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Behavioral treatment of obsessive-compulsive disorder in African Americans
COGNITIVEAND BEHAVIORALPRACTICE3,303-315, 1996
Behavioral Treatment of ObsessiveCompulsive Disorder in African Americans
Marjorie L. Hatch Southem Methodist University Steven Friedman Cheryl M. Paradis SUNY-Health Science Center at Brooklyn
This paper reviews some important features in the presentation, diagnosis, and treatment of obsessive-compulsive disorder (OCD) in African Americans. Some adaptations to the behavioral treatment of O C D in African Americans are illustrated through the use of case examples. The growing awareness in psychology that cultural and ethnic issues are important factors in effective treatment planning forms the basis for the present paper. African Americans with OCD in particular have tended not to seek help in mental health settings, and there is little published research in this area. Thus, many clinicians and researchers may be unfamiliar with issues relevant to treatment issues of OCD in this population.
As minority groups continue to grow in n u m b e r in the U.S., the need for mental health service will expand, and mental health professionals will be increasingly called, upon to provide culturally relevant services (Ponterotto & Casas, 1991). Although published w o r k addressing racial or ethnic issues in mental health has increased in the past two decades, this work has tended to focus on general issues in counseling (Aponte, Rivers, & Wohl, 1995) or more severe forms o f psychopathology (Adebimpe, 1981). Little work has been done on applying specific cognitive behavioral treatments for different ethnic groups. 303 1077-7229/96/2-303-31551.00/0 Copyright 1996 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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Thus, clinicians and researchers are likely to be only minimally familiar with diagnostic and treatment considerations in relation to minority clients with anxiety disorders (Neal 8: Turner, 199/). The present paper seeks to illustrate a culturally informed approach to the behavioral treatment of obsessive-compulsive disorder (OCD) through the description of several case studies of African American clients. OCD is characterized by persistent unwanted thoughts, impulses, or images and repetitive and ritualistic behaviors or mental acts the individual feels compelled to perform (American Psychiatric Association, 1994). These thoughts and urges are frequently experienced as intrusive and senseless. If untreated, OCD is usually chronic, and can significantly disrupt social and occupational functioning. Although the incidence of OCD has been shown to be evenly distributed across racial groups (Karno, Golding, Sorenson, & Burnam, 1988; Robins et al., 1984; Weissman et al., 1994), African Americans either do not appear to present for psychiatric treatment in the same proportion as Whites do, or they do not receive the diagnosis of OCD. In a survey of major OCD treatment centers, for example, Lewis-Hall (1991) found only 30 (2%) African American clients out of a total sample of 1,500 OCD sufferers. In one major medical center with a predominantly Black clientele, she found treatment records for only three African Americans with OCD. Although a detailed analysis of why African Americans have not traditionally sought psychiatric treatment for OCD (as well as for other psychiatric conditions) is beyond the scope of this paper, a few remarks seem in order. It appears that both culturally influenced help-seeking behavior on the part of the anxiety sufferer as well as misdiagnosis on the part of mental health professionals have played a role (Neal & Turner, 1991). Help-Seeking Behavior Neighbors (1988; Neighbors, Caldwell, Thompson, &Jackson, 1994) argued that African Americans most often consult members of their informal social network, including clergy, in times of emotional distress. More specifically, Friedman and colleagues (Friedman, Hatch, Paradis, Popkin, & Shalita, 1993; Hatch, Paradis, Friedman, Popkin, & Shalita, 1992) reevaluated Rassmussen's (1985) hypothesis that people with OCD tend to turn to medical specialists such as dermatologists. Examining the rate of OCD in a group of African American dermatology patients, they found a significantly higher rate ofundiagnosed cases in their sample (15%) than would be expected in a general medical population (2% to 3%). Misdiagnosis Similarly, Paradis and colleagues (Paradis, Friedman, Lazar, Grubea, & Kesselman, 1992) found evidence of misdiagnosis of anxiety disorders by psychiatric staff at an urban outpatient center with a primarily African American
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and Afro-Caribbean population. Clients who were initially diagnosed following a clinical interview by outpatient staff were reevaluated by anxiety disorder clinic staff using the structured Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo & Barlow, 1988). None of the original diagnoses of the 100 clients included a diagnosis of an anxiety disorder. Reevaluation resulted in nearly one-fourth being reclassified as having either a primary or secondary diagnosis of one or more anxiety disorders. It is unclear if the dermatologists in the Friedman et al. study (1993) or the psychiatric staff in the Paradis et al. study (1992) would have had a higher "hit rate" in diagnosing White clients. To our knowledge, the differential ability of mental health professionals to correctly diagnose O C D in members of different ethnic groups has not yet been studied. Adebimpe (1981), in his review of the literature, found that African Americans who presented for psychiatric treatment with an affective disorder were more often misdiagnosed with schizophrenia than were Whites. Thus, another explanation for the assumed rarity of O C D in Blacks has to do with misdiagnosis. In clinical practice, O C D sufferers may present in bizarre ways and are sometimes misdiagnosed as having schizophrenia. In an empirical examination of this observation, Carey and colleagues (Carey et al., 1986) examined the MMPI profiles of a group of 32 O C D patients and found elevations on the Schizophrenia scale. This elevation is consistent with the behavioral presentation of O C D where the patient may present with what appears to be bizarre and senseless behavior and the urge to ritualize. Although Carey et al. did not report on the racial background of their sample, our clinical impression is that it seems likely that misdiagnosis may be even greater for Blacks than for Whites. Previous Research Because there are a limited number of African Americans with O C D in treatment at university and medical school research clinics, this group is not included in research protocols (Lewis-Hall, 1991). Some published case descriptions exist. Perhaps the first published paper on O C D in Blacks was a clinical description of five cases in Benin, Africa (Bertschy & Ahyi, 1991). They reported that two of the five patients had checking rituals, one had obsessive doubting, one had washing rituals, and one had mixed washing and religious obsessions. Furthermore, four out of five patients had a history ofaffective disorder and two had comorbid depressive symptomatolog~. An extensive review of the literature on anxiety disorders in African Americans conducted by Neal and Turner (1991) concluded that there was a complete absence of empirical studies dealing specifically with OCD. Hollander and Cohen's (1994) review article on O C D in African Americans discusses psychopharmacologic treatment considerations and OCD-related disorders, such as trichotillomania. However, they do not present empirical data. This paper seeks to add to the information available on O C D in African Americans by discussing the clinical presentation and treatment of a variety of clients. A case presentation approach may be especially helpful to clinicians who
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lack experience working with this population. Specifically, we discuss the cases by focusing on clinical differences that we have noticed between our African American and White clients and how treatment was modified to make it more culturally relevant and effective. Hayes and Toarmino (1995) pointed out that behaviorally oriented practitioners who employ techniques they believe to apply universally to all individuals nevertheless acknowledge the importance of understanding particular clients' cultural backgrounds. They argued that formulating effective interventions requires taking into account both the client's individual history and the cultural context in which his or her behavior takes on meaning. We agree with Hayes and Toarmino that, despite the general applicability of behavioral principles in the treatment of OCD, understanding cultural differences that distinguish Black from White clients can lead both to improved diagnostic reliability and to more successful cognitive behavioral treatment. Finally, although we focus on differences as a way to highlight how we have modified a treatment protocol originally developed for White O C D sufferers, it is not our intent to suggest that individual differences within the African American community are unimportant in treatment planning.
