Loving Detachment and Non-Violent Resistance: New Family Based Approaches

for Managing OCD

Kathleen M. Rupertus, PsyD Yaara Shimshoni, PhDThe Anxiety and OCD Treatment Center, LLC Anxiety and Mood Disorders Program Wilmington, Delaware Yale Child Study Center

Barbara Van Noppen, PhD, LCSW Patricia Perrin Hull, Ph.D.University of Southern California OCD and Anxiety Treatment CenterKeck School of Medicine of Houston

Participants will be able to:

Describe the concept of loving detachment as an approach to managing OCD

Define 3 strategies of non-violent resistance

Describe 3 parental strategies of The SPACE Program

Workshop Objectives

Good intentions, bad outcomes…

parents feel guilt, shame and

responsibility

Some family responses are better than others…

* Providing reassurance (incessantly trying to convinceeverything is okay)

* Participating (excessive washing own hands)* Assisting (help patient avoid germs)* Facilitating (Buy soap, paper towels)* Modifying family routine (no guests in home)* Taking on extra responsibilities (chores/homework)* Modifying leisure activities (missing events)* Modify work responsibilities (calling in sick)

What is Family Accommodation?

What’s so bad about accommodating OCD?

FA associated with less response to behavioral therapy inadults and children(Amir et al., 2000 Freeman et al, 2014)

FA in Psychopathology: A synthesized review (Shimshoni, Shrinivasa, Cherian & Lebowitz, 2019) Review of 69 relevant articles between 2010-15 pediatric and adult In OCD and Anxiety Disorders, associated with sx severity, impairment,

caregiver burden and poorer treatment outcome FA restricts ERP opportunities to develop distress tolerance and habituation FA prevents collection of evidence to challenge maladaptive beliefs

Family Accommodation Effects

Extreme impact of family accommodation

During a calm time or in therapy, the person with OCD andthe family select situation- focus on changing family behavior

Clear and direct discussion about challenge and family’s job(ACT) to help reduce disruption from OCD

Negotiate rewards and use token economy Consequences and expectations defined (no surprises! Acting

out of love, acceptance and pride What is meant as family “support” is negotiated (hold hand vs.

ask); “publicize” disruptive behavior Gradual withdrawal of FA (similar to working up an exposure

hierarchy)

Behavioral Contracting

Family Contract ExamplesInstead of opening doors, person with OCD agrees to place hand over relative’s and open door together until gradually person with OCD touches knob/handle fully then opens the door themselves

Person with OCD has whispering compulsion, agree that until family can hear, they won’t respond

For reassurance, respond with a cue/question: “scooby snacks,” “time to walk the dog,” or a question: “What do you think I will say? What have I told you before?"

VIDEO DEMO

I am a person who has OCD

I have been treating OCD for the past 24 years (since 1995)

Two of my 3 children have been diagnosed with an anxietydisorder or OCD

Let’s Talk About Me

Love is an action. It is volitional versus emotional. Loveimplies commitment and the exercise of wisdom andconcern for another’s personal and spiritual growth.Love is a form of work and courage.

- M. Scott Peck, The Road Less Traveled: A New Psychology of Love, Traditional Values and Spiritual Growth

Love is not a feeling…

… to acknowledge and accept that notgiving at the right moment can be moreloving and compassionate than giving atthe wrong moment.

M. Scott Peck, The Road Less Traveled: A New Psychology of Love, Traditional Values and Spiritual Growth

Love Challenges Us

“… it is judicious giving and judicious withholding as well. It isjudicious praising and judicious criticizing. It is judicious arguing,struggling, confronting, urging, pushing and pulling in addition tocomforting. It is leadership. The word "judicious" meansrequiring judgment, and judgment requires more than instinct; itrequires thoughtful and often painful decision making.”

M. Scott Peck, The Road Less Traveled: A New Psychology of Love, Traditional Values and Spiritual Growth

Love is not simply giving…

Maintaining an emotional bond of love and concern withoutthe negative results of rescuing, enabling, fixing orcontrolling our loved one’s problem/s

Acknowledging, “I can't do it for someone else.” Allowing your loved one’s motivation to result from natural

consequences versus guilt, shame or coercion To care about rather than taking care of your loved one To permit your loved one to face the reality of OCD Letting go

Detachment with Love is…

“It gives my loved one the opportunity to draw on their owninner resources instead of mine; to learn to look within andtrust themselves for self-direction and to solve problems; andto learn when and how to ask for help in a way that will leavethem feeling good rather than embarrassed, ashamed,ineptor incapable... and from this direct experience of theirabilities- no matter how groping or uncertain - they can buildcompetence that often leads to confidence.”

