OMG CBT AND HRT FOR OCD, WTF??

We have begun intensive therapy in earnest for Jesse’s anxiety and OCD at an outpatient facility of the Rogers hospital system (which formerly would have been known as a mental institution, yeah?). In other words, Jesse has agreed (loosely) to allow us to stick her repeatedly with an emotional cattle prod.

Monday through Thursday, we leave home around 2:00 to travel to Oconomowoc, where we work hard from 3 to 6; we get home around 7 pm. It’s a really long evening, and it screws with our home life and extracurriculars immensely, but so it goes.

I like saying “Oconomowoc” frequently during the drive out. It’s not “AWK-oh-no-MO-awk.” It’s not “OH-ko-NO-mo-wok.” It’s Oh-CAW-numu-WOK,” which does indeed roll off the tongue sensibly once you get used to it.

What? you say I’m engaging in avoidance? No no, I just love Wisconsin names. Waukesha. Sheboygan. Wauwatosa. Kinnickinnic. Winnebago. Manitowoc. Menominee. On and on. What’s not to love? Don’t you love these names too? Do you think it’s okay that I’m talking about this?

What? You say I’m reassurance seeking? Stop, just stop. I think you’re being just a little bit overbearing and anxious about this whole conversation.

What? You say I’m projecting?? Now you’re really upsetting me. STFU.

What? Now you’re calling me infantile and hostile?

… You’re probably right.

* * * * * * *

Last week, Anthony, Jesse and I drove to Oconomowoc and met with the social worker on Jesse’s team for three hours on each of three consecutive days. We had lovely chats in which we went over as many of Jesse’s obsessions and compulsive behaviors as we could think of, as well as all of her expressions of anxiety and hostility. We filled out a host of forms and questionnaires. We were introduced to rudimentary ideas about cognitive behavior therapy, the main tool in the non-pharmaceutical fight against OCD and anxiety disorders. We catalogued all of Jesse behaviors and made a “hierarchy,” from most challenging to least, so we could pick the right ones to start her re-training with.

I challenge any grown up to begin therapy for mental illness like most children have to do it — sit in a room you’ve never  been in before and listen to the people you love and rely on most in the world, the people who know you best and with whom you’ve shared your deepest secrets, disclose just about everything that makes you suck to a total stranger.

Not surprisingly, Jesse was really pissed off.

* * * * * * *

In addition to the obvious extreme anxiety from which she suffers, Jesse seems to be somewhere in a shared zone between OCD and Tourette’s, and maybe her behaviors serve some attention-seeking motives as well. She’s a little messy, as most people are.

Jesse’s tics or compulsive behaviors, or whatever you want to call them, can be extreme: mostly they have to do with all things taboo.  Last summer and fall, issues of sexuality intruded most heavily in her mind and led to word blurts about sex and weird inappropriate physical behaviors. She also threw in a healthy, salty mix of something akin to George Carlin’s seven dirty words.

Then she evolved.

Some time in winter, she read a book at school in which one of the characters used the word “nigger.” Jesse brought the word home and we had intense conversations about the history of slavery and apartheid and inequality in America and the nature of the word, and about the many reasons why we never, ever use the word or say the word, except in some academic sense. She became obsessed with issues of racism and  and white supremacy. Now she blurts the word “nigger”, as well as other bigoted epithets, in all the wrong places and at all the wrong times.

I’m being a little facetious, of course. There’s never a right time or place for that word. As my brother Mark remarked, it’s on the top 5 list of worst words in America. Maybe even number 1. Totally, completely taboo, a word dripping in political and social sin, an evil word.

So of course, it calls to Jesse like a horrific siren song. It fills her head and pops out like a bursting boil, having no moral meaning in her usage except that it’s taboo, serving no purpose that we can discern except to fill her with shock and self-loathing.

This blurting occurs despite the fact that Jesse’s school has a significant minority population, despite the fact that many of her best buddies at school are black, despite the fact that her own mother is half Korean. There’s a really strange disconnect here. It makes no sense.

You can imagine the amount of aggressively negative and punitive feedback Jesse got from Anthony and me when this version of her taboo-blurting developed. We were loud, judgment, and frankly, ugly. We couldn’t bear it.

And still it took us months to realize that our current parenting skills and once-a-week talk therapy are simply inadequate to the task of addressing this problem.

