This podcast is about OCD. I share a sad story how a woman's obsessive behavior manifested in different ways to finally being directed to herself (SIB) and ripping out her hair. The love object can change, but the compulsion to be obsessed persists. Also is a story how I used behavior modification on a man with OCD to extinguish a behavior of doorbell ringing.
The Woman With Down Syndrome + OCD
The woman would come home with her pockets filled with something. For a few weeks, it was torn up papers, then it changed to batteries, then to straws. Each time, I did an intervention using verbal words that these objects were unhygienic, unsanitary, and she could get sick. I used her peers to reinforce this message. While the woman understood, and the object in her pocket changed, the compulsion continued. I wondered what would happen if she had no pockets on her pants? Answer: she came home with a bag filled with torn up paper. If it was not a bag, there were objects in the pockets of her jacket; if not her jacket, then in her lunch bag. The behavior was that she had to bring something back from work. “Work,” let’s be clear, for persons with mental health issues is dependent upon their abilities, and can be something such as working in a college to do the daily recycling, or being in a setting where various therapies are done (e.g. art therapy, music therapy, etc.).
I have found that often these centers have too many clients or too many clients with behaviors. I am saying this as if you want a behavioral intervention to stick, then it must be reinforced across all settings. It was something that I observed in my clients, that they would “get away with” many behaviors with their families or at work where no one was working on their behaviors. So, while it would have been nice to reach out to her work, this was not a viable option and hence the stuffed pockets behavior persisted.
In this same woman, her OCD manifested in fighting sleep every night. Despite sleeping medication, she had a penchant for trying to open her locked closet door. She would have to fold every item just so, a behavior called perfectionism. On one occasion, I decided to see how far the behavior would go. Usually, she would try to get the closet door open and continue with this behavior for hours, until her exhausted body forced her to sleep. On the night we left the closet unlocked, we found her in the morning completely exhausted. She had not slept at all, but was in a continuous cycle of folding clothes. Clothes were strewn all over the room, everything neatly folded. It appeared that she had taken every item out of the closet and each one had been perfectly folded. Yet once one round of perfect folding was done, the cycle had to be repeated again. And again.
With the closet locked again, the OCD went back to trying to wrench open the door, but then changed. She began to leave her room and had a fixation for lights. She would turn on all the lights, then go into other client’s rooms and turn on those lights. She would move a lamp here and then plug it there. The clients got upset, as she was waking everyone up. We found her one night trying to put her fingers into the socket, and had to childproof the light switches. After that, and with the others shouting at her to stop, the behavior then found a new form.
The form it took was to attempt to wrench the heating baseboards from the wall. This odd behavior began in the fall, but when the winter came around, it began dangerous, as she could potentially burn her hands. We were amazed that one of the boards had gotten bent, as they were made of metal and even a strong man would have to use a good deal of force to bend it. We called someone in to change the boards, and again the behavior moved on to something else.
As you can see, the object of the obsession doesn’t seem to have any reasoning behind it. I’m saying this because after these behaviors involving objects ended, the OCD now took the form of SIBing. Self-injurious behavior (or SIB) is where the person harms the body. It can have a sexual or pleasurable component to it, and is also seen as a form of self-stimulation. What one calls pain, another may call pleasure, and different people have different pain sensitivities. I worked with one woman who would create wounds on her arms every night, and we had to develop a protocol where mittens were taped onto her hands. This is an unusual intervention of self-restriction, and must be put in place for the safety of the person.
The SIBing behavior now took the form of hair pulling. She did not have much hair and it was kept quite short. Now, however, we would find her in the morning with small tufts on her bed. Over time, she had bald spots and her head was shaved. She did not look well, and there were large dark circles under her eyes from years of poor sleeping.
I eventually stopped working with this woman after she had a stroke. We were unable to provide the adequate care she needed. I cannot say what happened to her behaviors as she had to be pushed around in a wheelchair, but she passed on a few years later.
The Man With Autism + OCD
When you decide to do an intervention and modify a behavior, the rationale must be clear. That is another way of saying that behaviors which are innocuous are often left by the wayside (though others may find them weird), while behaviors that are maladaptive are those subject to intervention. A man who masturbates in his room daily is not an offensive behavior. That is his choice, and it is done in the privacy of his room. On the other hand, a man who masturbates frequently throughout the day and in various settings such as a bus, subway, car, at the mall, etc. has crossed the line, and even more so if his behavior prevents him from going to work and interacting with others socially.
In this case, I decided to intervene with a rather innocuous behavior. The man had many little quirks, such as touching objects, or having to check his coat periodically throughout the day. The behavior that I modified had to do with a door bell. The man would insist on ringing the bell whether I was there waiting for him to arrive, whether the door was open or closed.
Now that I had established that every time this man went out and returned home he had to ring the bell, it was time to create a flooding experience. I use this word flooding to explain that when you do an intervention, you must be prepared for the consequences. That is another way of saying that the person can react in an aggressive manner, whether with an object, himself, or the intervener. It is especially to be noted if the person has a penchant for aggressive behavior, yet I have observed many who did not have the tendency and reacted aggressively in dire situations where they felt extremely anxious or afraid.
I had seen this person screaming in the past, but aggressive behaviors to self, others or objects had not been observed. Still, one must be careful and be prepared for how the person may react.
I mentioned previously the level of intervention that should be implemented, from least to most invasive. In this case, I tried a verbal prompt. It did not work and he ignored the request to not ring the bell. I tried this intervention 3 times, with the same response. On the next 3 occasions, I used a verbal and gestural prompt. I pointed to the doorbell and told him not to ring the bell. His behavior was to ring the bell.
I finally used a physical intervention and placed my hand over the bell. In this case, he could have moved my hand, pushed me away, or something else. He looked at me, and then I told him (verbal prompt) not to ring the bell when the door was open. It worked. I continued with this pairing of physical and verbal for 1 week. Each time, he went to ring the bell, looked at me when I covered the bell with my hand, said not to ring the bell when the door was open, then walked into the house. After just a few weeks, he understood. He would see me in the doorway, with the door open.
I then faded the behavior (in other words, I went down to a lesser invasive prompt/intervention), and told him not to ring the bell. He didn’t. Soon, I faded telling him, and he stopped ringing the bell when the door was open.
This is a good example of using prompting, but also one where there is no reinforcement used. I did use schedules of reinforcement with some of my other clients, and found it worked exceedingly well. Stories to share on future occasions :)