Obsessive Compulsive Disorder (13 page)

Once the therapist and the young person have established that intrusive thoughts are normal, not bad and something which we can’t and shouldn’t try to control, the therapist then moves on to thinking with the young person that if the problem is not the intrusive thought, which part of the formula-Planning and carrying out treatment 63

tion helps them to understand where the problem lies? As with the vicious cycles, it can help to give real life examples or role play and think about two young people with the same thought (e.g. ‘Have I left my hair straight-eners plugged in?’ or ‘Have I left the computer turned on?’) that respond to it in a different way (e.g. one thinks ‘There could be a fire and our house could burn down and it would be my fault’ and so goes back and checks or asks their mum if they have left the plug in, while the other thinks ‘That’s just a silly thought’ and carries on without doing anything). Once the young person reaches the conclusion that it is the meaning of the thought or how the thought is interpreted that is important, it is helpful to think further about how different thoughts mean different things to different people at different times. This is particularly relevant for young people who have thoughts about harming others and have beliefs around them being a bad person.

Therapist:
Jack, I want you imagine that there is a boy sitting in the chair next to you and he is crying because he has just had a picture in his head and the picture is of him being in church and him shouting swear words at God. What kind of boy would find that picture so upsetting?

Jack:

I think he would be religious?

Therapist:
How come?

Jack:

Because he cares about God and that’s why he is so

bothered.

Therapist:
I see. Yes, that makes sense. So, I’m wondering what your thought means about you?

Jack:

I thought it meant I was a bad brother, but now I think it means I love my brother and that’s why it makes me feel like crying when I get the thought.

Therapist:
Okay, so you thought you were a bad brother but now you realise that actually it is the complete opposite. OCD made you think you were a bad brother but we know that really you are a lovely brother and that’s why you felt so sad. I think I get it. That’s why OCD is so sneaky, it actually picks things that we really care about and tends to pick people who are most bothered by these thoughts. But the good news is it also picks the people who are least likely to do these things because they care so much.

• Psychoeducation enables the young person and their family to think differently about the OCD.

• Most of the population experience the same kinds of intrusive thoughts, urges or images as people with OCD, but it is the meaning they attach to them that is the problem.

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• It is impossible to get rid of intrusive thoughts completely or to be able to control them and so the aim of therapy is to think about them in a different, less threatening way.

Understanding how anxiety works

The therapist should also explore the young person’s beliefs about what will happen to their anxiety if they do not perform a compulsion or take other action, such as avoidance. For example, Katie was a 14-year-old girl who had been badly bullied at school. Although the bullying had stopped, she had a great number of obsessional worries, including about being bullied again. As a result, she repeated actions a certain number of times, such as going through doorways a lucky number of times. She believed that by doing this she was making sure that she would not be bullied again. She also believed that if she did not do the compulsions, she would be so worried that she would not be able to deal with it and her anxiety would ‘go through the roof ’. Figure 4.2 shows the graph that Katie drew to illustrate what OCD

had been telling her would happen if she did not do compulsions. The therapist then went on to explain to Katie how anxiety works:
Therapist:
Katie, we know a bit about how anxiety or worry works generally and that when we feel worried a chemical called adrenalin pumps through our body and sends lots of energy to our muscles. So if you imagine being an animal in the jungle centuries ago, this helps you to run away if you are in a dangerous situation. But it only works for short periods of
Figure 4.2

Katie’s graph showing what OCD predicts will happen to her anxiety if she does not do a compulsion

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time to get you out of the situation and then it goes down.

Can you draw me a graph like before, but this time, show anxiety going up and then slowly going down in a curve?

Katie then draws another graph (see Figure 4.3).

Therapist:
What we also know is that for most people, their anxiety works like this and that includes situations like OCD. What I’m interested to know is whether this could be the same for you? Are there ever times when you have gone against what OCD has told you to do?

Katie:

I don’t know. I can’t think of any times I haven’t done what OCD says.

Therapist:
Are there any other times when you have felt nervous or worried, like before a test?

Katie:

I was nervous before a race on Sport’s Day.

Therapist:
And what happened to those feelings?

Katie:

Once I started running they weren’t so bad and after a bit I forgot about it.

Therapist:
So which of these two graphs did it look like?

Katie:

This one [points to Figure 4.3].

Therapist:
What do you think that might mean in OCD situations?

Katie:

I suppose it could be the same.

Therapist:
Okay, so let’s imagine that you go against what the OCD

says and you find out that your anxiety goes down. What would you imagine might happen the next time?

Katie:

Well, if nothing bad happened, I think it could get easier?

Therapist:
How come?

Katie:

Well I’ve done it before, so I know it’s going to be okay.

Therapist:
And if you did it again?

Katie:

I think if I did it enough times and nothing bad happened then I wouldn’t be worried any more.

Figure 4.3

Katie’s graph showing what normally happens to anxiety 66

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Figure 4.4

Katie’s graph showing what could happen to anxiety over time if you do not do a compulsion

Therapist:
So can you show me what that would look like with another graph?

Katie draws another graph (see Figure 4.4).

Therapist:
So, how do we find out if it works like this for you?

Katie:

I could try not to do something four times and just do it normally?

Therapist:
And what would you predict would happen?

Katie:

OCD would predict it would go through the roof, but I think that it might work like it did when I did on Sport’s Day and after a while it might go down.

