Unless you have been living under a rock, without your cell phone, and no other human contact, you’ve probably heard of COVID-19 or otherwise known as Coronavirus. Individuals who suffer from contamination fear obsessive compulsive disorder are inherently more vulnerable to fears related to sickness, illness, and death that may result from contagions. These fears may be realistic in some forms, and magical in others. Irrational or otherwise, we should aim, as health care providers, to not exacerbate these fears with our clients while still not recklessly increasing their risk of contracting any serious threat to their health. So before all of my contamination fear OCD clients give me the “I told you so,” speech, I’d like to take a moment and address it.
The first point is acknowledging their concerns and tempering them with reality. Yes, there are some diseases and illness that we should want to protect ourselves against. This is the thread of truth that lies within the maelstrom of deceit in OCD. This is why you would never see me utilizing exposure therapy with used needles from somebody who may, or may not have, HIV. There are some natural precautions that we should all take to keep ourselves healthy AND safe. Balancing the utility of cleaning and ritualized safety behaviors is what exposure therapy aims to provide. Where the line becomes blurred for those who struggle with intrusive thoughts related to contamination fear OCD is in the definition of “precautions.” Often in my conversations with individuals presenting with OCD, they are dumbfounded with how and why people are okay with not keeping everything “clean.” These sort of concept creep fallacies are important to tease out in exposure therapy.
Natural precautions would include some of the behaviors that we engage in every day to keep ourselves safe and healthy. One of those is washing our hands. An individual who is struggling with ritualized hand washing may over wash their hands because they still feel contaminated. Sometimes to the point of harm to their outermost layer of dermis. We wouldn’t suggest they stop washing their hands all together because this is a natural preventative measure to keeping ourselves healthy; while alternatively, we cannot allow them to continue this compulsive behavior that is quite literally harming them. We would suggest they follow some parameters such as washing their hands, once, with antibacterial soap and warm water in order to kill germs that could make them sick. These sort of common behaviors are very concrete examples of precautions that align with what we know can keep us safe during the spread of any illness; COVID-19 or otherwise.
Social distancing is another precaution we are asked to engage in at this time as well; however, this does not mean shutting yourself off to socializing all together. It is often the case that individuals who struggle with OCD will also present with some variant of mood deregulation; be it anxiety or depression. Individuals I work with have been encouraged not to seclude themselves entirely, but rather be mindful of the distance between them and the next person. To seclude themselves entirely can result in increase depressive symptomology that in turn can intensify their intrusive thoughts and compulsory behaviors. I have encouraged them to continue to reach out to those that are close to them on other platforms such as FaceTime or Skype. This type of social interaction could be enough socializing to stave off those negative responses to isolation. Another benefit of staying connected is combating their isolation in a context that often connected to their compulsions. Their house, shower, bathroom, or other areas of their living environment are their comfort spaces for compulsions. Reminding your clients to be mindful about how their environment can influence their compulsory behaviors encourages mindfulness and ability for our clients to remove themselves to aid in combating their ritualized behaviors. Even though you can't go to work or school, you can always get outside for a nice walk.
Other types of guidelines have been proposed from the Center for Disease Control and the World Health Organization (links attached). I will direct those I work with to their websites to review those guidelines; however, during their seeking of information, I’m often mindful of how this could result in some form of reassurance seeking. One question for this is: How much assurance is too much assurance? As an individual without the presence of OCD, following the guidelines above might be easy; but for a person with OCD, this could spiral into that compulsory behavior via cognitive fallacies that introduce uncertainty on their knowledge about safe precautions. I may review this information and share those concerns with them in session so they can be mindful of WHY and HOW MUCH they are seeking this information.
Some of this reassurance may transfer into the therapy office. As an OCD therapist, I'm always on the lookout for reassurance seeking and information gathering from my clients. There have been multiple times over the course of the last week in which I have caught my client's OCD trying to work its way into our conversations. It's in our nature to help alleviate our client's concerns, sometimes even directly. Placating the emotions of a presentation of OCD via reassurance can increase the overall intrusive thinking they are experiencing which is not a long term strategy for success. I avoid this by inquiring who I'm speaking with: John Doe or his OCD? I may also inquire how my answer may affect them and why that answer is so important to them. Fairly routine socratic processes in any therapy office. So if our clients are seeking reassurance, something we cannot readily give them, how can we proceed forward in therapy amidst a pandemic such as this?
I often suggest that my clients engage in contamination exposures that do not increase their overall exposure to illness, for the time being. Now this is not an explicit response from me; however, by suggesting prior exposures we have conquered, we still tap into the uncertainty of HOW contaminated they are, or feel they are, during the exposure. These feelings of uncertainty is what we are after, not necessarily increased exposures to harm (even though they can go hand-in-hand). During times of illnesses with low transmission rates, I may eat some snacks after touching a door knob in my office. However, right now, I would struggle to do that given the seriousness of what we face at this time. This goes back to a main principle of exposure therapy: Never ask your client to engage in an exposure you are not willing to participate in with them. Balancing those exposures that tap into their uncertainty, while balancing those risks is key.
One way of balancing those risks it looking at the statistics regarding COVID-19 and comparing them to each client. If your client is young and healthy, without any conditions that would increase their mortality IF exposed to COVID-19, you're probably fine to continue exposures with little to moderate risks. If you do have clients that have increased vulnerabilities, such as asthma or suppressed immune system, you'd want to consider your exposures and their risk to that client. Perhaps another form of CBT could be utilized.
Acceptance and Commitment Therapy (ACT) is a great adjunctive option during this time. ACT invites our clients to experience their negatively valence emotions and accept them; not control or avoid them. It encourages clients to not avoid situations that invite negative emotions and engage in tolerance building in those situations. During these times we draw from their motivators for change and tolerance for distress, drawing from the value systems in their lives. The value for freedom, strength, confidence in action, and a positive attitude.
One other option that I have been suggesting is bibliotherapy in form of workbooks. One workbook I have found to be especially helpful with individuals I've worked with is the Mindfulness Workbook for OCD by Jon Hershfield & Tom Corboy. This extends your work home with clients and allows them to complete some thoughtful cognitive work.
Being mindful of the each client's presentations will allow you to tailor a solution that will tap into their uncertainty even during times of increased stress and triggers. Balancing those solutions with unnecessary risks is key during this time when we are considering shut downs and threats of isolation.
Your clients are lucky to have you there to help combat their intrusive thinking patterns. If you find you need help brainstorming or navigating this new territory with your clients, please feel free to reach out at email@example.com, firstname.lastname@example.org, or call me at 405-513-0282.
P.S. Be sure to wash your hands!