My son is resistant to having treatment for his contamination fears. He refuses to talk about his obsessions and compulsions and says he wants to be left alone with them despite the fact that he’s clearly in distress. His therapist said he has magical thinking OCD. What is this?
Children (and adults) who have magical thinking OCD become preoccupied with lucky or unlucky numbers, colours, words, actions, objects, certain people, religion, or superstitions and link these to “bad things” happening.
My son will not touch objects handled by certain others and will not step or walk where other people have walked. He says he’ll be infected with germs and feel filthy forever?
Magical thinking is based on irrational thinking. By not touching an object for example your son perceives this as “preventing” himself from becoming contaminated and feeling filthy. Magical thinking is also called thought-action fusion. There are two elements with this. These are moral thought-action fusion (Moral TAF) and likelihood thought-action fusion (likelihood TAF)*. The first makes a child (or adult) believe a certain emotion is real (e.g., feeling guilt, shame, sullied), usually for a perceived wrongdoing, or thinking they’ve spread germs and feeling responsible for that; yet what they feel is based on just that, feelings not facts. Likelihood TAF is that a child believes a “bad thing” is more likely to happen simply because they had a thought about it; or because they didn’t do what OCD wanted.
What’s the solution?
First, avoiding touching objects is a compulsion which your child does to counter his fears and relieve anxiety associated with magical thinking obsessions. However, it is the compulsions that strengthens the obsessions and keeps OCD going in a circle. Other compulsions include confessing, seeking reassurance, checking, praying and uttering certain “safety” phrases under one’s breath. The solution therefore is cognitive behavioural therapy (CBT) with exposure response prevention (ERP).
Why doesn’t traditional counselling help?
Counsellors are active listeners as are CBT therapists. The difference however is that guidance in resolving personal or psychological problems is mostly what a counsellor assists with; yet CBT therapists bring in strategies for reducing the severity of obsessions. The way this happens is that intrusive thoughts are involuntary and cannot be controlled because these are a result of a biological problem and therefore are not classed as valid content. Unless a counsellor is familiar with OCD they might mistakenly attempt to analyse the intrusive thoughts instead of the thinking errors a child usually attaches to their obsessions.
So how does CBT with ERP correct the thinking errors?
The cognitive side of therapy helps address and resolve these.
Example: “My friends have dirty habits (thinking error); I feel that they have passed germs to me because I spent time with them and now I feel dirty (faulty belief). I will now have to de-contaminate by showering and washing my clothes (compulsion to relieve anxiety momentarily).
New rational interpretation: “Not all my friends have dirty habits; even if they do it doesn’t mean their habits transfer to me or spread germs on to me. This means de-contaminating isn’t required.”
What about the behavioural side, how does this work?
The behavioural side of therapy (ERP) is where a child delays doing their “safety behaviours” (compulsions). When preparing for exposures, a therapist helps a child write out a “magical thinking list” or for an older child this would be called a hierarchy or fear list. Each fear (obsession) on the list is graded in severity on a 0-100 scale. The least distressing fear is faced first (exposure) and the usual behaviours are resisted (response prevention) for an agreed length of time, and until the obsession no longer bothers the child. They continue like this until all their fears have been faced and each is reduced to around 20-25% on the anxiety scale.
How can I support my child through CBT/ERP?
Providing your child (and extended family) with psycho-education about OCD is helpful.
Here is a simple explanation.
OCD is an illness that makes you get unwanted thoughts that can be scary or upsetting. When this happens you will usually do compulsions (name what these are). Doing compulsions makes you feel a sense of relief from the distress you feel, but only for a little while. This is because compulsions reinforce the problem, meaning the more you do them, the more you get the urge to do the same things again and again.
It’s important to learn that obsessions are not real about other people, or you. By keeping hold of your OCD as though it protects you and others around you is a false way of making you feel safe; so believing that doing what OCD wants to prevent a bad thing from happening is nonsensical.
When you say no to doing compulsions, you figure out that even though your anxiety gets very high at first, this starts to come down naturally, usually within 15-30 minutes, and no longer than an hour, just like it shows on the anxiety graph below.
The anxiety graph
See how each time you do a compulsion how your anxiety gets higher. This makes you need to do the compulsion again because you get desperate to ease your distress.
The second anxiety diagram (below) shows how anxiety comes down gradually when compulsions or avoidance behaviours are not given into, which eventually means your obsessions weaken and you feel less of an urge to do the compulsions.
Notice how distress reaches high and then gradually decreases over a 20-60 minute period. By not doing compulsions you can see how this gets less high the more you resist the compulsions. This breaks the OCD cycle because you no longer need to do the compulsions to relieve anxiety.
How else can I help with ERP?
It’s a good thing to gauge anxiety before, during and after an exposure to help your child with monitoring progress and set-backs, and making adjustments where needed. For example, if an exposure on their fear list seems too high, they can come down one; or if too low, they can go up one. It’s also important to stand back and give your child leg room. Keeping a few paces back can help them manage anxiety without feeling closed in and they will begin to see that this does come down eventually without intervention. This teaches them that they are capable of building distress tolerance which encourages them to continue with their exposures. Occasional supporting comments are helpful, e.g., breathe easy, keep going, nearly there etc. Outside of exposures you can remind your child that the more they practice not giving into compulsions (all compulsions) the less high their anxiety will reach on the distress scale overtime.
What if my child remains resistant to therapy, and continues to believe OCD is keeping him “protected”?
Explain that it can’t ever be certain that nothing bad will happen in life; however, in all the hundreds of years that people have suffered from OCD, there has never been any proof to show that intrusive thoughts make things happen or that doing compulsions keeps people safe. Then explain that research has proved that CBT with ERP helps to reduce the fears associated with OCD, and sometimes medicine too. And then let your child know you’re there to support him through his illness when he’s ready.
Disclaimer: This article is information-based only. Please consult with your child’s doctor or mental health provider before carrying out suggested exposures.
* Arthur S. Reber
Photo Credit: pixaby.com
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