Obsessive Compulsive Disorder (19 page)

It is also critical that the therapist considers the role of the family in identifying predisposing, precipitating and maintaining factors that relate to the problem. For example, the young person may be given little responsibility within the family and the therapist may hypothesise that this may be contributing to the development and maintenance of the OCD. There may be certain standards or rules around cleanliness and hygiene or moral conduct that may be relevant and if not addressed may lead to problems in treatment. It is crucial that the therapist finds a way to incorporate this in therapy, either informally through discussion or, when necessary, more formally in a written formulation. This is covered in detail in Chapter 7 and consequently the focus of this chapter will be on how to work with the young person individually.

• The role of the therapist is to facilitate continuing connectedness with parents while respecting the choices the young person makes about family involvement.

• While the therapist is working primarily with the young person, they will need to address any systemic factors that may be maintaining the problem.

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Beginning to make sense of the problem

As outlined in Chapter 4, therapy starts with the development of a formulation that the therapist and young person use to make sense of the problem.

This is carried out in a collaborative way by using recent examples and focuses in at the problem level and maintenance cycles. As mentioned earlier, this does not typically include family factors or experiences that may have led to the development of the problem, although the therapist will have considered these and will aim to address relevant factors in therapy. The formulation is normally put together as a diagram. While younger children may prefer to be able to draw it out themselves and add pictures, this can feel embarrassing for adolescents and so many prefer for this to be done by the therapist.

Jacob was a 13-year-old who came to treatment after his mum became deeply concerned about him. This followed an incident on holiday where Jacob was in a public toilet and a young boy came into the toilets on his own. Jacob described having had a thought about having molested this boy and later on, as he went over the thought in his mind, he began to be concerned that he may have carried out the thought without being aware of it. The more he tried to argue with the thought, the more concerned he became that he may have ‘lost control’. Following this, he began to believe that he was a paedophile and took what he described as safety measures to stop him acting on his thoughts. This included avoiding situations where there may be young children, such as parks and playgrounds, keeping his hands in his pockets and crossing over the road if he was about to walk past a child. He worried that if he were to hear or read about any murderers, that by thinking about them or looking at their pictures he could turn into that person. He also described feeling that he may say something bad without knowing.

Consequently, he found it difficult to write text messages or cards to friends as he worried that he may write an insult without being aware of it and would check what he had written over and over again. Finally, he described feeling that if he ever said anything bad about anyone, this meant he was a bad person.

Figure 6.1 shows Jacob’s formulation. He had already noticed that he had spent a lot of time thinking the thought through afterwards and that this was because he wanted to feel certain about what had happened in the toilet. However, he was also aware that the more time he spent thinking about the thought and what it meant to him, the less certain he became. The therapist was able to use this to show how it acted as a vicious cycle, in that the more he thought about it, the more he kept the worry going. Jacob identified that the other behaviours worked in the same way and that being on the lookout and checking also kept him believing that he may have harmed the boy.

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Figure 6.1

Jacob’s formulation

Normalising intrusive thoughts

One of the key tasks in CBT is for the young person to come to the realisation that most people have intrusive thoughts. It can be interesting to ask the young person (and family members) to guess what percentage of people has intrusive thoughts. In most cases, people significantly underestimate the proportion, believing that it is the obsessional thought itself that is the problem in OCD. Research (e.g. Rachman and Hodgson, 1980) and personal examples can be helpful to support the point. This is particularly important in a case like Jacob’s, where many of his thoughts are around harming others and have led him to conclude that this means he is a bad and potentially dangerous person, with associated feelings of fear, guilt and shame.

As well as the therapist giving examples of thoughts that they and other people commonly have, it can be helpful to ask family members to share any examples of thoughts they have experienced. Often parents recollect having 102

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had thoughts of loved ones being in an accident or when their children were babies that they had stopped breathing (and perhaps gone in to check that they were still alive). When parents recall intrusive thoughts of harming others, they frequently recall thoughts of harming their children either accidentally (e.g. dropping them) or intentionally (e.g. smothering them, particularly when the child was a baby and cried a lot). Sometimes, family members cannot recall any intrusive thoughts and so it is often helpful to begin with examples to prompt their memories. When family members initially cannot recall any thoughts but then identify with examples provided by the therapist, this can be used to illustrate that it was not that they did not have thoughts, it is just that they were not seen as being meaningful and therefore they paid little attention to them, which helps to reinforce the formulation of the problem.

Once the young person accepts that most people experience intrusive thoughts, the aim is for them to reach an understanding that it is the meaning they attach to it that causes the distress and leads to compulsions. One way to achieve this with young people is to consider a scenario and think about how two different people might react, for example:
Therapist:
Let’s think about a situation involving two girls, Jessica and Charlotte. They are both standing on a train platform waiting for a train and they are standing right at the edge of the platform. Suddenly, out of the blue, they have a thought about throwing themselves off the platform in front of the train. Jessica does not have OCD so what do you think happens when she gets the thought?

Jacob:

She ignores it, doesn’t think it’s a big deal.

Therapist:
What do you think she does?

Jacob:

Nothing probably.

Therapist:
That’s right. She carries on standing and waits for the train, which then pulls into the station. Let’s now take Charlotte.

