Sunset Star 7 by Brian Sapere

 

It’s a Family Affair

 

 

OCD and CHILDREN

It’s a Family Affair

 

By Lynn Lyons

 

Psychotherapy Networker – July/August 2016

 

Seventeen-year-old David sat in my office and cried. “My friend has a four-year-old sister, and I had the thought that she was cute,” he whispered. “I keep thinking I might be a pedophile. Am I a pedophile?” David had spent hours on the computer researching pedophiles and refused to talk to his friend or parents about why he was so distressed. When his mother looked at his computer, she panicked. Was her son a child molester?

As 12-year-old Jade cleaned her newly pierced ears with hydrogen peroxide, she began to worry that she might pick up the bottle, guzzle it, and kill herself. When she told her mother of her thoughts, her mother hid all the chemicals in the house and slept in her daughter’s room, fearing she was suicidal. Dad was dealing with his own depression, so Mom wondered if her daughter was now following in his footsteps.

Bethany, a friendly and affectionate nine-year-old, suddenly began refusing to have any physical contact with her parents. Her mother became increasingly distraught as Bethany screamed whenever her mother came close or asked for a hug. Mom’s alarm and confusion peaked when she discovered that Bethany was sleeping on her wood floor with no pillow or blanket.

Madeline’s kindergarten teacher noticed a strange behavior emerge a few weeks into the school year: Madeline would lift her chin in the air, take several quick breaths, and repeat this action multiple times. Thinking Madeline was developing asthma or some sort of tic, her parents brought her to the doctor who could find nothing wrong. Madeline finally told her mother that when she saw spots on the sidewalk, she worried the spots meant there wasn’t enough air in the sky, so she needed to take extra breaths to fill up her lungs just in case. Her mother reassured her repeatedly that there was plenty of air, but it made no difference in the behavior.

Each of these children has OCD, and they all finally found their way to my office, where, after months and sometimes years of confusion and family turmoil, the right questions led to an accurate diagnosis, followed by family intervention. David wasn’t a pedophile, nor was Jade at all suicidal. Bethany worried that she was contaminated at school following many discussions in her classroom about the impending flu season; she worried that she’d come home and make her mother sick, and so she’d spend her time at home trying to avoid touching anything that might infect her family, including her bed, her pillows, and her blankets. She wasn’t angry at her mother. The reality was quite the opposite: sweet Bethany was trying to protect her. And little Madeline didn’t have asthma or a tic, but was exhibiting the first signs of childhood OCD, her little brain making a strange connection between spots on the sidewalk and air to breathe—a connection that she couldn’t understand at all.

 

 

The Cult Leader

 

In each of these cases, the diagnosis of OCD was a relief to the family, even though, of course, no family wants to hear that diagnosis. But once I explained how OCD works and assured them the symptom patterns were highly typical of what I see, the fear and confusion they’d been experiencing became more manageable. With families, I usually explain that OCD, like other anxiety disorders, is like a cult leader, demanding acceptance of a skewed view of reality. It shows up and makes an announcement that’s distressing (the obsessive thought): “You looked at the little girl and you were attracted to her!” “You might eat poison by mistake!” “Spots mean the air is running out!” “If you throw out your trash, you might throw something out that you’ll need!”

It then posits a solution to the distress, some action, either internal or external, that offers temporary relief (the compulsion). But the thought inevitably returns, and to get rid of the associated anxiety or fear, the compulsion is repeated. If you don’t obey the cult leader, I tell the families, it becomes furious and even more demanding and irrational. When the cult leader is disobeyed, the price for the child and the rest of the family to pay is more and more worry and fear. So falling in line is the best strategy—except that it doesn’t work.

“It never ends!” said Jade. “Even when I told my mom that I was afraid I’d drink the peroxide and she hid it, I kept thinking that I’d find something else.” Bethany also felt trapped. “No matter how hard I worked to get the germs off me,” she said, “I still thought I’d make my mom sick. And you can’t get all the germs off—they’re everywhere.” David described a long-term pattern of disturbing worries. He was currently wondering about pedophilia, but previously he’d wondered if he was a racist, and when he was much younger, he’d lived in fear for several months that he might impulsively jump out his bedroom window. He’d kept all these scary thoughts to himself, worrying constantly that he’d do something he shouldn’t. Self-doubt ruled him.

