Sandeep. Living with OCD

*Please note that this is a fictitious case example, however, is based loosely on real individuals and their experiences with OCD.

Background 

Sandeep had always been timid for as long as she could remember. She preferred to keep herself to herself at school. She had a couple of friends who she spent break times with but tended not to get too close to anyone. The beginning of her childhood was fairly ordinary for the most part until things changed…

When Sandeep was 11 years old, something happened in her family that devastated her. Her grandmother, who had raised her like her daughter, died suddenly in a car crash. She felt feelings she had never felt before. She felt extreme sadness, desperation, and disbelief. She wanted to disappear. She wanted the world to swallow her up. Sandeep’s mother also struggled a great deal. She became withdrawn from the family and Sandeep felt that it was her responsibility to console her. Sandeep’s own feelings had to be buried as quickly as possible, there was no other way…for how could she look after her mother if she was unstable herself?

There was one feeling however that she couldn’t shake..the sense that she was somehow responsible for her grandmother dying. It didn’t make sense of course, but it felt true. This feeling kept her up at night and led her into the depths of despair. Over time this feeling seemed to become a part of her very core…that somehow she was a bad, unforgivable person for causing the death of her grandmother. She buried this feeling deep into her unconscious, because how could she ever allow herself to live if she remained conscious of it? 

Shortly after her grandmother’s death, she witnessed the gradual decline of her parent’s relationship. She felt like everything was getting out of control and felt powerless and alone.

The beginnings of the OCD

As the years went by, Sandeep became more and more withdrawn. She could no longer face going into school and spent most days in her room alone. She became very fearful and on edge, and started to display strange behaviors like washing her hands repeatedly. She believed that she or her family would get very sick and die if she was unable to keep herself clean. By the age of 14 Satwant’s hands were red and raw from repeated washing. Each handwashing episode could take from 10 minutes up to 2-3 hours at a time. 

Diagnosis

Sandeep’s fears had become all-consuming. She would stay in her room for days without eating, bathing, or having any kind of social interaction. She did not ask her parents for help because she did not want to be a burden, however, things got so bad that her uncle urged Sandeep’s parents to seek help for her. Sandeep was eventually referred to an adolescent mental health team. This is where she was given the diagnosis OCD. Neither Sandeep, nor her parents knew much about what this meant, but they were somewhat relieved that there might be an explanation for her behaviour.

Sandeep was put on medication to see whether this would make a difference. It seemed to numb the anxiety, but it also numbed other feelings, happiness, and joy. Nevertheless, she continued to take the medication, as it seemed to keep her feelings at bay somewhat. She was offered talking therapies but did not take this up. Her parents were also skeptical, and they felt uneasy about Sandeep opening up to a complete stranger.  

Over the next 10 years Sandeep was put on many different medications to see whether one would suit her better than others. She continued to have OCD, and perform rituals around handwashing. However, when the OCD was “bad” it seemed to spread to other things e.g. checking of sockets before bed and checking the doors were locked. During difficult periods, Sandeep would spend every waking moment checking and handwashing, to the point that she avoided coming downstairs at all, and would eat very little (1 meal a day).  

There were other, better periods were Sandeep was able to hold down a part-time job, start engaging in hobbies (she loved photography), and was able to babysit her nephews and nieces, whom she loved spending time with. However, it was impossible to know how long the “good” periods would last, and every so often, there would be a setback triggered by different things, e.g. a work deadline, family conflict, bereavement etc. 

Finding religion

When Sandeep was around 25 years of age, her family turned towards religion. They had always had an interest in their faith and attended the Gurdwara weekly on a Sunday, but they had increasingly sought solace in their faith, feeling that they had nowhere else to turn to. Sandeep began to accompany her mother to the temple weekly, and It wasn’t long before she started enjoying these visits and experiencing peace. She was still washing her hands excessively and checking, but had found ways of minimizing these behaviours when out. Sandeep learned the daily prayers and made an effort to wake early in the morning to recite them. 

