OCD: Treatment for Contamination Fears
Before discussing currently accepted treatments for contamination obssessive-compulsive (OC) disorder, let’s cover treatments that should be avoided (but unfortunately are still used by some providers).
These treatments may be helpful for other problems, but the weight of evidence suggests that for contamination OC (and other forms of OCD), these should be avoided.
- Systematic desensitization: The functional component of this treatment involves relaxation in association with feared images and objects. Although this approach is of some value for other anxiety conditions, it is not advisable for contamination OC. One of the clearest reasons is that most people receiving this treatment find they cannot engage in relaxation exercises when they are ‘in the moment’ of their contamination fears. If this portion fails, then the whole treatment falls apart and the only thing left is frustration.
- Cognitive Disputations: Some have found that directly challenging ‘faulty beliefs’ associated with different conditions are valuable. However, many others feel that this approach is demeaning, where one is locked in a verbal battle with the treatment provider. Cognitive therapy is widely used for contamination OC, but proper use involves a style that is entirely tailored to OC, and it is unlike the format of cognitive disputation. This is discussed later in this article. Also, see the article Cognitive Behavior Therapy for Obsessive-Compulsive Disorder.
- Analysis: Some still adhere to the idea that contamination OC is best described as a problem associated with a breakdown of intrapsychic processes, and only through lengthy analysis does one resolve this difficulty. Unfortunately, this fails on two accounts. First, there is limited symptom focus, so one entering treatment typically remains symptomatic for some time, often with no relief in sight. The other problem is worse. Analysis fosters some doubt about past associations and the relations with current problems. For some problems this may be effective, but in contamination OC, where there is already considerable doubting, this actually creates a worsening of symptoms. Analysts have actually known that their form of therapy is of no value to people with OCD for many years. In 1965 (just prior to the initiation of programs of research using behavior therapy for OCD), the British Journal of Psychiatry declared that “traditional efforts to treat OCD are a complete failure and should you encounter a patient with this condition, tell them gently that nothing can be done.” Since there have been no appreciable advances in psychoanalytic theory for OCD since that time, the same statement holds true for this therapeutic approach when applied to OCD.
- Thought stopping: This approach takes the form of keeping a rubber band on one’s wrist and every time an urge arises to wash, the person is instructed to snap the rubber band. The goal is ultimately for one to be able to remove the rubber band, and instead state ‘stop’ to themselves as a means of alleviating the thought and preventing the ritual. This actually creates a worsening of symptoms. In fact, there has been much research to show that this is a harmful way of proceeding for people with OC, as well as for people without OC.
Given this list of treatments that should be avoided, let me describe treatment that has been accepted as more effective. There are basically five distinct steps involved that therapists repeat in cycles until there is symptom relief.
- Construct a hierarchy of fears: Here, the therapist and client collaborate over what things are least feared, to those most feared. For example, one may find it possible to carry a napkin that has touched the floor, but cannot bear the thought of directly touching the floor without washing. This can be applied to other feared items (such as public doorknobs, toilet seats, subway straphandles, etc.).
- Self-monitoring: Maintaining a record of frequency of hand washing (by keeping a log, or self-monitoring sheet) individuals often experience some reduction of symptoms. As treatment progresses (by inclusion of exposure with response prevention), self-monitoring can be extended to successful completion of behavioral exercises. The value of this stems from the ability to objectively evaluate progress over time. Further, in discussing weekly progress, it is then possible to recall more accurately how and under what circumstances improvement took place. For example, someone may do very well the first three days following a session, and then struggle a bit just before the next session. Without the objective data, someone could say they ‘are doing terribly.’ However, that is not entirely true. Instead, there was some variation in success, as noted in the self-monitoring forms.