Therapist:
That sounds like a good way to find out.

It can also be useful at this point to have a conversation about what OCD is currently doing to the young person’s levels of anxiety. Most young people will soon realise that although doing a compulsion helps in the moment because it reduces their anxiety, it does not help in the longer term as the next time they get an intrusive thought or urge their anxiety goes up just as high and they spend their day-to-day life going up and down the ‘anxiety yo-yo’ (see Figure 4.5).

Figure 4.5

What happens to anxiety if you do compulsions

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• The therapist should explore the young person’s beliefs about what will happen to their anxiety if they do not perform a compulsion or take other action such as avoidance.

• Psychoeducation about how anxiety works can be helpful in challenging beliefs.

Goal setting

Within the first two sessions it is important to establish clear, realistic goals for treatment. At times, it can be tempting to overlook the importance of establishing goals, especially if there is time pressure or a desire to begin treatment as soon as possible. Although there may be times when you can get away without establishing clear goals, this can lead to later problems.

This is because part-way through treatment the young person will often appear to reach a halt in therapy. Progress is not as fast as could be expected, or perhaps the young person fails to see any personal usefulness in carrying on with treatment. It is important to remember that for many young people the reason they present for treatment is because an adult in their lives, typically one of their parents, has decided for various reasons that the young person needs help (e.g. disruption in routine, school or family functioning).

However, these reasons will not always be the same as those that motivate a young person to engage in treatment for OCD. It is for this reason that the clinician should carefully consider who is in the room while discussing goals.

While it can be helpful to have a parent suggest useful goals, if they are not the same as the young person’s and/or they are unable to express a difference of opinion, these goals may end up being that of the parent or therapist rather than those of the young person. This could potentially reduce motivation and result in difficulties during treatment. The problem with unclear or inaccurate goals is particularly apparent when it is time for the young person to translate what they have learnt about OCD into real-life experiments, such as stopping rituals in order to find out if their problem is about worry or real danger. If the young person views such tasks as particularly distressing, and cannot see how it would be useful to their life, they will be less inclined to carry out such experiments. With this is mind, it is often useful to see the young person alone, as well as with their parents, while creating goals.

When establishing goals, it is helpful for the young person and the therapist to break these into short, medium and long-term goals. Short-term goals involve tasks that the young person can achieve from session to session and begin working on immediately, such as understanding how OCD works or stopping particular rituals in order to find out if the problem is about worry or danger. In contrast, tasks that can be achieved by the end of 68

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treatment are described as medium-term goals and may include stopping all rituals, accepting intrusions as normal and allowing intrusions to remain in the mind. Compiling a list of goals can also clarify any misunderstandings that the young person may have about the way OCD works. For example, a young person who does not fully understand that intrusions are a normal part of life for everyone may be surprised to hear that treatment does not aim to get rid of all intrusive thoughts. Long-term goals involve dreams and hopes for a future that does not involve OCD. These can include things such as learning to drive, going to college or university, going travelling, being in a relationship or pursuing a particular career. It is important not to underestimate the importance of long-term goals because some young people truly believe that many possibilities for the future are lost to them forever because of their OCD. Lost dreams and hopes may also be inadvertently reinforced by parents who verbally express fears about their child’s future and what they believe the young person can or cannot do. It is important to address these limitations by rediscovering what kind of future the young person would like and to help them to understand that every goal for the short and medium term is an important stepping stone toward achieving their dreams and hopes for the future.

It is important to establish the young person’s short, medium and long-term goals.

Building an alternative view of the problem

By this point in therapy, the therapist and young person will have made sense of the problem and learned that OCD has been telling them that they need to do certain things to get rid of their worries. However, they will have started to consider the possibility that undertaking their solutions to the perceived danger (e.g. rituals, avoidance, looking for danger and reassurance seeking) actually keep their worry going by stopping them from finding out that their solutions are not responsible for preventing harm. It can be helpful at this point to suggest that OCD has been telling them that the world works in a certain way, but that actually it may work in a completely different way and that at the moment it is not really clear which is right. Up until now OCD will have been giving the young person the impression that their problem is about real danger, in that bad things are going to happen if they do not do their rituals. Introducing an alternative view, that their problem is about worry, can be more effective than trying to disprove their current OCD-driven ‘danger’ view and can then provide the backdrop for the remainder of treatment. Behavioural experiments and cognitive techniques can be designed to test out the evidence for these two opposing views of how their problem and the world really works.

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Thus, the cognitive model of OCD can be simplified by writing two contrasting explanations about OCD that can be tested through experiments. The first, which is the explanation required for OCD to survive, might be written as follows:
The Problem is Danger: ‘You truly are in danger from
harm and you must do whatever you can to prevent this harm from happening.’

The second and alternative explanation would look something like this:
The
Problem is Worry: ‘You are a sensitive person who worries that things are more
dangerous than they are and you try too hard to stop this worry. All the things
OCD gets you to do make the worry worse.’
At this point in therapy it is helpful to encourage the young person to seriously consider each explanation by asking them if the problem really is about danger and they can prevent this harm, what should they do (i.e. carry out rituals)? In contrast, if the problem is about worrying that things are more dangerous than they actually are and trying too hard to make the worry go away, then what should they do (i.e. stop rituals)? It is important that each view and its ensuing actions are made as explicit as possible, so that the young person has a foundation on which to layer any new information gained from future experiments.