Obsessive Compulsive Disorder (24 page)

for herself based on her other threat appraisal, using theory A ‘The problem is Simon will no longer be able to function if he becomes too anxious’ and theory B ‘The problem is
worry
that Simon will not be able to function – but in fact we are both a lot tougher than we give each other credit for!’

The amount of time that Marco had set aside to attend the sessions did not allow the therapist to write up a detailed theory A/B with him. However, the main threat appraisal which had been uncovered during the session with him was discussed using theory A/B as a template – theory A ‘The problem is my son is cracking up and I can’t deal with this’ and theory B ‘The 132

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problem is my son worries excessively about his mother and I worry about my ability to cope with this – although I have a good relationship with my son and have the ability to help him through this.’ Evidence for theory A and B was discussed. Interestingly, Marco decided as a consequence that he needed to gather more evidence here and the only way of doing this would be to spend more time with Simon. This also tied in with what he concluded he would need to do if theory B were true, as the therapist believed.

Contrasting alternative, less threatening ways of perceiving the obsessional problem with the family members’ threat appraisals using theory A and B paved the way for setting up and carrying out behavioural experiments to test the two opposing theories. The results were then fed back into further experiments, and the findings were linked back into the theory A/B

framework.

• Theory A/Theory B is a useful technique for contrasting threat appraisals with the alternative, less threatening explanations provided by the therapist.

• This technique can highlight two conflicting ways of dealing with the problem, in order to encourage family members to tackle the problem in a uniform way.

• This can form the basis of future behavioural experiments.

Behavioural experiments

Simon, Marco and Dawn were encouraged to devise behavioural experiments to test out their beliefs about the problem and how it works. Because Simon was at first reluctant to test out anything which could potentially cause harm to his mother, the therapist modelled experiments for him which were initially based on trying to cause good things to happen by thinking them or imagining them as images. She then wished bad things on herself and on her family members, before encouraging Simon to have thoughts and images about her. The results were recorded very assiduously by Simon in his therapy book.

Dawn was also encouraged to devise and test her own behavioural experiments, most of which were focused on testing out the effects of not offering Simon reassurance and encouraging him to go out more. Because of her low confidence and self-esteem she was also encouraged to keep a positive data log, which provided her with very useful evidence in support of her as a capable, caring mother. Dawn also commented that she found the idea of finding different ways of being supportive to Simon other than by providing reassurance to be extremely useful (see Figure 7.4).

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Figure 7.4

Dawn’s behavioural experiment

Marco was similarly encouraged to set up and test out his own behavioural experiments, although he was initially reluctant to write these down. Nonetheless, he did devise some good experiments aimed at testing out his beliefs about his inability to help Simon with the obsessional problem. This empowered him and increased his confidence significantly. Carrying out the experiments also had a helpful side-effect, in that father and son spent more time together as a result. Having all of the family members involved in setting up and testing their own behavioural experiments also strengthened the externalisation of the obsessional problem, which enabled them to get on better with each other whilst fighting a common enemy with a united front.

• Family members can be encouraged to construct and carry out their own behavioural experiments.

• This engages family members in treatment, externalises the obsessional problem and can unite family members.

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Discussion techniques

The results of the behavioural experiments were linked with cognitive discussion techniques such as questioning the mechanism of problems, identifying and challenging unhelpful assumptions and cognitive biases, discussing pros and cons, developing responsibility pie charts and other techniques discussed elsewhere in this book. In addition to these standard cognitive therapy techniques, the rich family therapy literature on questions can also be extremely helpful for therapists working with families with OCD. Different types of questions (e.g. circular or reflexive – see Tomm, 1988) can be used to highlight differences and similarities in the beliefs of family members, as well as the interaction between the behaviours and beliefs of family members on each other.

An illustration of this occurred when working with a family whose daughter had been worrying obsessionally that she would throw bleach into the milk of a nearby dairy. Midway through the therapy sessions the family was invited in for a review – at which point the father surprised the therapist by stating that because his daughter was making so much progress, he had started to consider removing the lock he had placed on her bedroom door to lock her in at night. Further questioning revealed that the father did not believe that his daughter would poison the milk at night if she was not locked into her bedroom (he was surprised to even be asked this). However, he did worry that she would not be able to sleep all night without the reassurance of being locked in. Circular questioning was used to draw explicit links between his belief, the locking of the door and the reinforce-ment of his daughter’s view of herself as a dangerous individual who needs to be locked up.

Family therapy questions can be extremely helpful for therapists working with families with OCD, to highlight differences and similarities in the beliefs of family members, as well as the interaction between the behaviours and beliefs of family members on each other.

Problems encountered when working with families

The above approach is intended to illustrate how the CBT techniques discussed elsewhere in this book can be easily adapted to working with families.

It is worth noting that this approach will not always be applicable. It is most likely to be helpful when working with family members who have become involved in the maintenance of the problem, either due to a lack of understanding about how obsessional problems work, or due to their own concerns. However, it will often be the case that family members may be very
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supportive without being involved in the maintenance of the problem through the provision of reassurance,
etc.
Where this is the case, the therapist may wish to work individually with the young person, or involve family members as co-therapists. Therapists should also seek to reinforce effective familial support structures. Working with families also carries particular ethical responsibilities. Encouraging family members to disclose the content of their intrusive fears to each other can be crucial in overcoming the secrecy which often perpetuates OCD. However, working closely with family members can potentially place the therapist at risk of ethical transgressions, for example, when working with teenagers who do not wish the content of their obsessions to be disclosed to their parents.

