Therapy for abusive relationships
Should I Go To Couples Therapy With My Abusive Partner?
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We’re often asked how we feel about couples therapy, and whether we’d encourage that as a course of action.
Our answer loud and clear:
We at The Hotline do not encourage anyone in an abusive relationship to seek counseling with their partner. Abuse is not a relationship problem.
While there can be benefits for couples who undergo couple’s therapy, there’s a great risk for any person who is being abused to attend therapy with their abusive partner.
Relationship counseling can help partners understand each other, resolve difficult problems, and even help the couple gain a different perspective on their situation. It cannot, however, fix the unequal power structure that is characteristic of an abusive relationship.
An abuser may use what is said in therapy later against their partner. Therapy can make a person feel vulnerable. If the abuser is embarrassed or angered by something said in therapy, he or she may make their partner suffer to gain back the sense of control. Therapy is often considered a “safe space” for people to talk. For an abused partner, that safety doesn’t necessarily extend to their home.
Couples often enter couple’s therapy to fix their relationship. Deciding whether or not the relationship is better is extremely hard for a couple if one is being abused. The abuser has all of the power and can no longer gauge if a relationship is getting better because he/she does not see what their partner sees. The abused partner often cannot even rate how bad or good the relationship is because the abuse has affected him/her.
Another reason that couple’s therapy or counseling is not recommended is that the facilitator may not know about the abuse, which would make the entire process ineffective. The abuser may make their partner seem responsible for the problems, and if the therapist does not realize that abuse is present, her or she may believe the abuser.
If you or someone you know is considering entering therapy with an abusive partner, please have them call us at the hotline. We can talk to them, and give them a judgment-free sounding board for their hopes and concerns about the process.
Answers shouldn’t be hard to find.
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- Call 1.800.799.SAFE (7233)
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Can Couples Therapy Work in Abusive Relationships? I Psych Central
Couples therapy isn’t often recommended for abusive relationships, but individual counseling and other strategies may help.
Many couples seek counseling to learn better communication, get through a rough patch, or rebuild trust and understanding.
But some couples who seek couples therapy may be in an abusive relationship. Couples counseling is generally not recommended when a severe level of abuse is involved. But individual counseling and alternative treatments may be suggested.
It’s crucial to identify the different types of abuse and how they may be addressed in couples therapy, especially in terms of safety planning and risk assessment.
Couples therapy can be effective when both partners are:
- committed to improving and reflecting on dysfunctional behaviors
- exhibit empathy, understanding, and willingness to change negative behaviors and communication patterns
- are willing to overcome obstacles in the relationship to make the relationship work
But “The Clinical Handbook of Couples Therapy, 5th edition” notes that couples therapy isn’t usually suitable for:
- abusive relationships with severe or frequent physical violence or psychological aggression
- relationships with a high degree of fear of retaliation and a chance of abuse for what’s disclosed in therapy
- relationships where the person who’s abusive has a high degree of narcissistic traits or antisocial personality disorder (ASPD) and a lack of empathy that may impede their progress in therapy, depending on the type of therapy used
- relationships where the person who’s aggressive has an ongoing substance use problem that’s left untreated
In these cases, couples counseling may result in an escalation of abuse and retaliation.
The person experiencing abuse may not feel safe disclosing the full extent of the abuse, and the person who’s abusive may be unwilling to make efforts to change.
Physical abuse includes a wide variety of physically aggressive acts of violence — including shoving, hitting, punching, slapping, strangling, or physically restraining the other person.
When assessing for evidence of intimate partner violence, a couples therapist may ask directly about the use of physical, sexual, and emotionally abusive methods.
This assessment can begin with questions about how the couple navigates conflicts and arguments, including whether arguments ever get out of control and how each partner expresses anger or frustration.
Safety concerns may also be addressed by asking about weapons or the presence of children who may be harmed.
Specific terms may be used to ask whether partners have ever hit, shoved, or pushed one another.
Questionnaires such as the Couple Questionnaire or the Conflict Tactics scales may be used so that someone who prefers writing down their experiences also has a chance to disclose them without as much discomfort.
If the level of violence in the relationship is considered to be a hindrance to therapy, the partner who’s abusive may be referred to a gender-specific domestic violence treatment program, while the person being abused is referred to a place that will provide them with supportive and legal services.
Some couples therapists may decide that the abuse in the relationship can be addressed if the level of abuse is low and the partner who’s abusive is committed to improving. If that’s the case, a “safety contract” may be set up to establish boundaries in the relationship and continue with therapy sessions.
Dr. Michele Waldron, a certified sex and couples therapist in Massachusetts, assesses the chance of violence when deciding whether to continue with couples therapy.
“For high risk cases, the first priority is establishing safety as much as possible,” she says. “The most extreme is the survivor leaving the house or advocating for police involvement. Otherwise, establishing rules of engagement and healthy boundaries between them is the next priority. ”
Waldron often uses dialectical behavioral therapy (DBT) to help couples establish better emotional regulation and distress tolerance skills.
For couples therapy to work, Waldron emphasizes that both people must acknowledge an issue and be motivated to change. Waldron also uses safety planning and establishes “rules of engagement” to guide victims to recognize potential escalation, enforce boundaries, and enhance self-protection.
Dr. Lee Phillips, a certified sex and couples therapist in New York, says, “I assess the level of abuse. If a client is experiencing emotional abuse, there’s always a chance of physical abuse. In this case, safety planning is critical.”
