Part 1 of Occupational Therapy and OCD: Positive and Negative Occupations

Introduction

Law et al (1998) assert that occupational therapists believe that a direct link between occupation, health and well-being exists. However, little if anything is proposed to the role of occupation as a root cause for ill-health, distress or be the harbinger of occupational disruption and occupational dysfunction to the lives of  those who live and suffer from obsessive compulsive disorder (OCD). The current view seems to be  that any occupation that deviates from the ‘occupational norm’ is dysfunctional and hold no worth to occupational beings. This piece aims to challenge this notion.

I wish to pursue a discussion for the possibility of what may be perceived as ‘meaningful and purposeful activity’ leading to harm, injury or distress. For the purpose of this discussion I am going to analyse the common compulsion of hand washing related to ‘contamination OCD’ and discuss the potential for endangerment to health, well-being and occupational lives.

As this piece is directed mainly at occupational therapists, said ‘sufferers’ will be termed as ‘occupational beings’. That said, I welcome all to read my work related to OCD in order to raise awareness, understanding and the promotion of occupational therapy as a possible therapy often left unexplored and very misunderstood.

What is OCD?

We may in our own personal lives ignorantly use such phrases such as “I don’t like mess…yes ‘I’m a little bit OCD’ about things like that…”! This is easily done as the true nature of what is OCD is, and the wider symptomatology and behaviours are widely misunderstood. OCD is poorly portrayed by the media, with particular attention placed on cleaning, creating an image of the ‘clean freaks’ disorder or one of those eccentricities often aspired to be had by those who simply fancy a title for a fashion statement or fleeting accessory.

For the purpose of this discussion I will outline a broad description of OCD, but progress only onto the description of contamination OCD as the compulsions for this specific form of OCD will be outlined and analysed in an occupational context.

Smith et al (2012) outline that “Obsessive-compulsive disorder (OCD )is a debilitating disorder characterized by recurring distressing thoughts or images (obsessions), and behaviors intended to reduce distress,including repetitive overt or mental rituals (compulsions; American Psychiatric Association (APA), 2000) and avoidance. The relationship between obsessions and compulsions is such that obsessions evoke anxiety (or another state  of negative affect), and compulsions are enacted to ameliorate the aversive feeling.” (p. 54).

Now for contamination OCD, there are generally two elemental parts commonly referred to as ‘contamination obsessions’ and ‘decontamination compulsions’. There is a popular view that contamination OCD is isolated to fears of germs, dirt and viruses but this is quite a narrow view, for a far broader list of ‘contaminants’ are commonly associated.

Bodily excretions (urine, faeces, mucus, sweat, saliva etc…), blood, semen, rubbish, household chemicals, radioactivity, broken glass, sticky substances, people who appear unwell, dirty, or unclean looking, spoiled food, soap , lead, asbestos, pets, birds, dead animals, newspaper print. 

It is common for those who live with contamination OCD to hold irrational beliefs related their obsessions, such as how small amounts of a contaminant, for example a drop of blood, can ‘contaminate’ a large area, such as the entire person, a house, a car or even everything owned and come into contact with by the individual.  There are other forms of ‘contamination obsessions’, known to be ‘magical’ or those that one fears of contaminating others through a variety of methods or mediums. These can include:

Intrusive thoughts, intrusive mental images, colours, words, notions of bad luck, names of illness/disabilities/deceased, or of those who are ill or are disabled, overweight or unattractive.

An example of potentially contaminating others and fearing of causing harm to another is if one intrusively imagines poisonous substances on their hands and fears everything they touch will cause harm to others or believes that harm would come to those in close proximity to them if certain words, such as ‘death’ or ‘die’ are intrusively thought.

Common decontamination compulsions:

Excessive hand washing, disinfecting and sterilisation, changing of clothes, throwing things away, avoidance of touching certain objects, people or going to particular places and creating ‘clean areas’ where no-one is permitted to go.

(Adapted from the International OCD Foundation). 

Positive Vs Negative

As occupational therapists, we are committed to promoting the independence of others and where dysfunction occurs we problem solve how to enable occupational participation. We are taught that occupations are activities that have meaning and purpose to us as ‘occupational beings’ who engage in a range of dynamic environments, and as explained in the opening paragraph, we believe that these occupations shape our health and well-being (Law et al, 1998).

