Obsessive Compulsive Disorder (21 page)

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High blood pressure.

5

Not doing enough exercise.

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Diet.

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Being overweight.

Once she generated all these different factors, the therapist asked her to identify how much she believed each one contributed. As she went through this process, the therapist drew a pie chart and divided it up according to Ellie’s ratings. By beginning at the bottom of the list and ending with her own involvement, she was able to see it in relation to other significant factors (see Figure 6.6).

When the therapist asked Ellie what she made of this, she described being surprised that her thinking about her father dying had been such a small amount. When she considered it in the context of all the other factors, she felt it was insignificant. This, in conjunction with the evidence she had collected through other behavioural experiments, reduced her belief in her responsibility for her father’s death.

Dealing with uncertainty and perfectionism

It can be useful to use surveys to find out about other people’s feelings of certainty,
e.g.
asking people to rate as a percentage how certain they are that they locked their house that morning, closed and locked all the windows or did not make any mistakes at school or work. The young person can be asked to recall occasions in the past where certainty was not achieved and they had to live with doubt, such as waiting for exam results. Were they able to cope with this and get on with life? Using Socratic questioning, it can be helpful to think about how life would be if you were only able to do things
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Figure 6.6

Ellie’s responsibility pie chart

that you knew were certain and risk free or to consider the pros and cons of tolerating uncertainty.

As with trying to achieve certainty, there may also be beliefs around needing to be perfect. This involves the idea that there is a perfect solution to every problem, that doing something perfectly is not only possible but also necessary, and that even minor mistakes will have serious consequences. In this case, the aim is for the young person to find out that there are disadvantages in being perfect, that perfection is rarely achieved and mistakes are normal and do not result in serious negative consequences and to develop alternative ways of thinking that are not so ‘all or nothing’.

Jacob was encouraged to think about this through the use of a continuum (see Figure 6.7). After drawing it out and providing labels for each end, he then identified a number of people, such as family and friends and public figures (including people that he thought were really good and really bad,
e.g.

the Dalai Lama and Hitler) and placed them on the continuum. Finally, he put himself on it. This enabled him to see that people were all over the line, but that most people fell somewhere around the middle. He then thought about his friend Joe, who was someone he thought was a good role model for how he wanted to be. When he came to place Joe on the line, he realised that he was about three quarters of the way along and not at the very end. This told him that you do not need to be perfect all the time to be a good person.

Techniques such as pie charts or using continuums can be helpful in exploring and challenging beliefs around personal responsibility and the desire to be certain or perfect.

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Figure 6.7

Jacob’s continuum

Dealing with difficulties

Motivation

As acknowledged already, the request for help may not have actually been initiated by the young person and consequently they may feel ambivalent about change. This may not arise until some way into treatment as often this ambivalence is not expressed by the young person, but may be recognised through difficulty completing tasks inside or outside sessions. It is crucial that goals are identified early on and to be able to make links between having the OCD and whether the goals could still be achieved, particularly long-term goals such as finishing education, getting a job or moving out of home.

The process of identifying the pros and cons of staying the same and then the pros and cons of changing can be extremely helpful. When doing this, it is important that these are generated by the young person themselves rather than family. Typically there are more pros than cons to changing and many of the cons can be seen as speculative, in that they are what OCD tries to convince you rather than reality. If the young person is unsure about this, it could be helpful to suggest finding this out through experiments, rather than believing it without any evidence. If it turns out that the OCD is right, the therapist can then promise to help the young person to become obsessional again.

If the young person is quiet and unforthcoming

If the young person is quiet and unforthcoming in sessions, it is crucial to take a step back and explore what is going on rather than follow the session agenda. Clearly there may be a number of reasons for this:

• Is the young person having trouble understanding the content of the sessions?

• Are they feeling negative or overwhelmed and having trouble believing that therapy could help them?

• Are family members monopolising sessions and making it difficult for them to speak?

• Do they feel uncomfortable with the therapist?

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Some adolescents will be less verbally articulate than others and may find some of the concepts more difficult to understand. If this is the case, it is essential that the therapist makes adaptations to the therapy. The therapist may need to go slower, regularly check the young person’s understanding, get them to summarise what they have learnt more often and place more emphasis on metaphors, role plays and behavioural experiments. Some young people find therapy sessions awkward as they are with an unfamiliar adult talking about things that may be very uncomfortable. Therapists need to ensure that they are approachable, adapt their language and listen carefully to what the young person says. However, they may also need to keep sessions short, maximise the use of homework between sessions (perhaps with a parent or friend to help) and use written materials as an adjunct where possible.

Carrying out behavioural experiments

Before carrying out behavioural experiments, it is important to check that the young person understands the rationale for doing it and that they feel it would be helpful to carry out the experiment. Questions such as ‘What would be the reason for doing this?’ are important and if the young person is not clear about why the experiment is being carried out, it is important to consider the rationale with them. The risk of not doing this is that they may feel bullied into it and disengage from treatment and this can easily happen when therapists feel under time pressure and unintentionally become too didactic. It is always important to set up experiments so that the young person can say no and that the therapist responds to this without pressuring them. Control can be an important issue to consider when understanding a young person’s reluctance to carry out an experiment and it is crucial that the young person feels they are in charge of what they do.