When cases of emotional abuse are milder and less frequent, some skills can be learned depending on the willingness of the person who’s abusive. Phillips uses supportive therapy to enhance shared empathy and cognitive behavioral therapy (CBT) to challenge negative and anxious thoughts.
If the person who’s abusive grew up in a dysfunctional family, Phillips may use attachment theory to help increase awareness of where these behaviors were first learned.
“For emotional abuse, a treatment plan may contain an agreement with both partners agreeing to identify thoughts and feelings that trigger discord in their marriage,” Phillips says. “I may have each partner use reflective listening where they can mirror back what the other partner is saying, have them validate each other, and have them show empathy.”
Phillips cautions that severe emotional abuse can be difficult to manage.
He finds that many people who are abusive tend to end the therapy prematurely themselves, especially, he says, if they have narcissistic personality disorder (NPD) or ASPD.
“Often [they] will terminate because they’re called out on the abuse,” he says. “[They] may be terrified of therapy for this reason.”
Melanie Preston, a licensed mental health therapist in Indiana, asserts that verbal abuse isn’t always obvious, and couples may believe their ways of communicating are typical.
She usually asks couples how much knowledge they have about each other’s family of origin and helps them to recognize any adverse childhood experiences that may still be affecting their present-day behavior.
“It’s usually at this point that the couple is able to begin identifying the behavior as verbally abusive in nature,” Preston says. “Sometimes the [offender] is willing to learn new techniques to communicate, as there is the realization that ‘just because I witnessed it being done this way, doesn’t mean I have to continue the same behavioral pattern.’ Other times, the [offender] is unwilling to admit fault.”
In either case, Preston sees each partner individually for a “personal deep dive into the behavioral pattern.”
But if she senses that the person experiencing the abuse may be in danger due to information shared in individual sessions, Preston says, “I will terminate service with the person who’s abusive and assist the survivor in establishing a safety plan.”
If the person who’s abusive is willing to improve, Preston guides them to slowly unlearn negative behaviors by offering emotional regulation tools that help control their physiological state and offers additional sessions per week or anger management if needed.
According to Dr. Liz Jenkins, a licensed marriage and family therapist in Texas, a pattern of controlling a partner doesn’t always start out as abusive. It can begin innocuously, with one partner appeasing the other to avoid “potential hot spots of conflict.”
This control dynamic, she says, can be a result of a survival skill of conflict avoidance and escalation avoidance learned in childhood. As the control and isolation escalate, the survivor’s role may change to them being “their partner’s mood manager.”
The solution, she writes, is to recognize the triggers and examine the “elaborate planning that goes into managing their partner’s happiness.”
She uses therapy to guide couples to better understand the origins of their need for control while also offering individual sessions with each person and confidential individual assessments of potential abuse.
“My approach depends on the dynamics of the couple, the degree of abuse, and the willingness or readiness of each person to step into change,” she says.
She helps couples break down old habits and curb knee-jerk responses while celebrating their wins. But if the abuse appears to be escalating, she’ll terminate therapy.
“I’ll absolutely stop couples work if the abuse seems to be triggering escalations,” she says. “Physical and emotional safety is continually monitored, and all initial sessions cover my confidentiality, mandated reporting requirements, and expectations.”
Jeanae Hopgood, a licensed marriage and family therapist in Pennsylvania, who has worked mainly with couples who have had trouble with financial abuse, recognizes the importance of unlearning early patterns of coercion and control.
Depending on the dynamic, she says that couples therapy for financial abuse may include exploring belief systems and family-of-origin histories to better understand what each individual in the relationship comes to “believe about how two or more people are supposed to interact with one another.”
But Hopgood cautions that working with couples around this type of abuse requires a “buy-in” from all parties, mutual recognition of the problem, and a willingness to seek solutions.
“Even if the partners don’t agree on the language of abuse, they need to agree on the dynamic between them being harmful or causing friction within the relationship,” Hopgood says.
Celeste Labadie, a licensed marriage and family therapist from Colorado, agrees that financial abuse can be a learned behavior. She believes that participating in individual therapy first to explore those unresolved patterns of behavior before attending couples therapy is crucial.
In cases of sexual abuse, Hopgood uses both joint and individual assessments of the couple to gather additional information.
“In the separate sessions, I’m able to discern additional information about family history, as well as any unwanted touch, safety concerns, and problematic power dynamics that can be difficult to discuss in a couples session,” she says.
This helps her get the shared and individual views of the problematic dynamics.
Sexual abuse tends to thrive in secrecy, so it’s unlikely that couples experiencing this in their relationships would seek out couples therapy, Labadie says. “The person instigating the abuse wouldn’t want to be found out or pressured to look at their behaviors.”
Research from 2014 suggests that intimate partner violence disproportionately affects women, which means some abuse can also hold elements of patriarchal domination — when females are specifically degraded and devalued by exploiting their subordinate position in society.
Jason Polk, a licensed clinical social worker and owner of Colorado Relationship Recovery, notes that there’s usually some form of patriarchal dominance in many relationships. He uses relational life therapy (RLT), created by Terry Real, to guide couples through healthy communication skills.
This form of therapy also addresses what RLT therapy calls “psychological patriarchy,” where a partner with traditionally “masculine traits” such as assertiveness and invulnerability holds contempt for the partner with more “feminine traits” such as accommodation and vulnerability.
RLT works to help partners with masculine traits show more vulnerability while helping those with feminine traits be more assertive.
In working with any dysfunctional patterns arising from the family of origin, Polk says that the key is to remind the person who’s abusive of “what they will lose if they don’t stop as well as what they can gain.”