Myers, W. How detachment can be loving for all. (http://waylandmyers.com/4.html)

How Detachment isLoving for Others

“I am relieved of the strain of attempting the impossible. If Iaccept my powerlessness to control the inner lives and willsof others, I relieve myself of the stress and strain ofattempting what cannot be done. This creates more serenityin my life. My attention and energy are freed to focus onimproving my own life. This new freedom provides anopportunity to invest energies in my own life again.”

Myers, W. How detachment can be loving for all. (http://waylandmyers.com/4.html)

How Detachment isLoving for You

Which action, helping or lovingly detaching, do I believe willstrengthen my loved one the most in the long run?

Are any of the helpful things I've gotten into the habit ofdoing for my loved one things which are his/herresponsibility, or things which might be better for him/herto do or learn to do for him/herself?

Myers, W. How detachment can be loving for all. (http://waylandmyers.com/4.html)

When to Help,When to Lovingly Detach

Is the situation I am tempted to help my loved one with one that is anatural consequence of his/her choices or behaviors?

It is preferable to let people encounter the full force of the naturalconsequences of their actions to allow them the maximum opportunityto learn and become motivated to change.

You can make exceptions if you believe the emotional or physical harminvolved will be at a level you cannot live with in the long run.

When in doubt, always choose the option/s you believe you can live withbest in the long run.

I'd rather have my loved one hate the consequences than hate me forcreating them.

When to Help,When to Lovingly Detach

OCD-specific factors to consider:

become familiar with your loved one’s hierarchy

know which ERP goal/s your loved one is working on

if you deem that some aspect of accommodating is nolonger tolerable, you may need to disregard the hierarchyand initiate a loving conversation about no longer providingthat accommodation going forward

When to Help,When to Lovingly Detach

“I have not found loving detachment to be painless. I oftenfeel guilt, worry and doubt. But, my suffering is temperedwhen I believe that by resisting my urge to help, I may beoffering the person I love the highest form of love I can.”

Myers, W. How detachment can be loving for all. (http://waylandmyers.com/4.html)

* Psychological approach for overcoming destructive, aggressive,controlling, and risk-taking behavior.

* Developed to address serious behavior problems in young people,but also used for adult entitled dependence, anxiety relatedproblems (e.g., OCD), pediatric illness, internet dependency, anddomestic violence.

* Research has shown NVR to be effective in reducing childhoodviolence, improving relationships with family, and increasingparental confidence and mental health.

What is Non-Violent Resistance

* Based on socio-political practice of nonviolent resistancemethods, e.g., protests, civil disobedience, and economic orpolitical non-cooperation. Modern leaders using NVR wereMahatma Gandhi and Martin Luther King.

* Goal of de-escalation and refusing to engage in conflict can besummed up by quote of Gandhi: “An eye for an eye makes thewhole world blind.”

* New therapeutic intervention developed by Haim Omer andcolleagues at U of Tel Aviv to help parents of violent children.(More on history later)

Theoretical Basis forNon-Violent Resistance

* Uses “Anchoring Function of Attachment" which emphasizeschild’s need to become secure in relationship with a strong andwise adult.

* Relies on concept of the “New Authority”, based on principlesof transparency, interpersonal closeness, and accountability ofthe adult within community – vs. principles of positional power,hierarchy, and distance, aspects of traditional authority.

* NVR is designed to help families in which a family member doesnot cooperate in therapeutic process. Parents’ perseverance inface of child’s non-cooperation sends message of resistance.

Theoretical Basis forNon-Violent Resistance (cont’d)

Principle of Parental or Adult Presence

* Awareness of the person of the parent and their authorityin the home, school, etc.

* Practitioners often find parents of violent or difficultchildren to feel helpless and isolated

* NVR aims to increase parental presence in child’s mind anddecrease parents’ feelings of helplessness

Principles and Aimsof Non-Violent Resistance

Principle of Delayed Reaction

* “Strike when the iron is cold”- avoids escalation

* Issue is dealt with at a time of the parent’s choosing

* Restores power to the parent, parental authority, andparental presence

* NVR focuses on using action, not words

Principles and Aimsof Non-Violent Resistance

1. De-escalation- refusing to be drawn into battleEscalation can be:

a) symmetrical- both raising aggression in upward spiralb) complementary- parents give in to child’s demands

~ Both a and b weaken parental authority and family members ~c) de-escalation- restores parental authority, prevents power

struggle2. Breaking Taboos - Means not keeping the peace by followingrules set by the child, or by the child’s OCD. (Following certainrituals or avoidances.)

“Parental Disobedience”- Parents break the rules

Aims to Help Parents Gain Authority by Becoming Active in 4 Areas

3. Taking non-violent action

* rather than relying on punishment/consequences

* increases parent’s ability to be present and resist child’saggressive or self-risk behaviors

* including resisting child’s self-sabotaging behaviors like rituals, which disrupt child’s optimal functioning.