The Clinical Population The Anxiety Disorders Clinic at the Health Sciences Center o f the State University o f N e w York at Brooklyn serves a primarily African American and Afro-Caribbean clientele. Because a significant number of our clients are from the Caribbean, we will often refer to the racial identity of our clinic group with the racially inclusive term Black. Over the years, the clinic has gained a good reputation in the community, primarily through word of mouth, and we have seen a steady increase in the number of Blacks with O C D who present for treatment. The cases detailed in this report are representative of the 13 African American and Afro-Caribbean people with O C D treated to date at our clinic.' Table 1 shows demographic data for the entire group. It should be noted that in terms of age, marital status, occupation, and symptom severity, this group does not significantly differ from the White clientele at our clinic. Overall, our clients, both Black and White, present with severe cases o f OCD. Our sample of Black clients with O C D (n = 13) scored an average 24.7 on theYale-Brown ObsessiveCompulsive Scale (Y-BOCS; Goodman et al., 1989), which falls in the severe range of impairment. Goodman and colleagues reported pretreatment mean YBOCS scores for two different outpatient groups as 25.3 (+/- 6) and 26.6 (+/- 6; Goodman et al., 1990). The standard treatment for O C D in our clinic consists primarily o f in-session, in-vivo exposure and response prevention as described by Foa and Rowan (1990), with the goals of (a) desensitizing the client to the feared stimulus and 'The clinic's populationis primarilyAfricanAmerican;yet, of the 33 clients treated for OCD during this period, only 13 were AfricanAmerican.
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TABLE 1 DEMOGRAPHIC DATAFOR BLACKO C D CLIENTS (n = 13) Status
n
Ethnic Background African American Afro Caribbean African Marital Status (n = 12) Never married Married Divorced Occupation (n = 12) Unemployed Full-time Homemaker Student Retired Primary Symptom (n = 13) Mixed Washers, Doubters, & Checkers Washers/Cleaning Checkers Trichotillomania
Age Length of illness
7 5 1 7 4 1 5 2 2 2 1 4 5 3 1
M 38 years 14 years
Range 19 to 69 years 1 to 45 years
SD 13.25 14.09
Y-BOCS Average Y-BOCS total Average subtotal for obsessions Average subtotal for compulsions Average time spent obsessing Average time spent on compulsions
24.7 (out of 40; S D = 5.00) 10.9 (out o f 20; S D = 3.09) 13.8 (out of 20; S D = 5.01) 3-8 hours a day ("severe") 3-8 hours a day ("severe")
Treatment Outcome for Clients Who Engaged in Exposure and Response Prevention (n = 8) Significant improvement Moderate improvement N o treatment improvement
3 3 2
Note. Y-BOCS = Yale Brown Obsessive-Compulsive Scale (Goodman et al., 1989).
(b) demonstrating that anxiety reduction would occur even in the absence of performing rituals. Periodic home visits, therapist-accompanied field trips, and in-session imaginal exposure are also employed for the same purpose. Our Black clients were generally seen twice a week for 45- to 90-minute sessions for an average o f 37 sessions (range: 8-150). The very wide range of sessions, specifically the long length o f treatment in some cases, appears to be due mainly to our clinic policy that encourages attempting treatment even in cases where there are comorbid psychological disorders or significant psychosocial problems. A wide
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range in length of treatment is typical for our clinic patients as a group, regardless of racial or ethnic background. Notwithstanding, the average length of treatment tends be longer for our Black clients, for reasons detailed later in this paper. Although the majority of patients treated for OCD at our clinic receive both behavioral treatment and medication, our Black clients were more reluctant to agree to a psychiatric consultation for medication. Although medication was recommended by the primary therapist for 60% of the Black clients, less than half of these patients agreed to the medication consultation. There are a number of differences in the presentation and process of treatment between our Black and White patients that relate to secretiveness, family involvement in treatment, general knowledge about OCD, and therapist ethnicity. The first of these, the secretiveness of our Black clients in discussing their symptoms, appears to be an overarching factor related to the other characteristics in more or less direct ways. For example, a desire to keep obsessive-compulsive symptoms from family members has greatly hampered our efforts to include family members as "cotherapists" in treatment. In addition, secretiveness may increase when Black clients are treated by therapists from a different ethnic background. Treatment Differences and Case Illustrations
Secretiveness Clients with O C D often show reluctance or hesitance in discussing their obsessive-compulsive symptoms. Rassmussen and Tuang (1984) have discussed the "secretive and withholding nature of individuals with OCD" (p. 450). It is our overall clinical impression that Black clients are even more reluctant than our White clients to discuss details of their obsessive-compulsive symptoms. This is manifested during the initial evaluation as well as during the treatment phase. An additional observation is that our Black clients, for the most part, are extremely reluctant to involve family in both information-gathering and treatment phases. The importance of secrecy is demonstrated in the following three case examples. Mrs. A, a 37-year-old married woman, originally from Jamaica, was referred from a sex therapy clinic where she had presented with a vague complaint of loss of sexual desire. After a number of unproductive sessions, she reported to the sex therapist, "There's something else I should tell you, because I don't think it's right. I wash things a lot." Once referred to our clinic, she was at first unwilling to discuss her symptoms in detail. After several weeks establishing a trusting relationship with her therapist, she gradually elaborated on her obsessivecompulsive symptoms. Obsessions centered around people and places thought to have a high concentration of germs, such as homeless people, subways, bathrooms, and kitchens. Compulsions included handwashing (10 times a day for 1 minute) and cleaning, both at home and at the home of the woman for whom
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she was a home nursing aide. The fact that her husband worked long hours and that her client was blind and bedridden was a great comfort to her in carrying out her rituals. Although encouraged strongly, she absolutely refused to discuss her O C D with her husband and would not do therapy homeworkwhile he was at home. Mrs. A was strongly motivated for treatment and, despite the limitations brought on by her need for secrecy, she successfully completed therapy in 23 sessions. Ms. B, a 29-year-old pregnant woman, originally from Jamaica, was referred to our anxiety disorders clinic for the treatment of panic attacks and generalized anxiety. In spite of a lengthy initial evaluation of 3 hours (which included administering the ADIS-R; DiNardo & Barlow, 1988), the patient did not admit to any obsessive-compulsive symptoms. Only after six sessions of intervention for her panic attacks and a prolonged structured interview did she finally confide that she had a 15-year history of obsessions. Obsessions at the time of treatment involved fears of dying and of going crazy. She was "convinced and thought all day" that she would die in childbirth. When asked to explain why she believed this to be true, Ms. B related it to her culturally derived belief in voodoo and stated that perhaps someone had placed a "hex" on her. Only after the underlying psychological issues came to light was proper treatment able to be carried Out.
Mrs. C was a 39-year-old unemployed Trinidadian woman living with her husband and two children. During the initial evaluation, she reported a fear of blood, admitting only to symptoms of panic. After pursuing this fear of blood in the second and third sessions, she finally admitted, "I have been obsessed with thoughts for the past 8 years." She described the initial onset of her symptoms as occurring when she would look at dried, red-colored spots on the street and wonder whether she had touched the blood and, therefore, might get ill and spread the illness to her family. She engaged in compulsive activities of cleaning and showering because of her constant fear of contamination. Her initial evaluation by her internist, as well as her previous treatment experiences with mental health professionals, had resulted in the diagnosis of panic disorder with agoraphobia. She had been referred to our clinic by her internist only after she had refused a variety of recommended medical diagnostic procedures. Mrs. C had always kept her O C D secret from her husband and children, even though she reported spending 3 to 5 minutes washing various spots on her house at least 20 times a day, using both bleach and cleanser. She would wash her children's hands repeatedly without offering reasons for her actions. She would also check for red stains on her clothes and, in spite of financial problems, throw out clothes that she felt were contaminated. Mrs. C engaged in a series of elaborate lies to explain the absence of items she had thrown away, such as telling her husband his pants had been stolen at the laundromat. She reported that she "yielded 90% of the time, although I know it's crazy." She had only become willing to engage in treatment because her chronic medical condition had worsened and she was unable to go in for additional medical evaluations.