When I explain to families how OCD works, I usually see parents recognize this pattern of trying to placate the cult leader not only in themselves, but in their own families of origin. Sometimes one parent can now make sense of the marital struggles in a new way, understanding for the first time the controlling or “crazy” behavior of their spouse that’s made their relationship so challenging. Ideally, the parent acknowledges this recognition, a light bulb goes on, and they can see their own patterns in a new way. But even with their new understanding, the challenge of change can still be daunting.

Nevertheless, in my clinical practice, I consistently find that families with parents open to addressing their generational patterns are more successful in learning how to manage OCD than families with a parent in denial, and research supports my experience. One study, by Abbe Marrs Garcia, published in the Journal of the American Academy of Child and Adolescent Psychiatry in 2010, found that children with a parent and/or sibling with OCD did six times worse in cognitive behavioral therapy than their peers without a family history of OCD. It’s been posited that this is due to the difficulties of supporting a child with OCD when a parent remains trapped by his or her own OCD cult leader.

 

 

Recognizing the Rules of OCD

 

The Howard family illustrates what can occur when the denial in a parent shifts to an embracing of a family perspective. Peter and Cathleen first came to see me six years ago for help with their seven-year-old son, Timothy, who’d been showing significant anxiety for about two years. His fears revolved for the most part, they told me, around the family car. He constantly needed to check the level of fuel in the gas tank, often unbuckling his seat belt to eyeball the dashboard gauge himself. He repeatedly asked for reassurance about the inflation of the tires and the safety of the air bags. “I’ve gotten into the habit of opening the hood of the car before we leave the house and showing him that the windshield wiper fluid is full,” Peter told me. “And even when I stop and get gas with him in the car, he starts asking if we have enough gas within a mile of leaving the station. We just can’t figure out why he feels so scared about the car. Nothing has ever happened. I don’t think we’ve even had a flat tire since he was born.”

Cathleen described how Timothy had demanded she repeat the phrase “You’re safe, you’re fine” three times before she dropped him off at kindergarten, where he’d then spend hours writing his name over and over. The school behaviors disappeared in first grade, but most recently Timothy had created a bedtime ritual that involved taking his pajamas on and off multiple times and getting out of bed repeatedly to look in his closets and his drawers. This ritual could take up to two hours, but when Peter or Cathleen tried to stop him—with reassurances that he was safe and rewards if he stayed in his bed, as well as a fair amount of threatening and yelling—he’d scream and sob.

I explained how Timothy’s behaviors were typical of OCD in children, and that seeing these patterns show up at around five or six years of age is also indicative of a family with a generational pattern of OCD. “Do either of you have OCD?” I asked. “Or do you know of family members that might have it? Your parents maybe?”

“I used to have it a little bit, I think, but I grew out of it,” Peter said, whereupon Cathleen snorted in clear disagreement.

“He vacuums the rug in a certain pattern, and flips out if we walk on it,” she interjected. “Then he has to do it again. That’s just one example. I don’t think you’ve grown out of it, Peter. You just don’t want to talk about it.”

“Keeping the house neat is not a mental illness,” Peter said. “It’s not at all like what Timothy does. Not at all. We need to deal with his issues.”

Cathleen locked eyes with me and shook her head slightly. I held her gaze for an important few seconds, recognizing how deeply stuck she felt. “Timothy definitely needs help understanding this, and you both need some support, too,” I said, knowing I had to tread lightly at this point. “This OCD thing can really take over, so I’m sure you’re both exhausted.” As the session ended, I hoped Peter would begin to make the connection between his patterns and his son’s.

When they returned the following week with Timothy, I explained to him that what he worries about is really of no importance. The content of his worries and the details of his rituals would probably change, just as they’d shifted already. So what we needed to focus on was the process of how to manage his OCD—which, I told him, was like a giant boss who made rules that felt real and important. “I hear your OCD makes rules about what you need to do at bedtime,” I said. “And if you don’t follow the rules, your OCD makes you feel scared or worried that something bad might happen, right?”

Timothy nodded. To help him practice how to respond to the giant boss’s rules, we decided to name it Frank. When we drew a picture of Frank on my white board, he had a green face with bushy eyebrows and yellow teeth. Pretending to be Frank, I demanded that Timothy ask about the gas tank over and over. Then I modeled for Timothy how to roll his eyes and brush off Frank’s bossiness. Together, the four of us talked about how this change in reacting to Frank’s rules might at first feel scary, but coming up with a family plan to ride out the anxious feelings would help it get easier with practice. I stressed that getting rid of the OCD thoughts wasn’t the goal. “Frank won’t give up that easy,” I warned them. “He’ll be mad and bossy when you tell him he’s ridiculous, but I’ll help you learn as a family to respond to Frank in a different way.”