Some family members may be actively critical of the young person and their compulsive rituals. If this hostility is active and rigid, they or the therapist may decide that their involvement in the therapy sessions would be counterproductive. Family members can sometimes be supportive of each other but have significantly different goals. Some family members who elect not to involve themselves in compulsive rituals as a consequence of the sessions may alienate themselves from others, exacerbating rifts in the family. Family members whose relationships with the young person were previously defined by their involvement in the rituals may sometimes find it difficult to adjust once the OCD improves.

Lastly, the therapist may struggle when encountering cross-generational shared familial values (whether cultural, religious or more general). Therapists may struggle to persuade family members to test out behavioural experiments which require them to challenge some of these beliefs. In this instance it is often helpful to enlist members of the wider system,
e.g.
grand-parents, friends (through surveys) or members of the wider community, to find out whether the familial beliefs and customs are shared by other representative members of the broader group to which the family belongs.

• This approach is likely to be helpful when working with family members who have become involved in the maintenance of the problem.

• Where family members are supportive but not involved in rituals or the provision of support, individual therapy sessions may be preferable.

8

Issues and future directions in

childhood OCD

Paul M. Salkovskis, Polly Waite and Tim Williams
For the young people we work with, their future lies in getting rid of their OCD.

‘It’s weird not having OCD. It’s a lot more free and I don’t feel so weighed down. I can focus a lot more on things because I’d pushed things like schoolwork to the side, but that would add to the weight of it because it would still be there in the back of my mind annoying me. I have a lot more thinking time and I think “What shall I think about now because I’ve got nothing to worry me?” It’s quite good. I’m busier, full of energy and have other things to do to take up the space filled by compulsions and stuff. I can take new opportunities and I’m doing things now that I couldn’t have done with OCD. I can go to bed quickly and go to sleep and if I don’t feel like brushing my teeth I won’t. General things like that, I can choose what I want to do.’

‘OCD is not easy to overcome. It takes time, patience and understanding but it is worth it. It was like a weight being lifted. OCD is frustrating and CBT can be emotional but it does help and work. Since getting rid of the OCD, my self-confidence has improved vastly and since I started sixth form people say to me how much they have noticed it too. Also I now socialise with friends and participate in school social events. My family also comment on how happy I am.’

‘At the beginning of therapy I was scared and worried and also upset to discuss my OCD. As time went on I learnt that I could beat and control the OCD. I did activities like putting my hand down a loo and then licking it to prove I wouldn’t get ill or die from germs as I believed. Therapy was worth it because I found myself as a person in control and independent with life. Also it helped me recognise that just because I had OCD I am no different from any other person without it. I now think more positive.

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I now have determination to do what I want and also achieve what I want.’

These are the same three young people who described their OCD in Chapter 1, but this time describing how it feels to be rid of OCD. Taken together with the growing body of treatment outcome research, they establish the all important point: OCD can be cured – not just improved, not ‘learning to live with the problem’, but cured. The facts that it can at times be difficult, time consuming, incomplete, expensive and harrowing for all concerned do not detract from the simple observation that it can be done. This being so, the future needs to hold a new set of apparently achievable aspirations: how to cure childhood OCD earlier, more efficiently, in more people and more easily. It is also important to recognise that we need to work out how to help those young people who ‘partially respond’. To achieve these goals, we need to achieve a better understanding not only of factors involved in the origins and maintenance of OCD and the way in which it manifests, but also those which relate to the process of achieving and sustaining excellent treatment response.

A theme running through the work described in this book is the importance of reducing the young person’s worries, not only by helping them to discover that the things they fear will not happen, but also, at the same time, by providing them with an alternative, less threatening explanation of their difficulties. The girl who was afraid of contamination comes to see that it is the fear and not the contamination which is her problem, and goes on to overcome that fear by confronting rather than escaping contamination. The boy who feared that harm would come to his mother because of the thoughts he had is helped to see that he is not causing harm but fears it, and that fear can be dealt with without seeking to neutralise frightening thoughts. CBT emphasises the way in which ‘loosening up’ beliefs makes it easier to change behaviour, and that changes in behaviour further loosen up the beliefs. It is also clear that one of the belief changes that is crucial relates to ‘normalisation’; helping the young person see how their ideas about the problem showing that they are weird, mad or bad are incorrect and indeed almost the opposite – that they are caring and sensitive individuals with much to offer. Another key component of effective treatment is an implication of the previous points; that it is important for the young person not only to disengage from their worries, but to engage more fully in positive aspects of their life, including renewing their ambitions, hopes and dreams.

It is now clear that the majority of young people who receive an adequate dose of well-conducted CBT do well, and do not need much further help to keep OCD at bay. However, the challenges that face us include the need to further develop our understanding and ability to change several key areas: 1

We have only an incomplete understanding of how developmental issues link to the development and treatment of OCD in young people.

2

Sufferers, their families and teachers often fail to recognise the onset of OCD.