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Although clients with O C D are characteristically secretive about their disorder, we found that our Black clients are markedly more reluctant than our White clients to discuss the details of their obsessive-compulsive symptoms, which tends to result in increased average lengths o f treatment. Mrs. Ks reluctance during diagnostic interviews, for example, led to initial misdiagnosis of her problems as being of a primarily sexual nature and a fruitless referral to a sexual disorders clinic. Ms. B, as well as many other of our clients, had a history of being inappropriately treated because her reluctance to disclose her symptoms had contributed to the clinician's misdiagnosis. Family Involvement in Treatment We made two interesting observations regarding the role of the family in the diagnostic and treatment process. For the most part, our Black clients were extremely reluctant to involve the family in any part o f the treatment process. In fact, patients made every effort to keep their symptoms a secret from all family members. In addition, we almost never observed family members being drawn into or asked to participate in compulsive rituals (i.e., asking visitors to remove clothes or shoes before entering the house, or insisting that family members wash if they "were contaminated"; Calvocoressi et al., 1995), as is typical of many O C D patients. This is illustrated in the case of Mrs. C, discussed above. Despite acknowledging that her family "really suspects something is wrong with me," she refused to acknowledge that she had O C D or to explain her odd behavior, preferring, as she stated, to allow her children to think she was "just crazy." She steadfastly refused a home visit. After several months of treatment in which there was minimal progress, she agreed to participate in a family meeting, but canceled the appointment and terminated treatment soon thereafter. Experiences such as that with Mrs. C have taught us that it is often necessary to broach the idea of family involvement differently for our Black clients. Successful solutions have included coaching the client on how to convey information to family members rather than insisting on a face-to-face meeting and reconceptualizing our definition of family to include friends and neighbors. In the face of strong resistance, however, we abandoned family involvement rather than risk premature termination. The second observation related to the diagnostic and treatment process for our Black O C D clients was that for those cases in which permission was given and family members were contacted, it was common for them to be exceptionally tolerant of the client's OCD-related activities. This is illustrated in the following two cases. Mrs. F, a 69-year-old African American woman, came to the attention of the clinic through the hospital dermatology department, where she had presented with psoriasis on her hands and arms and thickened scabs on her elbows and knees. She and her daughter both described Mrs. F as "a clean person." She reluctantly reported that she washed her hands approximately 100 times day, washed her clothing in antiseptic solution, and cleaned floors on her hands and
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knees daily. This pattern had begun in early adulthood. Mrs. F rejected our offer of psychological treatment. Mrs2 F stated that her activities gave her something to do, a view shared by the family members with whom she lived, who were only mildly distressed by her rituals. Mr. G. was a 30-year-old single, unemployed African American man who lived with his mother. He was referred to the clinic by his mother because the client was "driving her craz~" Mr. G initially complained only about feeling depressed because he couldn't maintain ajob. Upon probing, he reported washing his hands for approximately 3 minutes throughout the da~ after touching objects like a telephone or coming into contact with people who "looked wrong." The skin on his hands was extremely dry and cracked. He also admitted to compulsively moving household objects from place to place, checking the house for intruders, and making sure doors were locked and the stove was off. He reported never being able to resist these urges: "I get very nervous ifI try to stop." He claimed that he only engaged in this ritualistic behavior in the privacy of his home, but it soon became clear that he rarely left home. Although his mother voiced concern about her son, she tended to minimize his obsessive-compulsive symptoms and to see his problems as related to a lack of social skills and declined to come to the clinic for even a diagnostic consultation. Mr. G's and his mother's refusal to conceptualize Mr. G's problems in terms of O C D made progress in therapy impossible, and treatment was ended after only a few sessions. The secrecy mentioned earlier also adversely affected our ability to involve family in the treatment. A number of therapists specializing in the treatment of O C D have recommended the inclusion of family members to serve as "cotherapists" to facilitate the completion of homework assignments and encourage compliance with treatment (Neziroglu & Yaryura-Tobias, 1991; Steketee & White, 1990). In contrast to our experience with White clients, this is extremely difficult to achieve in our Black OCD cases. Mrs. C's case represents the extreme, in which she ended treatment rather than engage in a family session. Although a significant proportion of our White clients had convinced family members to engage in ritualistic activities (e.g., shower immediately upon returning home) or to assist the client in performing rituals, with few exceptions, our Black O C D clients did not show this pattern. Understanding of O C D Although it is common for O C D clients to have only limited information about the disorder, we found this situation more pronounced for our Black clients. Misunderstanding of the disorder included our observation that all of our Black clients were secretly convinced they were or would become psychotic. Our Afro-Caribbean clients appear particularly fearful of the stigma of mental illness, which may strongly contribute to a reluctance to accept evaluations or treatment with appropriate medication. The fear of being stigmatized as mentally ill and the poor understanding of OCD is evidenced in the case of Ms. H,
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a 33-year-old Trinidadian woman, who had suffered from severe repeating rituals since the age o f 15. Although hospitalized at adolescence for a "nervous breakdown," she did not tell the treatment staffabout her obsessive-compulsive symptoms due to fear that she would be seen as crazy. Ms. H had never fully understood her behavior and had been encouraged to call our clinic only because we had successfully helped a member o f her church. In addition to fear of stigma contributing to a reluctance to receive treatment, almost every client expressed a belief that O C D was "a White person's problem." For example, when questioned, Mrs. A and Mrs. C each reported that this belief derived from television talk shows and magazine articles on OCD, to which they had been exposed, which featured only White sufferers. Each was secretly convinced of being unique among African American women in this sense, and felt that having O C D was particularly unacceptable in the African American culture. Early in treatment, Mrs. C expressed, in fact, that having O C D negated her identity as an African American. In an effort to address our Black clients' sense of isolation, our clinic has started compiling a series of videotapes of Black O C D clients discussing their symptoms and treatment. A number of the clients who volunteered to be videotaped have also offered to make their phone numbers available to new clients to facilitate a support network. Our Black clients who view the videotapes report feeling greatly relieved to know that other Blacks suffer with this disorder. The comfort they derive from this may help motivate clients to do the difficult work of exposure and response prevention. Therapist Ethnicity The majority o f therapists at our clinic are White. Although not an issue in every case involving a Black client, client discomfort with the ethnicity of the therapist is a dimension of the treatment that sometimes needs to be assessed and discussed, as illustrated in the following case example. Mrs. I was a 48-year-old, divorced African American woman who worked at a social service agency. She had a 5-year history of worsening obsessions about personal safety and compulsive checking at home. She reported that she severely restricted her social life to occasional attendance of church services in order to avoid revealing her problem. She was especially concerned about concealing her ritualistic behavior from her siblings during occasional visits to their homes. When visiting these siblings she would wake up 2 to 3 hours before any member o f the family so that she could complete her rituals unobserved. Mrs. I would experience anxiety in the weeks preceding these visits as she rehearsed how she could perform rituals undetected. One o f the initial issues in treatment involved Mrs. I's reluctance to agree to home visits (seen to be crucial in this case) at her apartment building for fear that her neighbors would think the White therapist was a welfare case worker. After some discussion, she decided to tell her neighbors that the therapist was a supervisor from her job coming by with paperwork. With this issue resolved, treatment progressed and, after 12 months, Mrs. I stat-
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ed she was satisfied with being "85% to 90%" improved and declined further treatment. Some of our clients expressed their concern that a White therapist wouldn't understand the stigma of using food stamps or applying for welfare. It can be extremely helpful, early in treatment, to raise this issue of ethnicity. First, it demonstrates to the client that the therapist is open to discussing potentially sensitive issues. This openness in turn often serves to lessen tension where it exists, create a safer therapeutic environment, and promote honesty in the therapistclient relationship. We would like to reiterate that ethnic differences between client and therapist are not necessarily a problem. Some Black clients, when assigned a White therapist, initially experience difficulty trusting that their culture and lifestyle will be understood, and worry that this will impede rapid amelioration of their presenting problem. But as is demonstrated in the case report, this can be overcome with frank discussion of racial differences and concerns early in the treatment process.