Somewhere along the line, however, she started to enter a bad patch again…the strong sense of guilt that was deeply embedded within her seemed to make an appearance again, but this time it was in relation to religion. She became obsessed with cleanliness and would recite her prayers over and over. She would obsessively pray to God for forgiveness for making mistakes during prayer. The  OCD had taken over again. She began to think of herself as a bad Sikh, and was constantly asking God for forgiveness.

It all became too much for her, and she went back to spending long periods of time in her room, avoiding going out, and she had become emaciated from eating very little. She felt a constant sense of intense anxiety. No matter what she did she could not make this feeling go away. She was exhausted from hand washing, from checking, from repeating prayers over and over, and the constant guilt that she was doing something wrong. 

Her relationship with her parents began to deteriorate as well. Sandeep felt extreme guilt over “burdening them”, and could not bear it anymore. She expressed to her mother that she would rather die than live a life like this. Sandeep had expressed suicidal thoughts and feelings before to her parents, however this time she seemed more desperate, and her mother knew that she needed to take action. Her neighbour had suggested that she see a counselor, so she looked one up online and made an appointment on her daughter’s behalf.  

Seeking therapy

Sandeep was highly anxious about seeing a therapist. She was embarrassed about her difficulties and was worried about the therapist judging her. She was worried that talking about her issues might make them worse. Every part of her was telling her not to go, and she even missed the first two appointments that had been arranged. 

Sandeep isn’t sure what pushed her to go, but she finally managed to attend a session. She was highly anxious, but the therapist seemed quite friendly and down to earth. Sandeep left the first session feeling surprisingly light. The therapist had asked her some personal questions about her, about the OCD, and a timeline of it from then till the present day. She didn’t probe too much and seemed happy to steer away from questions that Sandeep found too uncomfortable. She also spent some time talking with Sandeep about her goals/vision for her life, which Sandeep hadn’t thought about for so long. Talking about the future gave Sandeep hope that she might be able to overcome her difficulties. 

Sandeep continued to attend therapy and learned a great deal about herself and the OCD. For the first time she felt like she understood why she might have developed OCD. The therapist explained that some people with OCD feel very aware of responsibility, and it’s hard for them to tolerate the possibility that they could be even partly responsible for something terrible happening. Sandeep’s thoughts turned immediately to her grandmother. Prior to therapy, she had buried these events deep into her unconscious, but as she spoke about them in therapy, she could see how she still felt a deep sense of guilt for not being able to keep her grandmother safe. She realised that she become convinced that checking and hand washing, were a way of her ensuring that she could keep her parents safe and alive. Sandeep and her therapist started to challenge her belief with logic. 

Sandeep realised that for most people washing hands or checking sockets is not a matter of life or death, but for her, it was. She would have thoughts like “if I don’t wash, I will be responsible for spreading contamination, and I will cause harm to my loved ones”. Satwant would believe these thoughts to be true, and this would cause a great deal of anxiety. However, what she learned was that sometimes washing would help her to “feel better”, and sometimes it wouldn’t..or sometimes it would but only in the short term, until the next thought popped into her mind (which could be 5mins later). She realized that OCD was trapping her into a vicious cycle where she would feel the need to hand wash over and over until she “felt” she could no longer cause harm. 

Sandeep realised that these thoughts/fears of contamination were not truths, that they were simply worries. She had to start trying to learn to let the worries go, which was very challenging at first. Sandeep and her therapist then moved on to helping her to test out her theories that her loved ones would die if she didn’t wash her hands, through experiments. She learned that not washing her hands did not result in her or her families death. She began to learn to tolerate the anxiety that came with not washing. Sandeep’s parents were also involved in the therapy and were taught how to best support Sandeep with her OCD. 

Sandeep also made some lifestyle changes. She looked at her diet and exercise and started to make gradual changes in these areas. She also started to meditate daily using the app CALM which seemed to help her to become better able to let her fears and worries go.

Future 

Sandeep attended therapy on and off for a year. Near the end of therapy she was able to work part-time, she was spending more time with family and friends, and was pursuing her love of photography. She has built up a support network and is more open about her struggles. She still struggles with OCD symptoms, but they are minimal and she knows what she has to do to keep them at bay. She now has hope that she can continue to move towards her life goals.

