Obsessive Compulsive Disorder (7 page)

A relapse plan involves a review of what was helpful in treatment, consideration of what events could trigger further symptoms, further goals to work towards and a plan for dealing with setbacks.

The therapist’s role

The therapist’s role is that of an
active listener
who frequently summarises the material they have heard to check their understanding, and is able to respond to different situations in a flexible way. Together the therapist and young person create a formulation of how the current problems are being maintained; for example, how coping behaviours are inadvertently reinforcing thoughts and their meaning. Throughout therapy the therapist acts as a
guide
to help the young person investigate and discover new ways of thinking and behaving. Crucially, the therapist asks questions to identify thoughts and assumptions in order to open up new possibilities, rather than 30

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giving concrete advice. In CBT it is not all talk, however; experiencing is also an essential part of learning new ways of thinking and acting. The therapist prompts the young person to devise experiments to test out assumptions where the existing evidence is unclear or unconvincing.

Taking a
non-expert position
also allows the therapist to act as a model for the young person. For example, if the therapist and young person have worked out that the way to find out if touching the toilet bowl will cause a fatal disease is to go ahead and touch it, then the therapist should be prepared to do this first, both to encourage the young person to do the same and as an initial test of the hypothesis. From the therapist’s point of view, taking on this role gives greater insight into the discomfort that the young person is likely to be experiencing and a clear realisation of what the young person is being encouraged to do. Recognising the discomfort that will result from behavioural experiments promotes therapist empathy and compassion, both of which are essential to the therapeutic alliance. It might come as a relief to many of us that modelling fallibility can also be extremely useful for clients who set themselves high standards for success. Equally, the non-expert position leaves the therapist free to use personal examples where this is appropriate and there is a clear rationale, for example, normalising intrusive thoughts.

• The therapist is an active listener who acts as a guide to help the young person investigate and discover new ways of thinking.

• It is crucial that they do not take on the role of ‘expert’ but develop a collaborative relationship with the young person to work together as a team.

The parents’ role

Exactly how the young person’s family, particularly the parent(s), should be most effectively involved in CBT for OCD has not been clearly defined or evaluated. For example, where family-based CBT has been delivered (e.g.

Barrett
et al.
, 2004) it has been compared in different formats (group versus individual family members) rather than compared to non-family-based treatments. Certainly in relation to treatment of other anxiety disorders, outcomes of studies which compare individual child treatment to family treatment have been mixed and it is difficult to draw clear-cut conclusions (Creswell and Cartwright-Hatton, 2007). In the absence of studies to guide us, how we work with families must be determined on an individual basis, through formulation of what is serving to maintain the symptoms. For younger children (pre-adolescents), parents are likely to have a greater influence on their child’s developing cognitions (in contrast to adolescents who may be particularly influenced by their peers) (e.g. Rosenberg, 1979), so
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greater involvement of parents with younger children may give better results (e.g. Barrett
et al.
, 1996a; although see Bodden
et al.
, in press).

CBT with young people across different disorders has involved parents in a number of different ways:

1

As facilitators
, in which the parent acts as a coach, helping the young person with homework and maintaining the principles of therapy at home.

2

As co-therapists
, in which the parent models adaptive coping with the therapist and takes on the therapist’s role out of sessions; for example, helping the young person to identify thoughts and their meanings, to design experiments and evaluate results.

3

As clients
, directly targeting parental behaviours which may be accommodating or maintaining OCD such as performing compulsions for the young person, providing excessive reassurance and helping parents to promote the young person’s autonomy.

Within each role, parents play an essential part in normalising the young person’s experience in order to challenge their fears about what it means to have these thoughts. For this reason, it is essential that parents also receive psychoeducation. Parents need to be able to be open, non-judgemental and not scared of their child’s thoughts, moods and behaviours. This is likely to require investigation with the parents of what their child’s OCD symptoms mean to them and what they would expect their child to feel or act if put in an anxiety-provoking situation (for example ‘My child will not be able to cope’ or ‘They will go mad’). Perhaps most importantly, the therapist may need to help the parent (by modelling, using Socratic questioning or behavioural experiments) to relax and have fun with their child in order to be confident in their parenting.

Whether and how to include a parent in an individual session will depend on what the goals are of that session, whether the parent(s) have a maintaining role in what is being addressed and how the young person feels about parental participation. As mentioned above, the parent must be included in psychoeducation. They must also have the opportunity to understand the formulation, which may well contrast to the seemingly illogical nature of OCD. If the young person is keen to have sessions independently then this could be done through parallel sessions with the parents, telephone contact or allowing parents to watch videos of the sessions or read the handouts from the sessions. Obviously this needs to be negotiated with the young person and their family.

Research is limited on how family involvement affects treatment outcome for OCD but some level of family involvement is likely to be essential in order for parents to, at least, have a better understanding of the problem and support treatment.

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Involving others

Similarly the involvement of other people, including school personnel, peers and siblings, will be determined by the individual case formulation. For example, if a young person has worries about school germs and a belief that they will become ill if they come into contact with school, it can be helpful to have sessions in school to carry out behavioural experiments. In these cases, this will need to be planned and discussed with the young person’s teacher or another appropriate person at school, with the consent of the young person.

The young person may also benefit from involving others in behavioural experiments. For example, if they are carrying out compulsions to try to keep their friends safe from harm, they could survey their friends on how they would feel if they were to stop doing the compulsions. Would this make them a bad person or change the way they felt about them as a friend?

