Obsessive Compulsive Disorder (15 page)

For example, ‘It seems I have made a bit of a mistake here as I don’t think we should have tried this experiment quite yet. Let’s try something else now instead – what do you suggest?’

An additional reason why young people stop engaging in behavioural experiments is if they are constantly discounting results from them and therefore do not see the purpose of trying any more experiments. For example, they may think of harm and it does not occur and rather than conclude that thoughts do not cause harm, they may dismiss these results. If this occurs the therapist should cease trying to get the young person to conduct experiments that focus on disproving danger and instead shift to discussion and experiments that focus on proving the problem is worry (i.e.

the more you do your rituals, the more you worry, and the more you argue with OCD and listen to his lies and discounting, the more you worry, so it is
Planning and carrying out treatment

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better to stop listening to him completely and stop rituals and just carry on with life).

Another common obstacle to treatment success is when the young person has started to make some positive changes but then gets to the stage where they do not want to push on any further in case they ‘rock the boat and things go wrong’. In this instance it can be useful to use the analogy of ‘digging weeds out of the garden’, whereby the therapist asks the young person what problems they can see with someone just mowing over weeds in their garden to get rid of them (i.e. they will keep growing back). The therapist should ask the young person what they think would be a better solution to the weeds (such as pulling them out by the roots) and then help them to consider how this might relate to their OCD (i.e. unless they keep going and get right to the roots and really disprove the OCD it is likely to creep back in). Thus, despite some improvement the young person might complain that they are still bothered by intrusive thoughts about harm and responsibility.

In this situation, it is quite possible that they are still carrying out rituals on occasion and the therapist should ask the young person if this is the case, for example, ‘You have been doing really well in therapy so far, but I have just started to wonder if perhaps OCD is still getting you to do back-up rituals every once in a while. Do you think this could be happening?’ Then ask ‘What could be the problem with doing back-up rituals?’ ‘Why do you think I am concerned about the idea of you doing any back-up rituals at all, no matter how small?’ This encourages the young person to consider that this may stop them from completely finding out that they are not responsible for preventing harm.

Another strategy that can be helpful if motivation to (continue to) change becomes an issue is to go back to the young person’s goals and remind them that every little thing they do is actually helping them move along the path toward achieving their goals. It can be especially useful to refer back to the longer term goals as these relate to the young person’s dreams of what life would and could be like if OCD was eradicated from their life. Additional strategies such as reviewing the pros and cons or conducting a ‘cost-benefit analysis’ of staying as they are or attempting more things can also be helpful when trying to build motivation for further change.

If the young person appears unwilling to engage in treatment it is important to take a step back and address this.

Creating a blueprint and developing a setback plan
A blueprint of therapy aims to help the young person pull together what they have learnt about how their OCD works and the strategies that have been helpful in trying to eradicate OCD from their life. A blueprint also aims 76

Waite, Gallop and Atkinson

to plan for setbacks that the young person may encounter once treatment has come to an end. Creative techniques such as doing a documentary style video or doing a collage can be useful in helping the young person summarise treatment in this way. The therapist should begin with briefly reviewing the history of the young person’s OCD and how it took hold of them. This can be done verbally by asking the young person to talk about their formulation of OCD or by asking the young person about their understanding of when and why things started to go wrong. It is helpful to reiterate that OCD

took over due to their faulty beliefs (about the meaning of the intrusions) and them coming up with solutions that ultimately became the problem.

The therapist should then introduce the idea of setbacks to the young person and if possible should try to inoculate the young person against failure by normalising the occurrence of setbacks and reframing them as an opportunity to practise the strategies they have learnt in therapy. It can be helpful to strengthen the young person’s belief in their own ability to beat the OCD by reviewing experiments and homework they have carried out, by highlighting the fact that most of the work has been conducted by them between sessions and by reminding them of their successes by revisiting their goals. The therapist and the young person can then work on the setback plan and whilst doing so the therapist should remember to continue to bring the young person’s focus back to what the strategy would tell them about how the problem and the world works (i.e. that ultimately the problem is about worry and therefore does not require them to take any further action).

Topics to put in the setback plan include information on any:

• personal triggers for their OCD

• possible stressors that may exacerbate symptoms

• early warning signs that OCD may be creeping back into their life

• strategies to cope with early warning signs (e.g. refusing to do what OCD wants, doing the opposite, going over the top to really show OCD

who is boss)

• preventative solutions to keep OCD at bay (e.g. do one dirty thing every day, say something violent every day, just to spite OCD, intentionally put one thing out of place everyday, etc.).

• Treatment should end by pulling together what has been learnt in treatment and by developing a setback plan with the young person.

• Setbacks should be reframed as normal and an opportunity to practise strategies learned in therapy.

5

CBT with younger children

Linda J. Atkinson

Children as young as seven or eight years of age are able to benefit from CBT (Cartwright-Hatton
et al.
, 2004). Further, Stallard (2005) has argued that children as young as five may also benefit from CBT, given adaptations to content and presentation (Doherr
et al.
, 2005; Flavell
et al.
, 2001; Wellman
et al.
, 1996). As an example, Tolin (2001) reported the use of techniques such as externalising OCD, bibliotherapy and parental involvement in the treatment of a five-year-old child with OCD.

Children under the age of about ten years are most likely to be seen with a caregiver during treatment. While the general structure of the treatment follows that for older children and adolescents (i.e. psychoeducation, changing beliefs, changing behaviour and relapse prevention), adaptations include a greater use of humour, simpler language and a need to ensure that the family’s beliefs are acknowledged and managed (see also Chapter 7).

