Obsessive Compulsive Disorder (6 page)

• CBT should be delivered in a collaborative way that promotes the young person’s sense of self-efficacy and control.

• It is crucial to consider the young person’s motivation to change right from the start and therapy may need to address this in order to be successful.

• It is important that the environment is set up to promote change and this is likely to involve working with family members.

Structure of sessions

A basic but often neglected starting point is making sure that sessions have a clear structure and a set agenda. This is crucial from a practical point of view as the number of sessions that are available will generally be time-limited. The young person will also feel more in control of the content of sessions if they are predictable in structure and everyone’s items are set on the agenda for discussion. Agendas need to be set so that they are not overly ambitious and allow for repetition and practice of ideas. If the young person does not have items to actually add, at the very least they can dictate where the session should start. At times, family members may have different agendas, which the therapist will need to address without losing sight of the young person’s needs. It may be possible to deal with different agendas within sessions or it may be necessary to organise separate sessions for family members.

• Sessions should have a clear structure and agenda.

• If family members have different agendas, the therapist will need to address this and may need to organise separate sessions.

The basic tools

The key tools in CBT are:

1

Developing a joint formulation.

24

Creswell and Waite

2

Psychoeducation to make sense of the maintaining role of thoughts and behaviours.

3

Guided discovery using Socratic questioning.

4

Guided discovery using behavioural experiments.

5

Relapse prevention.

Developing a joint formulation

This describes the process of working with the young person to achieve a shared understanding of what is keeping the problem going. By definition, this formulation needs to be worked out explicitly with the young person: for example, using a large piece of paper or a flip chart and making sure the young person has a pen in their hand throughout so that they are free to write or draw as much as they wish.

For the young person to feel ownership of this formulation, it needs to be described entirely using their terms: for example, if they or the family have a particular name that is used to refer to OCD, or whether there is a picture image associated with it. Indeed, using pictures to illustrate the formulation can make it both livelier and more meaningful.

Formulations for OCD must pay specific attention not just to automatic thoughts but also to the meaning of these thoughts and how they then relate to feelings and behaviours. For example, the thought that ‘My Mum could get knocked down crossing a road on her way to work’ may be frightening enough, but may also be associated with other thoughts about what this means; for example, ‘If I don’t do a compulsion, it will be my fault if it happens.’ Even in cases where the presentation appears predominantly behavioural (i.e. compulsions) there are still likely to be associated cognitions that are maintaining the disorder, for example, a belief that they will be overwhelmed by distress if the compulsion is not performed. To elicit these it will be necessary to ask, for example, ‘What would you worry deep down would happen if you didn’t do X?’ or ‘In your worst nightmare, what would happen if you weren’t able to do X?’ Examples of formulations are given in Chapters 4 to 7. Typically, the therapist and young person regularly revisit the formulation in subsequent sessions as they acquire more information through discussion and behavioural experiments.

• A shared formulation, written down in the young person’s terms, is a way of making sense of the problem.

• It enables the young person to see how the problem has evolved and why it keeps going.

Psychoeducation

In order to help the therapist and young person to develop an idiosyncratic explanation of what is maintaining the symptoms, it is useful to help
The use of CBT with children and adolescents

25

them to recognise the role that thoughts and beliefs can play in determining feelings and behaviour. Seeing from the outset that it is perfectly normal for our thoughts to take on this role can help young people (and their families) to view their behaviours as quite understandable, rather than being weird or a sign of madness. This also provides an opportunity to be creative and allow the young person to have fun within the therapeutic environment. Cartoons can be readily employed to illustrate different ways of interpreting scenarios, as can reference to television programmes, for example, soap operas where characters endlessly misinterpret situations and create problems for themselves. Figure 2.1 illustrates one way of playing a family game to demonstrate associations between thoughts, feelings and behaviour. This particular example could be used with a young person who had worries and compulsions that are not around contamination as the point is to pick something that is unrelated to the young person’s OCD. This example can engage young people as it is quite silly and different reactions appear odd when people do not know what is written on each other’s cards.

Commonly in OCD, it is the meanings attributed to intrusive thoughts that are critical to the emergence and maintenance of anxiety and avoidant and compulsive behaviours. Consequently, providing information about the frequency and content of intrusive thoughts in the general population serves an essential normalising function. In addition, imagery, metaphor and nar-ratives can all be used to illustrate other key concepts, for example, the repetition of behaviours as attempts to prevent harm. This will be discussed in greater detail in following chapters.

Figure 2.1

Thoughts, feelings and behaviour game

26

Creswell and Waite

• Psychoeducation is crucial in starting to generate a different way of making sense of the problem.

• With OCD in particular, information about how common intrusive thoughts are in the normal population is an essential part of therapy.

Guided discovery

Guided discovery refers to the process of helping a young person to consider other points of view and put alternative thoughts or beliefs to the test.

A variety of techniques can be used to achieve this goal and these need not be limited to techniques traditionally associated with cognitive therapy as long as the choice of strategy is based on the case formulation and the goals of the particular session. Socratic questioning and behavioural experiments are, however, central to cognitive therapy so will be reviewed briefly here.

Socratic questioning

Socratic questioning is a way of asking questions to explore beliefs and assumptions, to uncover issues and problems and to work through the logical implications of beliefs. Rather than directly challenging a young person’s interpretations and thoughts, the therapist works with the young person asking questions to examine thoughts, test their validity and utility and examine alternatives. Typical questions that are used with adults can also be used with young people and some examples are given in Figure 2.2.