They looked hopeful as they left that session, but a few days later I received an email from Peter thanking me for helping them get started with Timothy and letting me know they weren’t going to return. “I think we can take it from here,” he wrote.

Four years later, Peter left me a message. “I hope you remember us. We need some help. We want to come back.”

When the Howards returned, Timothy was an 11-year-old middle-school student. They also brought along Maisie, their now eight-year-old daughter, whom I hadn’t met before. Timothy no longer obsessed about the car (and laughed when his parents reminded him of these obsessions), but was so concerned with making a mistake on his homework that he was spending hours each night on simple math worksheets. He’d also started a pattern of coming home after school and telling his mother the events of the day, and then returning over and over with more details, worried that if he forgot any detail, he was a liar. Before going to sleep, he wanted to again go through his whole day with Cathleen, afraid that he might have misrepresented something or left out an interaction.

Peter and Cathleen had seen some behaviors in Maisie that were setting off alarm bells. Although they always knew that Maisie liked to keep “treasures” and resisted getting rid of old toys and stuffed animals, they recently found several bags of trash hidden in her closet, as well as piles of old school papers under her bed. When Cathleen told Maisie that she’d cleaned up her room and removed the trash, Maisie “freaked out,” sobbing while she combed through the trash cans in the garage.

Perhaps most significantly, Peter’s obsessions with his neat home, combined with an emotional, downward spiral he’d experienced when he made an error at his job, had put his marriage in jeopardy. Cathleen, seeing the increasing OCD in both her children, was now pushing back against his denial of his own symptoms. More and more, she refused to accommodate his demands for cleanliness and order, and intervened when he became angry with the kids for being messy. She was no longer willing to accept the tyranny of the internalized cult leader that was ruling her husband, her children, and her marriage.

In our two-hour family session, four years after I’d first seen them, we talked openly about OCD. I explained to the kids how OCD works—Timothy vaguely remembered how he’d named his OCD Frank—and gave them examples of its consistent pattern of offering a disturbing thought or worry, and then requiring they do something to prevent the horrible outcome it threatened. They nodded as I described patterns that hit close to home (a girl Timothy’s age was failing in school because she wouldn’t turn in her “imperfect” homework assignments) and opened their eyes wide as I gave examples that were, to them, “crazy” (a boy arrived in my office crying, having been pestered all day by his OCD worry that he’d eaten his little dog).

For the first time, Peter talked to his children about his own OCD, acknowledging that his desire to keep the house perfect was because of his cult leader, not their laziness. They pointed out to him that he never wanted to play with them when they were visiting their grandparents on the lake because he spent all his time tidying up. In turn, he shared with them how his OCD made him feel like things were never quite right, and how he couldn’t fall asleep at night if he felt that something in the house or at work was out of place.

Together, they began to recognize the OCD patterns in Peter’s mother and aunt. The recognition resulted in laughter, as if they’d finally unlocked the secret of why holidays and visits felt so weird and tense. Cathleen told her kids how she’d tried for years to figure out how to manage all of these OCD rules, and that they needed to work together as a family to rise up against the cult leader, instead of feeling so anxious and mad at each other all the time.

After that, the Howards have come to see me as a family once a month. In one session, Timothy came up with a plan to spend 30 minutes on his math homework, more than enough to complete it when he reminds his OCD that it won’t be perfect. Rather than trying to avoid the anxiety and discomfort that his OCD triggers when he disobeys it, he tells his OCD that he’s supposed to feel anxious as he continues to step away from his compulsions. When he slips and asks his mom for reassurance about something he might’ve done wrong (his worries about lying have at times morphed into other imagined transgressions, like cheating or being mean to friends by mistake), Cathleen says hello to Frank, and reminds Timothy that he’s getting sucked into content by saying something like, “Oh, Frank, really? Are you trying to trick us with that again? Timothy, please let Frank know that we’re onto him.”

A few months after our family meetings began, Peter and Cathleen arrived alone. Now that Peter was willing to discuss his OCD openly, Cathleen needed to talk freely about how hard the early years of the marriage had been. She told Peter how confused she’d been by his constant anger at her. She felt his OCD was another partner in their marriage, and she couldn’t please either one of them, no matter how she tried. Peter talked about his family growing up and the shifts he knew he needed to make in his own parenting. He could finally see the price he’d paid as a child with his mother’s OCD running the family, and he didn’t want to continue to pass on this generational legacy.