He then works with the couple on building better relational skills so that neither partner is in a “one-up grandiosity” position or a “one-down toxic shame” position.
Couples counseling can be helpful and effective when both people are committed to learning new skills and overcoming destructive relationship patterns and have the empathy to better understand one another.
But couples counseling is generally not recommended when the level of abuse is severe or the traits and behaviors of one person interferes with therapy.
Although couples therapists vary in their approach, many use individual and joint sessions to perform risk assessments and determine whether to continue with couples therapy in cases of abuse.
Couples may instead be referred to individual treatment, as couples therapy may actually escalate abuse in some cases. Safety planning with the survivor is especially crucial in severe cases.
Therapies such as dialectical behavior therapy (DBT), supportive therapy, and cognitive behavioral therapy (CBT) may be used depending on the unique patterns present in the relationship.
If you’re in crisis, help is available right now.
If you believe you or someone you know may be in an abusive relationship, there is help available.
You can reach out to the National Domestic Violence Hotline at 800-799-7233 (SAFE) or text “START” to 88788. You can also check out these resources at Victim Connect.
You can also do a risk assessment of your situation using the Mosaic system created by security analyst Gavin D. Becker.
Remember that your safety and mental health come first.
relationship therapy to stop abuse
• Couples often wonder if therapy can fix emotional abuse, psychological abuse and verbal abuse in their relationship.
• If yes, which mental health professionals treat emotionally abusive relationships?
• If you are in an emotionally abusive relationship, find out why you should get the right help. If you're not sure you're in an abusive relationship, use our Emotional Abuse Test.
Therapy can stop emotional abuse, psychological abuse and verbal abuse.
Marital and couple therapy for emotional abuse can be very helpful if you find the right therapist. With the right therapeutic help, even seemingly insurmountable problems can be overcome - emotional abuse, psychological abuse, verbal abuse. The right therapy can change the relationship between you and your partner.
Instead of simply accepting or leaving a bad relationship, with the right relationship therapy, you will develop the tools and skills needed to repair a broken marriage or permanent relationship. You can create relationships that are healthy, happy and long lasting, a home environment that is beneficial to everyone who lives in the family.
Domestic violence and physical abuse are a separate category from emotional abuse, psychological abuse and verbal abuse and are not covered in this article. Domestic violence and physical abuse often cause immediate safety issues and decisions must be made immediately to end the risk of bodily injury. To learn more about domestic violence and physical abuse, read my Free Marriage and Committed Relationship Counseling Information about Domestic Violence and Physical Abuse.
Types of mental health professionals trained to treat emotionally abusive relationships
Most psychologists, psychiatrists, and social workers do not have the specialized training needed to deal with complex relationship problems. Finding the right therapist starts with finding a therapist who is trained and certified to work with relationships.
These are the best sources for qualified relationship professionals:
- American Association of Marriage and Family Therapy
- Canadian Associations of Marriage and Family Therapy
Look for a therapist, psychologist, psychiatrist, clergyman, or social worker who can show you, at your request, his or her specialized training and certification in dealing with relationship problems, which proves his or her competence.
Unfortunately, many well-intentioned professionals have made things worse because they have not fully mastered the skills needed to deal with the serious relationship problems that usually arise in emotionally abusive relationships.
Relationship therapy is a highly specialized relationship procedure. Having an opinion about a "relationship" or anecdotal information about it is not a qualification for treating a couple who are in the depths of emotional abuse.
For many couples in emotionally abusive relationships, finding the right therapeutic help is a critical factor in whether or not the emotional abuse can be overcome and replaced with respect, trust, safety, and love.
It is also important that you find a therapist who truly cares about you and your family and is willing to devote himself to improving your situation.
In addition, if you are in an emotionally abusive relationship, your relationship or marriage therapist should contact the perpetrator of the emotional abuse, psychological abuse, and verbal abuse. If the therapist, instead of building a therapeutic relationship with an abusive partner, denigrates him or her, then it is very difficult to provide effective therapy.
We can disagree with what someone does and still love and respect that person. This is the attitude that a good abusive relationship therapist should take. When a therapist successfully connects with an abusive person, it bodes well for successful marriage or committed relationship therapy.
If you are in an emotionally abusive relationship, effective relationship therapy has many benefits.
The right therapist can save a life. The therapist can connect with your abusive partner and explain to him or her that there are no benefits to continuing to abuse you, but the benefits of learning to treat you with respect, kindness, and consideration. A good therapist can help you join the ranks of couples who are hard at work building healthy, happy, and long-lasting relationships.
With the treatment of abusive marriages and committed relationships, you can avoid complete breakups and divorce. If you have children, this is especially important. Children are often traumatized in many ways when their parents divorce. However, this does not mean that you should put up with emotional abuse. Rather, before considering divorce, you should make every effort to change the situation so that you are no longer in an emotionally abusive relationship.
Good therapy can restore relationships and fill them with respect, trust, security and love.
If you need a therapist to restore your self-esteem, you don't necessarily need a relationship specialist. The average psychologist or social worker is well trained to help you achieve this goal.
We all know the value of using the services of doctors, dentists, lawyers or accountants when needed. Likewise, you should be aware of the value of seeing a relationship specialist to help you resolve serious relationship issues such as emotional abuse, psychological abuse, and verbal abuse.
Get the help you and your partner need to build a healthy, happy, and lasting relationship as a team.