* * * * * * *

Enter Rogers and a whole new bag of acronyms to teach us a whole new bag of tricks. Jesse is now admitted to the intensive outpatient OCD/anxiety program for children and adolescents, known affectionately as IOP OCD AC. The treatment approach for her will rely mainly on the cognitive behavior therapy approach, CBT, as well as a related theoretical model called habit reversal therapy, HRT. Both approaches bring to mind how one might train a dog, only maybe more sophisticated. At its most basic, the patient works on developing self-awareness regarding what triggers bring on negative behaviors, and then engages a “competing response” (the inevitable “CR”) to help block the tics and compulsions.

This sounds easy. It’s not.

Jesse describes the urges she experiences as overpowering. She reports that she tries all the time to control them, and  she simply can’t. She’s a failure, moment to moment. She experiences the urges not as a tingling or a funny feeling, like some OCD patients do. Rather she says it feels like big rocks are pressing on her heart and it’ll explode if she doesn’t follow through on the compulsion. There’s no hint of malingering or make-believe when Jesse finds her way to sharing these little details. There’s just the reality of her suffering.

* * * * * * *

Every day, rain or shine, fun or no, Jesse has to do two basic things as part of her treatment at the IOP OCD AC.

One, Jesse journals her negative compulsive behaviors (with a large assist from adults for now), with the goals of increasing self awareness and tracking progress. We have a wee notebook, and on each page there are three columns: “S” for submit, “R” for resist, and “CR” for competing response. If Jesse gives in to an urge, hashmark under the S; if she fights it off, hashmark under R. Either way, if she engages her competing response (pursing her lips tightly and clasping her hands together), hashmark under CR.

Again, it sounds pretty straightforward, but it’s actually excruciating when tics and compulsions are occurring every few minutes. Writer’s cramp ensues. Also for the first couple days, we weren’t using hashmarks. We were instructed to write down the descriptions of the behaviors. Can you picture how that went? Jesse resists an urge to say the word “ass.” She writes it down under R: “didn’t say ass.” She has effectively come through on her compulsion in a different form, so now she feels an even stronger desire to blurt it and she can’t fight it off.

Fail. We moved quickly to hashmarks.

Two, Jesse does exposure exercises, which basically go like this. She sits down with a timer and engages her competing response. Then I hit her with the cattle prod by presenting her with a trigger that heightens her anxiety. Right now we’re working on a lower-anxiety trigger. Basically, I stare into her eyes and bark something like, “DON’T SAY THE WORD FART. AND DON’T REPLACE IT WITH ANY OTHER WORDS OR BEHAVIORS. FART FART.” And she has  to sit there with her lips clamped, fighting the urge to blurt. She’s supposed to ride the wave of anxiety until it weakens to a place where she experiences it as “low” — until she habituates — or until she gives in. Stop the timer, record the result.

Eventually, we hope, we’ll move to more critical triggers. Show her a photo of two people kissing romantically. She fights back the compulsion to say sexual things or engage in sexual behaviors, through pure will power. Show her a photo of a black face, or of a scene from the deep south in the 60’s, maybe of cops attacking civil rights protestors. She fights back the compulsion to spew racist trash talk.

A strange torture all around.

* * * * * * *

I honestly don’t know how Jesse is hanging on. But she’s this amazing little beast, feral and beautiful and desperate.

On day one at Rogers last week, Jesse told the social worker that her behaviors don’t bother her at all. I pushed back. “Really, Jesse? None if it makes you feel bad?” Nope, she answered. It doesn’t bother me at all. On day two, the social worker wrote down some basic emotion words. Bad. Sad. Angry. Ashamed. Frustrated. She asked Jesse to circle the word that described how she feels about her behavior. Jesse hid her face, resting her cheek on her left forearm. Her scrawny little right hand reached out with a pencil and surreptitiously circled the word “ashamed.”

I felt big rocks pressing on my heart and I thought it might explode.

I don’t want Jesse to be ashamed anymore. It’s time for her to accept that the beast inside her doesn’t define her, any more than cancer or diabetes or MS define a person. Yes, her OCD and anxiety are part of who she is and always will be. Yes, the intrusive thoughts reflect something about her brain. But it’s time for her to comprehend that all the nasty, offensive stuff she does isn’t driven by a moral compass. It’s driven by a disease in her brain.

And the deeper, harsher truth is that it’s time for me to accept and comprehend these things as well. I’m working on it, day by day.

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2 thoughts on “OMG CBT AND HRT FOR OCD, WTF??

  1. Wow. What a powerful post, and what a strong girl. And mama. Hugs and support to you and your family. ❤ XOXO

  2. Pingback: The road not taken (well I’m taking it now, so back off) | grumpy for no reason

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