Obsessive Compulsive Disorder (18 page)

• They can not give in to OCD and make OCD smaller

• They can do ‘pushing it’ experiments and totally get rid of OCD.

For example, if the child has a fear of contamination the therapist could drop a pen on the ground and ask the child what they should do if they want
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to give into OCD (e.g. don’t pick up the pen or wash their hands after picking up the pen). The child is then asked what they could do if they decide not to give in to OCD (e.g. pick up the pen normally and do not wash their hands). Lastly, the child is asked what they could do if they want to do a ‘pushing it’ experiment so that OCD is kicked out of their life (e.g. rub their hand all over the floor while picking up the pen and then wipe their hand over their face).

‘Pushing it’ experiments are helpful in working towards getting rid of the OCD completely.

Dealing with reassurance seeking

Many parents of younger children describe how they themselves become involved in the OCD as their child asks them for reassurance,
e.g.
that their intrusive thoughts will not come true. The cycle of reassurance seeking can be illustrated to the family and child using the itchy bite metaphor again.

Reassurance seeking provides initial relief, but ends up making the problem worse because the child wants reassurance again, just as scratching relieves an itch initially but not in the longer term. Using the formulation of the problem, the therapist should guide the child to draw an arrow from ‘reassurance’ back to the ‘belief’ to show that reassurance ends up making the problem worse. The child is also asked what kind of thoughts they have when they ask for reassurance; that is, do they think about intrusive worries or do they think about everyday fun stuff? Most children acknowledge that asking for reassurance results in even more worrying thoughts and questions. Again, the child can show this on the diagram by drawing an arrow from ‘reassurance’ all the way to ‘intrusive thoughts’ in bright red ink.

Many parents report that they are at a loss with regard to how to manage their child’s request for reassurance. Although the general aim is to help parents withdraw from providing reassurance, if this is done suddenly without the child’s awareness it can lead to an increase in distress and oppositional behaviour. It is preferable to engage the child in designing a plan for managing reassurance seeking. It is best to begin this conversation after the child has a basic understanding of how reassurance works (i.e. it is like scratching an itchy bite and makes the problem worse). The therapist can then ask the child if they should continue asking for reassurance and if they think their parents should continue giving reassurance. As soon as the child agrees that reassurance needs to stop in order to beat OCD, the therapist asks the child what their parents could do to help them when they want reassurance. A list of possible ideas can be presented to the child and parent if they are unable to generate their own solutions, for example: 94

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• play a game together

• watch a DVD

• talk about something else

• tell OCD that he is a big bully and to go away

• Mummy could remind you that this is OCD being a mean bully

• Mummy could say ‘Let’s do something else and ignore OCD’

• remind myself that Mummy is not being mean to me, but she is being mean to OCD.

It may be helpful if the child and therapist write out a plan on a sheet of paper using words and pictures. It can also be helpful to set up a score sheet for OCD and the child. The child receives a point if they do not ask for reassurance over a specified time, whereas OCD receives a point if he bullies the child into asking for reassurance. The child is encouraged to reflect on why they want to win more points (e.g. because reassurance is like feeding OCD and if you stop giving reassurance OCD will starve to death). As the child asks for reassurance less, the child and parent are encouraged to recognise that the problem lessens as reassurance declines.

• If parents suddenly withdraw reassurance without the child’s awareness, this can lead to an increase in distress and oppositional behaviour.

• It is crucial that the child understands why reassurance can keep the problem going and helpful if they are engaged in designing a plan for managing reassurance.

Obstacles to treatment

If the child does not report thoughts or beliefs

It is common for many young children to report that they do not have intrusive thoughts. It may then be helpful to ask the child what would happen if they do not do their rituals, or if they do their rituals wrong. If the child is still unable to describe any intrusive thoughts, the therapist could say that it is perfectly normal to forget why we do things, especially if we have been doing things like rituals for a long time. This means that there is really a reason, but that we have forgotten what that reason is. The child might then be encouraged to view OCD as a mean horrible bully who makes the child do rituals without telling them why. Then the therapist and child consider the possibility that OCD’s reasons for rituals might not be very good and might even be lies. Together, they work to discover OCD’s reasons by refusing to do a ritual next time and then carefully listening for the reason OCD

gives them. Even if OCD does not provide a good reason, this experiment is
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still helpful because the child may learn (a) that he or she does not have to do rituals and (b) that nothing bad happens.

Managing oppositional behaviour

Although parents are usually present in sessions, if a child becomes increasingly oppositional it may be helpful to see the child on their own for some of the time. One technique for managing oppositional behaviour involves asking the child if they are someone who likes to be bossed around all the time or if are they someone who likes to stand up for themselves. The aim is to build motivation for treatment by helping the child conclude that OCD is pushing them around too much and that they will not put up with this.

Relapse prevention

Setback planning for younger children involves family members as well as the child themselves. The therapist should describe the appearance of new habits as helping families to view relapse as an opportunity to practise beat-ing OCD. Working together, the family and therapist prepare a plan so that they can react calmly. With younger children this plan can be summarised and presented in whatever format is most suitable for the child (e.g. as an OCD picture book, in poster format, on audio tape and video-recording, or colourful pamphlets). The plan should remind the child that they can respond to OCD in three ways: • give in to OCD the bully

• not give in to OCD

• do experiments that make OCD disappear (e.g. doing ‘pushing it’

experiments).

