Alexis is a 19-year-old Hispanic American who was referred to A Greater Grace Counseling service by her mother, Amy who believes that her daughter has Obsessive Compulsive Disorder. She has gotten progressively worse with the need for cleanliness. She yelled at her mother for leaving footprints on her freshly vacuumed carpet. Alexis states that dirt and germs make her nervous and anxious. Amy came with her to the counseling center because she worries that Alexis washes too much, noting that Alexis takes several showers a day. Additionally, Amy feels that her daughter hates her. Alexis feels that her mother is overbearing and asks too many questions. This is Alexis’s first time in therapy.
Alexis presents with obsessive behaviors, such as frequent washing and excessive housecleaning. She has repetitive and intrusive thoughts that the house is dirty or that she needs to shower. Alexis states that she cannot go into stores because they are very disorganized, and she gets anxious and needs to go home and shower. These rituals are causing anxiety, which is affecting her temperament and causing physical and emotional tension. The obsessions have been present for 3 years and the anxiety has presented within the last 8 months. Alexis does not think that she has Obsessive Compulsive Disorder but agrees that she has anxiety-related symptoms.
Amy states that Alexis has always been a clean child. After she turned 16, she became obsessively clean. Alexis would often stay with friends during high school because Amy did not like to clean house. Amy provides for Alexis financially and has agreed to continue while Alexis is in treatment. Alexis appears very neat but looks fatigued as evidenced by the circles under her eyes. She is well-mannered and well-spoken; however, she seems guarded and irritable in front of her mother.
Alexis is half Caucasian, and half Latino. She speaks English and some Spanish. She states that English was the primary language spoken in the home, although her father could also speak Spanish fluently. She has never been a victim of race discrimination and has many Caucasian friends. She identifies as white and Latina.
Her father, Joe, and mother, Amy have been married for 27 years. She has an older brother who has been in the military since Alexis was 16. They were very close growing up. Alexis moved out of her family home when she graduated high school and turned 17 because she believed that the home was filthy. Her mother still supports her financially. Her father is a recovering alcoholic. Her mother has a history of depression and her brother suffers from PTSD, resulting from his last deployment to Afghanistan. He is still enlisted in the military.
Amy still financially supports Alexis; however, the father is unaware of it. Amy is the only person who is aware of Alexis’s state of mind and presenting issues. Amy feels that Alexis is going “crazy”. Alexis admits that she cannot stand to live in filth and her family should understand that since their house is always dirty. She has recently been at odds with her mother, as evidenced by the yelling and no longer allowing Amy into her apartment.
Alexis has a high school diploma and has no current desire to attend college. She admits that the thought of going to school causes anxiety. Alexis is unemployed but is supported by her mother. Alexis has an apartment in mid-town that her mother paid for. Currently, her utilities and daily expenses are covered by her mother. Alexis worries about her brother, who is still enlisted in the military. He was shot in Afghanistan during his last deployment.
Alexis was raised in the church and identifies as Catholic. Until 8 months ago, Alexis actively attended church with a group of friends and was active in the choir. She stopped attending after she had a dinner party with her congregation at her apartment, and someone spilled coffee on the floor.
Alexis appears clean and intelligent. She has no financial concerns, nor does her immediate family. Alexis has three close friends from high school that she still stays in contact with, but she has not been in contact with any of the members of her church. She relies heavily on her mother for financial support but does not confide in her about anything.
Alexis was born healthy, with no illness or accidents occurring, is not on medications currently, has no genetic illness other than a predisposition to depression and alcoholism, and has no physical limitations. Alexis has no history of substance use but drinks wine occasionally on Christmas and Easter. She denies previous mental health issues. She presents with Obsessive Compulsive Disorder and Generalized Anxiety Disorder.
Section II: Models of Intervention
Cognitive-behavioral therapy (CBT) is a widely used method that has been proven effective in the treatment of anxiety-related behaviors (Marom & Hermesh, 2003). Additionally, the practice of cognitive restructuring can help mediate somatology associated with obsessive-compulsive disorder when utilized with exposure therapy (Marom & Hermesh, 2003; Marom, Hermash, & Gilboa-Schechetman, 2009)). Examined is a session where both cognitive restructuring (CR) and exposure therapy (ET) are applied.