Recommendations To summarize our key recommendations for clinical practice: 1. We strongly recommend the use of a structured interview to help overcome reticence in discussing obsessive-compulsive symptoms (Goodman et al., 1989). Structured interviews often help normalize the intake process, and directed questions make evasiveness easier to recognize. 2. In terms of family involvement, expect resistance, and broach the topic carefully and flexibly. We have found that suggesting the involvement of a friend or neighbor may meet with less resistance. In the face of strong resistance, however, we have learned to abandon the idea despite any potential therapeutic benefits later in treatment. 3. It is the clinician's responsibility to raise the issue of cultural and ethnic incongruity between therapist and client. This can both foster a therapeutic alliance, and uncover potentially destructive feelings the client may harbor such as, "You can't understand what it's like to be on public assistance." Ponterotto and Casas (1991) have stated, "Perhaps the strongest criticism leveled at the status of racial and ethnic minority counseling focuses-on inadequate training models and subsequent counseling services. Without quality, culturally relevant and meaningful research, the status of minority mental health counseling stands little chance of witnessing significant improvement" (p. 6). We are pleased to note that this situation is starting to change. One example of this is Chambless and WiUiam's (1995) recent study examining symptom severity and treatment outcome in a relatively large clinical sample of African American and White outpatients with agoraphobia. They found that the Black clients, although similar to Whites on most measures, were more severely phobic, and improved to a somewhat lesser degree with in vivo exposure treatment. These findings,
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when combined with others from studies now in progress, should do much to further our understanding of racial differences in anxiety disorders. Relevant topics for future work in the specific area of O C D are numerous. In terms of etiology, how closely does O C D in minority populations mirror that in the White population? More specifically, what is the role of social factors, such as prejudice, in explaining the Black-White differences we observed? In terms of treatment, what are the effects of matching African American clinicians with African American clients? What is the effect of educational level and socioeconomic status in the provision of culturally informed treatment? Finally, what are the implications of these and other clinical observations for relapse prevention? Given that the preponderance of research on OCD has been focused almost exclusively on White sufferers, a fair question is: Does our knowledge apply equally well to Black clients? We find no particular reason to assume that important factors in the etiology and maintenance of obsessive-compulsive symptoms differ from Whites to Blacks, and, in fact, our observations are that their symptoms are quite similar. However, we do believe that race and ethnicity are sociocultural factors that influence the way individuals present for treatment, what initial diagnosis they receive, and how the treatment process develops. References Adebimpe, V. R. (1981). Overview: White norms and psychiatric diagnosis of Black patients. The American Journal of Psychiatry, 138, 279-285. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Aponte, J. F., Rivers, R. Y., & Wohl, J. (1995). Psychologicalinterventions and cultural diversity. Needham Heights, MA: Allyn & Bacon. Barlow, D. H., & Cerny, J. A. (1988). Psychological treatment ofpanic. N e w York: Guilford Press. Bertschy, G., & Ahyi, R. G. (1991). Obsessive-compulsive disorders in Benin: Five case reports. Psychopathology, 24, 398-401. Calvocoressi, L., Lewis, B., Harris, M., Trufan, S.J., Goodman, W. IC, McDougle, C.J., & Price, U M. (1995). Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry, 152, 441-443. Carey, R.J., Baer, L., Jenike, M. A., Minichiello, W. E., Schwartz, C., & Regan, N.J. {1986). MMPI correlates of obsessive-compulsive disorder.Journal of Clinical Psychiatry, 47, 371-372. Chambless, D. L., & Williams, ICE. (1995). A preliminary study of African-Americans with agoraphobia: Symptom severity and outcome of treatment with in vivo exposure. Behavior Therapy, 26, 501-515. DiNardo, P. A., & Barlow, D. H. (1988). TheAnxiety Disorders Intervknv Schedule-Revised (ADIS-R). Albany: Phobia and Anxiety Disorders Clinic, State University of NewYork at Albany. Foa, E., & Rowan, V. (1990). Behavior therapy of OCD. In A. E. Bellack & M. Hersen (Eds.), Handbook of comparative treatmentsfor adult disorders (pp. 256-265). NewYork: John Wiley & Sons. Friedman, S., Hatch, M. L., Paradis, C., Popkin, M., & Shalita, A. R. (1993). Obsessive-compulsive disorder in two Black ethnic groups: Incidence in an urban dermatology clinic.Journal of Anxiety Disorders, 7, 343-348. Goodman, W. K., Price, L. H., Delgado, P L., Palumbo, J., Krystal, J. H., Nagy, L. M., Rasmussen, S. A., Heninger, G. R., & Charney, D. S. (1990). Specificity ofserotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder: Comparison of fluvoxamine and desipramine. Archives of General Psychiatry, 47, 577-585.
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Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale: I. Development, use and reliability; II. Validity.Archives of General Psychiatry, 46, 1006-1016. Hatch, M. L., Paradis, C., Friedman, S., Popkin, M., & Shalita, A. R. (1992). Obsessive-compulsive disorder in patients with chronic pruritic conditions: Case studies and discussion.Journal of the American Academy of Dermatology, 26, 549-551. Hayes, S. C., & Toarmino, D. (1995). If behavioral principles are generally applicable, why is it necessary to understand cultural diversity? the Behavior Therapist, 18, 21-23. Hollander, E., & Cohen, L. J. (1994). Obsessive-compulsive disorder. In. S. Friedman (Ed.), Anxiety disorders in African Americans (pp. 185-202). New York: Springer. Karno, M., Golding, J. M., Sorenson, S. B., & Burnam, A. (1988). The epidemiology of obsessivecompulsive disorder in five U.S. communities. Archives of General Psychiatry, 45, 1094-1099. Lewis-Hall, F. (1991, July). [Quoted in report]. OCD said to be underdiagnosed in minority populations. Psychiatric Ntnvs, p. 5. Neal, A. M., & Turner, S. M. (1991). Anxiety disorders research with African Americans: Current status. PsychologicalBulletin, 109, 400-410. Neighbors, H. W. (1988). The help-seeking behavior of Black Americans.Journal of the National Medical Association, 80, 1009-1012. Neighbors, H. W., Caldwell, C. H., Thompson, E., &Jackson, J. S. (1994). Help-seeking behavior and unmet need. In S. Friedman (Ed.), Anxiety disorders in African Americans (pp. 26-39). New York: Springer. Neziroglu, F., & Yaryura-Tobias,J. A. (1991). Over and over again. Lexington, MA: D.C. Heath. Paradis, C. M., Friedman, S., Lazar, R. M., Grubea, J., & Kesselman, M. (1992). Panic disorder in an inner-citypsychiatric outpatient department: Results of a structured interview. Hospital and Community Psychiatry, 43, 61-64. Ponterotto, J. G., & Casas, J. M. (1991). Handbook of racial/ethnic minority counseling research. Springfield, IL: Charles C. Thomas. Rassmussen, S. A. (1985). Obsessive-compulsive disorder in dermatologic practice. Journal of the American Academy of Dermatology, 13, 965-967. Rassmussen, S. A., & Tuang, M. T. (1984). The epidemiology of obsessive-compulsive disorder. Journal of Clinical Psychiatry, 45, 450-457. Robins, L. N., Hezler, J. E., Weissmann, M. M., Orvaschel, I. H., Gruenberg, E., Burke, J. D., & Regier, D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry, 41,949-958. Steketee, G., & White, K. (1990). When once is not enough. Oakland, CA: New Harbinger. Weissman, M. M., Bland, R. C., Canino, G.J., Greenwald, S., Hwu, H., Lee, C. K., Rubio-Stipec, M., Wickramaranme, E J., Wittchen, H., & Yeh, E. (1994). The cross national epidemiology of obsessive-compulsive disorder.Journal of Clinical Psychiatry, 55, 5-10. This work was supported, in part, by National Institute of Mental Health Grant #42545 and funds from the Department of Psychiatry's practice plan. An earlier version of this paper was presented at the World Congress of Behavioral and Cognitive Therapies, Copenhagen, July 1995. Correspondence concerning this article should be addressed to: Steven Friedman, Ph.D., Department of Psychiatry, Box 1203, State University of New York Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, NY 11203. RECEIVED:November 22, 1995 ACCCEPTED:September 24, 1996
Behavioral Treatment of ObsessiveCompulsive Disorder in African Americans
Marjorie L. Hatch Southem Methodist University Steven Friedman Cheryl M. Paradis SUNY-Health Science Center at Brooklyn
This paper reviews some important features in the presentation, diagnosis, and treatment of obsessive-compulsive disorder (OCD) in African Americans. Some adaptations to the behavioral treatment of O C D in African Americans are illustrated through the use of case examples. The growing awareness in psychology that cultural and ethnic issues are important factors in effective treatment planning forms the basis for the present paper. African Americans with OCD in particular have tended not to seek help in mental health settings, and there is little published research in this area. Thus, many clinicians and researchers may be unfamiliar with issues relevant to treatment issues of OCD in this population.