A fun way to help the child plan is for the therapist to pretend to be OCD

and try to trick the child with lots of lies (e.g. ‘All germs are dangerous.’ ‘It is all your fault if something bad happens.’ ‘Rituals make you feel happy.’).

The child is encouraged to tell OCD the real truth (e.g. ‘Most germs are fine.’

‘It is not my fault.’ ‘Rituals make me worry.’).

Alternatively, treatment can be summarised by making a list of questions about OCD and attaching these questions to the back of photos of various children. The child is asked to pretend that they are on a talkback radio show for children with OCD. The child is asked to pick one photo at a time and to answer that child’s question about OCD. An example of a typical question is as follows: ‘Hello, my name is Emily and I have scary thoughts that my mother will die. Is this normal?’ At the end of treatment, it can be helpful to offer the family two or three booster sessions and encourage them to contact the therapist if they require further support.

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• Setback planning should involve family members as well as the child themselves.

• The plan should be summarised and presented in a suitable format for the child, such as on video-tape or as a picture book.

• Games and role plays can be fun and helpful in consolidat-ing what has been learnt.

6

CBT with adolescents

Polly Waite

The nature of adolescence

Adolescence characterises the period between childhood and adulthood, as young people go through a number of changes physically and mentally and become more independent. As puberty occurs earlier and with more young people going into higher education, this period can span up to a decade, which can make generalisations difficult.

As youngsters move through adolescence, cognitive skills develop and there is a shift towards more abstract thinking and a greater ability for logical and scientific reasoning (Coleman and Hendry, 1999). Skills develop so that adolescents are better able to generate hypotheses and explanations about concrete events. Abilities such as problem solving improve as they are able to suggest alternative hypotheses, test them out against facts and then disregard hypotheses that prove to be wrong. They are more able to stand back and think about their own thinking processes as well of those of other people.

For many years, adolescence has been considered to be a transitional period. This transition can be positive and may involve looking forward to the future and the freedom and opportunities it brings, such as leaving school, establishing greater independence from the family or developing relationships. However, it can also bring feelings of anxiety about the future, in adjusting to new roles with family, friends and others and developing a sense of identity. Psychological problems can interfere with the young person’s progress through adolescence,
e.g.
becoming more independent, getting through school and developing relationships.

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CBT with adolescents

Given that developing autonomy and independence is one of the key tasks for adolescents, it is important that therapy gives the young person experience of achieving control over their life. To begin with, this may consist of making decisions around whether and how family members are involved in therapy. As therapy progresses, the young person will be encouraged to develop goals that guide the direction and pace of therapy. This is often a time where family members (and therapists) may also have ideas about what goals may be helpful and make a difference. However, these may not always be the same goals as the young person’s and therefore it is important that it is the young person’s goals that remain primary. As with younger children, parents and family members may often have requested treatment so for the young person to engage in therapy and feel motivated to change, it is essential that they are making choices and working towards goals that will make a difference to them.

The same principles apply when it comes to planning and carrying out behavioural experiments. As therapists, we often have ideas about what may be a good first step and yet discussion with the young person may reveal this to be out of line with where they want to begin. It is essential that the young person does not feel under pressure to carry things out that they do not want to do and, when possible, that they take the lead in planning experiments. However, there may be times when working on the adolescent’s agenda may result in them struggling to make progress. If this is the case, it can be helpful to revisit the young person’s goals. In most cases, they will have specified getting rid of the OCD as a medium to long-term goal and so it can be helpful to think through whether they are currently on track to achieve it and if not, what they would need to do differently to get there.

Therapy needs to give the young person experience of achieving control over their life and to facilitate adolescent tasks of developing autonomy and independence.

Role of the family in treatment

When carrying out therapy with young people, the therapist must take into account that they are unlikely to have separated entirely from their parents or family during adolescence. Factors such as the circumstances of the family, ethnicity and culture will affect the degree to which the young person maintains their ties with their family as they move into adulthood.

In general, there is evidence that a continuing connectedness with parents
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is helpful (Grotevant and Cooper, 1986), in a relationship that involves warmth, structure, a support for autonomy and good communication (Coleman and Hendry, 1999). Consequently, it is the role of the therapist to facilitate this, while also respecting the choices the young person makes about family involvement.

In general, the young person will decide whether or not they would like family members to attend sessions and typically as adolescents get older they may prefer to have sessions on their own with the therapist. Sometimes family members may have very little involvement in therapy and this can work well. However, there may be other occasions where a lack of involvement can be detrimental,
e.g.
if a parent continues to provide reassurance to the young person and this impedes the progress of therapy. Thinking about the involvement of family members should always be guided by the individual case formulation. If the therapist has reason to think that it may be helpful for the family to be involved, they may need to work out with the young person how they can achieve this. This could include having a parent in the room for the last ten minutes of a session so that the young person can convey any important information, having separate sessions with family members or the therapist speaking to family members over the telephone.

Equally, there may be times when the family is attending sessions and the therapist feels that it may be helpful to have sessions on their own with the young person,
e.g.
if the young person needs to develop autonomy or if the presence of family members leads to conflict. This is covered in more detail in Chapter 7.