If money is an issue, you can always get self-help materials. However, getting an extra credit card, as you might for a luxurious getaway every few years, is definitely smart to save your family, relieve emotional pain, and protect your mental health. Learning how to build happy relationships is a great investment in your future.
Relationship therapy with the right person is probably the best financial investment you'll ever make. This can prevent years of suffering, whether it be living with an abusive person or living alone, or perhaps entering into another relationship that is likely to have its own set of problems.
If you have children, remarriage will usually be difficult for them and put them at risk of emotional, behavioral and educational problems. Solving problems between you and your partner would be the perfect solution for everyone, especially your children.
Are you in an emotionally abusive marriage or committed relationship? Find out NOW with our free emotional abuse test. No email required and immediate results.
About the Author
Abe Kass, MA, RSW, RMFT, CCHT. is a Registered Social Worker, Registered Couples and Family Therapist, Certified Hypnotherapist, and Award-winning Educator. He maintains an active clinical practice in Toronto, Canada and around the world via phone or Zoom.
After many years of clinical practice and research, Abe came to the conclusion that practical solutions were urgently needed, requiring concentrated efforts of no more than a few minutes a day to solve very specific relationship problems. GoSmartLife Publishing was created to meet this need.
A prominent role among mental illnesses is played by syndromes (complexes of symptoms), united in the group of obsessive-compulsive disorder (OCD), which received its name from the Latin terms obsessio and compulsio.
Obsession (lat. obsessio - taxation, siege, blockade).
Compulsions (lat. compello - I force). 1. Obsessive drives, a kind of obsessive phenomena (obsessions). Characterized by irresistible attraction that arises contrary to the mind, will, feelings. Often they are unacceptable to the patient, contrary to his moral and ethical properties. Unlike impulsive drives, compulsions are not realized. These drives are recognized by the patient as wrong and painfully experienced by them, especially since their very appearance, due to its incomprehensibility, often gives rise to a feeling of fear in the patient 2. The term compulsions is also used in a broader sense to refer to any obsessions in the motor sphere, including obsessive rituals.
In domestic psychiatry, obsessive states were understood as psychopathological phenomena, characterized by the fact that phenomena of a certain content repeatedly appear in the mind of the patient, accompanied by a painful feeling of coercion [Zinoviev PM, 193I]. For N.s. characteristic involuntary, even against the will, the emergence of obsessions with clear consciousness. Although the obsessions are alien, extraneous in relation to the patient's psyche, the patient is not able to get rid of them. They are closely related to the emotional sphere, accompanied by depressive reactions, anxiety. Being symptomatic, according to S.L. Sukhanov , "parasitic", they do not affect the course of intellectual activity in general, remain alien to thinking, do not lead to a decrease in its level, although they worsen the efficiency and productivity of the patient's mental activity. Throughout the course of the disease, a critical attitude is maintained towards obsessions. N.s. conditionally divided into obsessions in the intellectual-affective (phobia) and motor (compulsions) spheres, but most often several of their types are combined in the structure of the disease of obsessions. The isolation of obsessions that are abstract, affectively indifferent, indifferent in their content, for example, arrhythmomania, is rarely justified; An analysis of the psychogenesis of a neurosis often makes it possible to see a pronounced affective (depressive) background at the basis of the obsessive account. Along with elementary obsessions, the connection of which with psychogeny is obvious, there are “cryptogenic” ones, when the cause of painful experiences is hidden [Svyadoshch L.M., 1959]. N.s. are observed mainly in individuals with a psychasthenic character. This is where apprehensions are especially characteristic. In addition, N.S. occur within the framework of neurosis-like states with sluggish schizophrenia, endogenous depressions, epilepsy, the consequences of a traumatic brain injury, somatic diseases, mainly hypochondria-phobic or nosophobic syndrome. Some researchers distinguish the so-called. "Neurosis of obsessive states", which is characterized by the predominance of obsessive states in the clinical picture - memories that reproduce a psychogenic traumatic situation, thoughts, fears, actions. In genesis play a role: mental trauma; conditioned reflex stimuli that have become pathogenic due to their coincidence with others that previously caused a feeling of fear; situations that have become psychogenic due to the confrontation of opposing tendencies [Svyadoshch A. M., 1982]. It should be noted that these same authors emphasize that N.s.c. occurs with various character traits, but most often in psychasthenic personalities.
Currently, almost all obsessive-compulsive disorders are united in the International Classification of Diseases under the concept of "obsessive-compulsive disorder".
OKR concepts have undergone a fundamental reassessment over the past 15 years. During this time, the clinical and epidemiological significance of OCD has been completely revised. If it was previously thought that this is a rare condition observed in a small number of people, now it is known that OCD is common and causes a high percentage of morbidity, which requires the urgent attention of psychiatrists around the world. Parallel to this, our understanding of the etiology of OCD has broadened: the vaguely formulated psychoanalytic definition of the past two decades has been replaced by a neurochemical paradigm that explores the neurotransmitter disorders that underlie OCD. And most importantly, pharmacological interventions specifically targeting serotonergic neurotransmission have revolutionized the prospects for recovery for millions of OCD patients worldwide.
The discovery that intense serotonin reuptake inhibition (SSRI) was the key to effective treatment for OCD was the first step in a revolution and spurred clinical research that showed the efficacy of such selective inhibitors.
As described in ICD-10, the main features of OCD are repetitive intrusive (obsessive) thoughts and compulsive actions (rituals).