Part 3: What can be done to start to shift this dynamic?

Terri Apter in her book suggests that it requires “high-level skills” to manage this dynamic and one of the first steps is to see how OUR OWN behaviour should change, only then will the other’s behaviour be modified. Both MIL, DIL and husband need to ask themselves “what role am I playing here”, “what do I need to change?”

Mother-in-Law

  • An important development for Sharanjeet will be to accept that her son is now a man and a husband and that she no longer has the same authority over him. In order to enable him and his new relationship to flourish she will need to allow the new couple the space to build a close bond. If this is not allowed to happen, she may be edged out of the couples life or have to live with a resentful DIL and son. 
  • Sharanjeet can start to recognise and show appreciation for what Gurpreet offers her son, which in turn will lead Gurpreet to be more willing to respect and appreciate her.
  • Sharanjeet can reflect on her own experiences of being a DIL and reflect on how she would like to have been treated. Increasing her awareness of her conditioning and the different cultural values will also help her to better understand her DIL, and not personalise her behaviour.

Daughter-in-Law

  • Reviewing her expectation that her MIL should care about her as a daughter, may help Gurpreet to feel less hurt when this doesn’t happen. It takes time to form relationships, and Gurpreet and Sharanjeet do not have the benefit of shared histories and being blood relatives as a mother and daughter do.   
  • By being vocal about demands that she does not want to give in to (e.g. attending certain family events or sacrificing couple time to do tasks around the house etc.), whilst at the same time assuring her MIL that she wants her to feel included (e.g. by inviting her out to dinner), Gurpreet would ensure that she is not always sacrificing her needs at the expense of her MIL, and would reassure her MIL of the family connection to her
  • Gurpreet could show appreciation for her MIL and respect for her knowledge base by asking her to teach her how to cook an Indian dish. She could also show her willingness to be part of the family by aligning with her sister in law/ others in the family.
  • Gurpreet could gently encourage her husband to offer his support by persisting in telling him how she feels without blaming/criticizing. Further, communicating to him that she appreciates the importance of maintaining a close relationship with his mother may help Jasdeep to feel more able to listen to his wife’s  feelings (and not feel he is betraying his mother in the process)

Son/Husband

  • Jasdeep is faced with a difficult task and at times thinks that by not actively dealing with the issues they may somehow resolve themselves over time. This is unlikely and there are things he can do to help shift things.
  • Jasdeep can ensure that his wife’s needs for connection and understanding are met by validating her feelings. Feeling understood will enable her to feel better able to consider others’ perspectives (his and his MIL’s) and will strengthen the couple bond.
  • Jasdeep could help his mother to see that a strong relationship with both her and Gurpreet can exist alongside each other. He could do this by 1) assuring his mother that he continues to respect and value her, and 2) praising his wife in his mother’s presence, to show that he appreciates them both.
  • Learning to set boundaries ( for example telling his mother that being critical of Gurpreet behind her back is not acceptable to him or setting aside regular protected couple time) would help his mother to respect his commitment to his wife. And it would be important for him to recognise that doing this does not mean that he is being disloyal to his mother.

As mentioned above, the dynamics between MIL and DIL’s are highly complex and vary greatly across families. The above suggestions may work to a lesser or greater extent depending on a number of different factors, particularly the willingness of each person to accept their role in the dynamic and to take action to improve it. 

Please comment below with any additional thoughts/suggestions you have on this topic, I would love to read them and incorporate them into future posts.

Part 2: How do we make sense of the MIL, DIL dynamic?

Part 2 takes a look at factors that may have contributed to difficulties in the family.

Attachments to parents run deep. Sharanjeet was her sons first love. Mother and child have an intimate and absorbing bond that is essential in terms of the infant’s survival and ability to thrive in the world. The parent takes an active role in all aspects of their son/daughters life from childhood to adulthood.

This bond does not suddenly disappear when the child gets married, however, after marriage, when the child (in this case son) shifts his primary attachment from parent to spouse (Gurpreet), Sharanjeet has mixed feelings. She is happy to see her adult son form a new family, but experiences anxiety that she will lose him, and no longer be “special to him”. She feels replaced and rejected, and on an unconscious level blames Gurpreet for this. There are few parents who do not experience these feelings.