Alexis and I sat together to discuss her obsessive behaviors and the anxiety that is associated with them. She revealed to me that ever since she moved away from her childhood home, she felt relief from the “mess”. She stated, “My mother is a pig! She never washed a single dish in her life. It was so embarrassing when people came over because there was never a place for them to sit. There was trash and laundry piled everywhere!” I asked, “What is it about the mess that upsets you?” She replied, “It’s just disgusting!” As she said this, she reached into her purse and pulled out a bottle of hand sanitizer and began to rub her hands vigorously. It is time to restructure her thoughts… “Alexis, do you think my office is dirty?” She replied, “No.” I ask, “Then what’s with the sanitizer?” Alexis, “Oh, I didn’t even realize I did that (As she holds up the bottle).” In cognitive restructuring, we identify cognitive distortions that produce abnormal behaviors and identify means to assess the current situation prior to acting upon it (Marom & Hermesh, 2003; Marom et al., 2009). “Alexis, I want you to hold this bear.” She takes the bear and notices that it has been worn. I ask, “Do you like him?” She replies, “I’m not sure, he looks a little dirty (scrunches her nose).” As she goes to set the beardown, I stop her. I told her, “I want you to hold him for five minutes.” This is exposure therapy. The bear, while worn, is not dirty; but to Alexis, it is filthy. By holding him in brief intervals throughout our sessions, she will make the connection between dirt and safety (Marom & Hermesh, 2003; Marom et al., 2009). I allow her to set the bear down as we talk without the use of sanitizer (ET). Every 5 minutes, she must pick him up again. The expectation is that she slowly begins to realize that a little dirt is not a terrible thing (Marom & Hermesh, 2003; Marom et al., 2009). The more she recognizes this, the less anxiety the bear will evoke. I assign her homework and ask her to take the bear home and hold him each time she feels obsessed to take shower (ET) (Marom & Hermesh, 2003; Marom et al., 2009). One shower per day is the maximum (CR). She will take notes on how often she feels compelled to hold the bear (CR and ET).
The next session, Alexis came in the office with the bear under her arm. She was smiling and seemed less fidgety than on our first visit. We reviewed her notes and assessed her current state of mind. She stated, “I feel a little better. I had a lot more free time because I was only allowed to shower once a day. I still think this bear could use a shower (laughing).” I noted her lightheartedness and humor. I asked, “Did you bring hand sanitizer with you?” She admitted that she did, so I asked her to place it on the table beside the bear. I said, “At any time during our meeting, you may hold the bear, but I want you to try to refrain from using the sanitizer, ok?” She agreed, and we began to discuss her plans. I asked, “Are you interested in school?” Alexis said, “I really enjoyed high school, but I found that most places are filled with germs and I get really anxious about that.” I saw her looking at the sanitizer as she said this, but she quickly looked away. “Alexis, do you think that my office has a lot of germs?” She looked around and said, “Probably, but I can’t tell.” I assured her that my office was not perfect (CR) and that although it looks clean, there are a few germs there that are unavoidable (CR) (Marom & Hermesh, 2003; Marom et al., 2009). She looked at her sanitizer on the table as I spoke. I asked her, “Do you believe that my office is as dirty as your mother’s house?” She stated, “No.” I asked, “Then why would you think that working in an office or going to school would be so bad?” (CR) (Marom & Hermesh, 2003; Marom et al., 2009). She agreed that it would not be as bad as going to her mother’s house and looked a little bit relieved. “Alexis, if there was something that you could do that does not involve cleaning, what would it be?” Alexis stated that she enjoyed writing and researching about people. I explained to her that she could go to school online until we were able to work through some of her anxieties and compulsions (ET) (Marom & Hermesh, 2003; Marom et al., 2009). I strongly believe that preoccupying Alexis with healthier choices is naturally a good idea (CR); however, I do not think that she is ready to be thrown into social situations that would interfere with the progress she and I are making. I noted a comment that Alexis made about her current situation: I don’t really need to work or school, mom takes care of everything. I sent her home with the bear and chuckled after she closed the door because she left the sanitizer behind. Her homework was to research schools and find one that best suits her. Additionally, I asked that she bring her mother to the next visit.
Walsh (2015) describes systems theory as the combination of elements, both social and environmental, that have a cause-and-effect reaction the components of the system. Each element is influenced by the other and in families, the parallel strongly exists (Walsh, 2015). According to current research, parental influence on healthy lifestyles, social behavior, and education after adolescence carries over into adulthood (Walsh, 2015). The range of support a parent provides can impact the perception that growing adolescents have on the world. Bowen's family systems theory suggests that human behavior assumes a family unit as emotional and that each member’s feelings, emotions, behaviors, and actions affect each element, or family member (Walsh, 2015). Emotional interdependence is increased as family members change behaviors or disrupt the cohesiveness of the family unit (Walsh, 2015). If Alexis’s behavior toward her mother is related to childhood events, it should surface during session (Walsh, 2015); however, Amy’s overcompensation to appease Alexis could be the trigger for Alexis’s abnormal behavior (Walsh, 2015). Taking a structural family systems approach, I will utilize role-play between Alexis and her mother to evaluate the structure of their relationship (Marom & Hermesh, 2003; Marom et al., 2009).