As minority groups continue to grow in n u m b e r in the U.S., the need for mental health service will expand, and mental health professionals will be increasingly called, upon to provide culturally relevant services (Ponterotto & Casas, 1991). Although published w o r k addressing racial or ethnic issues in mental health has increased in the past two decades, this work has tended to focus on general issues in counseling (Aponte, Rivers, & Wohl, 1995) or more severe forms o f psychopathology (Adebimpe, 1981). Little work has been done on applying specific cognitive behavioral treatments for different ethnic groups. 303 1077-7229/96/2-303-31551.00/0 Copyright 1996 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.
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Thus, clinicians and researchers are likely to be only minimally familiar with diagnostic and treatment considerations in relation to minority clients with anxiety disorders (Neal 8: Turner, 199/). The present paper seeks to illustrate a culturally informed approach to the behavioral treatment of obsessive-compulsive disorder (OCD) through the description of several case studies of African American clients. OCD is characterized by persistent unwanted thoughts, impulses, or images and repetitive and ritualistic behaviors or mental acts the individual feels compelled to perform (American Psychiatric Association, 1994). These thoughts and urges are frequently experienced as intrusive and senseless. If untreated, OCD is usually chronic, and can significantly disrupt social and occupational functioning. Although the incidence of OCD has been shown to be evenly distributed across racial groups (Karno, Golding, Sorenson, & Burnam, 1988; Robins et al., 1984; Weissman et al., 1994), African Americans either do not appear to present for psychiatric treatment in the same proportion as Whites do, or they do not receive the diagnosis of OCD. In a survey of major OCD treatment centers, for example, Lewis-Hall (1991) found only 30 (2%) African American clients out of a total sample of 1,500 OCD sufferers. In one major medical center with a predominantly Black clientele, she found treatment records for only three African Americans with OCD. Although a detailed analysis of why African Americans have not traditionally sought psychiatric treatment for OCD (as well as for other psychiatric conditions) is beyond the scope of this paper, a few remarks seem in order. It appears that both culturally influenced help-seeking behavior on the part of the anxiety sufferer as well as misdiagnosis on the part of mental health professionals have played a role (Neal & Turner, 1991). Help-Seeking Behavior Neighbors (1988; Neighbors, Caldwell, Thompson, &Jackson, 1994) argued that African Americans most often consult members of their informal social network, including clergy, in times of emotional distress. More specifically, Friedman and colleagues (Friedman, Hatch, Paradis, Popkin, & Shalita, 1993; Hatch, Paradis, Friedman, Popkin, & Shalita, 1992) reevaluated Rassmussen's (1985) hypothesis that people with OCD tend to turn to medical specialists such as dermatologists. Examining the rate of OCD in a group of African American dermatology patients, they found a significantly higher rate ofundiagnosed cases in their sample (15%) than would be expected in a general medical population (2% to 3%). Misdiagnosis Similarly, Paradis and colleagues (Paradis, Friedman, Lazar, Grubea, & Kesselman, 1992) found evidence of misdiagnosis of anxiety disorders by psychiatric staff at an urban outpatient center with a primarily African American
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and Afro-Caribbean population. Clients who were initially diagnosed following a clinical interview by outpatient staff were reevaluated by anxiety disorder clinic staff using the structured Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo & Barlow, 1988). None of the original diagnoses of the 100 clients included a diagnosis of an anxiety disorder. Reevaluation resulted in nearly one-fourth being reclassified as having either a primary or secondary diagnosis of one or more anxiety disorders. It is unclear if the dermatologists in the Friedman et al. study (1993) or the psychiatric staff in the Paradis et al. study (1992) would have had a higher "hit rate" in diagnosing White clients. To our knowledge, the differential ability of mental health professionals to correctly diagnose O C D in members of different ethnic groups has not yet been studied. Adebimpe (1981), in his review of the literature, found that African Americans who presented for psychiatric treatment with an affective disorder were more often misdiagnosed with schizophrenia than were Whites. Thus, another explanation for the assumed rarity of O C D in Blacks has to do with misdiagnosis. In clinical practice, O C D sufferers may present in bizarre ways and are sometimes misdiagnosed as having schizophrenia. In an empirical examination of this observation, Carey and colleagues (Carey et al., 1986) examined the MMPI profiles of a group of 32 O C D patients and found elevations on the Schizophrenia scale. This elevation is consistent with the behavioral presentation of O C D where the patient may present with what appears to be bizarre and senseless behavior and the urge to ritualize. Although Carey et al. did not report on the racial background of their sample, our clinical impression is that it seems likely that misdiagnosis may be even greater for Blacks than for Whites. Previous Research Because there are a limited number of African Americans with O C D in treatment at university and medical school research clinics, this group is not included in research protocols (Lewis-Hall, 1991). Some published case descriptions exist. Perhaps the first published paper on O C D in Blacks was a clinical description of five cases in Benin, Africa (Bertschy & Ahyi, 1991). They reported that two of the five patients had checking rituals, one had obsessive doubting, one had washing rituals, and one had mixed washing and religious obsessions. Furthermore, four out of five patients had a history ofaffective disorder and two had comorbid depressive symptomatolog~. An extensive review of the literature on anxiety disorders in African Americans conducted by Neal and Turner (1991) concluded that there was a complete absence of empirical studies dealing specifically with OCD. Hollander and Cohen's (1994) review article on O C D in African Americans discusses psychopharmacologic treatment considerations and OCD-related disorders, such as trichotillomania. However, they do not present empirical data. This paper seeks to add to the information available on O C D in African Americans by discussing the clinical presentation and treatment of a variety of clients. A case presentation approach may be especially helpful to clinicians who
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lack experience working with this population. Specifically, we discuss the cases by focusing on clinical differences that we have noticed between our African American and White clients and how treatment was modified to make it more culturally relevant and effective. Hayes and Toarmino (1995) pointed out that behaviorally oriented practitioners who employ techniques they believe to apply universally to all individuals nevertheless acknowledge the importance of understanding particular clients' cultural backgrounds. They argued that formulating effective interventions requires taking into account both the client's individual history and the cultural context in which his or her behavior takes on meaning. We agree with Hayes and Toarmino that, despite the general applicability of behavioral principles in the treatment of OCD, understanding cultural differences that distinguish Black from White clients can lead both to improved diagnostic reliability and to more successful cognitive behavioral treatment. Finally, although we focus on differences as a way to highlight how we have modified a treatment protocol originally developed for White O C D sufferers, it is not our intent to suggest that individual differences within the African American community are unimportant in treatment planning.