DIL’s expectations. When Gurpreet got married she had certain hopes and fears about her MIL and new family. She expected that her MIL would embrace her and support her like a daughter, and on some level, she thought that her new family would be like an improved version of her primary family and fill some needs that weren’t met. When she felt that this expectation was not met, this led her to feel hurt and rejected.

She also held the expectation that as the wife she would be the most important woman in her husband’s life. However, in reality, she felt that she was always having to compete with her MIL for this status. She felt angered by the constant demands her MIL made on Jasdeep, and she began trying to limit her MIL’s role in their lives.

Status and Power: Anecdotally (and increasingly in research studies), power struggles are cited as a major cause of conflict between MIL and DIL. In Asian culture, the mother-in-law traditionally occupies a dominant position in the family, often leading decisions in all areas of family life, social, financial, etc. When Gurpreet entered the household, Sharanjeet feared a loss of status and power. She wanted to make sure that she was still the most important woman in the household and the main influencer on the direction of the family.  

Her anxiety that she could lose this status led her to try even harder to establish her status, by keeping Gurpreet out of the kitchen, by leaving her out of important family discussions and, marginalizing DIL’s role in the family. She would also try to assert her authority by making demands on her son that she suspected her DIL would not agree with.

Cultural stories and conditioning: Sharanjeet’s anxiety is rooted in deeply embedded cultural narratives about what “daughter in laws are like”, and how they need to be “kept in check”. Humiliation, intrusion, gossip, rebelliousness, under-handedness, even death threats are the dominant themes in many Indian dramas about MIL’s and DIL’s. Sharunjeet doesn’t fully buy into the things she sees on dramas, but they do unconsciously affect her perception and behaviour with Gurpreet. Furthermore, she herself was dominated by a controlling mother in law and struggled with this environment. She vowed not to repeat this with her own DIL but finds herself re-enacting elements of her experience.

Different generation, different values: Sharanjeet and Gurpreet, although both Indian, have very different cultural beliefs and values. Sharanjeet feels that the daughter in law should uphold tradition or at least respect it, whereas Gurpreet has been brought up in a Western environment and is questioning/challenging of this. They also have different perceptions of what a MIL and DIL relationship should look like; Sharunjeet feels the MIL is a dominant figure and should be treated with utmost respect and trepidation. Gurpreet on the other hand tries to befriend her MIL, and be open with her about feelings. Sharanjeet on some level appreciates this, but at the same time fears a more egalitarian relationship with her DIL.

The role of the husband. Jasdeep feels torn. He wants to maintain a close relationship with his mother, but also wants to reassure Gurpreet that she is important to him. He flits between experiencing frustration with his mother and blaming his wife for the difficult dynamic. He feels that he loves both women, but doesn’t manage to assure either woman that she has a secure secure, special relationship with him. He cannot decide whose needs to prioritise and fills up with panic whenever there is conflict. He avoids dealing with the issue.

So….what then ensues?

“The panic of losing a relationship you treasure can turn good people into difficult in-laws” (Terri Apter). Sharanjeet, being fearful of losing her son, power and status seeks to prove that she is still the most important person in his life. She makes demands on her son and encroaches on the couples personal time. She seems to constantly have domestic emergencies that require practical help from her son, and regularly tests his son’s loyalty to his wife by criticizing her when alone with her son.

In turn, Gurpreet feels resentful and marginalized. She increases her MIL’s anxiety by being cold and/or critical to her. She begrudges any time/attention given to her MIL and tries to constantly show her how close her and Jasdeep are as a couple. She minimizes the mother/son bond to Jasdeep, slowly trying to edge her MIL out of their lives.

Each woman seeks reassurance from Jasdeep that she had a special exclusive role as wife/ mother, but he is unable to give them this. He feels an intense empathy for both his mother and his wife, and cannot see how he can negotiate re their needs. Gurpreet and Sharnjeet both feel betrayed and resentful towards each other and towards Jasdeep.

