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.