ERP Therapy Stories: Perinatal OCD
I created this “ERP Therapy Stories” series to share a glimpse of how the application of ERP therapy could look within the context of different OCD subtypes. I hope to provide some examples of ERP therapy while channeling my creative and imaginative side. The stories and characters that I write about are fictional, but the ERP strategies depicted are ones that I teach and use in therapy with my clients. This particular post focuses on illustrating Perinatal OCD symptoms, including commonly seen Perinatal OCD obsessions and compulsions. As an OCD therapist who enjoys storytelling, I hope these vignettes can help you feel less alone and see hope in ERP therapy.
Sofia is a 28-year-old first-time mom living and working in Orange County, CA. She is on a 6-month maternity leave from her Marketing Manager job in Irvine. She had a baby daughter named Julissa a month ago and continues to navigate the postpartum phase. It’s been exciting and fulfilling, but also tiring and isolating. Sofia is ready to socialize again and joins an Orange County mom group. She wants to meet other moms and get Julissa and herself out of the house. She joins them on their weekly meetups and takes stroller walks at various trails and parks. They meet in various South Orange County neighborhoods in Irvine, Newport Beach, Laguna Beach, etc. It has been fun and Sofia looks forward to attending more of these activities throughout her leave.
A week ago, Sofia was swaddling Julissa for her nap. She thought “What if I accidentally swaddle her face and she can’t breathe?” The thought startled her and was followed by “What if I suffocate her with this swaddle blanket right now?” Sofia was creeped out by these thoughts and quickly put Julissa in her crib. She was too afraid to hold and rock her like she usually does.
“Why am I thinking this? Am I capable of hurting my baby?”
The thoughts were disturbing. She rationalized why they could not be true, “No, I love her. I would never hurt her. I’ve been wanting to be a mom forever.” Normally she is quick to take advantage of nap time and get some chores done. But this time she had to mentally reassure herself before moving on to the next task. “You’re a good mom. You’re a loving mom,” she reminds herself.
These thoughts were not a one-time thing. Sofia started having them more and more as the weeks passed. And they became scarier and darker. Sometimes she kept moving along by neutralizing her unwanted thoughts. She would replace the scary thoughts with more pleasant and positive ones by repeatedly saying “You’re a good mom. You’re a loving mom”. While taking Julissa down the stairs, she would have horrifying mental images of Julissa at the bottom of the staircase with a head injury. While bathing Julissa, her mind would go to “What if you spontaneously push her head under the water and drown her?” While taking Julissa on stroller walks, she would have thoughts of “What if you impulsively push the stroller into street traffic?” The thoughts made her sick to her stomach.
Sofia starts questioning herself more and more.
“Why am I having these thoughts and terrifying images? Does this mean I’m going to act on them? Could I be capable of snapping and doing something terrible to my baby? Am I experiencing postpartum psychosis? Sofia begins to avoid certain caregiving tasks. She finds excuses to wait for her husband, Tyler, to do them when he gets home from work. She spends a lot of time researching “symptoms of postpartum psychosis”. Sofia excessively checks Julissa for potential signs of bodily harm and checks that she is breathing. She wants to be certain that she didn’t unintentionally drop or suffocate her. She begins seeking reassurance from Tyler by asking him questions like “Does Julissa look ok to you?” or “Do you think I’m a good mom?”
Sofia starts to reach a point where she can’t handle these obsessions anymore. Tyler has also noticed that Sofia has become intensely anxious, withdrawn, and avoidant. He tries to talk to Sofia about it but she is too afraid to share her thoughts. Will Tyler think she is a monster and divorce her? One day Sofia can’t hold it in anymore and breaks down in tears. She confesses to Tyler the terrifying thoughts that she has been having. She worries that she will be deemed an unfit mother and Julissa will be taken from her. Tyler was very supportive. He knows that Sofia is going through something. But whatever it is, he is certain she would never harm Julissa. He helps Sofia schedule an appointment with her OBGYN who ends up diagnosing her with OCD.
Sofia decides that she wants to take medication and also meet with an OCD therapist in Orange County.
Sofia begins meeting with the OCD therapist who confirms that she is dealing with Perinatal OCD symptoms. She learns that her Perinatal OCD obsessions cause her so much anxiety and distress because they are ego-dystonic. Sofia has no desire to act on them because they go against who she is as a person. She feels compelled to perform compulsions in an attempt to prevent her fears from coming true and to lessen her distress. Sofia was afraid of having postpartum psychosis, which was ruled out. She learns that clients with postpartum psychosis are out of touch with reality. They do not believe anything is wrong with their thoughts and they don't experience the ongoing internal conflict and doubt as someone with OCD. Their thoughts do not generally cause distress and they don’t perform compulsions. This is contrary to Sofia’s experience. This education helped validate some of Sofia’s fears and helped her understand her OCD diagnosis. Her OCD therapist also advised that it would be important to resist turning to this educational information when she experiences a Perinatal OCD obsession. Over-relying on it could become compulsive.
Tyler joins a session to learn how to best support Sofia without reinforcing the OCD.
The best approach is to provide his presence and validation without reassurance. Sofia learns to work through the difficult feelings in the absence of reassurance. She learns through repetition that the feeling of urgency eventually subsides. Sofia's ERP therapy goal is to cut down on compulsions and return to a level of functionality when she is alone with Julissa. Sofia starts re-engaging in the caregiving and bonding experiences she has been avoiding.
Sofia decides that she wants to get back to attending the Orange County mom group activities. She stopped when her Perinatal OCD symptoms started to worsen a few months ago. Sofia attends the next meetup at Castaways Park in Newport Beach. It's been a while since she last saw her mom friends. They greet her with excitement. It's a beautiful day and the moms are pushing their strollers on the paved park path. They converse and catch up while taking in the fresh air and gorgeous views of the Newport Harbor.
Sofia anticipates potential Perinatal OCD obsessions.
But, she feels more confident since starting ERP therapy a few months ago.
They stop at a comfortable spot to give their babies a break from their strollers. Some of the moms stand by the rail overlooking the water. Sofia carries Julissa out of her stroller and notices the thought "You could easily throw her over this rail." It brings a little jolt to her chest and makes her heart jump. "What if you lose it and toss her over?" Sofia knows not to take these thoughts as facts. She chooses to accept all possibilities instead. "That could happen, or it might not. I guess we'll see", Sofia says in her mind. She knows that these thoughts have been disproven many times before. She disproved the thoughts by confronting her fears and allowing herself to experience the outcome. She decides to do that again. She carries Julissa and faces the gorgeous view of the Newport Harbor with her. They stand there for a few minutes, enjoying the scenic view together. Sofia learns once again that she gets to decide how much of her life she allows OCD to take.
