Obsessive Compulsive Disorder (16 page)

The following transcript from Dan’s first therapy session demonstrates the process of developing a formulation. The therapist pretends to be the student in order to learn about OCD from Dan, who becomes the teacher:
Therapist:
What was the very first sign that let you know OCD was around?

Dan:

I couldn’t find Mum and I thought that she might be hurt.

Therapist:
So a scary a thought about your mum suddenly popped into your head all on its own?

Dan:

Yes.

Therapist:
What kind of harm did you imagine could happen to your mum?

Dan:

Someone might hurt her with a knife.

Therapist:
That sounds pretty scary. Thank you for telling me about this scary thought. It will help us to beat OCD. Let’s write down your scary thought in a box called ‘intrusive thoughts’ [the therapist asks Dan to write or draw an image of ‘My mum might be hurt with a knife’].

Therapist:
Do you know why I called this thought an intrusive thought?

Dan:

No.

Therapist:
Intrusive thoughts are words or pictures that suddenly pop into your mind all on their own. You don’t want them to come
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Figure 5.1

Shared understanding of Dan’s OCD

into your mind, but they come in anyway. Intrusive thoughts are like burglars who come into people’s houses without asking. Did your thought about harm come into your mind all on its own, without asking?

Dan:

Yes.

Therapist:
Okay, so this thought about mum was an intrusive thought. I want you to watch me closely now because I am going to write the word ‘normal’ next to ‘intrusive thoughts’ on our picture [Figure 5.1]. How come I am calling your intrusive burglar thoughts ‘normal’?

Dan:

I don’t know.

Therapist:
Because it is normal to have upsetting thoughts come into your mind. Everyone has scary intrusive thoughts that come into their heads. It is normal. I will talk to you more about this later, but right now I want to find out why you are so upset by your normal intrusive burglar thoughts. When this intrusive thought about harm popped into your head, what made you so scared about it?

Dan:

I had to do a mind-battle (e.g. fight imaginary monsters in my mind).

Therapist:
I am going to slow you down a bit because you are my teacher and I have to make sure I really understand how your 82

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OCD works. When you had the thought about harm coming to your mum, what did you imagine could be the worst possible thing that could happen?

Dan:

Someone might hurt her and she could die.

Therapist:
That sounds really scary. I think I understand your OCD much better now. It seems that the reason you were very upset about these thoughts is because you believe that having these thoughts means that your mum really could die. I think I would get upset too if I believed the same thing as you. But I am curious about something? When you had the thought that your mum could be harmed, did you think that this was a normal thought?

Dan:

No, because no one else has these thoughts.

Therapist:
Can I ask you another question? When this thought about something bad happening to your mum popped into your mind, did you think that having this thought could make it happen?

Dan:

Yes.

Therapist:
How does that work exactly?

Dan:

Well why would I think about Mum being hurt, if it was not going to happen?

Therapist:
So far I have learnt that the reason why you were so upset about thoughts of harm coming into your mind is because you believe that having these thoughts is not normal and that these thoughts are a sign that harm will happen. Is that right, or do I have it a bit wrong?

Dan:

That’s right.

Therapist:
How much do you believe this from 0 to 10 (0 = I don’t believe, 10 = I completely believe).

Dan:

10. I totally believe it.

Therapist:
When you had these beliefs, did you feel as if you had to do something?

Dan:

I cried and then had to do a mind-battle in my head.

Therapist:
Can you please teach me, as your student, what that this battle (ritual) looked like and what you had to do?

Dan:

I imagined killing monsters with a machine gun.

Therapist:
Why did you have to win?

Dan:

Because if I didn’t win, it would be like letting bad things happen to Mum, and then I would be sure that bad things would happen.

Therapist:
It seems that you believe that you must do mind-battles to stop bad things from happening to your mum. Is that right?

[Dan nods.] This might be another belief that we need to write down.

Having identified the child’s beliefs, the therapist explores their effect on emotional reactions, avoidance, reassurance seeking and selective attention.

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For young children it is often necessary to provide examples of what each question means. For example, when asking a child how their thoughts made them feel, it is helpful to show them some pictures of possible emotions (e.g.

scared, worried, frightened, happy, angry). When asking about avoidance, it can help if the therapist gives examples of different avoidance strategies (e.g.

pushing thoughts away, moving away from people or things that scare you, emptying your mind, trying hard not to be alone). As soon as the therapist has been able to identify: (a) the child’s intrusion; (b) how the intrusion has been interpreted; (c) the effects of these beliefs, the therapist summarises what has been learnt about OCD and importantly emphasises that the problem is not the intrusion, but is what the child thinks the intrusion means. To consolidate the learning, the child is then asked to explain in their own words what they have learnt.

• When introducing the cognitive model of OCD to younger children, it can be helpful to compare OCD to a bully.

• With young children, a formulation is important, but more time is taken to introduce the task and to help the child identify beliefs associated with intrusive thoughts.

• When developing the formulation, it can be helpful for the therapist to take on the role of student to learn about OCD from the child.

• It may be necessary to provide examples of what questions mean and use pictures to think about emotions associated with OCD.

The vicious cycle of OCD: the itchy bite metaphor

As part of the preparation for behaviour change, the therapist attempts to loosen the child’s belief in the usefulness of rituals and other unhelpful strategies by discussing whether the child’s solutions might be making the problem worse rather than better. For example, when looking at Dan’s diagram of OCD (Figure 5.1), the therapist may ask the following questions: • Have you ever wondered, even for a little bit, if the things you do such as rituals and pushing your thoughts away might make the worry worse rather than better?

