The Bizarre Ritual Counter

   This case reported by Neale et al. (1982), illustrates the employment of reaction formation as a coping mechanism in response to unacceptable impulses. The patient, Karen, was a 30 year-old married woman and the mother of four children who was subjected to two sources of stress: a chronically unhappy marital relationship and disciplinary problems in managing her children. Her husband became physically debilitated due to a serious heart condition. Karen took all the responsibility for the household chores and family errands. "Her days were spent getting the children dressed, fed, and transported to school; cleaning; washing; shopping; and fetching potato chips, dip, and beer whenever Tony [her husband] needed a snack" (p. 2). Karen resented her children due to their difficult disciplinary problems, which she had to cope with alone, and particularly because they constituted an obstacle in fulfilling her desire to leave the marriage.

     Karen became increasingly depressed by her living conditions. Karen began to experience intrusive, repetitive thoughts related to her children’s safety. Often she imagined that a serious accident occurred, and was unable to keep these thoughts out of her mind. Her daily activities became seriously disrupted by an extensive series of counting rituals. For example, Karen believed that if she purchased the first product on the shelf, something horrible would occur to her oldest child. If she selected the second item, a disaster would come to her second child, and so on for all four children. Additionally, the patient attributed significant meaning to the children’s ages. Her compulsive rituals were generalized to several other activities, such as the pattern in which she smoked cigarettes and drank coffee (e.g., if she smoked one cigarette she continued to have at least another four in a row, believing that one of her children would be harmed if she would not do so). It seems that counting rituals enabled her to repress stressful thoughts relating to her marital life and that she intuitively chose these symptoms primarily because they reduced her fear of losing control over her unacceptable feelings of hostility toward her children. As noted by Neale et al. (1982), "instead of injuring the children, she spent a good deal of time every day performing irrational responses aimed at protecting them" (p. 12). Further, although Karen’s bizarre rituals did not physically distance her from the original stressors (i.e. husband and children), they were time consuming enough to provide temporary relief. As noted by Neale et al. (1982), the symptoms ensured that she would be away from her home for extended periods of time. If she went to her neighbor’s house for coffee, she would be gone for at least 2 hours before she could consume enough cups and smoke enough cigarettes to satisfy the rituals. Grocery shopping, which she did by herself, had also turned into a long, complicated process. (p. 13).

    Another factor which affected her specific choice was availability of rituals in her "premorbid" state. "Her family was deeply religious, and she was raised to be a devout Roman Catholic…The formal rituals of the church played an important role in her life" (p. 3). The high prevalence of OCD among religious subjects (e.g., Abramowitz et al., 2004), and the excessive religious themes in their obsessive thoughts and compulsive rituals (e.g., Greenberg & Witztum, 1994; Raphael, Rani, Bale, & Drummond, 1996; Rasmussen & Eisen, 1992; Steketee, Quay, & White, 1991), can be viewed as a deliberate exaggeration of the available behavioral repertoire for purposes of pathological coping purposes.

    Some indication that she was satisfied with her intuitive choice is reflected by her statement that she acknowledged the irrationality of her behaviors, but nevertheless felt much more comfortable when she observed them conscientiously. Similarly, when a patient like Karen performed compulsive counting rituals to protect her parents from injury was pressed, "She agreed that her rituals did not afford them direct protection but felt that the rituals were helpful in the same way prayers are. She concluded that her rituals were irrational only to the extent that prayers are irrational" (Rachman & Hodgson, 1980, p. 19; See also a case study by Rofé, 2010).

     This case also meets PBT's criteria of madness: (1) the OCD symptoms heavily occupied her attention and severely disrupted her daily functioning; (2) onset was spontaneous, in the absence of an event that could account for the severe behavioral change; (3) although the patient rationalized her behaviors as protective measures for her children, she was clearly unaware of the underlying causes of her symptoms; (4) her symptoms were obviously rare (the total prevalence of all OCD is less than 2%); (5) regarding social judgment – the mental health system would have classified her as “bizarre”, which is also the case with OCD symptoms (e.g., see Erdelyi, 1985; Shevrin &Dickman, 1980). Additionally, the patient's symptoms were preceded by stress and she suffered from an intense level of depression.