferer is this unreasonable expectation that the caregiver has, from the sufferer. Since the anxiety inducing stimuli for the sufferer are (for the caregiver) mundane activities, such as say, touching the door knob and then not washing hands, or switching off the light just once, instead of three times, the caregiver is at times unable to understand the extent of anxiety faced by the sufferer and the resultant inability to complete the ‘mundane activity’.
In my experience of working with OCD sufferers and their caregivers or their families, I have often noticed frustration, mixed with anger on the part of the caregiver. The understanding is perhaps limited and there is subsequent disdain towards the sufferer’s inability to prevent response, which is often dubbed as unwillingness by the caregiver. The sufferer is therefore put out by the callous attitude of the caregiver and discouraged to even try. The sufferer feels a sense of abandonment when the caregiver does not understand why it is so difficult for the sufferer to resist the compulsion. The caregiver, in his ‘good intent’ forces the sufferer to not do the compulsion and this often results in conflict, which has the potential to undo any progress that might have been possible, had the sufferer been in a peaceful state of mind.
To add to it, the sufferer feels that the caregiver is putting him down, when the caregiver either forgets to or chooses not to appreciate the small progresses made by the sufferer. The progresses in the mind of the sufferer are not small at all, but they may be so for the caregiver. It takes too much effort and it would augur well for the caregiver to notice and appreciate it. The caregiver instead, is often too put out with the whole thing and bickers with the sufferer, using words that agitate the sufferer even more.
I often ask the caregivers to treat the sufferer like an intelligent child and not like a dumb adult. What would you do when an intelligent child does something that is simple for you but difficult for him? Would you put down the child for thinking so highly of himself for having accomplished something so silly or would you laud his progress? Caregivers make the mistake of treating the sufferer like a dumb adult, instead and pooh-pooh the effort made, leading to the feeling of ‘why should I even try’ in the sufferer, since he feels unappreciated. And because of this reason, the sufferer and the caregiver rarely seem to be on the same page with regard to the efforts put in by both.
And the sufferer’s progress is viewed through different lenses by both, the caregiver’s lens being stricter and less yielding. And more often than not, the sufferer’s resolve breaks down for want of the right kind of, and right amount of encouragement from the caregiver.
So what do you do? That is where the importance of starting small comes in. When I was a caregiver (or rather when my wife’s OCD was at its peak), I had fallen into the same trap of high expectations and little encouragement. Till we realised one day that she and I were engaging in way too many arguments and squabbles for it to be considered healthy. For me, for our relationship, for our child, and most importantly, for her mental health. After a few hits and misses, we hit upon the thought of dialling the ERP down a few notches. All this while, I realised that her resistance to therapy was that it was too much for her to handle. I needed a way to make it palatable for her to do and yet let it be effective. Her counsellors had all constantly kept pushing her to achieve various milestones, which since she couldn’t, left her feeling dejected. That I realised was the reason why progress was at a standstill. It also got her to lie to them at times, just to not be pressurised more.
My wife’s OCD is contamination OCD, with the added need to keep the house free of ants and hence we hadn’t been keeping sugar or other sweet things in the house, because sweets attract ants. So once, when I was wearing the hat of a co-therapist, and sitting with her to understand what we could achieve and what we couldn’t, I asked her if she felt brave enough to keep sugar at home. Her reaction was that of horror. She answered in the negative. She also answered in the negative for getting just a sachet of sugar at home, or getting a little sugar at home for therapy purposes and keeping it in a big plate, while she could look at it and do her exposure. Ok, how about one grain? No, she said. Even thinking about it causes me anxiety.
And it was a small epiphany for me. I realised that even if the thought is causing her anxiety, dialing down the exposure meant we needed to start there. Just thinking of having sugar at home. After all, if I have to eat a watermelon, how would I eat it? In bite sized chunks. So the therapy needed to be in bite sized chunks for her. Over the next few days, I tried to get her to desensitise herself to the thought of having sugar at home.
In addition to that, she also imagined going to a garden and walking on grass, since that was an issue with her as well. And when I would return from work, she would describe her thoughts in detail. And it worked. Slowly, she began to get desensitised to the fear and after some time, she actually went to a garden and walked on grass. And yes, we keep sugar at home now, although, in sachets.
I have since then gotten all my clients to face only as much as they are willing to. It may take time but it makes sure there is willingness and helps the sufferer find a solution that is both palatable and effective.