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“It’s as if this horrible dark feeling just comes over me and everything seems extremely gross and dirty. My whole life seems disgusting.” This is how my client Roselle described her internal experience when her OCD symptoms became triggered. To avoid this feeling or to “make it go away”, she would engage in a multitude of cleansing rituals. (Note: Roselle is a pseudonym and details of her life have been changed.)
When I first met Roselle she described her OCD as contamination fears. But it soon became clear that she was not struggling with worries of becoming sick when touching something she imagined was contaminated, which typically characterizes contamination fears. Instead, she was avoiding a “horrible dirty feeling of doom coming over me.” She said that anything that looked like it might be related to birds or bird poop could trigger the fear, as well as smells that reminded her of the birds her father kept when she was a child.
Roselle had already come to realize that her fear was not really about birds or their excrement, but instead about reminders of childhood experiences in which she had felt not safe in her home.
Her parents were struggling and often fought loudly. Roselle’s mother would leave – sometimes for days at a time – and the children didn’t know when or if she would return. In addition, Roselle and her siblings were subjected to sexually inappropriate touches by a family friend who often came to visit. When Roselle told her father about this, he didn’t really pay attention and did nothing to prevent it from happening in the future.
Roselle’s abuser was connected to the bird breeding community her father was a part of, and she regularly encountered disgusting reminders of the birds around her house. Bird excrement that had not been cleaned up for weeks dotted her living space. Sometimes the birds would soil her prized possessions, like her favorite jacket. As an adult, all of these memories had become linked to anything related to birds.
What she called cleansing rituals were directed at avoiding any contact with birds and throwing away anything that could have been in contact with birds. But there were also purely symbolic rituals such as saying certain cleansing phrases like “clean and free” in an area where the fear had become triggered.
Roselle wasn’t experiencing typical OCD contamination fears, but rather mental contamination. Mental contamination is a fear of contamination without physical contact with a contaminant. For Roselle this could be seeing a spot on somebody’s pants that reminded her of bird excrement. Research has linked mental contamination to traumatic experiences, particularly sexual trauma. In the aftermath of sexual trauma, people are more likely to report an urge to clean themselves in response to the traumatic memory being triggered, as well as an overall sense of feeling dirty.
In my practice, where I specialize in OCD treatment, I have seen a variety of clients who reported experiences of mental contamination. They often describe an overwhelming feeling of dirtiness and doom. My clinical observation when working with these clients, admittedly anecdotal, is that more often than not they report a connection of their OCD symptoms to complex trauma experiences.
Complex trauma is defined by continued or repetitive traumatic experiences that create an overall sense that the world is an unsafe place, which can lead to traumatic stress symptoms that may be harder to directly link to a single index memory (a clearly delineated traumatic event), but are more involved in shaping a person’s overall experience of life.
There are inherent similarities between evidence-based treatment approaches for intrusive trauma memories and OCD, such as exposure therapy. In cases of complex trauma, however, it can be more difficult to develop such exposures due to the lack of an index trauma.
When Roselle and I began working on OCD with mental contamination experiences, I introduced her to the principles of exposure and response prevention (ERP), the gold standard evidence-based treatment approach for OCD. ERP offers opportunities to practice tolerating distress when OCD is triggered, and is an alternative to finding a specific trauma memory to expose to.
In ERP we plan and create situations that will trigger a client’s obsessive fears – in Roselle’s case mental contamination – and subsequently the urge to engage in a compulsion. The client will then practice tolerating the feelings that exposure brings up while resisting the urge to engage in the compulsion.
Such exposure exercises are carefully calibrated and always mutually planned and agreed-upon with the client. A hierarchy of exposures is developed using a subjective units of distress (SUD) scale where a client estimates how high their anxiety, discomfort, or uncertainty levels may become during an exposure. Exercises are then chosen from this hierarchy with the goal of creating a feeling of distress that is palpable yet tolerable. On the SUD scale this often translates to a number from five to seven.
ERP exercises that Roselle engaged in included saying the words “bird poop”, drawing birds, and looking at photos and videos of birds. As she became more able to tolerate mental contamination experiences, she then sought out various exposures to real birds as well as their smells. She would forgo cleansing rituals and, particularly, resist throwing away items of clothing such as shoes if they had become “contaminated.“
When treating OCD, it is of great importance to help clients avoid creating new compulsions, which can happen when certain trauma treatment interventions are not carefully adjusted for OCD. For example, Roselle wanted to use relaxation and breathing techniques during ERP work. During prior trauma treatment she had learned these helpful strategies, but they had now become compulsions for her. Instead of helping her, they had become avoidance strategies. Encouraging people to allow all of their anxiety to emerge in a planned and thoughtful way, and then learn to tolerate (and even accept) it, is the main tenet of ERP.
For Roselle, learning to engage in ERP work and being willing to resist any efforts to make her anxiety “go down” eventually felt empowering. She was the one to decide when and how to let the feeling of dirtiness and doom arise and to what extent, and she became able to move around the world much more freely. When she could tolerate the idea of encountering birds she was able to visit friends who had birds, and while not yet wanting to get too close, she also didn’t avoid the room with the birdcage.
Working with clients who experience mental contamination, have a history of complex trauma, and have cleansing compulsions is a clinical experience that can at times seem somewhat baffling. But it has also shown me various ways to personalize evidence-based treatment approaches and help clients experience a sense of empowerment and mental autonomy that trauma memories and OCD can hold hostage.
If you want help with OCD or the consequences of trauma, Lyra can connect you to a behavioral health solution that is right for your needs. You can get started today if Lyra is offered by your employer.
The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
ABOUT THE AUTHOR
Ursula Steck, LCSW, BCD is a therapist in private practice in San Francisco. She specializes in cognitive and behavioral treatment approaches for anxiety, OCD, and PTSD and incorporates evidence-based methods focused on mindfulness, values, and meaning. She has a background in community mental health and has worked at Langley Porter Psychiatric Institute at UCSF in an intensive outpatient program for children and youth struggling with OCD. She is board certified in advanced clinical practice by the American Board of Examiners in Clinic Social Work (ABE).