Featured Team Members: Aaron Wallis, Ph.D, LP
Obsessive-Compulsive Disorder (OCD) is frequently used as a colloquialism for highly orderly or particular people. However, for those who actually meet the diagnostic criteria, it can be an extremely distressing and confusing experience. At Open Sky, our approach to OCD treatment is to come alongside students to help them understand their symptoms, treat the disorder and empower them to overcome challenges both in the wilderness and back home.
What is OCD?
People with OCD have difficulty controlling their thoughts and experience intrusive, repetitive worries or desires (obsessions), or they feel a strong urge to engage in repetitive behaviors that are usually illogical or taken to an unnecessary extreme (compulsions or rituals). Compulsions usually take five distinct forms: cleaning, checking, repeating, ordering/arranging or counting.
While frequently co-occurring, it is not necessary for a person to have both obsessions and compulsions to qualify for such a diagnosis. A person must have either obsessions or compulsions in addition to an at least transient understanding that their worries or behaviors are illogical and that these symptoms cause significant disruption in their functioning. The primary emotion demonstrated in OCD is usually anxiety, which is only partially mitigated by the compulsions or rituals in which a person engages. However, even a partial relief from anxiety can increase the likelihood that a person will engage in such rituals again and can strengthen that particular compulsion. Similar to substance addiction, this ritual becomes less effective over time and must be modified or increased in order to see the same relief.
Though the neurological underpinnings of OCD are still being explored and largely too complex to discuss in this context, I believe it is important to have a basic understanding of what is happening in the brain of a person with OCD. This disorder, as with many other mental health concerns, does not represent a failure of character or lack of personal constitution. In OCD there seems to be a disconnect in the neural circuitry that relays primitive urges and sensory information. In people with OCD, parts of the brain do not appear to filter sensory information adequately. Minor sensory information (i.e. “did I leave the stove on?”) is perceived with the same intensity usually associated with biological imperatives (i.e. “I MUST use the bathroom now” or “The stove is burning my hand, I MUST remove it”). This can be extremely frustrating and confusing for people with OCD, as they recognize the obsessions are not as urgent as they seem, however they feel intense pressure to engage in a compensatory compulsion.
Presentation in Wilderness
When a person arrives in wilderness with a diagnosis of OCD, they often initially have significant anxiety as many of their routines are disrupted. Usually, this is related to specific daily activities that simply do not exist in wilderness, like compulsive hand washing, checking to see if doors are locked, etc. The inability to engage in these compulsions or rituals creates initial anxiety followed by relief.
Often in the first few weeks of wilderness therapy, the student’s OCD symptoms, especially behavioral compulsions, appear to diminish. The student feels excited by his or her apparent progress, occasionally expressing a desire to complete treatment and return home. However, once wilderness activities begin to feel routine, there can be a resurgence of OCD symptoms often related to food, the organization of personal items, journaling or letter writing activities, arranging of hiking backpacks and group chores. While this is a normal part of OCD treatment in the wilderness, it is important to educate students and families about this process in order to alleviate fears of regression.
Treatment
There’s an adage in therapy that, “what happens in the macrocosm must eventually show up in the microcosm,” or more simply, larger patterns in our lives eventually permeate our smaller experiences. This is especially true in wilderness, and once OCD patterns of anxiety, obsessions, and compulsions show up in treatment, the wilderness setting provides a vital opportunity to disrupt those patterns.
The crux of treatment for OCD is exposure and response prevention. Essentially a person must be exposed to the feared stimulus (i.e. dirt, disorganization, imperfection in an assignment, etc.) and prevented from engaging in the preferred response (i.e. excessive cleaning, organization, continual rewriting, etc.). During this time, they are exposed to the anxiety they have been trying to avoid or mitigate with compulsions. At this point, students are encouraged to engage in a myriad of coping skills designed to, among other things, force the brain to integrate sensory information and connect to concrete physical experiences. At Open Sky, we emphasize and practice mindfulness activities like yoga and meditation, which help with this. Over time these practices can disrupt the well-worn neural pathways associated with anxiety and compulsive coping and provide new avenues for healthy ways to deal with obsessions.
There is significant evidence that pharmacological treatment, especially medications working with the serotonin system can be effective in mitigating OCD symptoms, alongside the therapeutic strategies mentioned above. It is important to do a detailed assessment and work with a qualified psychiatrist to determine exactly what is needed for a student with OCD. A significant advantage of our approach at Open Sky is the immediate availability of consultation with our psychiatrist and medical staff. We can both actively assess the initial pharmacological needs of a student as well as monitor for any psychological or physiological side effects from the implementation of a new medication. This allows us to make well-informed and if needed, rapid changes to a medication regime to ensure a student is able to take full advantage of therapeutic interventions. It is not uncommon to see a temporary initial increase in OCD symptoms as the brain adjusts to the medication, leading students and families to want to discontinue a medication before it has reached its potential therapeutic benefit. It is important to be patient and consistent in the medication process as well as educate OCD sufferers and their loved ones on the entire course of treatment.
The wilderness is a powerful setting in which to treat OCD. Wilderness therapy can be a highly effective intervention for OCD and have long-lasting effects on the structure of the brain, allowing an individual with OCD to live a long and fulfilling life. At Open Sky, our clinicians, field guides, and medical team provide a combination of individual and group therapy, mindfulness activities and medical attention that help students with OCD take control and overcome the challenges of their diagnosis.
December 7th, 2017