Obsessive Compulsive Disorder (11 page)

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March and Mulle’s treatment involves a cognitive component, in that youngsters learn cognitive tactics for resisting OCD, such as construct-ive self-talk (‘bossing back the OCD’) and positive coping strategies to use during exposure and response prevention (ERP). In contrast, this approach sees faulty cognitions at the heart of the problem and so treatment focuses on psychoeducation about thinking in OCD, works to identify the young person’s beliefs and then tests out whether these beliefs are true.

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This is done through behavioural experiments that are set up in order to find out how the world really works. This differs from traditional approaches where the cornerstone of treatment is ERP, involving a graded hierarchy that the young person works their way through. Within our approach, there is no hierarchy as young people are encouraged to carry out experiments that relate to their specific beliefs and treatment goals. Rather than having a list of tasks that they have to work through, they are encouraged to take a curious stance to try to understand how the problem is working and experiments are devised in order to learn information. Very often the young person will choose to start with tasks that are less anxiety provoking in order to be able to achieve them and leave the most difficult experiments to later sessions. However, this comes from the child, giving them more flexibility and allowing them to feel more in control of the process.

• OCD arises from misunderstanding thoughts.

• Behavioural experiments are designed to test specific predictions.

Number of sessions

Before treatment begins, it is helpful to give the young person and family an idea of the number of sessions that may be required. This can assist the young person to feel that the problem is treatable and that they will not need therapy indefinitely. It can keep momentum going and also supports the idea of the young person taking increasing amounts of responsibility in therapy as they work towards ending treatment. The number of sessions will depend on the severity of the problem as well as any comorbid problems or
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other issues that may need to be addressed. Treating the OCD may have a beneficial effect on other problems (especially other anxiety disorders) as the young person learns skills that they can apply elsewhere. However, it may be necessary for treatment also to focus on other problems, such as self-esteem or family factors. While a young person with mild to moderate OCD and little comorbidity may require as few as five treatment sessions, youngsters with more severe problems are likely to benefit from a greater number and clinicians may need to consider somewhere between 12 and 20 sessions. Although there is a relationship between early response in treatment and success at follow-up (e.g. Allsopp and Verduyn, 1988), there is also evidence to suggest that initial non-responders may show significant improvements when therapy is extended (e.g. de Haan
et al.
, 1998), so clinicians should always ensure that the young person has received an adequate dose of CBT.

Planning treatment

At the end of the initial assessment, the therapist should be clear that the primary problem is OCD and remain aware of any other existing diagnoses and how they interact with the young person’s OCD. The therapist will have gained information about other factors that may be relevant in planning treatment, such as how the OCD is managed within the family and the impact on school functioning. By this stage, they will have collected much of the information necessary to begin making sense of the problem, understand why the problem has persisted for so long and why it has been so difficult to get rid of it. Specifically, it is helpful to have an idea about any triggers and precipitating factors that may be maintaining the OCD before treatment begins.

When planning the first session, the therapist needs to think about who should actually be in the room for the session. This decision will be driven by factors such as the initial formulation about how the problem is working and the wishes of the young person. If family members are present, it can be helpful to share the formulation and any psychoeducation about the nature of intrusive thoughts and anxiety. There are good reasons to include family members if the therapist believes that their behaviour may be maintaining the problem, for example, through giving reassurance or undertaking compulsions for the young person. It can also be helpful to have family members present if the assessment has highlighted that the young person tends to minimise the extent of their OCD. However, this must be balanced with the views of the young person and for adolescents especially having family members present may not always be appropriate. For example, the presence of the parent may be a form of reassurance, or the parent may be highly critical or anxious within the session (e.g. speaking on behalf of the young person too much). In other cases, the young person may find it hard to talk openly in front of their parents or they may feel responsible for not worrying 54

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their mum or dad with their concerns. In these cases, it may be possible to negotiate other solutions with the young person, such as taping or videoing the session and allowing family members to watch or listen to some or all of them, having them present for certain parts of the session or having some time with the family members alone to go through important issues at the end of the session.

Carrying out CBT

At the beginning of the first session, it is important that the therapist provides information about the nature and process of CBT: 1

The therapist explains that they will all be
working as a team
to try and deal with the problem.

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In many ways
the young person is the ‘expert’
because they are the one who knows how their OCD works on a day-to-day basis. It can be helpful to emphasise that one of their jobs is to teach everyone else about the problem so everyone understands how it currently works.

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It is helpful if the young person understands that
CBT is an active
treatment
where they will have to try out different and new ways of dealing with the problem. This can be achieved by asking the young person what problems they anticipate if the sessions just involved talking about the OCD and not trying out anything new.

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The importance of
trying out tasks outside the sessions
needs to be highlighted and again it can be helpful to get the young person to think about the purpose of these tasks to build motivation and encourage the young person to ‘own’ them. Tasks between sessions are not just for the young person and there may be times when it is appropriate for the therapist or family members to try things out to get extra information and model tackling the problem.

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The therapist should inform the young person that each session will
start by setting an agenda
so that they can plan and prioritise what they are going to talk about during the session. The young person and family members should be encouraged to add items to the agenda and be involved in deciding what the most important things to be covered are.