When designing behavioural experiments, it is often the case that compulsions cannot be easily replicated in the clinic room or when the triggers are not available. In most cases, home visits are of enormous value in understanding the problem and creating opportunities that are more ‘real life’ and more easily generalised to outside sessions.

The nature of behavioural experiments means that anything can happen and as a consequence sometimes results may initially appear to support OCD. For example, in experiments designed to test out the idea of whether thinking something can make it happen, there are occasions where the thought may come true. If the thought is about something that is not that unlikely to happen, such as the young person’s younger brother falling over and hurting themselves, it can be helpful to consider this when planning the experiment. If he falls over now and again, how much would he have to fall over for it to be out of the ordinary, or could the prediction be more specific (e.g. he will fall over as soon as I’ve thought it and he will twist his left ankle and bang his right elbow)? Discussing the idea of coincidence beforehand can often be helpful and allows the young person to be able to deal with the various possible outcomes.

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Completely eradicating the OCD

Most young people want to get rid of the OCD completely and state this as their medium or long-term goal. Although they will still experience intrusive thoughts (as do most of the population), they can dismiss them because they will not be interpreted in a meaningful way. Commonly in OCD, the young person will make progress and get around 70 per cent of the way towards eradicating the OCD and then struggle to go further. It is important to be able to normalise this experience, consider what may be going on and think about whether it is necessary to work towards completely getting rid of it. Analogies can be helpful, such as getting rid of weeds in the garden and thinking about how if you just pull out the weed without getting out the roots it grows back. Often the OCD has crept in and got worse over time and many young people recognise that this is what has happened in the past and that there is a danger that this would happen again.

It is helpful then to consider how it is possible to completely get rid of OCD and whether it works the same or differently to what they have already done. This was an issue that cropped up with Ellie:
Therapist:
One of the things you mentioned last time is feeling that you are not strong enough to get to your final goal of getting rid of the OCD.

Ellie:

Yes, I think generally I am coping quite well and I’m able to do stuff that is not so hard, but I’m not sure I will ever be able to completely get rid of it.

Therapist:
You know when we did some of that stuff that was not so hard? If you cast your mind back to before we did it, did you feel that was going to be not hard or at the time did you think it would be hard?

Ellie:

I thought it would be really hard.

Therapist:
That’s interesting. Are there other times recently when you’ve done things that are really hard?

Ellie:

Started a new school.

Therapist:
Yes, how did you manage to do that?

Ellie:

I thought about when I had done it before and thought if I can do that I can do it again.

Therapist:
So what does that suggest?

Ellie:

I can do stuff that is scary.

Therapist:
So what does that mean for what you might go on to do?

Ellie:

I could think about the things I’ve already done to power me.

I can go on to do things that I think will be hard.

Therapist:
So bringing it back to our session today, what do you think would be good to do?

Ellie:

I don’t know.

Therapist:
Is that ‘I don’t know’ or ‘I kind of know but what I’m thinking is too scary’?

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Ellie:

Well, I know that I need to touch my school stuff but I don’t want to do it.

Therapist:
If you think about your friend Catrina and if she was in a situation like this, what advice would you give her?

Ellie:

To push herself as far as she could but still be comfortable with the situation.

Therapist:
That sounds like really good advice. So if you were giving that advice to yourself what would you do in this session that would mean that you pushed yourself but still felt comfortable?

Ellie:

I don’t know.

Therapist:
Well, we know from before that it is really important that you feel in control and that you are the one making the decision.

So let’s take a bit of time now and I’d like you to think about what we could do so that you feel you are pushing yourself but still feel comfortable.

Ellie:

I could touch my history folder and not wash my hands.

Therapist:
Okay, let’s go and do it. You are in charge and you tell us what to do. Before we do it though, what do you predict will happen?

As with Ellie, in most cases, it is about the young person realising that they just need to carry on with what they have been doing and if they keep going they will eventually get there.

Difficulties can arise when the young person is not sure whether change is worth it, if they do not understand the rationale for experiments, if they feel pressurised to do experiments and if they do not feel in control. If this occurs, it is crucial to step back and address this before moving on.

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Working with families

Blake Stobie

Introduction

The involvement of family members and significant others in OCD is a common phenomenon. Family members may become involved in providing reassurance and assisting with the completion of compulsive rituals – sometimes to the extent that they may spend significantly more time ritualising than the young person. Alternatively, family members may refuse to participate in rituals and provide reassurance. With either response, the family system is likely to experience increased tension and conflict, as well as disruption to the goals and functioning of individual family members within their life cycle stages. In recognition of this, many clinicians advocate the explicit involvement of family members in therapy sessions where the individual case formulation suggests that the involvement of family members may be beneficial.

• Family members are often involved in OCD, through the provision of reassurance and assisting with rituals; they are likely to experience tension, conflict and disruption.