In a broad sense, the core of OCD is the syndrome of obsession, which is a condition with a predominance in the clinical picture of feelings, thoughts, fears, memories that arise in addition to the desire of patients, but with awareness of their pain and a critical attitude towards them. Despite the understanding of the unnaturalness, illogicality of obsessions and states, patients are powerless in their attempts to overcome them. Obsessional impulses or ideas are recognized as alien to the personality, but as if coming from within. Obsessions can be the performance of rituals designed to alleviate anxiety, such as washing hands to combat "pollution" and to prevent "infection". Attempts to drive away unwelcome thoughts or urges can lead to severe internal struggle, accompanied by intense anxiety.
Obsessions in the ICD-10 are included in the group of neurotic disorders.
The prevalence of OCD in the population is quite high. According to some data, it is determined by an indicator of 1.5% (meaning "fresh" cases of diseases) or 2-3%, if episodes of exacerbations observed throughout life are taken into account. Those suffering from obsessive-compulsive disorder make up 1% of all patients receiving treatment in psychiatric institutions. It is believed that men and women are affected approximately equally.
The problem of obsessive-compulsive disorders attracted the attention of clinicians already at the beginning of the 17th century. They were first described by Platter in 1617. In 1621 E. Barton described an obsessive fear of death. Mentions of obsessions are found in the writings of F. Pinel (1829). I. Balinsky proposed the term "obsessive ideas", which took root in Russian psychiatric literature. In 1871, Westphal coined the term "agoraphobia" to refer to the fear of being in public places. M. Legrand de Sol , analyzing the features of the dynamics of OCD in the form of "insanity of doubt with delusions of touch, points to a gradually becoming more complicated clinical picture - obsessive doubts are replaced by ridiculous fears of" touch "to surrounding objects, motor rituals join, the fulfillment of which is subject to the whole life sick. However, only at the turn of the XIX-XX centuries. researchers were able to more or less clearly describe the clinical picture and give syndromic characteristics of obsessive-compulsive disorders. The onset of the disease usually occurs in adolescence and adolescence. The maximum of clinically defined manifestations of obsessive-compulsive disorder is observed in the age range of 10-25 years.
Main clinical manifestations of OCD:
Obsessional thoughts - painful, arising against the will, but recognized by the patient as their own, ideas, beliefs, images, which in a stereotyped form forcibly invade the patient's consciousness and which he tries to resist in some way. It is this combination of an inner sense of compulsive urge and efforts to resist it that characterizes obsessional symptoms, but of the two, the degree of effort exerted is the more variable. Obsessional thoughts may take the form of single words, phrases, or lines of poetry; they are usually unpleasant to the patient and may be obscene, blasphemous, or even shocking.
Obsessional imagery is vivid scenes, often violent or disgusting, including, for example, sexual perversion.
Obsessional impulses are urges to do things that are usually destructive, dangerous or shameful; for example, jumping into the road in front of a moving car, injuring a child, or shouting obscene words while in society.
Obsessional rituals include both mental activities (eg, counting repeatedly in a particular way, or repeating certain words) and repetitive but meaningless acts (eg, washing hands twenty or more times a day). Some of them have an understandable connection with the obsessive thoughts that preceded them, for example, repeated washing of hands - with thoughts of infection. Other rituals (for example, regularly laying out clothes in some complex system before putting them on) do not have such a connection. Some patients feel an irresistible urge to repeat such actions a certain number of times; if that fails, they are forced to start all over again. Patients are invariably aware that their rituals are illogical and usually try to hide them. Some fear that such symptoms are a sign of the onset of insanity. Both obsessive thoughts and rituals inevitably lead to problems in daily activities.
Obsessive rumination (“mental chewing gum”) is an internal debate in which the arguments for and against even the simplest everyday actions are endlessly revised. Some obsessive doubts relate to actions that may have been incorrectly performed or not completed, such as turning off the gas stove faucet or locking the door; others concern actions that could harm other people (for example, the possibility of driving past a cyclist in a car, knocking him down). Sometimes doubts are associated with a possible violation of religious prescriptions and rituals - “remorse of conscience”.
Compulsive actions - repetitive stereotypical actions, sometimes acquiring the character of protective rituals. The latter are aimed at preventing any objectively unlikely events that are dangerous for the patient or his relatives.
In addition to the above, in a number of obsessive-compulsive disorders, a number of well-defined symptom complexes stand out, and among them are obsessive doubts, contrasting obsessions, obsessive fears - phobias (from the Greek. phobos).
Obsessive thoughts and compulsive rituals may intensify in certain situations; for example, obsessive thoughts about harming other people often become more persistent in the kitchen or some other place where knives are kept. Since patients often avoid such situations, there may be a superficial resemblance to the characteristic avoidance pattern found in phobic anxiety disorder. Anxiety is an important component of obsessive-compulsive disorders. Some rituals reduce anxiety, while after others it increases. Obsessions often develop as part of depression. In some patients, this appears to be a psychologically understandable reaction to obsessive-compulsive symptoms, but in other patients, recurrent episodes of depressive mood occur independently.
Obsessions (obsessions) are divided into figurative or sensual, accompanied by the development of affect (often painful) and obsessions of affectively neutral content.
Sensual obsessions include obsessive doubts, memories, ideas, drives, actions, fears, an obsessive feeling of antipathy, an obsessive fear of habitual actions.
Obsessive doubts - intrusively arising contrary to logic and reason, uncertainty about the correctness of committed and committed actions. The content of doubts is different: obsessive everyday fears (whether the door is locked, whether windows or water taps are closed tightly enough, whether gas and electricity are turned off), doubts related to official activities (whether this or that document is written correctly, whether the addresses on business papers are mixed up , whether inaccurate figures are indicated, whether orders are correctly formulated or executed), etc. Despite repeated verification of the committed action, doubts, as a rule, do not disappear, causing psychological discomfort in the person suffering from this kind of obsession.