The following paragraphs will analyse whether what we are taught as occupational therapists offer the fullest perspective of what occupation truly is or if there is a spectrum to consider in the complexity of occupation.

Occupation is commonly researched as something that we engage in that is positive, productive and enabling (Townsend, 1997) however, Twinley and Addidle (2012) argue that not all occupations promote health nor well-being, using violence and anti-social behaviour as their examples. This leads me to question the nature of occupation and what can be classed as a positive or negative occupations? Are occupations simply socially acceptable activities or is there a darker dimension unexplored? In this blog I use OCD to propose how meaningful and purposeful activities can both be positive and negative occupations, related to compulsions.

Hand Washing as an Occupation

Hand washing is what occupational therapists refer to as a self-care occupation and is an essential activity of daily living to avoid the spreading of pathogens to ourselves and others. We learn the importance of having clean hands as children and it inevitably integrates in our daily habituations for the rest of our lives. For some though, hand washing can become a much more important and ritualised occupation than to most and is often the most commonly looked for behaviour to identify signs of OCD.

The ritualistic ‘hand washer’ may spend hours washing their hands. This becomes a dysfunctional method of controlling anxieties, through washing away intrusive thoughts or images, but offers a sense of relief until the next time one may feel contaminated. To the person living with the torture of OCD, hand washing may be perceived as a behaviour with meaning and purpose, as it reducing anxiety and aids in their ability to function temporarily in their occupational lives. But for healthcare professionals, and wider society, this is viewed as dysfunctional behaviour perpetuating the pattern and cyclical continuation of OCD. My analysis of this compulsion leads me to argue that for the person living with OCD, this can be classed as a ‘negative occupation’, that has meaning and purpose.

Excessive Hand Washing and its Effects to Health

Excessive hand washing in OCD can lead to numerous health complaints, some more obvious than others. The most commonly understood effect of over washing is a loss of essential oils in the skin leading to damage to the dermis and dermatitis. Blistering, redness, bumps and peeling skin are common when excessively scrubbing in attempt to rid the hands of perceived contaminants. In more severe cases of OCD, chemicals may be used as a radical means of decontamination, such as the use of bleach. As a result, chemical burns, soreness and ultimately limited range of movement in the hands may be experienced.

Less thought of is the mental effects that hand washing as a compulsion can have on the individual. The compulsion can take over the individuals life to such an extent that participation in any other activities of daily living can be almost impossible due to fears of contamination and a preoccupation of finding sinks to wash in, or avoiding anywhere where washing may be impossible.

Heyman et al (2006) suggest that a greater awareness of the symptoms, presentation and various manifestations of OCD is crucial amongst healthcare and non-healthcare settings and that clinicians need to more confident in recognising the spectrum of signs and symptoms. Therefore, occupational therapists should be more aware of this disorder and consider it an area in which occupational therapy skills can be utilised.

In part 2 of this blog I will propose the potential role of occupational therapy for mild to severe OCD and discuss the possible therapeutic interventions to utilise in the treatment of this disorder.

References

Heyman, I., Mataix-Cols, D. and Fineberg, N. A. (2006) “Obsessive Compulsive Disorder”. British Medical Journal. 333, pp. 424-429.

Law, M., Steinwender, S. and Leclair, L. (1998) “Occupation, Health and Wellbeing”. Canadian Journal of Occupational Therapy. 65 (2), pp. 81-91

Smith, A. H., Wetterneck, C. T., Hart, J. M., Short, M. B., and Bjorgvinsson, T. (2012) “Differences in Obsessional Beliefs and Emotion Appraisal in Obsessive Compulsive Symptom Presentation”. Journal of Obsessive Compulsive and Related Disorders. 1, pp. 54-61

Townsend, E. (1997) “Occupation: Potential for Personal and Social Transformation”. Journal of Occupational Science. 4 (1), pp. 18-26

Twinley, R. and Addidle, G. (2012) “Considering Violence: the Dark Side of Occupation”. British Journal of Occupational Therapy. 75 (4), pp. 202-204

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