Fifteen-year-old Jeremy sat across from me, postured rigidly upright in his chair as he attempted to discreetly pick at the scabs on his hands. The sores were the byproduct of over 30 daily hand washes. He watched me with a vacant gaze as his mother appealed to me for help, her voice faltering every few sentences.

I had just finished reviewing the results of my initial assessment of Jeremy including the Children’s Yale-Brown Obsessive Compulsive Scalewith mother and son. My conclusion: Jeremy had severe Obsessive-Compulsive Disorder requiring intensive outpatient therapy.

A psychiatrist had reached a similar conclusion about this young man just a month prior, but his mother, fearful that “the doctor just wanted to make him a zombie with drugs,” came to hear my opinion.

Now that they heard it, his mother wanted to know only one thing: What could she do to help her son, intellectually gifted and emotionally sensitive, regain his life from the bizarre thoughts and ritualized behaviors that had overtaken him?

I explained to her, as I do with all parents in these situations, that medication may be indicated in treating juvenile OCD and I would be happy to refer them out for a consult. However, I emphasized, both individual and family therapy are probably the most powerful weapons in treating children and adolescents with this illness.

A growing body of research indicates that OCD has strong links to family dynamics that can be treated therapeutically, and there is no better time than childhood or early adolescence to bring these factors into focus. This is not to say that families or parents cause OCD, but that the way parents and children interact can bring a predisposition towards anxiety into full-blown OCD (there is no evidence of a specific genetic tendency towards OCD at this time).

In an eye-opening study, researchers Jennifer Hudson and Ronald Rapee at Macquarie University in Sydney, Australia observed mother-child interactions while the child completed two cognitive tasks. Three groups of mothers and children were studied: mothers and their clinically anxious children, mothers and their oppositional-defiant children, and mothers with their non-clinical children. The investigators found that mothers of the anxious and the oppositional-defiant children were more involved and intrusive than those of the non-clinical kids. Additionally, mothers of the anxious children were more negative than the rest.

A later study conducted by Paula Barrett and her colleagues at Griffith University in Australia drew similar conclusions. They observed two sets of families those with a child diagnosed with OCD and those with non-clinical childrenengaged in two five-minute family discussions about what the child would do if faced with a hypothetical physical and social threat. The parents could advise, but ultimately the child in each family had to determine what course of action to take in these two perilous situations. The investigators found that parents of the children with OCD used less positive problem-solving, were less rewarding of their child’s independence, and showed less confidence in their child’s ability to handle these fictional situations.

 

What this research tells us is that these parents, in their desire to protect their children and to do what is best for them, may be doing more harm than good. Facing anxious situations is the way most of us learn how to deal with them. As we successfully navigate a range of scary experiences, we gain confidence, too, in our ability to handle them. If a parent trying to protect us from being fearful and making even a hypothetical mistake derails this natural process, our immediate anxiety may be relieved, but our fear of danger will snowball and our confidence will never grow.

In David Clark’s “Cognitive Control Model of OCD,” obsessions reach a clinical stage precisely because the individual does not believe they can adequately control their thoughts and, ultimately, their behavioral response, fearing they will act upon them even though they do not want to.

Noted anxiety expert David Barlow has theorized that a “chronic inability to cope with unpredictable uncontrollable negative events” is one of three primary characteristics that can predispose one to anxiety disorders. This sense of personal uncontrollability can be fostered in parent-child dynamics that are over-protective and intrusive.

Recent research in the field of expressed emotion has added another dimension to the role familial interactions can have on the development of and relapse into mentally ill states. Expressed emotion is the attitude families express toward the disorder and the person experiencing it. The three faces of expressed emotion are hostility (in which the family has a negative view of the patient and blame them for the illness, for not trying hard enough to get better); emotional over-involvement (in which the family members blame themselves for the patient’s illness); and criticalness (in which the family acknowledges factors other than the patient or themselves are involved in the illness but are still critical towards it). There is growing evidence that high levels of expressed emotion in a family can increase the risk that a young person will develop a disorder such as OCD and may worsen the prognosis for the patient who is undergoing treatment.

Within the confines of my office, OCD clients recite stories of well-meaning moms and dads trying to make everything all right for their children, but impeding their maturation in the process. Others recall feeling left impotent by intrusive parents who would not let them learn by exploration and mistakes. Many bitterly describe families in which they were told to “snap out of it” and ridiculed when they couldn’t stop washing their hands, checking the door locks or asking for reassurance. Ultimately, many of these children grow into adults with deep resentments against their intrusive parents, but who are apprehensive about expressing this anger even now in the safety of the therapeutic relationship.

In the final analysis, then, we cannot ignore the importance of psychotherapy for both the individual and their immediate family, especially when treating children and adolescents. To do so would be mortgaging their future happiness and relinquishing a powerful tool for lasting change.

 

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