4. Reconciliation gestures

* show that parents care for and love them

* help to reestablish a loving connection

Aims to Help Parents Gain Authority by Becoming Active in 4 Areas

Written Announcement - Initially involves therapist guidingparent in writing and planning how to make announcementwithout escalation, arguing, etc. Therapist helps choosebehavior that works for the parent to stop doing.

* Expresses love, support, empathy for one’s suffering with OCD

* Provides encouragement and confidence in child’s ability to toleratediscomfort

* Provides rationale for behavior change

* Announces parents’ behavior change (e.g., not supporting rituals and avoidance

Application of NVR Techniquesto OCD

Support network - Involves development of an adultnetwork of supporters. Aims to remove secrecy andsupport parents, by providing solidarity.

* By making behavior of parents and child public, it keeps bothaccountable. Reinforces parents’ message of resistance.

* Members may play role in “campaign of concern” or “messagecampaign,” by contacting the child, by letter writing or phonecalling, and expressing concern for them and others affected(parents), and by giving encouragement.

Application of NVR Techniquesto OCD

Support Network (cont’d.) – May be involved in helping, e.g., ifchild refuses to ride bus home, support person may temporarilyprovide transportation, which child may find embarrassing,inconvenient, or undesirable.

Reconciliation Gestures – After any demonstration of resistanceto child’s aggressive or self-sabotaging behavior, adults usereconciliation gestures to express unconditional care, respect,and love, to establish a loving connection.

Once one behavior change is made by child, i.e., after familyaccommodation ceases in one area, research has found child able tomake other behavior change, (response prevention in ERP sense).

Application of NVR Techniques to OCD

The SPACE Program

Supportive Parenting for Anxious Childhood Emotions

Parent-based treatment for child anxiety and OCD

NVR-informed Short-term Active and practical Effective

Eli LebowitzHaim Omer

Why Parents?

Systemic nature of anxiety and OCD Parents are not to blame Self-control instead of controlling child behavior Focuses on parent behavior

In a Nutshell

Increase Support

Decrease Accommodation

Accommodation Cycle

Distress related to the disorder

Family accommodation

Short-term reduction in

distress

Continued dependence on

parents for regulation

Maintenance of symptoms

Accommodation in Research

Present in ~95% of parents of anxious/OCD children (especiallymothers)

Shimshoni et al. 2019; Benito et al., 2015; Storch et al, 2015

Associated with more severe anxiety/OCD symptomsNorman et al, 2014; Lebowitz, et al., 2016

Associated with more severe impairment for child and familyThompson–Hollands et al., 2014

Leads to additional problems (e.g., sleep problems)Shimshoni et al., 2019

Support

Acceptance Validation Confidence Support

“I see that this is hard for you, but I am 100% sure you can handle this”

Support

‘He can’t handle it’

Patiently providing reassurance

‘She should be more independent’

“Stop asking me!/doing that!”“you’ve asked 20 times already!”“this is not scary at all!”“you are acting like a baby!”

“I know it’s hard for you when you have OCD thoughts and want me toreassure you again and again, but I’m sure you can handle it”

Wanting to protect

Wanting to promote independence

Where do you stand on Accommodation and Support?

Charting Accommodation

Time of Day What happens? Who is involved? Frequency (Tally)

Morning(Getting up, getting

dressed, breakfast, going to school)

Afternoon(Pick up from school,

Lunch, homework, after school activities, social

activities)

Evening(Dinner, family time,

pre-bedtime)

Bedtime(Getting ready for bed, washing up/showering,

going to bed)

Nighttime

Weekend

Dear Lila,

We love you very much and are so proud of the kind and beautiful young woman you are becoming. We also see how much you suffer from your OCD thoughts and how much they scare you. We know you are strong and brave and see your struggle to overcome it.

We realize now, that when we agree to do what OCD says we are not helping you in your struggle, we are actually helping OCD and making it worse for you. That is why we have decided to make some changes in the way we behave that we believe will help. The first thing we are going to change is that from now on we will not change our clothes when we return home from work or anywhere else.

This might sound hard at first, but we are 100% sure that you can handle this. We are not trying to hurt you or punish you in any way. We are your parents and our job is to help you in any way that we can – but our help cannot be by giving into your OCD.

Love, Mom and Dad

Session Modules

Dealing with Disruptive Responses

Recruiting support from outside the

home

Dealing with Threats of Self

Injury or Suicide

Improving Collaboration

Between Parents

SPACE vs. CBT

Lebowitz et al., 2019

0

10

20

30

40

50

60

70

80

90

100

Response (PARS) Remssion

CBT SPACE

SPACE vs. CBT

Secondary Outcomes

Independent Evaluator PARS

Parent Rated MASC

Child Rated MASC

Resources

spacetreatment.net