The Clinical Population The Anxiety Disorders Clinic at the Health Sciences Center o f the State University o f N e w York at Brooklyn serves a primarily African American and Afro-Caribbean clientele. Because a significant number of our clients are from the Caribbean, we will often refer to the racial identity of our clinic group with the racially inclusive term Black. Over the years, the clinic has gained a good reputation in the community, primarily through word of mouth, and we have seen a steady increase in the number of Blacks with O C D who present for treatment. The cases detailed in this report are representative of the 13 African American and Afro-Caribbean people with O C D treated to date at our clinic.' Table 1 shows demographic data for the entire group. It should be noted that in terms of age, marital status, occupation, and symptom severity, this group does not significantly differ from the White clientele at our clinic. Overall, our clients, both Black and White, present with severe cases o f OCD. Our sample of Black clients with O C D (n = 13) scored an average 24.7 on theYale-Brown ObsessiveCompulsive Scale (Y-BOCS; Goodman et al., 1989), which falls in the severe range of impairment. Goodman and colleagues reported pretreatment mean YBOCS scores for two different outpatient groups as 25.3 (+/- 6) and 26.6 (+/- 6; Goodman et al., 1990). The standard treatment for O C D in our clinic consists primarily o f in-session, in-vivo exposure and response prevention as described by Foa and Rowan (1990), with the goals of (a) desensitizing the client to the feared stimulus and 'The clinic's populationis primarilyAfricanAmerican;yet, of the 33 clients treated for OCD during this period, only 13 were AfricanAmerican.
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TABLE 1 DEMOGRAPHIC DATAFOR BLACKO C D CLIENTS (n = 13) Status
n
Ethnic Background African American Afro Caribbean African Marital Status (n = 12) Never married Married Divorced Occupation (n = 12) Unemployed Full-time Homemaker Student Retired Primary Symptom (n = 13) Mixed Washers, Doubters, & Checkers Washers/Cleaning Checkers Trichotillomania
Age Length of illness
7 5 1 7 4 1 5 2 2 2 1 4 5 3 1
M 38 years 14 years
Range 19 to 69 years 1 to 45 years
SD 13.25 14.09
Y-BOCS Average Y-BOCS total Average subtotal for obsessions Average subtotal for compulsions Average time spent obsessing Average time spent on compulsions
24.7 (out of 40; S D = 5.00) 10.9 (out o f 20; S D = 3.09) 13.8 (out of 20; S D = 5.01) 3-8 hours a day ("severe") 3-8 hours a day ("severe")
Treatment Outcome for Clients Who Engaged in Exposure and Response Prevention (n = 8) Significant improvement Moderate improvement N o treatment improvement
3 3 2
Note. Y-BOCS = Yale Brown Obsessive-Compulsive Scale (Goodman et al., 1989).
(b) demonstrating that anxiety reduction would occur even in the absence of performing rituals. Periodic home visits, therapist-accompanied field trips, and in-session imaginal exposure are also employed for the same purpose. Our Black clients were generally seen twice a week for 45- to 90-minute sessions for an average o f 37 sessions (range: 8-150). The very wide range of sessions, specifically the long length o f treatment in some cases, appears to be due mainly to our clinic policy that encourages attempting treatment even in cases where there are comorbid psychological disorders or significant psychosocial problems. A wide
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range in length of treatment is typical for our clinic patients as a group, regardless of racial or ethnic background. Notwithstanding, the average length of treatment tends be longer for our Black clients, for reasons detailed later in this paper. Although the majority of patients treated for OCD at our clinic receive both behavioral treatment and medication, our Black clients were more reluctant to agree to a psychiatric consultation for medication. Although medication was recommended by the primary therapist for 60% of the Black clients, less than half of these patients agreed to the medication consultation. There are a number of differences in the presentation and process of treatment between our Black and White patients that relate to secretiveness, family involvement in treatment, general knowledge about OCD, and therapist ethnicity. The first of these, the secretiveness of our Black clients in discussing their symptoms, appears to be an overarching factor related to the other characteristics in more or less direct ways. For example, a desire to keep obsessive-compulsive symptoms from family members has greatly hampered our efforts to include family members as "cotherapists" in treatment. In addition, secretiveness may increase when Black clients are treated by therapists from a different ethnic background. Treatment Differences and Case Illustrations
Secretiveness Clients with O C D often show reluctance or hesitance in discussing their obsessive-compulsive symptoms. Rassmussen and Tuang (1984) have discussed the "secretive and withholding nature of individuals with OCD" (p. 450). It is our overall clinical impression that Black clients are even more reluctant than our White clients to discuss details of their obsessive-compulsive symptoms. This is manifested during the initial evaluation as well as during the treatment phase. An additional observation is that our Black clients, for the most part, are extremely reluctant to involve family in both information-gathering and treatment phases. The importance of secrecy is demonstrated in the following three case examples. Mrs. A, a 37-year-old married woman, originally from Jamaica, was referred from a sex therapy clinic where she had presented with a vague complaint of loss of sexual desire. After a number of unproductive sessions, she reported to the sex therapist, "There's something else I should tell you, because I don't think it's right. I wash things a lot." Once referred to our clinic, she was at first unwilling to discuss her symptoms in detail. After several weeks establishing a trusting relationship with her therapist, she gradually elaborated on her obsessivecompulsive symptoms. Obsessions centered around people and places thought to have a high concentration of germs, such as homeless people, subways, bathrooms, and kitchens. Compulsions included handwashing (10 times a day for 1 minute) and cleaning, both at home and at the home of the woman for whom
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she was a home nursing aide. The fact that her husband worked long hours and that her client was blind and bedridden was a great comfort to her in carrying out her rituals. Although encouraged strongly, she absolutely refused to discuss her O C D with her husband and would not do therapy homeworkwhile he was at home. Mrs. A was strongly motivated for treatment and, despite the limitations brought on by her need for secrecy, she successfully completed therapy in 23 sessions. Ms. B, a 29-year-old pregnant woman, originally from Jamaica, was referred to our anxiety disorders clinic for the treatment of panic attacks and generalized anxiety. In spite of a lengthy initial evaluation of 3 hours (which included administering the ADIS-R; DiNardo & Barlow, 1988), the patient did not admit to any obsessive-compulsive symptoms. Only after six sessions of intervention for her panic attacks and a prolonged structured interview did she finally confide that she had a 15-year history of obsessions. Obsessions at the time of treatment involved fears of dying and of going crazy. She was "convinced and thought all day" that she would die in childbirth. When asked to explain why she believed this to be true, Ms. B related it to her culturally derived belief in voodoo and stated that perhaps someone had placed a "hex" on her. Only after the underlying psychological issues came to light was proper treatment able to be carried Out.
Mrs. C was a 39-year-old unemployed Trinidadian woman living with her husband and two children. During the initial evaluation, she reported a fear of blood, admitting only to symptoms of panic. After pursuing this fear of blood in the second and third sessions, she finally admitted, "I have been obsessed with thoughts for the past 8 years." She described the initial onset of her symptoms as occurring when she would look at dried, red-colored spots on the street and wonder whether she had touched the blood and, therefore, might get ill and spread the illness to her family. She engaged in compulsive activities of cleaning and showering because of her constant fear of contamination. Her initial evaluation by her internist, as well as her previous treatment experiences with mental health professionals, had resulted in the diagnosis of panic disorder with agoraphobia. She had been referred to our clinic by her internist only after she had refused a variety of recommended medical diagnostic procedures. Mrs. C had always kept her O C D secret from her husband and children, even though she reported spending 3 to 5 minutes washing various spots on her house at least 20 times a day, using both bleach and cleanser. She would wash her children's hands repeatedly without offering reasons for her actions. She would also check for red stains on her clothes and, in spite of financial problems, throw out clothes that she felt were contaminated. Mrs. C engaged in a series of elaborate lies to explain the absence of items she had thrown away, such as telling her husband his pants had been stolen at the laundromat. She reported that she "yielded 90% of the time, although I know it's crazy." She had only become willing to engage in treatment because her chronic medical condition had worsened and she was unable to go in for additional medical evaluations.
