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A free-range approach to treating OCD

Cockroach as co-therapist

In Florida, no matter how clean you keep your house, you will be visited occasionally by cockroaches. They are so common that Floridians have a polite name for them – “water bugs” (as in, “excuse me, I believe a water bug just skittered across your kitchen floor”). This is the story of how one particular “water bug” named “Cocky” played a critical role in cracking a severe case of obsessive compulsive disorder.

As with all the cases I will describe henceforth, patient-identifying factors will be altered to protect privacy, but the essential details of what happened are presented as they occurred.

Here is a brief rundown on the case –

A very wealthy couple and their son flew across the country to see me in the context of a well reputed intensive OCD treatment program. A crippling fear of germs had gained a foothold in their son’s life after he finished high school and he had retreated to the family compound thereafter. In an effort to keep him comfortable, his parents had been purchasing brand new towels and sheets for him – daily – for many years. His parents obviously loved him and meant well, but did not realize that when life is allowed to conform to a patient’s fears, it strengthens and locks in the fear response. This particular patient – let’s call him David – was 26 years old, living in near-total isolation in his own wing of the family mansion for several years due to pervasive contamination-type OCD.

I wondered, what approach could overcome the strength of David’s fears?

Before jumping into treatment, I spent 3 hours over 2 days interviewing David, hoping to generate a possible answer to this question. I learned several things.

1) First, I learned that David was once able to make friends and connect with others his age. I found him very likable. So, he was not socially avoidant by nature – rather, the OCD was the primary cause of his isolation.

2) David wanted to go to college but felt that he would never be able to make it given the strength of his fears. Again, the OCD was the primary obstacle.

3) Finally, David had a strong interest in film-making and his greatest dream was to attend film school in New York City, but once again, the OCD had limited his travels. He had a particular issue with “crowded city germs” especially as he thought about taking the subway.

One of my graduate school advisers was a brilliant social psychologist who encouraged me to read widely across the social psychology literature. I had learned about different social psychology experiments that influence behavior, and therefore had much more than passing understanding of the social facilitation effect. Social facilitation basically means that when we are being observed by others, our performance improves and we are more likely to behave in socially valued ways. Essentially, people will do a lot for “bragging rights.”

Just how strong is the social facilitation effect? Strong enough to get David onto a subway in New York City four weeks after we started treatment.

Here is what I proposed – David and I would collaboratively create a list of “germ-ridden” things to interact with, leading up to biggest challenge - holding a live cockroach by the end of week 3. We would film the process as he actively confronted his fears. He would be allowed to keep the footage of how he overcame his fears, ultimately accomplishing something most people would not be able to do – to hold a living, moving cockroach in his bare hands. (This was before the days of “Fear Factor” but I suspect the same social facilitation effect applies. Also, what is interesting is that aside from myself, there were no other observers – however, the implied “audience” that might view the footage in the future was a powerful catalyst for change in David’s case).

Holding a cockroach was defined as the final treatment program challenge before taking the therapy into New York City. That is, we agreed that once he had succeeded in all of the challenges we set for a three week period, he would then film himself travelling to New York City, riding the subway, and touring some of the film schools he might want to attend in the future.

We met with his parents and without knowing our plan, they agreed that if he wanted to travel to New York City in 4 weeks, they would happily foot the bill for the trip to tour film schools. (Based on their past behavior, I was fairly sure that they would have booked David a ticket on the Concorde for a world tour if he could overcome his fears).

What I could not have predicted is that once we had the therapeutic narrative in place, “Cocky” the cockroach would take on such an important role. I just knew that my job was to find a cockroach, support David as he challenged his fears, and hold the camera steady.

A sizable “water bug” helpfully scuttled into my house at the beginning of week 2. I trapped him in an old Tupperware container and brought him to my office. I encouraged David to see Cocky as a “co-therapist,” a friendly (if disgusting) support in helping him get his life back. David named him “Cocky” and observed him at close range over several days. Cocky, in turn, witnessed David bravely march through his fears, ultimately progressing to being able to hold him gently in his palm, sweat dripping from the tiny aperture in his loosely curled fist.

And, just as we planned, he (David, not Cocky) then went on to New York City and rode the subway. I got a letter from his parents a few months later to relay that he was in the process of applying to film schools.

So, what made this approach effective? Certainly, it was based on an empirically supported behavioral approach to the treatment of OCD – exposure and response prevention. Narrative therapy also played a role. However, I think the strongest factor was tapping the power of social facilitation in a way that reflected David's biggest dreams and strongest motivators. This is the essence of free-range psychology.