- Exposure with response prevention: Once a hierarchy of fears has been established, the therapist and client ‘climb the hierarchy’ by exposure to low items on the list. The important portion associated with this approach involves not washing after the activity. As part of this experience, it is important to introduce items that are contaminated into the individuals’ contamination free zones. That is, the most effective treatment involves ‘spreading’ the contamination, which (a) prevents keeping track of what is dirty or clean and (b) promotes more rapid treatment response. An additional feature of this spreading of the contaminant prevents ‘contrast effects.’ This may be most painful by individuals establishing strong safe zones in close proximity to contaminated zones.
- Re-Exposure: Once the person actually washes (which therapists acknowledge is completely necessary for hygiene, of course), it is most important for the person to engage in re-expose to a feared contaminant. This is sometimes the most difficult thing to do in therapy, but also fosters rapid treatment gains. The rationale behind this involves fostering a sense that one can never be completely clean, and that contaminants are pervasive. It also addresses the concern over intolerance of uncertainty. That is, one can be clean yet still be contaminated.
- Contractual matters: A final important aspect. Treatment, and progress through the hierarchy, is akin to a contractual agreement. However, in actual practice, people encounter feared items that are not part of the contract. We would encourage washing after contact with these items, but immediate re-exposure to contracted items. For example, it may be contracted that exposure takes place with doorknobs, but not for the bathroom doorknob (yet). If contact is made with the bathroom doorknob, wash but immediately touch a different doorknob.
What is the rational behind this treatment? This form of treatment has emerged from a rich theoretical tradition in psychology that is now referred to as cognitive-behavior therapy. This form of treatment is described on this site.
Treatment Rationale for Contamination OC
The most frequently cited reason for engaging in treatment activities of the sort described here is to achieve habituation. I have described habituation to others as sand in the shoe after going to the beach. At first, you notice a few grains between the toes, and it is quite irritating. But if you don’t do anything about the sand, after a short while it is forgotten. Exposure therapy works in a similar manner. At the beginning, the anxiety associated with the activity is distressing, but diminishes after a short while.
The hierarchy provides a pace chart for treatment. If one moves up the hierarchy too quickly, then the client will not only struggle with treatment, but may get worse. If we refer to the shoe example, a little sand is typically tolerated. However, if there was a great deal of sand in the shoe, it has to be dealt with. In fact, if you leave a large mass of sand in the shoe, blisters could develop and result in intolerable pain. This is the situation if someone climbs the hierarchy too fast.
Sometimes, people refer to exposure as an effort to ‘bend the pole.’ That is, at the point of entering therapy, clients with contamination OC are at one end of the normal curve for washing. Treatment suggests moving to the other side of the normal curve for a short while, in an effort for people to get to the middle (average washing). This is important, because sometimes in therapy, people are asked to do things that sound ridiculous. For example, as part of treatment I have demonstrated to clients that I can touch my tongue to the bottom of my shoe, or am capable or touching various items in a bathroom then go enjoy a bag of popcorn. Yes, this is extreme, but demonstrating that this is possible illustrates the possibility of doing exercises like this (one day, not the first day) as part of bending the pole to the other extreme.
Cognitive therapy for OCD has evolved significantly over the past several years. One significant change involves going from level of ‘disputation’ to instead relying on a collaborative approach in which client and therapist explore ways to ‘re-appraise’ functional ideas regarding contamination. For example, people with contamination OC who are concerned with harming others might feel that they are responsible for many things, and appraise most situations as ones over which they can exercise control.
One goal of therapy, then, is to assist in altering appraisals such as these. Other appraisals may involve perfectionism, probabilitistic thinking, and assigning over-importance to thoughts. Perfectionism is a concern that one has to engage in many (or all) activities perfectly, with washing being part of that framework. Probabilistic thinking is that assigning of probabilities to the likelihood of thoughts will turn into events.
Over-importance of thoughts is a more recent construction that involves a belief that having a thought is the functional equivalent of the associated action. So if you think you are dirty, then you are more likely to be dirty. Cognitive therapy can be successfully utilized as an adjunct to behavioral treatment described before (hierarchy/exposure/re-exposure). In fact, some have suggested that although cognitive therapy may not appreciably increase treatment effectiveness, people are able to stick to the demands of behavior therapy more when cognitive therapy is used as well.
