Couples Therapy for OCD. When OCD Becomes a Family Affair

by Jonathan S. Abramowitz, PhD, ABPP

This article was initially published in the Winter 2009 edition of the OCD Newsletter

Joshua’s Story

Joshua’s problems with obsessive thoughts about violence began when he was a teenager, but when he and his wife, Rachel, brought their firstborn daughter, Amy, home from the hospital things worsened dramatically. He began having intrusive thoughts of harming his beloved infant on a daily basis. Thoughts about punching the baby, dropping her down the steps, and even putting her in the microwave, came to mind and created an enormous amount of distress. Of course, Joshua loved his baby with all his heart and never acted on any of these thoughts. They were the exact opposite of his usual personality. Still, Joshua believed he was an awful parent for having these thoughts and was at a loss for what to do. He couldn’t tell anyone about the obsessions — they’d surely lock him up!  so he avoided having anything to do with his baby. This was a disappointment to Rachel, who didn’t know what was happening and soon resented that she was changing all the diapers, doing all the feedings, and giving all the baths without any help from Joshua. Joshua and Rachel’s relationship went downhill. They had endless arguments over caring for Amy, and the level of stress in their relationship became very high. This added stress of course exacerbated Joshua’s OCD symptoms. Joshua even moved in with his parents for a short time.

Mary’s Story

Mary, who had suffered from OCD since childhood, married her high school sweetheart, Tom, at the age of 21. Her obsessions focused on the fear of contamination from germs from strangers. She was specifically afraid of contracting the AIDS virus. Her compulsive rituals included washing, showering, and changing her clothes whenever she thought that she might have been exposed to HIV, and she involved Tom in many rituals as well. For example, she would ask Tom for reassurance about the chances of getting AIDS from doing activities such as touching a doorknob or using a public restroom. Tom helped Mary wash off all mail and groceries that were brought into the house. At times, Mary would call Tom in the middle of the day to leave his job and come calm her down. Tom complied willingly with Mary’s compulsive urges — after all, he couldn’t stand to see Mary suffer. What if she had a “nervous breakdown” or something? He ended up doing just about everything possible to prevent Mary from ever having to suffer from obsessional fear. When Tom and Mary came to our clinic for therapy, Tom was performing compulsive rituals for Mary almost as often as Mary was performing them herself.

OCD and Couples

Both Joshua’s and Mary’s stories show how OCD can negatively impact close relationships such as marriages and partnerships. Joshua’s story is rather straightforward. His symptoms led directly to avoidance, which angered his wife and led to arguments and havoc in his relationship. But Mary’s story is a little less straightforward. She and her husband, Tom, rarely had arguments over OCD. Tom showed his love for Mary by keeping her as anxiety-free as possible. But OCD had become a part of their relationship. Their life as a couple was centered on helping Mary complete her rituals and avoid being in distress. It was like OCD was another family member. On the surface this kind of caretaking might seem like a wonderful way for Tom to show his love for Mary, but the fact was that that this pattern only made Mary’s problems with OCD worse. As much as Tom hoped that Mary could get over her problems, and as much as he reassured her that she was not in any danger from getting AIDS, Mary continued to suffer. Ironically, Tom’s accommodation of Mary’s symptoms played a large role in why Mary continued to suffer with OCD.

Treating OCD When it Affects Relationships

Cognitive behavior therapy (CBT) using the techniques of exposure and response prevention (ERP) is the most effective treatment available for OCD — it often leads to a 60% to 70% reduction in obsessions and compulsions. Unfortunately, most CBT work is done with only the OCD sufferer, leaving out other family members who might in one way or another influence the course of OCD symptoms. This is particularly the case for people with OCD who are in close relationships. For this reason, at the University of North Carolina’s Anxiety and Stress Disorders Clinic we have developed and are currently testing the effects of a CBT treatment that is conducted as a couples-based therapy. The person suffering with OCD attends all of the 16 therapy sessions along with his or her spouse or partner, and the couple learns to implement the CBT skills (primarily ERP techniques) together. We also teach couples how to improve their communication and problem-solving skills so that arguments like the ones that Rachel and Joshua were having could be more easily resolved. Recognizing and stopping accommodation patterns, as in Mary and Tom’s example, are also emphasized in our therapy. Both partners take responsibility for working hard to help the person with OCD overcome his or her problems. We are hoping to find that this treatment program improves upon the long-term outcome for individuals with OCD, especially those who are in close relationships. We also expect that it will lead to improvements in relationship satisfaction.

Our Couples-Based OCD Treatment Program

Our treatment program has a number of similarities to individual therapy for OCD. During the first few sessions the therapist learns all about the patient’s problems with OCD, including situations that trigger obsessional thoughts and anxiety patterns of avoidance behavior and patterns of compulsive rituals. Time is also spent learning about the way that the couple interacts around the OCD symptoms. For example, how does OCD play a role in the relationship? How do the partners cope when the person with OCD becomes very anxious? The therapist uses all of this information to formulate a treatment plan for the rest of therapy. This plan is discussed with the couple so that both partners understand OCD and how a couples-based approach to ERP is a sensible way to reduce its symptoms.

Some Closing Words

Our treatment program involves a total of 16 therapy sessions, although couples work very hard between sessions practicing ERP and relationship enhancement skills so that they have an “intensive” therapy experience. The results of our initial study have been encouraging so far. We have observed an average of 50% reduction in OCD symptoms and substantial improvements in relationship functioning and relationship satisfaction. As difficult as it might be to find therapists who are well-trained to provide good CBT (specifically ERP techniques), it is even harder to find therapists with expertise in both OCD and couples therapy. Thus, once our study has ended we will work hard to disseminate our treatment program through trainings and workshops so that more therapists can incorporate couples work into CBT for OCD. As a long-time practitioner of individual CBT, I am now convinced that it makes sense to consider incorporating the spouses or partners of OCD patients into therapy.

Dr. Abramowitz is the Director of the Anxiety and Stress Disorders Clinic at the University of North Carolina (UNC) at Chapel Hill.