• The involvement of others, such as friends or school, can be beneficial, particularly in carrying out behavioural experiments.

• However, this will be determined by the individual case formulation and be based on a clear rationale with the agreement of the young person.

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Cognitive behavioural assessment

of OCD in children and adolescents

Catherine Gallop

Comprehensive assessment of any presenting problem is essential for effective treatment planning and should consist of a detailed and individualised process that is theoretically driven and combines standardised and idiographic measures with clinical interviews. This process is core to the cognitive behavioural assessment of OCD in children and adolescents in the main part due to the diverse content of obsessions and compulsions that are reported. Furthermore, as with any other childhood presenting problem, it is vital that an individualised psychosocial assessment is undertaken to confirm the diagnosis of OCD and so that the young person’s OCD can be formulated and treated within their unique context and wider system. The overall aims of cognitive behavioural assessment are as follows: • to gather detailed information on the young person’s main presenting difficulties

• to work towards developing a psychological formulation based on predisposing, precipitating and maintaining factors

• to assess suitability for CBT

• to generate goals for treatment.

In order for these aims to be achieved the therapist should gather information on the following areas:

• family history

• developmental history

• specific OCD symptomatology

• history of OCD

• avoidance and interference

• cognitive appraisals and beliefs

• comorbidity and risk

• motivation and suitability for treatment.

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Gallop

The therapist should aim to gather information from the young person, their parents (or main carers) and from the young person’s wider system (e.g.

school) where appropriate (Rapoport and Inoff-Germain, 2000). A clinical interview with the young person with their parents present is recommended in order for a full developmental, family and symptom-based assessment to occur. However, the therapist should be aware that discrepancies between child and parent report can occur. As a general rule priority should be given to the young person’s report for internal states (e.g. thoughts and feelings) and to the parents’ report for more observable, external behaviours if discrepancies occur. However, parents of adolescents are sometimes unaware of the full extent of their child’s symptoms and can therefore underestimate their frequency and severity. In such cases it may be advisable to give greater weight to the report of the young person.

Setting the scene

In addition to the aims of assessment previously highlighted, the assessment process also begins the process of engagement with the young person and their family. For this reason it is often helpful to start the interview by taking a family and developmental history, before moving on to the presenting difficulties. At the beginning of the interview the therapist should explain the areas that will be covered in the assessment and start to build on the idea that assessment (and treatment) is a collaborative process: ‘I am going to be asking you lots of different questions about your family, about you when you were little and growing up and then about the things that you may be finding difficult at the moment and when they started. There will also be some questionnaires for you and your parents to fill out. You might be thinking that it sounds like an awful lot of questions and you’d be right. The reason there’s so many questions is because I want to find out as much about you and your family as possible so that between us we can try and come to the best understanding we can about what’s been going on for you and why. This will help us decide what is going to be most helpful in terms of the way forward.’

It is important at this stage to inform the young person and their family that there are no right or wrong answers and that assessment is an ongoing process. Before beginning the assessment, the therapist should discuss and agree with the family whether it would be helpful to have some time as a family together but also to have some time with the young person and family members separately. This can be especially important with adolescents as they often find it difficult to articulate specific thoughts and feelings in front of the parents, such as those of a sexual nature. In addition, it is helpful to spend some time alone with parents to try and elicit parental beliefs and
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behaviours that may be involved in the maintenance of their child’s OCD

and that can be hard to discuss in front of their child.

• The overall aims of cognitive behavioural assessment are to gain information on the young person’s main presenting difficulties, to assess suitability for CBT, to develop a psychological formulation, and to generate goals for treatment.

• Assessment should utilise a range of different measures including structured diagnostic interviews, clinician-rated interviews, self-report questionnaire measures and idiosyncratic measures such as diaries. Information should be gathered from multiple sources and at the very least be based on both child and parent report.

Family and developmental history

The main purpose of taking the family and developmental history is to identify possible vulnerability, precipitating and maintaining factors that can aid formulation and treatment planning. There is clear evidence for the family aggregation of OCD and other anxiety disorders and earlier age of onset has been associated with the presence of OCD in the family (Shafran, 2001). The therapist should therefore enquire about the presence of OCD

(both current and past) or other anxiety disorders within the child’s family.

Given that vulnerability may not only lie in genetic heritability but also socialisation to relevant beliefs and behaviours, specific questioning around the young person’s knowledge and experience of the family member’s OCD

and the way in which the parents feel this may have impacted on the young person may be helpful.

Central to the cognitive behavioural theory of OCD is the notion that normal intrusive thoughts are misinterpreted as being more significant than they really are. It is suggested that certain individuals may be more vulnerable to making these catastrophic misinterpretations (Rachman and Hodgson, 1980) and this may include young people who are prone to anxiety, excessive conscientiousness, perfectionism or depression. The therapist should therefore enquire about early personality characteristics such as the young person’s typical reaction to new and potentially anxiety-provoking situations and should note any history of depression or other anxiety disorders. Early obsessional behaviour (and the family member’s beliefs and reactions to this) may also be significant in the development of childhood OCD. The therapist should therefore aim to gather detailed information on early obsessive compulsive behaviours and fears but should remain mindful of the distinction between these and normal fears (see Carr, 1999) and behaviours.