Obsessive memories include persistent, irresistible painful memories of any sad, unpleasant or shameful events for the patient, accompanied by a sense of shame, remorse. They dominate the mind of the patient, despite the efforts and efforts not to think about them.
Obsessive impulses - urges to commit one or another tough or extremely dangerous action, accompanied by a feeling of horror, fear, confusion with the inability to get rid of it. The patient is seized, for example, by the desire to throw himself under a passing train or push a loved one under it, to kill his wife or child in an extremely cruel way. At the same time, patients are painfully afraid that this or that action will be implemented.
Manifestations of obsessive ideas can be different. In some cases, this is a vivid "vision" of the results of obsessive drives, when patients imagine the result of a cruel act committed. In other cases, obsessive ideas, often referred to as mastering, appear in the form of implausible, sometimes absurd situations that patients take for real. An example of obsessive ideas is the patient's conviction that the buried relative was alive, and the patient painfully imagines and experiences the suffering of the deceased in the grave. At the height of obsessive ideas, the consciousness of their absurdity, implausibility disappears and, on the contrary, confidence in their reality appears. As a result, obsessions acquire the character of overvalued formations (dominant ideas that do not correspond to their true meaning), and sometimes delusions.
An obsessive feeling of antipathy (as well as obsessive blasphemous and blasphemous thoughts) - unjustified, driven away by the patient from himself antipathy towards a certain, often close person, cynical, unworthy thoughts and ideas in relation to respected people, in religious persons - in relation to saints or ministers churches.
Obsessive acts are acts done against the wishes of the sick, despite efforts made to restrain them. Some of the obsessive actions burden the patients until they are realized, others are not noticed by the patients themselves. Obsessive actions are painful for patients, especially in those cases when they become the object of attention of others.
Obsessive fears, or phobias, include an obsessive and senseless fear of heights, large streets, open or confined spaces, large crowds of people, the fear of sudden death, the fear of falling ill with one or another incurable disease. Some patients may develop a wide variety of phobias, sometimes acquiring the character of fear of everything (panphobia). And finally, an obsessive fear of the emergence of fears (phobophobia) is possible.
Hypochondriacal phobias (nosophobia) - an obsessive fear of some serious illness. Most often, cardio-, stroke-, syphilo- and AIDS phobias are observed, as well as the fear of the development of malignant tumors. At the peak of anxiety, patients sometimes lose their critical attitude to their condition - they turn to doctors of the appropriate profile, require examination and treatment. The implementation of hypochondriacal phobias occurs both in connection with psycho- and somatogenic (general non-mental illnesses) provocations, and spontaneously. As a rule, hypochondriacal neurosis develops as a result, accompanied by frequent visits to doctors and unreasonable medication.
Specific (isolated) phobias - obsessive fears limited to a strictly defined situation - fear of heights, nausea, thunderstorms, pets, treatment at the dentist, etc. Since contact with situations that cause fear is accompanied by intense anxiety, the patients tend to avoid them.
Obsessive fears are often accompanied by the development of rituals - actions that have the meaning of "magic" spells that are performed, despite the critical attitude of the patient to obsession, in order to protect against one or another imaginary misfortune: before starting any important business, the patient must perform some that specific action to eliminate the possibility of failure. Rituals can, for example, be expressed in snapping fingers, playing a melody to the patient or repeating certain phrases, etc. In these cases, even relatives are not aware of the existence of such disorders. Rituals, combined with obsessions, are a fairly stable system that usually exists for many years and even decades.
Obsessions of affectively neutral content - obsessive sophistication, obsessive counting, recalling neutral events, terms, formulations, etc. Despite their neutral content, they burden the patient, interfere with his intellectual activity.
Contrasting obsessions ("aggressive obsessions") - blasphemous, blasphemous thoughts, fear of harming oneself and others. Psychopathological formations of this group refer mainly to figurative obsessions with pronounced affective saturation and ideas that take possession of the consciousness of patients. They are distinguished by a sense of alienation, the absolute lack of motivation of the content, as well as a close combination with obsessive drives and actions. Patients with contrasting obsessions and complain of an irresistible desire to add endings to the replicas they have just heard, giving an unpleasant or threatening meaning to what has been said, to repeat after those around them, but with a touch of irony or malice, phrases of religious content, to shout out cynical words that contradict their own attitudes and generally accepted morality. , they may experience fear of losing control of themselves and possibly committing dangerous or ridiculous actions, injuring themselves or their loved ones. In the latter cases, obsessions are often combined with object phobias (fear of sharp objects - knives, forks, axes, etc. ). The contrasting group also partially includes obsessions of sexual content (obsessions of the type of forbidden ideas about perverted sexual acts, the objects of which are children, representatives of the same sex, animals).