Special impediments to successful treatment outcome
There are several things that can create difficulties with treatment outcome for people with contamination OC. One of them involves the role assigned to the therapist during the course of treatment. Given the description of treatment to this point, it is clear that it is important for people to demonstrate, through potentially anxiety-producing exercises, that contamination can be tolerated.
However, in some instances, by virtue of the therapist being present during exposure, the client assigns responsibility to the therapist. This ensures that should illness befall either the client or others around, then it is the therapists’ fault since the therapist was present when the exercise was being conducted (whether it be touching a napkin to the floor, or coming into contact with items in public restrooms).
This is a difficult problem to overcome, and I would like to emphasize that it is not done intentionally. This is frequently a natural reaction to fear and anxiety. The best way to overcome this problem is by successfully completing assignments designed to reproduce the therapy experience outside the office (without the therapist present). Although this forms an important part of therapy anyway, it is particularly crucial in cases such as these.
Another important problem that can occur in contamination OC (as in other forms of OCD) is the presence of overvalued ideas. This has been shown to be associated with poorer treatment outcome, and at this point, it is not entirely clear how to best deal with the problem. Overvalued ideas are characterized as falling on a continuum from frank acknowledgement that the idea is not rational but the urges are compelling, to an inability to identify the idea as irrational. For example, if one with contamination OC felt genuinely that only by washing 36 times would all the contaminants be washed away, and that anything less would result in illness, then that person would have high overvalued ideas.
When overvalued ideas are high, they have been described as two sides of a double-edged sword. One side of the sword represents rational thought, and the other side irrational thought. As is the case of a sword, one can quickly switch from one side to the other. People with high overvalued ideas regarding the necessity of washing usually require more time in treatment, and the prognosis is not typically as positive. This does not mean that there is no hope, simply that treatment may need to be more intensive or for a greater duration, or both.
Finally, sometimes individuals simply cannot effectively engage in treatment related exercises. This problem manifests itself frequently when the fear associated with engaging in behavioral exercises is too high to be tolerated. When this happens, the onus is placed more upon the therapist to develop exercises that can be completed. Creativity is the key here. I’ve highlighted this as a number of previous clients of mine complained that prior therapists were unwilling to work with them as they could not do the assignments. When this happens, it is not surprising that the client feels defeated and demoralized. My suggestion, however, is that if the therapist is unwilling to determine methods that are ‘do-able,’ then perhaps that is not a good match in treatment anyway.
Maintaining Treatment Gains
Although many sufferers recover from contamination OC, it is widely acknowledged that special attention must be paid to matters related to staying recovered. Although at the end of treatment many behavioral exercises no longer produce anxiety, it is important for people recovering from contamination OC to continue to engage in activities that were previously anxiety producing. The way that one can justify the ongoing self-therapy approach is to consider this like any of their other health maintaining activities. Just as some engage regularly in physical exercise to remain physically healthy, it is likewise important for those with contamination OC to engage in mental and behavioral exercises to remain mentally healthy. If physical exercise is a metaphor that doesn’t appeal to you, then consider it like brushing your teeth. Here, regular behavioral exercises serve to ‘brush your brain.’
Some Concluding Thoughts…
Contamination OC can be disabling, and sufferers struggle mightily with symptoms that are frequently tormenting and painful. Further, our knowledge of how to best treat contamination OC is still developing so that therapy may be either faster, more thorough, or capable of helping those for whom treatment fail. Yet there is treatment available, and the results are often encouraging. Some recent research has suggested that when therapy is conducted in this manner, approximately 80% of participants are capable of experiencing symptom relief.
Psych Central. (2013). OCD: Treatment for Contamination Fears. Psych Central. Retrieved on July 1, 2015, from http://psychcentral.com/lib/ocd-treatment-for-contamination-fears/