Alexis and her mother came in together but neither of them appeared interested in talking to one another. It was already made clear that Amy believed that Alexis was crazy, and Alexis had little respect for Amy. As such, I placed them in chairs facing each other and forced a conversation (Marom & Hermesh, 2003; Marom et al., 2009). I asked Amy to tell Alexis how she was feeling. Amy stated, “I worry about you. You are too clean, and you won’t go to work or go school. If you put as much effort into life as you do cleaning, you might be a successful person”. Alexis replies, “I’m clean, yes! I am disgusted by filth. And why should I do anything? You have all the money and you can pay the bills.”
Amy looked at me and stated, “See? This is what I am talking about!” I respond, “I have an idea, are you ladies willing to hear it?” Such questions evoke a healthy working relationship and help clients become more receptive to ideas and suggestions (Walsh, 2015) “Alexis has already started making changes toward a healthier lifestyle. What if, you reward her for progress rather than enable her to stay stuck in the same place?” Alexis looked at me inquisitively and then looked at her mother. Amy said, “How do I do that?” Facilitating change in family systems requires all parties to invent a goal, work cohesively to achieve that goal, and reward each other when goals are met. My theory suggests that Alexis is given a budget and must adhere to that budget until she can work and care for herself. As Alexis makes progress toward her recovery, Amy can reward her with extras like lunch out together or a girl’s shopping expedition. Often family members will concede to another member’s irrational or abnormal behaviors thinking that they are helping when the enabling is making the problems worse (Marom & Hermesh, 2003; Marom et al., 2009). By nudging the notion of self-reliance, Alexis will learn that she cannot take advantage of her mother’s kindness. Moreover, Amy will recognize that Alexis is much stronger than she has previously given her credit for.
Section III: Critical Critique
Cognitive-behavioral therapy and family systems therapy are both beneficial when working with clients presented with the disturbances noted in the case study (Marom & Hermesh, 2003; Marom et al., 2009). Although it is not typical to have such quick and all-positive results as I have presented with this case, the approaches applied over time could produce similar outcomes (Marom & Hermesh, 2003; Marom et al., 2009). Both approaches have strengths and limitations but when introduced appropriately, can serve to benefit individuals like Alexis in the long term.
The cognitive-behavioral approach to obsessive-compulsive disorder and the symptoms of anxiety associated with it is best suited in this situation because Alexis is frozen by her symptoms (Marom & Hermesh, 2003; Marom et al., 2009). She is incapable of attending school or going to work because her fear of germs outweighs her desire for independence. She needs to change her patterns of thinking. The family systems approach seeks to benefit Alexis and her mother by teaching them that enabling is holding Alexis back (Marom & Hermesh, 2003; Marom et al., 2009). The ‘nothing changes if nothing changes’ approach will greatly benefit Alexis by urging her to seek independence because the reality is, she has no choice.
Although Bowen suggests a multigenerational perspective when applying family systems theory, I did not see the benefit because the family history that Alexis presented did not warrant such an investigation (Walsh, 2015). Had her father been aware of the financial support that Amy was providing her daughter, I would have felt compelled to include him in the session. I could convey this to Amy in future sessions, but the primary focus of this therapeutic intervention was to get Alexis well. As such, I suggest that cognitive-behavioral treatment is the best option for treating Alexis until her symptoms are well under control, as highlighted by the treatment goal and its objectives.
Treatment goal: Have Alexis gain her independence
Alexis can gain her independence by changing cognitive distortions associated with obsessive-compulsive disorder. To do this, I have incorporated a gently used bear to help Alexis identify that “dirty” is not such a terrible concept if taken retrospectively
Help Alexis refrain from the overuse of hand sanitizer and over-bathing. Taking notes and replacing the urge to shower with holding the bear will help her redirect her focus onto more healthy behaviors
Have Alexis begin school. An interest in writing and research will serve her well in her search for independence. Additionally, it will help her redirect negative thoughts associated with her surroundings by putting her focus onto more promising things.
Since Alexis’s case is complex, I would like to meet with her regularly to track her progress. Additionally, her situation is very connected to her mother’s enabling, therefore, it is important to include her in the process. The main issue that I could predict as a barrier would be Amy. Without her assistance in creating a budget and providing Alexis an allowance, the likelihood that Alexis will stay dependent on her mother is increased exponentially.
References
Marom, S., Aderka, I. M., Hermesh, H., Gilboa-Schechtman, E. (2009). Social Phobia: Maintenance Models and Main Components of CBT. Israel Journal of Psychiatry and Related Sciences, 46(4).
Marom, S. & Hermesh, H. (2003). Cognitive Behavior Therapy in Anxiety Disorders. The Israel Journal of Psychiatry and Related Sciences, 40(2).
Walsh, J. (2015). Theories for direct social work practice (3rd ed.). Belmont, CA: Brooks/Cole Cengage.