Obsession by Jonathan Kellerman Page B

beginning.
     
     
    The tape-loop soundtrack of obsessive-compulsiveness is powered by anxiety. The noise can be switched off by SSRIs—drugs that increase the flow of serotonin to the brain. But not much is known about how psychoactive meds affect kids long-term, and when the patient stops taking the pills, the soundtrack cranks up again.
    Cognitive behavior therapy takes longer and requires active participation by the patient, but it has no side effects and teaches self-help skills that can endure. By the time Tanya first came to see me, I’d successfully treated scores of kids with OCD, sampling from a grab bag of CBT methodologies.
    I try to view every patient with a fresh eye, but after you’ve been in practice for a few years, preconceptions are inevitable, and when she arrived I had a plan in mind.
     
1. Build trust.
    2. Find the anxious core.
    3. When the time’s right, use thought-stopping, guided exposure, desensitization, or some combination, to replace tension with relaxation.
     
    By the fourth session, rapport seemed set and I was ready to work. Tanya marched into the office and sat at the play table and said, “They’re gone.”
    “Who is?”
    “My habits.”
    “Gone,” I said.
    “I don’t do them anymore.”
    “That’s great, Tanya.”
    Shrug.
    “How’d you do that?”
    “You said I was being nervous so when I got nervous I chased the habit feelings away.”
    “Chased them?”
    “I said, ‘Stop, that’s stupid,’ and put other feelings inside.” Tapping her temple.
    Would you like your clinical license to go, or will you eat it here?
    “What other feelings did you put into your head?”
    “Taking a walk with Mommy. Going to Disneyland.”
    “Disneyland’s a favorite place?”
    “Small World’s boring,” she said. “I like the Spinning Teacups.” Rotating one hand. “I like the pink cup.”
    “Spinning Teacups is something you’ve done before with Mommy.”
    “No,” she said, looking vexed. “We don’t
really
do it, Mommy gets sick when she spins. We watch.”
    “You’d
like
to do it.”
    “I
pretend
to do it.” Rotating both hands, now. Fast and choppy, like an agitated bus driver.
    “You pretend to spin.”
    “Fast,” she said.
    “That makes the nervous feelings go away.”
    Doubt sharpened the pale green eyes. “You
said
the habits were being
nervous
.”
    “You’re absolutely right, Tanya. You did a great job.”
    “I didn’t do it all,” she said.
    “Someone helped you?”
    Emphatic head shake. “I didn’t do it all the first
time
.”
    “You did some of it.”
    She turned away from me. “I looked under the bed. A little. I washed my hands a bunch of times. The second time I didn’t look under the bed and I only washed my hands once. I
had
to wash. To be clean, Mommy says to use soap and water before I go to sleep, and brush my teeth.”
    “Sounds like a good idea.”
    “Washing only once is a good idea,” she said. “More is
stupid
.”
    “Mommy said it was stupid?”
    “
No
! I say it to myself.” She picked up a pencil, twirled, poked the playhouse.
    “I’m really impressed, Tanya.”
    No response.
    “You must be proud of yourself.”
    “Having habits made me tired,” she said, airily.
    “And now you can handle them.”
    “When I get nervous, I say ‘You’re being nervous, you don’t need those habits.’”
    I said, “Perfect. You could be a doctor.”
    She manipulated dolls. Worked hard at a poker face. Gave up and surrendered to a smile. “Mommy says no one’s perfect but I’m close.”
    “Mommy would know.”
    Giggle. “Um…can I draw?”
     
     
    The second time, three years later, I expected dejection due to relapse, was surprised to see her straight-backed and strutting as she entered the office. Still small for her age, she dressed older—pressed khakis, white shirt under a navy V-necked sweater, immaculate brown loafers. Her hair was combed out and straight. Suggestions of maturity had begun to firm the contours