Figure 2.2

Examples of Socratic questioning

The use of CBT with children and adolescents

27

As the young person answers the questions, the therapist listens and reflects, summarises what they have heard and asks the young person further questions to think about the new information in relation to their original belief. The young person is more likely to believe a new way of thinking if it is based on information they have provided rather than information provided by the therapist.

The tone in which these questions are asked is the key to their success. If a young person feels as if they are being asked a question to which the therapist has a ‘right’ answer in mind, they will feel like they are being tested or are somehow wrong or silly to think as they do. Instead the questions must be asked genuinely out of curiosity with no desired outcome in mind.

The purpose of the questioning is to help the young person to consider different ways of thinking.

When considering the evidence for particular beliefs, it is helpful to ask the young person to consider whether they have had any experiences that have showed that their belief is not true or when they are not feeling anxious whether they think about it in a different way. In our experience, young people often find it helpful to consider different ways of thinking when it is in reference to a different person doing the thinking, for example, ‘What would your friend X think if this happened to them?’ With younger children, the use of characters from stories or television programmes may help them to be able to consider a different perspective (see Figure 2.3).

It may be necessary to use prompts or make tentative suggestions to help a young person to answer these questions. At times, however, the young person may respond with ‘I don’t know’. If this is the case, the job of the therapist and young person is to work out how we could get to know the answer. This is one role of behavioural experiments.

• The therapist works with the young person to explore their beliefs and assumptions and examine alternatives through Socratic questioning.

• They are encouraged to think about the evidence for their old belief versus an alternative viewpoint.

Figure 2.3

Questioning beliefs

28

Creswell and Waite

Behavioural experiments

The purpose of behavioural experiments is to test thoughts to assess their validity and utility. This can be necessary when there is not enough available evidence to fully evaluate a thought, or when the available evidence is just not convincing to the young person (‘I know I shouldn’t think it, but I still do’ or ‘I know it, but I don’t feel it’). Experiments must have a clear hypothesis to be tested and alternative explanations for possible results need to be taken into account from the start, so that the results cannot be discounted after the experiment has taken place. Following the experiment, the results need to be considered with explicit reference to the initial thought being tested.

There are various types of behavioural experiments, ranging from active experiments, such as real situations or role play, to observational experiments, such as the young person observing the therapist performing an experiment, carrying out surveys or gathering information from other sources.

In OCD, active experiments are essential for challenging the young person’s beliefs, such as the likelihood of harm occurring or to test the idea that thinking something can make it happen. Historically, exposure and response prevention (ERP) has been used to treat OCD, where the young person is encouraged to experience the intrusive thought without carrying out the compulsion. For example, if the young person is worried about contamination, they may be encouraged to touch a door handle without then washing their hands. With a more cognitive approach, ERP may still be used but this would always be specifically as a behavioural experiment to test out a particular cognition. For example, if the young person’s belief is ‘If I touch the door handle without washing my hands I could get ill’, then the experiment may involve ERP. However, if the belief is ‘If I touch the door handle, I will be so anxious that I will go mad’, then the experiment may involve the young person touching the door handle and then allowing a sufficient amount of time to pass so that they are able to learn that the anxiety eventually remits.

In this case, they could wash their hands afterwards without affecting the outcome of the experiment. Rather than designing a graded hierarchy of exposure tasks for the young person to work through, behavioural experiments are set up as a way of finding out how the world really works, and as a result they are designed in an idiosyncratic way according to the young person’s beliefs. Other information such as that provided by surveys can also be helpful to find out that other people have intrusive thoughts, to consider how often other people are able to achieve perfection or a ‘just right’ feeling or to find out about other people’s experiences of anxiety.

As much as possible, the young person should be encouraged to take the leading role in designing the experiment. Where this is not possible, for example, if the therapist suggests an in-session experiment, the young person must have clear permission to say no. To encourage young people to get involved in the design of experiments, again it will be necessary to be creative and have fun. For example, when carrying out experiments to find out whether thinking something can make it happen, the therapist could encourage the young person to begin by thinking something funny rather
The use of CBT with children and adolescents
29

than anxiety provoking to see if it comes true,
e.g.
the therapist’s hair turning blue. Once they are comfortable with this, they could then be encouraged to begin to think thoughts that are more anxiety provoking and more related to OCD to see if they work in the same way.

• Behavioural experiments are an essential component of CBT for young people with OCD.

• The purpose of experiments is the test the validity of the young person’s existing beliefs and to construct and test out new alternative beliefs.

• Behavioural experiments need to have a clear rationale and, where possible, the young person should be encouraged to take the leading role in designing them.

Relapse prevention

Many young people report that their symptoms increase in times of stress or illness and so it is possible that events such as coming up to exams, moving house or school or changes to friendship groups can reactivate symptoms.

As a result, towards the end of treatment it is helpful to introduce this so that the young person is prepared and able to deal with it. Most relapse plans incorporate a review of what was helpful in treatment, consideration of what events could trigger further symptoms, further goals to work towards and then a plan for dealing with setbacks. It can also be helpful to teach the young person to deal with stress and other life difficulties. Towards the end of treatment, increasing the length of time between sessions and offering booster or follow-up sessions can also be helpful.