• Has your worry become bigger or smaller since you started doing rituals?

• If your worry has been getting bigger, does this mean that your rituals are making the problem better or worse?

A useful metaphor for rituals is the
itchy bite
, because most children know that scratching an itchy bite makes the itching worse later. This metaphor can be brought to life by acting it out. The therapist draws a red dot on 84

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their own arm and begins to scratch it while asking the child, ‘How do I feel while I scratch this itchy bite?’ (i.e. better and relieved), ‘But then what happens to the itchy bite?’ (i.e. it gets bigger, redder and itchier). At this point, the therapist draws a larger itchy bite on their arm and asks the child, ‘Now that the itchy bite is larger, what do I want to do even more?’ (i.e.

scratch it). The therapist then asks if the scratching solution is making the itchy bite better or worse. The therapist might then suggest that the rituals might be similar to scratching and could ask the child if the rituals are making the problem better or worse.

The itchy bite metaphor can highlight how the child’s rituals and other strategies can make their OCD worse.

Normalising intrusive thoughts

As with adolescents, one way of normalising intrusive thoughts with younger children is to provide examples of intrusive thoughts, such as those of the therapist and the parent. Often when the child realises that their thoughts are normal, their distress is reduced and the need to ritualise may also reduce. To show how common intrusive thoughts are, the therapist can draw a circle to represent all the people in the world. Both the child and parent are asked to show how many people in the world have intrusive thoughts by colouring part of the circle. Children and parents typically colour a quarter to three quarters of the circle. The therapist then explains that lots of people in the world have been asked if they have intrusive thoughts and around 90 per cent say they do, which means nearly all the circle should be coloured in. The child is encouraged to reflect on this new information by answering the following questions: • Are you surprised that so many people have intrusive thoughts?

• Did you know that it is usual to have these thoughts?

• What is it like to find out you are like others?

• If your intrusive thoughts are normal, do you have to fix them?

• What do you do when you have other intrusive thoughts (i.e. carry on doing what anyone would do and leave the thought alone)?

• Does OCD try to make you think you are not normal?

• Why is OCD a liar for making you think that?

Normalising intrusive thoughts is an essential part of therapy and pictures can be used to demonstrate this with younger children.

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Changing beliefs about the meaning of intrusive thoughts

Reappraising what it means to have intrusive thoughts

Children with OCD need to reinterpret their intrusive thoughts as meaning that they ‘care’ rather than as a sign of ‘danger’. This can be achieved by carrying out a role play where the therapist pretends to be a professional killer who does not care about people’s lives. The therapist pretends to receive a letter and reads out loud the name of the person to be killed, ‘I must kill Johnnie Bonnie today at 12 pm.’ The therapist then pretends to happily read the newspaper while having a thought that they will kill someone. The therapist asks the child why the trained killer is not upset or bothered by the thought of killing someone. Discussion focuses on the idea that the trained killer is not upset because he is a horrible person who does not care about life or death. The therapist then pretends to be a loving kind mother who has had a stressful day with her children. The mother suddenly has a thought of killing her children and is a bit upset by this thought. The child is asked if the mother is upset by the thought of killing her children because (a) the mother is a horrible nasty person who wants to kill her children or (b) because the mother really cares and loves her children. Discussion focuses on the idea that noticing intrusive thoughts means we care.

Children with OCD need to learn to reinterpret their intrusive thoughts as meaning that they care, rather than a sign of danger. This can be illustrated by the therapist carrying out a role play pretending to be a trained killer.

Understanding that thoughts are not enough to cause harm

Many young people believe that thoughts and urges are extremely important and should not be ignored because they can directly lead to harm. For example, Samia was a nine-year-old girl with repetitive intrusive thoughts and urges around touching her sister’s genitals. She believed that these thoughts and urges would cause her to behave sexually inappropriately unless she carried out rituals to prevent this from happening. The therapist illustrated how Samia was seeing these thoughts as overly important by drawing a dot on a piece of paper and describing this dot as an upsetting thought or urge that suddenly flew into her mind. At the bottom of the page the therapist wrote down the feared outcome (e.g. I will do sexual things to my sister). The therapist then pointed to the ‘dot’ and asked Samia, ‘Does OCD try to make you believe that this little thought is enough to make harm happen?’ The therapist then drew an arrow from the thought all the way down to the feared outcome to emphasise the unhelpful belief that thoughts can directly cause harm. The therapist then planted a seed of doubt into 86

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Figure 5.2

Thoughts are not enough to cause harm

Samia’s mind by asking her if she was really sure that thoughts are enough to make bad things happen and then getting Samia to consider all the things that actually need to happen in order to turn a thought or urge into action (see Figure 5.2). These actions were written in a long list directly underneath the dot representing her thought. Samia was then asked what she thought the diagram showed. Discussion focuses on the idea that thoughts are not enough to cause harm because so many other more important things need to happen.

It is also important to learn that thoughts alone are not enough to cause harm and that many other important things need to happen.

Treating thoughts as meaningless

Another issue to consider is what other people do with intrusive thoughts.

The goal is to help the child realise that it is better to leave intrusive thoughts alone and to carry on with life rather than reacting and pushing intrusive thoughts away. Useful metaphors for managing intrusive thoughts include ‘
the wave
’ and ‘
the rude guest
’. If a child is familiar with ocean waves, it can be helpful to ask the child what happens if you try to run away from big waves (i.e. the wave may pick you up or knock you over). It is better to duck
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