Obsessions of pollution (mysophobia). This group of obsessions includes both the fear of pollution (earth, dust, urine, feces and other impurities), as well as the fear of penetration into the body of harmful and toxic substances (cement, fertilizers, toxic waste), small objects (glass fragments, needles, specific types of dust), microorganisms. In some cases, the fear of contamination can be limited, remain at the preclinical level for many years, manifesting itself only in some features of personal hygiene (frequent change of linen, repeated washing of hands) or in housekeeping (thorough handling of food, daily washing of floors). , "taboo" on pets). This kind of monophobia does not significantly affect the quality of life and is evaluated by others as habits (exaggerated cleanliness, excessive disgust). Clinically manifested variants of mysophobia belong to the group of severe obsessions. In these cases, gradually becoming more complex protective rituals come to the fore: avoiding sources of pollution and touching "unclean" objects, processing things that could get dirty, a certain sequence in the use of detergents and towels, which allows you to maintain "sterility" in the bathroom. Stay outside the apartment is also furnished with a series of protective measures: going out into the street in special clothing that covers the body as much as possible, special processing of wearable items upon returning home. In the later stages of the disease, patients, avoiding pollution, not only do not go out, but do not even leave their own room. In order to avoid contacts and contacts that are dangerous in terms of contamination, patients do not allow even their closest relatives to come near them. Mysophobia is also related to the fear of contracting a disease, which does not belong to the categories of hypochondriacal phobias, since it is not determined by fears that a person suffering from OCD has a particular disease. In the foreground is the fear of a threat from the outside: the fear of pathogenic bacteria entering the body. Hence the development of appropriate protective actions.
A special place in the series of obsessions is occupied by obsessive actions in the form of isolated, monosymptomatic movement disorders. Among them, especially in childhood, tics predominate, which, unlike organically conditioned involuntary movements, are much more complex motor acts that have lost their original meaning. Tics sometimes give the impression of exaggerated physiological movements. This is a kind of caricature of certain motor acts, natural gestures. Patients suffering from tics can shake their heads (as if checking whether the hat fits well), make hand movements (as if discarding interfering hair), blink their eyes (as if getting rid of a mote). Along with obsessive tics, pathological habitual actions (lip biting, gnashing of teeth, spitting, etc.) are often observed, which differ from obsessive actions proper in the absence of a subjectively painful sense of persistence and experience them as alien, painful. Neurotic states characterized only by obsessive tics usually have a favorable prognosis. Appearing most often in preschool and primary school age, tics usually subside by the end of puberty. However, such disorders can also be more persistent, persist for many years and only partially change in manifestations.
The course of obsessive-compulsive disorder.
Unfortunately, chronization must be indicated as the most characteristic trend in the OCD dynamics. Cases of episodic manifestations of the disease and complete recovery are relatively rare. However, in many patients, especially with the development and preservation of one type of manifestation (agoraphobia, obsessive counting, ritual handwashing, etc.), a long-term stabilization of the condition is possible. In these cases, there is a gradual (usually in the second half of life) mitigation of psychopathological symptoms and social readaptation. For example, patients who experienced fear of traveling on certain types of transport, or public speaking, cease to feel flawed and work along with healthy people. In mild forms of OCD, the disease usually proceeds favorably (on an outpatient basis). The reverse development of symptoms occurs after 1 year - 5 years from the moment of manifestation.
More severe and complex OCDs such as phobias of infection, pollution, sharp objects, contrasting performances, multiple rituals, on the other hand, may become persistent, resistant to treatment, or show a tendency to recur with disorders that persist despite active therapy. Further negative dynamics of these conditions indicates a gradual complication of the clinical picture of the disease as a whole.
It is important to distinguish OCD from other disorders that involve compulsions and rituals. In some cases, obsessive-compulsive disorder must be differentiated from schizophrenia, especially when the obsessive thoughts are unusual in content (eg, mixed sexual and blasphemous themes) or the rituals are exceptionally eccentric. The development of a sluggish schizophrenic process cannot be ruled out with the growth of ritual formations, their persistence, the emergence of antagonistic tendencies in mental activity (inconsistency of thinking and actions), and the uniformity of emotional manifestations. Prolonged obsessional states of a complex structure must be distinguished from the manifestations of paroxysmal schizophrenia. Unlike neurotic obsessive states, they are usually accompanied by a sharply increasing anxiety, a significant expansion and systematization of the circle of obsessive associations, which acquire the character of obsessions of "special significance": previously indifferent objects, events, random remarks of others remind patients of the content of phobias, offensive thoughts and thereby acquire in their view a special, menacing significance. In such cases, it is necessary to consult a psychiatrist in order to exclude schizophrenia. It can also be difficult to differentiate between OCD and conditions with a predominance of generalized disorders, known as Gilles de la Tourette's syndrome. Tics in such cases are localized in the face, neck, upper and lower extremities and are accompanied by grimaces, opening the mouth, sticking out the tongue, and intense gesticulation. In these cases, this syndrome can be excluded by the coarseness of movement disorders characteristic of it and more complex in structure and more severe mental disorders.
Speaking about hereditary predisposition to OCD, it should be noted that obsessive-compulsive disorders are found in approximately 5-7% of parents of patients with such disorders. Although this figure is low, it is higher than in the general population. While the evidence for a hereditary predisposition to OCD is still uncertain, psychasthenic personality traits can be largely explained by genetic factors.
Approximately two-thirds of OCD patients improve within a year, more often by the end of this period. If the disease lasts more than a year, fluctuations are observed during its course - periods of exacerbations are interspersed with periods of improvement in health, lasting from several months to several years. The prognosis is worse if we are talking about a psychasthenic personality with severe symptoms of the disease, or if there are continuous stressful events in the patient's life. Severe cases can be extremely persistent; for example, a study of hospitalized patients with OCD found that three-quarters of them remained symptom-free 13 to 20 years later.