Soon after that session, the kids happily reported to me that a picture had fallen off the wall and left a big scratch in the paint. “And Dad is going to leave the picture leaning against the wall, and he’s not going to fix the scratch for now,” they said. To his credit, Peter actually left the “mess” in the hall for a few months, saying he’d fix it when he felt like it, not when OCD demanded it. Walking by the picture propped against the wall and the scratch in the paint, he said, felt like a victory.

Maisie has been the slowest to change in regard to her hoarding patterns. She participates fully in the sessions and is great at pointing out when others are “OCDing,” but she resists cleaning out her room and at times wants to argue about the value of her scraps of paper or bags of trash. Progress is being made, though. She arrived to one session with a small bag of trash. “Why don’t you keep this here until our next session,” she told me. “I’ll see if I miss it or if I’m okay.” She forgot about the bag for several months, and I let her. When I reminded her of its hiding place in my desk, she laughed, and a month later she spontaneously announced, “I’m ready to clean my room.” She’d been watching her father and her brother make changes, and their modeling and successes had been contagious.

 

 

Overcoming Denial

 

Not all families are as open and committed as the Howards were when dealing with the family impact of OCD. Elizabeth, Jack, and their 12-year-old son, Bryan, were more of a challenge, mainly due to Jack’s denial of his own OCD. Unlike Peter’s eventual recognition of his symptoms, Jack was less receptive and as result, the therapy was a bit bumpier.

The run-up to therapy occurred when Bryan’s school guidance counselor recommended some counseling because of his difficulty completing his homework assignments. Elizabeth and Jack knew Bryan could do the work, but night after night he’d procrastinate and then completely melt down. “I can’t do it! I don’t know what to do!” he’d cry. Lately, he’d been refusing to go to school, afraid to get in trouble because his homework wasn’t done. His parents felt trapped.

“He won’t do it, but he won’t let us help. Then he won’t go to school so the teacher can help,” an exasperated Elizabeth told me. When I asked for an example of when Bryan felt really distressed, he described a recent science project that involved illustrations. He completed the writing assignment, but couldn’t get the drawings to look the way he wanted them. So he secretly stayed up much too late, drawing and erasing over and over again. When he went to school the next day, he didn’t turn his work in. The teacher noticed the missing project a few days later and emailed Elizabeth. “We had a huge fight,” said Bryan. “I couldn’t tell Mom why I didn’t turn it in. She was mad, but I just couldn’t give it to my teacher.”

At this point, I explained to Bryan about the bossy rule-maker in his head called OCD. I guessed out loud that it probably felt like there were rules he had to follow, even if they didn’t make much sense. For example, I told him, there was a boy I knew whose OCD demanded he walk up and down his stairs five times before he left for school in the morning, or else his parents might get a divorce. “What was the rule inside of you that felt so powerful you couldn’t turn in the project?”

Bryan’s answer wasn’t a surprise. “It didn’t look right. I had to keep going until it was done. I couldn’t stop. What if it wasn’t done and I stopped? What if I stopped too soon?” When I asked about more rules and things needing to be just so, the obsessions and rituals came tumbling out. Dressing for school in the morning was agonizing. Bryan needed to ask his mother repeatedly if his outfit was perfect. Recently, a ritual about the temperature outside had emerged: Bryan would ask his mother the weather, she’d tell him, he’d ask two or three more times, and then would have to go the computer to look it up for himself three times. It’s this feeling of doubt—this desire to keep at bay the agonizing feelings of uncertainty—that ties a family dealing with OCD in knots.

I then asked if anyone else in the family had rigid rules or rituals that needed to be followed. Did anyone have weird things they had to do? Elizabeth immediately looked at Jack.

“I don’t think there’s anything wrong with making sure the house is picked up,” he shot back immediately. “If people drop by, I want them to see that we keep a clean house. That’s not a problem, it’s a strength.”

“It’s a problem,” said Bryan without looking up.

With more prodding, Bryan and Elizabeth described how if a blanket on the couch wasn’t folded precisely and draped over the middle of the couch exactly, Jack yelled. If Bryan was drinking something and left his cup to go to the bathroom, it was gone when he returned. Jack was consistently late for the kids’ games or recitals because he couldn’t go straight from work to the event: he had to go home to make sure the house was perfect, not trusting the others to pick up. He didn’t see his rigid habits and expectations as a problem, though. “If they’d follow the rules, we’d have a clean and peaceful house,” he said. “But they won’t. They’re fine with the house being a mess and I don’t get that.”

