A conundrum that I will never forget involved a 20-something female client from rural Indiana, we’ll call her Claire, plagued by fears about sexual abusing children. The client was Amish, and so even coming all the way to my clinic in Louisville was a major hurdle because the family had to hire a driver to take her two hours each way. Claire would arrive at each session with her older sister, who had helped look after her over the years. The two were close and the client wanted her sister to be involved as much as possible. Her sister was very kind and sincere, and was only too willing to do whatever she could help Claire get better. She gave me a small book about Amish culture to help me better understand their ways.
Claire was suffering from a severe form of obsessive-compulsive disorder (OCD) that involved worries about causing harm to children. It is fairly well known that people with OCD often fear harming others accidentally – for example, by leaving a stove turned on, thereby causing the home to catch fire. To prevent this feared outcome a person with OCD would then engage in repeated checking of the stove. It is less well known that people with OCD also worry about causing harm on purpose, for example by impulsively pushing someone onto subway tracks or stabbing them with a steak knife at dinner. OCD sufferers with these sort of worries are generally very gentle people, mortified at the idea of violence against anyone, which is one reason these unwanted thoughts are so upsetting to them. In this case, the client worried excessively about harming children by touching them inappropriately, and thus she had become convinced that she was a danger to her community. This is sometimes called POCD, for “pedophile OCD,” although these patients are in no way pedophiles.
We spent some time getting a complete mental health history, and after only a few sessions, the client disclosed to me that she had, in fact, sexually abused an identifiable small boy in the family general store. She gave a graphic description of event, and seemed dead serious about her story. Of course, I found this rather alarming. People with OCD generally have some insight into their worries and are able to admit their fears are exaggerated or even ridiculous. It is, however, possible for people with OCD to completely believe their fears will come true. But this was different. I had not encountered someone with OCD who thought they had committed their most feared outcome – especially something this awful and with such certainty.
Claire's sister relayed to me that she had made many such statements in the past, and each time the situations were investigated and found to be untrue. She believed that Claire made these stories up to get attention. Correspondingly, there was no evidence that Claire had done any such thing this time either, yet she maintained her insistence that she had. Although I was fairly sure she had not abused any children, APA Ethical Principles require disclosure of information learned in therapeutic sessions to protect others from harm, and Kentucky law requires a report if there is even a suspicion that a child has been abused. I did not yet know what was causing Claire to say these things and could not be one hundred percent certain it was simply her OCD. On the other hand, I worried that if I made a report, it would harm our therapeutic relationship and she would not continue treatment. Amish are a very communal and tight-knit group, and so it was quite likely that the client could only work with me with the permission of the community leadership. So, I further worried that a bogus CPS investigation would erode whatever trust the community had placed in me as a psychologist to help this client, which might also have negative implications for future Amish from that community in need of outside mental health services.
I agonized over what to do about this. After careful consideration and consultation, I sat down with Claire and her sister together and explained the laws concerning my requirement to make a report. I asked her again if she was sure she had sexually abused a child, because if so I would have to call Child Protective Services (CPS), and give them her name, address, and other pertinent details. I hoped and believed that she would tell me she was not completely sure about all this, which would be indicative of OCD and not something I would be inclined to report. Her sister was hoping she would just admit to having made it all up.
Claire seemed confused that we didn’t believe her, and said of course she had done this act. I then left he client alone with her sister to discuss the matter between them, and I heard them having a loud argument in their native Amish language. Sadly, Claire would not relent, so I made the to call CPS. I explained to the social worker that my client was mentally ill, had made statements like this before, and that we did not think her admission was true. I said that Claire was likely suffering from psychosis in addition to OCD. I also informed Claire’s psychiatrist of this, who subsequently added an atypical antipsychotic to her drug regimen.
However, as I predicted, the trust was eroded and the client did not return for treatment. I did hear later that she saw another therapist and that the medication change helped her a great deal. Yet I am still not sure if I made the right decision. In situations like this it’s too easy to worry about my own professional liability and possible consequences of not making a report. At the time it seemed like that was my legal obligation, but in hindsight I wish I had put more trust in my clinical judgment in order to effectively have helped Claire. I sometimes think about her and wonder if she ever got the help she so desperately required. I also wonder about others suffering from psychotic OCD and imagine the hurdles they must face getting the care they need.