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  • Writer's pictureEdmund Ng

B08: Work-in-Progress of an OCD

Updated: Feb 4, 2023

Unhealthy shame is often passed down from one generation to the next and so the transmission of shame is transgenerational. If the primary caregivers are shame-prone, they will model to the child their shame-based characteristics and pass down their unhealthy shame through their negative responses to the child’s needs.

Patty’s mother lived with much shame after marrying an irresponsible husband who did not provide for his family and abandoned them for many extended periods of time without any trace of contact. Her mother had often isolated herself from her neighbors and friends as she felt very shameful when they asked her about the whereabouts of her husband.

Since baby Patty had the physical features of her father, her mother had often taken it hard on her because her looks would remind her of her husband and aroused deep anger in her. Through the mother’s harsh responses to the infant’s needs, often raising her voice at her, she had been modeling and passing down her unhealthy shame on Patty.

Something happened when Patty was about three years old. During one of her father’s brief stay at home, he went close to her and held her. Instead of feeling the fatherly love, Patty experienced his closeness as a man molesting her. This was because she was already predisposed to be shameful of her father with the unhealthy shame passed down from her mother. Indeed, the felt shame of being “molested” by her father was so traumatic to her that the shame was internalized, infecting her core identity as someone who is now “dirty”.

Hence, Patty grew up constantly ashamed of her “dirtiness”. Whenever she uses the toilet or bathroom and touches her underwear, she would feel dirty and washes her hands several times as an obsessive-compulsive disorder (OCD) ritual to get rid of her “dirtiness”. Over time, the OCD molded her to be more and more perfectionistic in not accepting anything that does not meet her expectations. As a result, she also acquired a few other OCD habits as part of her daily rituals.

Exposure and response prevention

When Patty, now in her 40s, first came to me for treatment of her OCD, I immediately started her on a cognitive-behavioral therapy called Exposure and Response Prevention. She was asked to list down her OCD behaviors and then assess the anxiety level triggered by the thoughts of each behavior using the Subjective Units of Disturbance Scale.

She listed down three: repeatedly washing her hands after touching her underwear, rechecking that the main door is locked, and rechecking that the kitchen water filter is switched off at night. It turned out that rechecking the main door causes her the least distress while the repeated washing of her hands causes her the most distress.

Starting with her least stressful symptom, Patty was asked to lock her front door and not recheck it again. When the thought of going to recheck resurfaces, she will just accept it as a neutral thought without succumbing to any fear that the door is still unlocked. The same process is repeated 20 times until the obsession is completely desensitized and there is no more emotional or behavioral response to it.

The next day, she practices switching off the water filter without rechecking on it. On the third day, she finally proceeded to touch her underwear without washing her hands repeatedly. It took a little longer before she felt undisturbed by her obsession but she eventually sensed a breakthrough that she can move on without washing her hands.

Memory reframing psychotherapy

After a few months, Patty came back to me again and complained that she has to exercise a lot of effort and willpower to manage her urges without going back to her OCD rituals. She desires to be set free more completely. That was when I proposed to her to try out a psychodynamic technique called Memory Reframing Psychotherapy.

I explained to her that her obsessive thought of “dirtiness” was rooted in the perceived “sexual abuse” of her father during her childhood. Thus, when she touches her naked body or underwear, the action triggers her shame memories that she is “dirty”. So, she constantly washes her hands to give her the temporary relief from the shame that her body is “dirty”. I also explained to her the therapeutic process that I will bring her through.

Then I got Patty to relax while seated comfortably on a chair, close her eyes, focus inwards on her breathing, and imagine herself by a quiet beach, entering through a door into her past memories. I then asked her to dwell fully into the past “sexual abuse” incident and re-experience what happened as real as possible. She is led to describe the surroundings, narrate the time sequence and details of her experience, verbalize and feel especially the record of her senses and emotions embedded in her memory.

When Patty is in the thick of the re-traumatization of this past incident, she is asked to imagine bringing someone into the scene who will rescue her from her perceived sexual molestation. Prior to starting the intervention process, we have already discussed which significant person Patty will bring into the imagery as her rescuer. Hence, Patty imagined her mother coming into the room and snatching her from her father. Her mother then held her in her arms and told her wayward husband to leave the house, never to come near Patty again.

Patty described that she felt safe and vindicated when her mother held her close. She was asked to stay in those comforting emotions a little longer so that they are fully internalized and itched in her new memories. During the debriefing, Patty reported a feeling of lightness and release from her past bondages.

Indeed, the purpose of this psychotherapeutic exercise is to repair the shame of her original experience to create through imagery a new and favorable memory out of the same past scene as an alternative route for the neuronal synapses to travel. The realistic “experiencing” of the old and new imagery scenes is key for the effectiveness of this protocol.

Follow-up and Update

I followed up with Patty a month after our last session and she was in a cheerful mood. She told me that the compulsion to wash her hands repeatedly has much diminished. Then came the Covid-19 pandemic and she caught the infection. She started to fear the virus, bacteria, germs – in fact, anything that she perceives as dirty. As a result, her repeated hand-washing ritual came back and she asked if she needed to see me again for further therapy.

This time around, new factors are involved and I will have to explore with her what are the specific triggers that set off the new compulsions before proposing to her the next course of action.

3 Feb 2023

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