As I continued to work with Bryan, I used his father’s denial to help Bryan see how his own OCD could negatively impact the relationships in his life if he demanded that everyone follow its rules. I also worked to help him distinguish between what I described as “total cray-cray” and “tidbit-of-truth” symptoms. Now, I can’t take credit for this colorful perception of OCD thinking. I owe its existence to one of my clients, an outgoing and warm 14-year-old named Joseph. One day, he and I were discussing how, when it comes to OCD, many people get stuck in examining the content of the obsessions, looking for some meaning or connection. Parents do it all the time, trying to link the behaviors to some event in hopes of finding the root of the problem. Therapists who take a psychoanalytic approach to OCD can make all sorts of connections and hypotheses as to the meaning of certain thoughts and rituals. But in my approach, I regard the content of OCD as meaningless. Eventually, Joseph and I agreed that it’s important to determine when something is an OCD thought versus a regular “brain thought,” even though differentiating the two can be tricky because OCD sometimes pulls you in by hooking onto something that makes some sense.

“Now I know I have two types of OCD thoughts: ‘total cray-cray’ [meaning crazy, for us old people] and ‘tidbit of truth.’ I’m getting good at catching my total cray-cray thoughts,” Joseph told me. “They’re easy. My OCD comes up with some weird rules that make no sense. Like it says that if I walk on the wrong side of the hall, I’ll lose all my friends. No sense.” Tidbit of truth is harder to recognize, he continued, because there’s some truth to the rule and the consequence. For instance, Joseph was an athlete, so when his OCD demanded he do exactly eight minutes of push-ups every day or he’d lose his athletic edge, this rang true for him. Why shouldn’t he stay in shape? This, explained Joseph, is harder to step away from.      

In Bryan’s case, he could see that his father’s OCD was tricky because having a neat house was a good thing—a tidbit of truth. Getting good grades and doing well on school projects? These made sense, too. But since Bryan and I have worked on telling the difference between doing well and OCD, he’s learned to pay attention to the quality of his thoughts and rules, noticing how strongly they make him feel and react, even if there’s some truth in the content. If he gets frustrated because he can’t figure out a math problem or disappointed because his drawing of a fighter jet is off, that’s one thing. But if he stays up all night, convinced he must not go to sleep until he’s checked his homework over and over for errors, panicked that he might miss something, that’s something else. His father serves as a helpful illustration, although we both wish it could be different. While Peter shows his children by example how to be flexible in the face of rigid OCD, Jack is showing Bryan the price of rigidity in a family, and given Jack’s unwillingness to give up his OCD-driven parenting, that’s probably the most useful lesson for Bryan to draw from recognizing his family’s pattern. Jack comes to the sessions when asked, but he’s yet to have the breakthrough that so helped Peter and the Howard family. There’s work to be done, and Jack will show up, but I know it’d move faster if Jack were more engaged.

 

 

Working with the Non-OCD Parent

 

In contrast, sometimes the parent with OCD works hard to change herself and help her children, while it’s the non-OCD parent who refuses to get on board. For example, Mandy, a caring mother with three active boys, came to see me several years ago because she realized her OCD was negatively affecting her parenting. Her father, she told me, also had OCD, as did many other relatives. The family’s various OCD issues were acknowledged as “the Costello way,” with a fair amount of sarcastic acceptance. No one, as far as she knew, ever went for help, even though her father’s need for perfection bordered on being abusive. He’d wake her and her siblings up late at night to clean what he determined were unacceptable messes, and he wouldn’t allow them to leave the house until complete symmetry of light switches, towels, and pillows was achieved. Mandy’s kids were still young, but she recognized that her need to control the environment so that nothing would be out of place was a problem. After a horrible morning, in which her children all left for school crying after one of her “OCD rants,” she decided that things needed to change.

Mandy was the perfect client. She worked hard, held herself accountable, and talked honestly about the successes and struggles she had as she learned to step back from her OCD and let her boys be children. Within a few months, she left therapy equipped with an approach that worked for her. Two years later, however, she called about one of her sons who was showing telltale signs of emerging OCD. It had taken her a while, however, to recognize that his seemingly obstinate behavior was OCD. At first, she’d taken him to the doctor because he had several bouts of constipation and some increasing difficulty at bedtime. The doctor treated the constipation with laxatives and diet changes, but missed the source of the problem: the OCD process that was well under way. When Mandy began to ask the right questions, however, eight-year-old Devon revealed the rules he had about finishing things before he was allowed to stop or interrupt himself. He wasn’t using the bathroom or listening to his body’s signals because he couldn’t allow himself to stop, sometimes refusing to go to the bathroom for hours at a time. The refusal to go to bed also now made sense.