We can begin to see why the MIL and DIL dynamic is so difficult, and this is without looking at factors such as the psychological/emotional impact of moving home, adjusting to living with new family, dealing with issues in the couple relationship and individual personalities, etc.

See part 3 for things that each family member can do to start shifting these difficult dynamics.

 

 

The Mother-in-Law, Daughter-in-Law Dynamic: Part 1

Part 1: Understanding the Mother-in-Law, Daughter-in-Law Dynamic

(Based on Terry Apter’s book “What do you want from me: learning to get along with in-laws”).

The mother-in-law (MIL), daughter-in-law (DIL) dynamic has been cited as one of the most challenging of issues that couples have to deal with, particularly in Asian culture where it is common for the daughter in law to live with her husband and his family for the first year/two after marriage (and for some indefinitely).

The DIL and MIL dynamic is certainly a complex one, and the way that it plays out varies greatly from family to family. Experiences range from a harmonious relationship in which both women work hard on themselves and the relationship to ensure that their own and each other’s needs are met. These women and are able to appreciate and celebrate openly what one another brings to the household.

On the other end of the spectrum, the DIL and MIL experience a great deal of conflict. This often results in psychological/emotional problems for all involved, and either leads the husband and DIL to completely shut the MIL out of their lives, or  leads the husband,  unable to manage the competing loyalties, to “choose” his MIL over his wife, typically resulting in a resentful unhappy wife, or a breakdown of the marriage.

This series of posts will look at how we can better understand this difficult dynamic and the factors that may influence it. The focus will be on Asian/Indian families broadly speaking, however, much of this content can apply to other cultures too.

This series of posts starts with a case study to illustrate the issues that commonly occur between DIL and MIL (part 1), followed by hypotheses about why these may be occurring (part 2). The final post (part 3) will identify with some suggestions for how to manage the dynamics.

Meet the family

Gurpreet and her husband Jasdeep have been married for just under two years. They have had a rocky start to their marriage, the primary reason being; difficulty in dealing with issues between Gurpreet and Jasdeep’s mother (Sharanjeet).

Prior to getting married Gurpreet met with her mother-in-law (MIL) Sharanjeet a fair few times and quite liked her. She admired how independent and positive she was, in spite of losing her own husband a few years ago. She could imagine herself living in their family home, and was looking forward to being part of a close-knit family that was welcoming, open and involved in each other’s lives.

However, what ensued after marriage was very different from Gurpreet’s expectations. She felt that after marriage, her MIL changed. She felt hostility from her MIL and didn’t feel appreciated for what she brought to the family home. She did not experience the love that she had been expecting, and this led her to feel hurt and angry. She found her MIL intrusive, demanding of her husband, and critical towards her.

Gurpreet felt close to her husband, however, they often got into conflict over his mother. Gurpreet knew deep down that Jasdeep loved her but felt insecure and often found herself wondering whether she was his priority. She also felt betrayed and resentful when he would ask her “to make more of an effort” with her MIL as if she was to blame for the issues.

The issues escalated and there seemed to be conflict in the family home on a daily basis. The relationship between Gurpreet and her MIL deteriorated to the point that they would rarely be in the same room together, and there was little to no communication between them. Jasdeep became quite down and felt at a loss as to how to improve the situation. The issues led Gurpreet to question whether she could continue with the marriage.

See part 2 for some hypotheses about how this situation developed.

 

 

 

 

Helping your children to manage anger

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Anger is a normal emotion, however, both adults and children alike find it difficult to deal with effectively.

When working with children on helping them to manage angry feelings I often use externalised images of emotions, like the anger gremlin or anger monster to help families get a handle on anger, and this is why.

When families first come to see me, they talk about their child’s anger issues in this way: ‘Jay is so angry, he’s always been an angry kid and now he’s out of control’. Through these statements, we unintentionally contribute to the fusing together of our child’s identity with the anger, to the point where the child thinks that they’re a problem kid, and there’s no hope for them.