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Although clients with O C D are characteristically secretive about their disorder, we found that our Black clients are markedly more reluctant than our White clients to discuss the details of their obsessive-compulsive symptoms, which tends to result in increased average lengths o f treatment. Mrs. Ks reluctance during diagnostic interviews, for example, led to initial misdiagnosis of her problems as being of a primarily sexual nature and a fruitless referral to a sexual disorders clinic. Ms. B, as well as many other of our clients, had a history of being inappropriately treated because her reluctance to disclose her symptoms had contributed to the clinician's misdiagnosis. Family Involvement in Treatment We made two interesting observations regarding the role of the family in the diagnostic and treatment process. For the most part, our Black clients were extremely reluctant to involve the family in any part o f the treatment process. In fact, patients made every effort to keep their symptoms a secret from all family members. In addition, we almost never observed family members being drawn into or asked to participate in compulsive rituals (i.e., asking visitors to remove clothes or shoes before entering the house, or insisting that family members wash if they "were contaminated"; Calvocoressi et al., 1995), as is typical of many O C D patients. This is illustrated in the case of Mrs. C, discussed above. Despite acknowledging that her family "really suspects something is wrong with me," she refused to acknowledge that she had O C D or to explain her odd behavior, preferring, as she stated, to allow her children to think she was "just crazy." She steadfastly refused a home visit. After several months of treatment in which there was minimal progress, she agreed to participate in a family meeting, but canceled the appointment and terminated treatment soon thereafter. Experiences such as that with Mrs. C have taught us that it is often necessary to broach the idea of family involvement differently for our Black clients. Successful solutions have included coaching the client on how to convey information to family members rather than insisting on a face-to-face meeting and reconceptualizing our definition of family to include friends and neighbors. In the face of strong resistance, however, we abandoned family involvement rather than risk premature termination. The second observation related to the diagnostic and treatment process for our Black O C D clients was that for those cases in which permission was given and family members were contacted, it was common for them to be exceptionally tolerant of the client's OCD-related activities. This is illustrated in the following two cases. Mrs. F, a 69-year-old African American woman, came to the attention of the clinic through the hospital dermatology department, where she had presented with psoriasis on her hands and arms and thickened scabs on her elbows and knees. She and her daughter both described Mrs. F as "a clean person." She reluctantly reported that she washed her hands approximately 100 times day, washed her clothing in antiseptic solution, and cleaned floors on her hands and
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knees daily. This pattern had begun in early adulthood. Mrs. F rejected our offer of psychological treatment. Mrs2 F stated that her activities gave her something to do, a view shared by the family members with whom she lived, who were only mildly distressed by her rituals. Mr. G. was a 30-year-old single, unemployed African American man who lived with his mother. He was referred to the clinic by his mother because the client was "driving her craz~" Mr. G initially complained only about feeling depressed because he couldn't maintain ajob. Upon probing, he reported washing his hands for approximately 3 minutes throughout the da~ after touching objects like a telephone or coming into contact with people who "looked wrong." The skin on his hands was extremely dry and cracked. He also admitted to compulsively moving household objects from place to place, checking the house for intruders, and making sure doors were locked and the stove was off. He reported never being able to resist these urges: "I get very nervous ifI try to stop." He claimed that he only engaged in this ritualistic behavior in the privacy of his home, but it soon became clear that he rarely left home. Although his mother voiced concern about her son, she tended to minimize his obsessive-compulsive symptoms and to see his problems as related to a lack of social skills and declined to come to the clinic for even a diagnostic consultation. Mr. G's and his mother's refusal to conceptualize Mr. G's problems in terms of O C D made progress in therapy impossible, and treatment was ended after only a few sessions. The secrecy mentioned earlier also adversely affected our ability to involve family in the treatment. A number of therapists specializing in the treatment of O C D have recommended the inclusion of family members to serve as "cotherapists" to facilitate the completion of homework assignments and encourage compliance with treatment (Neziroglu & Yaryura-Tobias, 1991; Steketee & White, 1990). In contrast to our experience with White clients, this is extremely difficult to achieve in our Black OCD cases. Mrs. C's case represents the extreme, in which she ended treatment rather than engage in a family session. Although a significant proportion of our White clients had convinced family members to engage in ritualistic activities (e.g., shower immediately upon returning home) or to assist the client in performing rituals, with few exceptions, our Black O C D clients did not show this pattern. Understanding of O C D Although it is common for O C D clients to have only limited information about the disorder, we found this situation more pronounced for our Black clients. Misunderstanding of the disorder included our observation that all of our Black clients were secretly convinced they were or would become psychotic. Our Afro-Caribbean clients appear particularly fearful of the stigma of mental illness, which may strongly contribute to a reluctance to accept evaluations or treatment with appropriate medication. The fear of being stigmatized as mentally ill and the poor understanding of OCD is evidenced in the case of Ms. H,
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a 33-year-old Trinidadian woman, who had suffered from severe repeating rituals since the age o f 15. Although hospitalized at adolescence for a "nervous breakdown," she did not tell the treatment staffabout her obsessive-compulsive symptoms due to fear that she would be seen as crazy. Ms. H had never fully understood her behavior and had been encouraged to call our clinic only because we had successfully helped a member o f her church. In addition to fear of stigma contributing to a reluctance to receive treatment, almost every client expressed a belief that O C D was "a White person's problem." For example, when questioned, Mrs. A and Mrs. C each reported that this belief derived from television talk shows and magazine articles on OCD, to which they had been exposed, which featured only White sufferers. Each was secretly convinced of being unique among African American women in this sense, and felt that having O C D was particularly unacceptable in the African American culture. Early in treatment, Mrs. C expressed, in fact, that having O C D negated her identity as an African American. In an effort to address our Black clients' sense of isolation, our clinic has started compiling a series of videotapes of Black O C D clients discussing their symptoms and treatment. A number of the clients who volunteered to be videotaped have also offered to make their phone numbers available to new clients to facilitate a support network. Our Black clients who view the videotapes report feeling greatly relieved to know that other Blacks suffer with this disorder. The comfort they derive from this may help motivate clients to do the difficult work of exposure and response prevention. Therapist Ethnicity The majority o f therapists at our clinic are White. Although not an issue in every case involving a Black client, client discomfort with the ethnicity of the therapist is a dimension of the treatment that sometimes needs to be assessed and discussed, as illustrated in the following case example. Mrs. I was a 48-year-old, divorced African American woman who worked at a social service agency. She had a 5-year history of worsening obsessions about personal safety and compulsive checking at home. She reported that she severely restricted her social life to occasional attendance of church services in order to avoid revealing her problem. She was especially concerned about concealing her ritualistic behavior from her siblings during occasional visits to their homes. When visiting these siblings she would wake up 2 to 3 hours before any member o f the family so that she could complete her rituals unobserved. Mrs. I would experience anxiety in the weeks preceding these visits as she rehearsed how she could perform rituals undetected. One o f the initial issues in treatment involved Mrs. I's reluctance to agree to home visits (seen to be crucial in this case) at her apartment building for fear that her neighbors would think the White therapist was a welfare case worker. After some discussion, she decided to tell her neighbors that the therapist was a supervisor from her job coming by with paperwork. With this issue resolved, treatment progressed and, after 12 months, Mrs. I stat-
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ed she was satisfied with being "85% to 90%" improved and declined further treatment. Some of our clients expressed their concern that a White therapist wouldn't understand the stigma of using food stamps or applying for welfare. It can be extremely helpful, early in treatment, to raise this issue of ethnicity. First, it demonstrates to the client that the therapist is open to discussing potentially sensitive issues. This openness in turn often serves to lessen tension where it exists, create a safer therapeutic environment, and promote honesty in the therapistclient relationship. We would like to reiterate that ethnic differences between client and therapist are not necessarily a problem. Some Black clients, when assigned a White therapist, initially experience difficulty trusting that their culture and lifestyle will be understood, and worry that this will impede rapid amelioration of their presenting problem. But as is demonstrated in the case report, this can be overcome with frank discussion of racial differences and concerns early in the treatment process.