Within a few sessions, Devon was well on his way to understanding and changing his responses to his OCD cult leader, whom we called Sticky. We set up a plan for Devon that rewarded him when he did the opposite of what Sticky wanted, which in large part meant either listening to his body, his mom at bedtime, or the teacher’s schedule. He knew when Sticky was likely to show up and was prepared to tell Sticky to knock it off.

“I find Sticky annoying, don’t you?” I’d ask him. “I mean, really, he’s making up some pretty whacky rules.”

Devon enjoyed pointing out his mom’s OCD, which they called Witchy-Poo. We imagined that Sticky and Witchy-Poo went to the movies together. They changed seats 73 times and complained to the manager about all sorts of things. Also, they hated the movie.

Sadly, this playful, therapeutic momentum was short-lived. After several visits, Mandy told me that, despite her husband Eric’s previous frustration with her own controlling behavior and his acknowledgement of her improvement, he didn’t believe in therapy and wouldn’t support her and Devon’s efforts to address the OCD. He wouldn’t prevent her from coming to get help for her issues, but balked at labeling his son with some mental problem. According to him, Devon needed to learn to change his behavior through more parental discipline, not more therapy sessions. Although Mandy wasn’t the type of person to kowtow to her husband and he didn’t explicitly forbid treatment, the mixed messages at home resulted in confusion and shame for Devon. Maybe he didn’t have OCD, he told me. Maybe he just needed to listen better and stop misbehaving at home. Mandy continued to bring Devon to see me on an as-needed basis when symptoms ramped up or new content emerged. But without her husband’s willingness to work with the program, and given the frequent disagreements they had about it, the sessions dwindled to nothing.

I’m still hopeful that Devon will return to see me, especially now that he’s entering his teens, a time when OCD content often becomes more confusing and difficult, as it grabs on to the prominent social and sexual aspects of development. I worry how his father will handle this. And I kick myself for not sticking to what I know is such a critical component of my approach: family psychoeducation and involvement. My policy when working with anxious children is that both parents must be involved in treatment when at all possible. But because I knew Mandy and saw how well she understood the approach to OCD, I didn’t press her when she repeatedly gave excuses for Eric’s absence at Devon’s sessions. In retrospect, I should’ve insisted that we meet.

While I understand his resistance to having his child labeled with OCD, I believe that Eric would’ve benefited from seeing OCD symptoms demystified and being part of a family plan to deal with them. If I’d been able to make sense of what he’d been observing for years with Mandy and her family and was now seeing in his son in a straightforward, no-nonsense way, the outcome might have been different. Instead, the case served as a solid reminder of why I believe treating OCD in children should always be a family affair.

Of course, it’s true that treating a family together is more cumbersome: the appointments are harder to schedule, and there’s more to manage dynamically in each session. Plus, these days, most parents are interested in quick fixes, like psychotropic drugs, for their children. But treating a family works. In fact, a 2014 study published in JAMA Psychiatry concluded that a family-based OCD treatment model tailored to the developmental and familial needs of early-onset OCD sufferers was remarkably effective, with 72 percent of the children rated as much improved.

Still OCD is a clever opportunist with the ability to pull children, families, schools, and therapists into the dizzying trap of decoding its meaningless content in a misguided effort at getting rid of symptoms, which often masquerade as something valuable. For instance, a physician I treat is admired professionally for his thoroughness, his long hours, and exactitude. His wife and children, however, talk about his paralyzing attention to detail and an inability to manage his time, which keeps him disconnected from his family. Another family told me of their son’s need to shoot 200 foul shots every single day during middle school, something his basketball coach regards as a model of discipline for the rest of the team.

Part of the goal of family treatment is to expand everyone’s view of the long-term emotional and relational cost of OCD, whatever its short-term payoffs in anxiety reduction may be. So I try to use humor and playfulness to help them grasp a larger story of their shared experience, which recasts the role of OCD in their lives and exposes the price family members pay for playing by its rules. When I succeed, that can be a first step toward enhancing the mental health of an entire family for generations to come.