TREATMENT: BASIC METHODS AND APPROACHES
Despite the fact that OCD is a complex group of symptom complexes, the principles of treatment for them are the same. The most reliable and effective method of treating OCD is considered to be drug therapy, during which a strictly individual approach to each patient should be manifested, taking into account the characteristics of the manifestation of OCD, age, gender, and the presence of other diseases. In this regard, we must warn patients and their relatives against self-treatment. If any disorders similar to mental ones appear, it is necessary, first of all, to contact the specialists of the psycho-neurological dispensary at the place of residence or other psychiatric medical institutions to establish the correct diagnosis and prescribe competent adequate treatment. At the same time, it should be remembered that at present a visit to a psychiatrist does not threaten with any negative consequences - the infamous "accounting" was canceled more than 10 years ago and replaced by the concepts of consultative and medical care and dispensary observation.
When treating, it must be borne in mind that obsessive-compulsive disorders often have a fluctuating course with long periods of remission (improvement). The apparent suffering of the patient often seems to call for vigorous effective treatment, but the natural course of the condition must be kept in mind in order to avoid the typical error of over-intensive therapy. It is also important to consider that OCD is often accompanied by depression, the effective treatment of which often leads to an alleviation of obsessional symptoms.
The treatment of OCD begins with an explanation of the symptoms to the patient and, if necessary, with reassurance that they are the initial manifestation of insanity (a common concern for patients with obsessions). Those suffering from certain obsessions often involve other family members in their rituals, so relatives need to treat the patient firmly, but sympathetically, mitigating the symptoms as much as possible, and not aggravating it by excessive indulgence in the sick fantasies of patients.
The following therapeutic approaches exist for the currently identified types of OCD. Of the pharmacological drugs for OCD, serotonergic antidepressants, anxiolytics (mainly benzodiazepine), beta-blockers (to stop autonomic manifestations), MAO inhibitors (reversible) and triazole benzodiazepines (alprazolam) are most often used. Anxiolytic drugs provide some short-term relief of symptoms, but should not be given for more than a few weeks at a time. If anxiolytic treatment is required for more than one to two months, small doses of tricyclic antidepressants or small antipsychotics sometimes help. The main link in the treatment regimen for OCD, overlapping with negative symptoms or ritualized obsessions, are atypical antipsychotics - risperidone, olanzapine, quetiapine, in combination with either SSRI antidepressants or other antidepressants - moclobemide, tianeptine, or with high-potency benzodiazepine derivatives ( alprazolam, clonazepam, bromazepam).
Any comorbid depressive disorder is treated with antidepressants at an adequate dose. There is evidence that one of the tricyclic antidepressants, clomipramine, has a specific effect on obsessive symptoms, but the results of a controlled clinical trial showed that the effect of this drug is insignificant and occurs only in patients with distinct depressive symptoms.
In cases where obsessive-phobic symptoms are observed within the framework of schizophrenia, intensive psychopharmacotherapy with proportional use of high doses of serotonergic antidepressants (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram) has the greatest effect. In some cases, it is advisable to connect traditional antipsychotics (small doses of haloperidol, trifluoperazine, fluanxol) and parenteral administration of benzodiazepine derivatives.
One of the main tasks of the specialist in the treatment of OCD is to establish fruitful cooperation with the patient. It is necessary to instill in the patient faith in the possibility of recovery, to overcome his prejudice against the "harm" caused by psychotropic drugs, to convey his conviction in the effectiveness of treatment, subject to the systematic observance of the prescribed prescriptions. The patient's faith in the possibility of healing must be supported in every possible way by the relatives of the OCD sufferer. If the patient has rituals, it must be remembered that improvement usually occurs when using a combination of the method of preventing a reaction with placing the patient in conditions that aggravate these rituals. Significant but not complete improvement can be expected in about two-thirds of patients with moderately heavy rituals. If, as a result of such treatment, the severity of rituals decreases, then, as a rule, the accompanying obsessive thoughts also recede. In panphobia, predominantly behavioral techniques are used to reduce sensitivity to phobic stimuli, supplemented by elements of emotionally supportive psychotherapy. In cases where ritualized phobias predominate, along with desensitization, behavioral training is actively used to help overcome avoidant behavior. Behavioral therapy is significantly less effective for obsessive thoughts that are not accompanied by rituals. Thought-stopping has been used by some experts for many years, but its specific effect has not been convincingly proven.
We have already noted that obsessive-compulsive disorder has a fluctuating (fluctuating) course and over time the patient's condition may improve regardless of which particular methods of treatment were used. Until recovery, patients can benefit from supportive conversations that provide continued hope for recovery. Psychotherapy in the complex of treatment and rehabilitation measures for patients with OCD is aimed at both correcting avoidant behavior and reducing sensitivity to phobic situations (behavioral therapy), as well as family psychotherapy to correct behavioral disorders and improve family relationships. If marital problems exacerbate symptoms, joint interviews with the spouse are indicated. Patients with panphobia (at the stage of the active course of the disease), due to the intensity and pathological persistence of symptoms, need both medical and social and labor rehabilitation. In this regard, it is important to determine adequate terms of treatment - long-term (at least 2 months) therapy in a hospital with subsequent continuation of the course on an outpatient basis, as well as taking measures to restore social ties, professional skills, family relationships. Social rehabilitation is a set of programs for teaching OCD patients how to behave rationally both at home and in a hospital setting. Rehabilitation is aimed at teaching social skills to properly interact with other people, vocational training, as well as skills necessary in everyday life. Psychotherapy helps patients, especially those who experience a sense of their own inferiority, treat themselves better and correctly, master ways to solve everyday problems, and gain confidence in their strength.