Recommendations To summarize our key recommendations for clinical practice: 1. We strongly recommend the use of a structured interview to help overcome reticence in discussing obsessive-compulsive symptoms (Goodman et al., 1989). Structured interviews often help normalize the intake process, and directed questions make evasiveness easier to recognize. 2. In terms of family involvement, expect resistance, and broach the topic carefully and flexibly. We have found that suggesting the involvement of a friend or neighbor may meet with less resistance. In the face of strong resistance, however, we have learned to abandon the idea despite any potential therapeutic benefits later in treatment. 3. It is the clinician's responsibility to raise the issue of cultural and ethnic incongruity between therapist and client. This can both foster a therapeutic alliance, and uncover potentially destructive feelings the client may harbor such as, "You can't understand what it's like to be on public assistance." Ponterotto and Casas (1991) have stated, "Perhaps the strongest criticism leveled at the status of racial and ethnic minority counseling focuses-on inadequate training models and subsequent counseling services. Without quality, culturally relevant and meaningful research, the status of minority mental health counseling stands little chance of witnessing significant improvement" (p. 6). We are pleased to note that this situation is starting to change. One example of this is Chambless and WiUiam's (1995) recent study examining symptom severity and treatment outcome in a relatively large clinical sample of African American and White outpatients with agoraphobia. They found that the Black clients, although similar to Whites on most measures, were more severely phobic, and improved to a somewhat lesser degree with in vivo exposure treatment. These findings,
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when combined with others from studies now in progress, should do much to further our understanding of racial differences in anxiety disorders. Relevant topics for future work in the specific area of O C D are numerous. In terms of etiology, how closely does O C D in minority populations mirror that in the White population? More specifically, what is the role of social factors, such as prejudice, in explaining the Black-White differences we observed? In terms of treatment, what are the effects of matching African American clinicians with African American clients? What is the effect of educational level and socioeconomic status in the provision of culturally informed treatment? Finally, what are the implications of these and other clinical observations for relapse prevention? Given that the preponderance of research on OCD has been focused almost exclusively on White sufferers, a fair question is: Does our knowledge apply equally well to Black clients? We find no particular reason to assume that important factors in the etiology and maintenance of obsessive-compulsive symptoms differ from Whites to Blacks, and, in fact, our observations are that their symptoms are quite similar. However, we do believe that race and ethnicity are sociocultural factors that influence the way individuals present for treatment, what initial diagnosis they receive, and how the treatment process develops. References Adebimpe, V. R. (1981). Overview: White norms and psychiatric diagnosis of Black patients. The American Journal of Psychiatry, 138, 279-285. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Aponte, J. F., Rivers, R. Y., & Wohl, J. (1995). Psychologicalinterventions and cultural diversity. Needham Heights, MA: Allyn & Bacon. Barlow, D. H., & Cerny, J. A. (1988). Psychological treatment ofpanic. N e w York: Guilford Press. Bertschy, G., & Ahyi, R. G. (1991). Obsessive-compulsive disorders in Benin: Five case reports. Psychopathology, 24, 398-401. Calvocoressi, L., Lewis, B., Harris, M., Trufan, S.J., Goodman, W. IC, McDougle, C.J., & Price, U M. (1995). Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry, 152, 441-443. Carey, R.J., Baer, L., Jenike, M. A., Minichiello, W. E., Schwartz, C., & Regan, N.J. {1986). MMPI correlates of obsessive-compulsive disorder.Journal of Clinical Psychiatry, 47, 371-372. Chambless, D. L., & Williams, ICE. (1995). A preliminary study of African-Americans with agoraphobia: Symptom severity and outcome of treatment with in vivo exposure. Behavior Therapy, 26, 501-515. DiNardo, P. A., & Barlow, D. H. (1988). TheAnxiety Disorders Intervknv Schedule-Revised (ADIS-R). Albany: Phobia and Anxiety Disorders Clinic, State University of NewYork at Albany. Foa, E., & Rowan, V. (1990). Behavior therapy of OCD. In A. E. Bellack & M. Hersen (Eds.), Handbook of comparative treatmentsfor adult disorders (pp. 256-265). NewYork: John Wiley & Sons. Friedman, S., Hatch, M. L., Paradis, C., Popkin, M., & Shalita, A. R. (1993). Obsessive-compulsive disorder in two Black ethnic groups: Incidence in an urban dermatology clinic.Journal of Anxiety Disorders, 7, 343-348. Goodman, W. K., Price, L. H., Delgado, P L., Palumbo, J., Krystal, J. H., Nagy, L. M., Rasmussen, S. A., Heninger, G. R., & Charney, D. S. (1990). Specificity ofserotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder: Comparison of fluvoxamine and desipramine. Archives of General Psychiatry, 47, 577-585.
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Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale: I. Development, use and reliability; II. Validity.Archives of General Psychiatry, 46, 1006-1016. Hatch, M. L., Paradis, C., Friedman, S., Popkin, M., & Shalita, A. R. (1992). Obsessive-compulsive disorder in patients with chronic pruritic conditions: Case studies and discussion.Journal of the American Academy of Dermatology, 26, 549-551. Hayes, S. C., & Toarmino, D. (1995). If behavioral principles are generally applicable, why is it necessary to understand cultural diversity? the Behavior Therapist, 18, 21-23. Hollander, E., & Cohen, L. J. (1994). Obsessive-compulsive disorder. In. S. Friedman (Ed.), Anxiety disorders in African Americans (pp. 185-202). New York: Springer. Karno, M., Golding, J. M., Sorenson, S. B., & Burnam, A. (1988). The epidemiology of obsessivecompulsive disorder in five U.S. communities. Archives of General Psychiatry, 45, 1094-1099. Lewis-Hall, F. (1991, July). [Quoted in report]. OCD said to be underdiagnosed in minority populations. Psychiatric Ntnvs, p. 5. Neal, A. M., & Turner, S. M. (1991). Anxiety disorders research with African Americans: Current status. PsychologicalBulletin, 109, 400-410. Neighbors, H. W. (1988). The help-seeking behavior of Black Americans.Journal of the National Medical Association, 80, 1009-1012. Neighbors, H. W., Caldwell, C. H., Thompson, E., &Jackson, J. S. (1994). Help-seeking behavior and unmet need. In S. Friedman (Ed.), Anxiety disorders in African Americans (pp. 26-39). New York: Springer. Neziroglu, F., & Yaryura-Tobias,J. A. (1991). Over and over again. Lexington, MA: D.C. Heath. Paradis, C. M., Friedman, S., Lazar, R. M., Grubea, J., & Kesselman, M. (1992). Panic disorder in an inner-citypsychiatric outpatient department: Results of a structured interview. Hospital and Community Psychiatry, 43, 61-64. Ponterotto, J. G., & Casas, J. M. (1991). Handbook of racial/ethnic minority counseling research. Springfield, IL: Charles C. Thomas. Rassmussen, S. A. (1985). Obsessive-compulsive disorder in dermatologic practice. Journal of the American Academy of Dermatology, 13, 965-967. Rassmussen, S. A., & Tuang, M. T. (1984). The epidemiology of obsessive-compulsive disorder. Journal of Clinical Psychiatry, 45, 450-457. Robins, L. N., Hezler, J. E., Weissmann, M. M., Orvaschel, I. H., Gruenberg, E., Burke, J. D., & Regier, D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry, 41,949-958. Steketee, G., & White, K. (1990). When once is not enough. Oakland, CA: New Harbinger. Weissman, M. M., Bland, R. C., Canino, G.J., Greenwald, S., Hwu, H., Lee, C. K., Rubio-Stipec, M., Wickramaranme, E J., Wittchen, H., & Yeh, E. (1994). The cross national epidemiology of obsessive-compulsive disorder.Journal of Clinical Psychiatry, 55, 5-10. This work was supported, in part, by National Institute of Mental Health Grant #42545 and funds from the Department of Psychiatry's practice plan. An earlier version of this paper was presented at the World Congress of Behavioral and Cognitive Therapies, Copenhagen, July 1995. Correspondence concerning this article should be addressed to: Steven Friedman, Ph.D., Department of Psychiatry, Box 1203, State University of New York Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, NY 11203. RECEIVED:November 22, 1995 ACCCEPTED:September 24, 1996