She has exactly the same thought but she has OCD. What do you think she makes of it?

Jacob:

She might know that she wouldn’t really do it, but might still be scared in case she might do it, in case she just loses control.

Therapist:
Right, so if she thinks that, what do you think she might do?

Jacob:

She might move away from the edge of the platform and only walk to the edge when the train is there and she feels safe or she might ask someone like her mum whether she is okay.

Therapist:
So what is different about these two girls?

Jacob:

What they do. Jessica ignores the thought and carries on, but Charlotte is worried and so she moves away from the edge.

Therapist:
What is it that makes them act so differently?

Jacob:

It’s what they think the thought means. Jessica thinks it doesn’t mean anything, but Charlotte thinks it means that she might lose control.

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This scenario can also be used to demonstrate the maintenance cycle of OCD, as the young person is encouraged to think about how the two girls might behave in the future. For example, Jessica is likely to carry on standing at the edge of the platform and not be bothered by the thought if it pops into her mind again, whereas Charlotte may ask for further reassurance, stop catching trains or putting herself in other situations where she feels she may lose control. As she does more to try to stop herself losing control, this will have the effect of making her believe more and more that she may lose control if she does not do these things.

It can also be helpful to ask the young person which of these girls is likely to have more of these intrusive thoughts and why that might be, to illustrate that as Charlotte carries out more and more compulsions or

‘safety’ strategies, intrusive thoughts become more frequent and more intense. Finally, it can be helpful to then turn to look at how the problem is working for the young person themselves and whether it may be working in the same way.

• Therapy starts with the development of a formulation that the therapist and young person use to be able to make sense of the problem.

• This is carried out in a collaborative way by using recent examples and focuses in at the problem level and maintenance cycles.

• Once the young person accepts that most people experience intrusive thoughts, the aim is for them to reach an understanding that it is the meaning that they attach to it that causes the distress and leads to compulsions.

Goal setting

In general, the aim of goals is to identify what the person wants to change, guide plans for change and provide guideposts to track progress. With adolescents in particular, it is worth spending time on long-term goals and this is often the best place to start. By the time some young people reach their teenage years they may have had OCD for a long time and may also have received previous treatment. Consequently, it is not uncommon for some young people (and their families) to already hold beliefs about their OCD

being untreatable and some will already have adjusted their expectations accordingly. It is crucial that the therapist encourages the young person to think about getting rid of the OCD, not just moderating or learning to live with it. Often young people and their families are surprised to learn that OCD is treatable and have not even dared hope that there might be a day 104

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when the young person no longer has to worry when they get intrusive thoughts or carry out time-consuming compulsions. It is the role of the therapist to engender hope and encourage the young person to think about their dreams for the future and how life might be without OCD. It is these dreams, in the form of long-term goals, that the young person and therapist return to when treatment is scary and difficult and this can enable the young person to keep going.

Goals are most helpful when they are specific and measurable and set within definite timeframes, such as the next week, two weeks or months. The following questions can be helpful to identify goals and break them down:

• How would things be different?

• How would someone else know if you had reached this goal?

• What are the steps you would need to take to reach your long-term goal?

• How would you know if you were half-way there?

• What would you need to do for things to be 1 per cent better?

• If your friend had this as a goal, what would you advise them to do to begin to work towards it?

Ellie was a 16-year-old who had a fear of germs. This began gradually around three years ago, after her dad died unexpectedly of a heart attack.

She worried about becoming contaminated through contact with germs, through touching door handles, light switches, objects in the bathroom and her brother’s hamster. School felt especially contaminated and as a result she would shower excessively when arriving home from school and insist on keeping her school uniform, bag, folders and books in the spare room. Her worry was about spreading germs to her mum, nan and two younger brothers. She was concerned that this could cause them to become ill, with symptoms including vomiting, diarrhoea, a raised tem-perature and coughing or sneezing, which in the worse possible scenario could lead them to die. She avoided touching anything she worried was contaminated and so would open doors with her foot, use tissues to touch objects and found it difficult to prepare food or drinks for other people.

Ellie’s goals are shown in Figure 6.2. By starting with long-term goals, she was able to see that she needed to be able to get rid of the OCD in order to live the kind of life she wanted. This made it easier to identify medium-term and short-term goals. Not all the goals are directly related to getting rid of the OCD and some are around re-establishing normal activities and starting to do the things she has been avoiding. Short-term goals are regularly reviewed and further goals are developed as therapy progresses.

Goals that are set by the young person are essential in order to help with motivation and it is crucial that they are regularly reviewed and that sessions are clearly related to goals.

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Figure 6.2

Ellie’s goals

Building an alternative view of the problem

Early on in therapy, it is helpful to externalise the OCD and to set up two opposing ways of making sense of how the world works. As with younger children, this helps the young person to step outside the beliefs and be able to think about them in a more objective way. With adolescents too it is extremely helpful to phrase questions in a way that allows them and their families to see OCD as separate to them,
e.g.
‘What does OCD tell you would happen if you did not do a compulsion?’

When building up an alternative way of understanding how the world works, the therapist and young person write out the two contrasting explanations about OCD that can be tested through experiments. On one side is the OCD and on the other side is the opposite of OCD and the specific predictions on each side will be related to the individual’s idiosyncratic beliefs.