Working with young children with OCD usually requires more extensive education about OCD than is required for older children.

Engaging the child and their family

Young children may need longer to establish a successful working partner-ship with the therapist, which will often be facilitated through a parent. They are often used to being taught rather than discovering things for themselves so encouraging the child to take charge of as many tasks as possible during therapy helps them take an active role (e.g. asking the child to hang the engaged sign on the door). Using humour and asking the child for their ideas on how to make treatment fun will also encourage participation.

Many children do not know why they have come to the clinic. The explanation can usefully be combined with discovering the child’s knowledge of OCD, their expectations of treatment and then explaining what treatment 77

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is and is not. The therapist explains that CBT involves finding out how OCD

works and learning better ways of dealing with the problem. Parents should also be told that there are many ways that they can support their child throughout treatment. For example, parents can attend treatment sessions, learn how their child’s OCD works, model helpful behaviours (e.g. if a parent values cleanliness they could focus on becoming less clean), develop a plan for managing requests for reassurance or encourage the child to come up with their own solutions (rather than solving problems for the child).

Introducing therapy

After a brief explanation of what OCD stands for and what obsessions and compulsions are, the therapist starts to develop a description of the child’s OCD. The child’s understanding should be checked throughout by asking them to explain it back to the therapist. Displaying the information on a flipchart helps to fix the ideas in the child’s mind and enables them to take things home as a reminder of the session’s content. The therapist should explain that CBT is short for cognitive behaviour therapy, which is an adult phrase that means doing things and thinking in new ways that will help to get rid of OCD. It is important to tell the child that CBT does not mean going to hospital or taking pills or medicine (unless the child is already). It does however mean that the therapist will ask lots of questions, that it works best when the child, therapist and family work together as a team, and that the child will have to practise at home.

The therapist will then explain how common OCD is. For teenagers, it may be sufficient to provide prevalence rates, but in younger age groups it helps to give concrete examples. For example, the therapist can ask the child how many other children in their school might have OCD (e.g. in a school of 1000 pupils at least ten other children have OCD). The therapist might then ask if the child is surprised by the numbers of fellow sufferers, and why other children do not talk about it.

• Children as young as five may benefit from CBT, given adaptations to content and presentation.

• While the general structure of the treatment follows that for older children, adaptations include simpler language, a greater use of stories, metaphors, role plays and humour, more extensive education and a need to ensure that the family’s beliefs are acknowledged and managed.

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Beginning to make sense of the problem

Thinking about OCD as a bully

As described in Chapter 4, the aim of the first treatment session is to introduce the cognitive model of OCD. With younger children, a simple way is to compare OCD to a bully. Most children know that bullies are mean, scare people and try to make them do things that they don’t want to do (e.g. give away their money or toys). OCD is similar because OCD is mean, it scares people and makes children do things they don’t want to do (e.g. rituals).

The therapist can ask:

• What do you know about bullies?

• How do bullies make people feel: happy, cheerful or scared?

• What sort of things do bullies do to make people feel scared (e.g.

threaten to hit you)?

• What happens if you give in to a bully?

These concepts can be illustrated by role playing a bully and demanding that the child gives them one pound. The therapist then asks the child what will happen the next day when the bully sees you at school (e.g. the bully will ask you for money again)? Then the therapist asks the child: • If giving in to a bully makes the bully worse, what is the thing to do to stop a bully?

The child should be encouraged to think about standing up to or ignoring the bully so that the bully realises there is no point in continuing to behave in this way, as they are not going to get what they want. Once the child understands how a bully works, they are asked how OCD might be the same as a bully. The child’s knowledge of their own OCD is then explored so as to enhance the comparison, for example: • How does OCD make you feel?

• What does OCD say will happen if you don’t do what it says?

• What sorts of things does OCD make you do?

• What happens the next day when you give in to OCD, does OCD get worse?

• Do rituals make OCD come back and bother you again and again?

• What do you need to do to stop OCD?

• If you stand up to OCD, what do you think you might you find out about OCD’s lies?

Reviewing a recent example of OCD

A key task of CBT is to develop a formulation of the problem so that the child and their parents can make sense of what is happening. However, more 80

Atkinson

time needs to be taken with younger children to help the child identify beliefs associated with intrusive thoughts, that is, how the child thinks about their thinking. The therapist can introduce this exercise by explaining that the best way to beat OCD is to uncover OCD’s secrets and lies by talking about him.

It is often helpful to provide a younger child with information rather than engaging in guided discovery. For example, rather than asking the child

‘What do you think this thought meant?’, the therapist may say:

‘Sometimes OCD tells us that if we have a thought like this it means it is going to come true. So if someone had a thought of their mum getting ill and dying, OCD would tell them that it meant that she would get ill and die unless they did something to stop it. I wondered if this is what it says to you?’.

To ensure that the belief acknowledged by the child is a genuine belief that they hold, the therapist can then ask the child to elaborate on the belief by asking ‘How come you believe this?’ and ‘What makes you think this?’

It is common for young children to struggle to recall a recent incident. If this occurs, parents may be able to help the child remember. The therapist can then check with the child that it is a good example. Throughout, the therapist writes up a shared understanding of how the child’s OCD works, using the child’s own words. Figure 5.1 shows the formulation for Dan, a ten-year-old boy who repeatedly engages in covert rituals (e.g. imagining monsters in his mind) whenever he worries about his mother coming to harm.