In CBT with kids, creating an image with the child, to represent their emotion, anger in this case (but works well for worries and sadness too), helps the child to begin to create a distance between the anger and themselves. What does this do?

Through this, the child begins to feel like they themselves are not the problem, or the sole cause of the problem. ‘Oh it’s  The Anger Gremlin making his appearance again’. This reduces guilt/shame, instantly gives hope and makes the problem much easier to look at, figure out and tackle.

Crucially, externalising the problem allows parents and child to unite to wage war against the anger monster, rather than parent waging war against their child. The child feels that his parents are on his side, and feels more confident in tackling the problem. Parents are supporting and no longer blaming the child, resulting in a much improved parent-child relationship (which will in itself have a powerful impact on everyone’s stress levels and angry feelings). You can try this with your own kids. Draw up an image together to represent a feeling that your child is struggling with. Learn more about grumpy gus or the angry monster, or the worry monster.

*In which situations does he/she make an appearance?
*What does he sound like?
*What makes him tick/ become angrier?
*When has your child been able to show him who’s boss? How?
Give this powerful method a try and let me know how you get on.

Panic attacks: an introduction

Those of us who have experienced a panic attack know how frightening it can be. The symptoms (e.g shortness of breath, palpitations, chest pain, dizziness) can feel so severe that they can be mistaken for a heart attack or serious illness (or even imminent death). Having one panic attack can often lead to worry about it happening again.

Because these symptoms feel so bad, it can be hard to see how they could be a product of an emotional state, anxiety !! Welcome to the body’s alarm system!!!

When the body perceives danger/threat it goes into self-protection mode. Signals are sent to the fear centres in the brain and the result?? the body gets itself ready to deal with the perceived threat. How? It gets the body ready to fight the attacker or run away (“fight or flight”), by speeding the heart rate, slowing digestion, shunting blood flow to major muscle groups, and changing other autonomic nervous functions- all to give the body a burst of energy and strength.

Now, what has this got to do with panic attacks? If we experience the above symptoms, in the absence of an identifiable threat (and they feel like they’re coming out of the blue) we may misinterpret these symptoms to be a sign of a serious illness/ imminent death. If we do this, then we will fear the symptoms themselves. If we fear the symptoms, then every time we experience them, the body’s alarm system gets activated, and we experience the symptoms as even more severe. This is what happens in a panic attack!!

As soon as we start to recognize and truly believe that the symptoms are an anxiety response, this should prevent them from escalating into a panic attack. There are lots of things we can do to help this process along. 1) changing our thought process is essential. If we can remind ourselves that these symptoms are an anxiety response and not a sign of anything serious/sinister, the symptoms should reduce 2) deep breathing (look up deep belly breathing on youtube) is incredibly effective for slowing breathing down and reducing the exacerbation of symptoms that often occurs during a panic attack).

Panic attacks are among the most treatable of mental health issues. See the links below to learn more about how you can help yourself, and please share with others who could benefit. If you have tried the suggestions in this blog post but would like additional help, please feel free to contact me for more information or to arrange a free consultation.

https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Panic
https://www.getselfhelp.co.uk/panic.htm (Illustration by Gemma Corell)
(* You should always get any medical symptoms you are worried about checked out by your GP)

Another side to mental health

There’s a lot of bad press around mental health. What if I was to suggest that for some people the experience of a mental health ‘crisis’ ‘episode’ or ‘breakdown’ (terms that many people I have seen used to refer to their experience), is the very thing needed to take us to a new, higher level of thinking and being?

Throughout my career and in my personal life (both myself and close friends), I have seen adversity and challenge, resulting in symptoms that would be described as anxiety and depression, have been the crucial turning point in someone’s life.
It has been like an alarm bell signaling ‘something needs to change in my life’. Many people feel forced to stop in their tracks immediately and take a long hard look at everything from their work-life balance to relationships they have in their lives, to the relationship they have with themselves.

And at the end of it, they report:

  • a new appreciation for life
  • more meaningful relationships
  • deeper empathy for others’ suffering
  • a sense of feeling better prepared to deal with whatever life brings.

I wonder if any of you can relate to the growth that comes from struggle? I certainly can.