• When planning the first session, the therapist needs to think about who will be in the room for sessions.

• At the beginning of the first session, the therapist needs to provide information about the nature and process of CBT.

• The young person needs to understand that CBT is an active
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treatment that involves trying out different and new ways of dealing with the problem.

• Sessions start by setting an agenda to plan and prioritise what they are going to talk about during the session.

The young person’s understanding of OCD

At the beginning of therapy, the therapist will aim to explore the young person’s understanding of OCD, and specifically what they think obsessions and compulsions are and how they relate to each other. There may be some words that the young person feels uncomfortable with, for example, some young people prefer not to use the word ‘ritual’ as for them it conjures up ideas of witchcraft. Consequently, this discussion should also involve finding out what the young person already calls or would prefer to call obsessions (e.g. ‘worries’ or ‘thoughts’), compulsions (e.g. ‘habits’, ‘rituals’, ‘jobs’) and the OCD generally (e.g. ‘OCD’, ‘the worry monster’). This also helps to externalise the OCD and reinforce the idea that it is the OCD that is the problem, not the young person.

Making sense of the problem

Once this is established and the young person can clearly identify the difference between obsessions and compulsions, the focus of the first treatment session is to gain a greater understanding of the problem. The young person and the therapist begin to build a picture of how the problem is working. It can be helpful to begin by asking the young person to think of a recent time where OCD was a problem. They should try to recall a time that is fairly fresh in their memory and that is typical of how the problem often arises.

Once they have identified a time, the therapist encourages them to tell them more about the situation in order to prime their memory. This includes when it was, where they were, whether anyone else was present and what happened just before. It is important to remember that the trigger to an episode of OCD can be external (e.g. seeing something on television) or internal (e.g.

remembering something bad that has happened in the day). Once this has been established, the therapist moves on to help the young person identify what was going through their mind, what they made of the thought (or picture or urge), how it made them feel and what it made them do. The therapist should frequently summarise what they have learned in order to clarify their understanding and make the young person feel that the problem is understood. As well as asking about compulsions, it is important to prompt for other behaviours that may contribute to the maintenance of the 56

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problem, including any avoidance, reassurance seeking, hypervigilance (i.e.

being on the alert and looking out for danger), emotional responses, arguing or trying to push the thought out.

Jack was an 11-year-old boy who described a range of obsessions and compulsions which had been around for a few years. One of the most disturbing obsessions for him was the thought or image of harming his younger brother Charlie. Jack and his therapist used this obsession to start to develop an understanding of how the problem was working:
Therapist:
So Jack, if I’ve got this right, you were in the park with your brother Charlie and your dad and it was Sunday afternoon and you had just finished a game of football. You and Charlie decided to climb onto the climbing frame and you were right at the top.

Jack:

That’s right and I was feeling happy because I had scored a goal.

Therapist:
Okay and you were feeling happy because you had just scored a goal. So what was the first sign of trouble?

Jack:

I was leaning over the bar at the top of the climbing frame and suddenly imagined Charlie lying under the bar and me squashing him. I started to feel really sad and wanted to go home. I started to cry and Charlie wanted to know why but I couldn’t tell him. I told Dad that I wanted to go home.

Therapist:
And when you had that picture of squashing Charlie under the climbing frame, what did you believe that meant?

Jack:

That the next time Charlie and I might be playing in the park, I might do it, but I wouldn’t!

Therapist:
Even though you know you wouldn’t, you felt worried that the next time you and Charlie were playing in the park you might squash him.

Jack:

Yes.

Therapist:
And so you felt sad and wanted to go home.

Jack:

Yes.

Therapist:
Other than sad, did it make you feel anything else?

Jack:

I felt guilty, like I’m a bad brother, and I felt hurt.

Therapist:
That doesn’t sound like a very nice feeling. When you had that picture of squashing Charlie did you do anything to try to make the thought better?

Jack:

Yes, I touched the climbing frame and thought that I love Charlie and when I got home I told Mum what I had thought and asked her whether I would really do it and she said not to worry about it.

Therapist:
Did you do anything else, like staying away from Charlie or anything you thought could be dangerous?

Jack:

Well I didn’t really want to play with Charlie later in case I did something and also I made sure that there wasn’t anything in the playroom that I could use to squash him.

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Therapist:
And when you had that thought of squashing Charlie, did you try and push the thought out or argue against it?

Jack:

I tried to argue with the thought. I tried to say to myself that I would never do it.

At this stage it is often helpful to have a discussion about knowing things in your head and knowing them in your heart. Jack describes how he knows that he would not hurt Charlie but also describes feeling that he might do it.

Typically, the person ‘knows’ that their obsessions may be senseless, but in the situation ‘feels’ differently. As a result, they may feel embarrassed in the session when they are identifying their intrusive thoughts. At this time, it can be helpful for the therapist to say something like ‘I’ve learned that OCD

doesn’t work at a brain level and that is not about what you know in your head but what you feel in your heart’ and to check out with the young person if they feel that this is the case for them too. Making this differentiation now can be helpful later on in therapy when the therapist is trying to track belief change so that the young person understands that the focus is on what they believe at the time of the obsession rather than later, in the session.