The enclosed protocol, techniques and procedures were adapted materials from several source. Probably the major source, at least in terms of format, is ‘OCD in Children’ [the Guilford Press, 1998]. In addition, we selected articles by Steven Phillipson from his web site and found here the most coherent description and approach to OCD. Finally, we used materials from the ‘OCD Workbook’ of Bruce M. Hyman & Cherry Pedrick [New Harbinger Publications, 1999]. While all of these offered excellent cognitive approaches, all except Phillipson made their work incoherent by reverting to medical model explanations. Therefore, if you go to the source literature, you will find major differences in description, but not in intervention.
INTRODUCTION
What is an obsessive compulsive disorder [OCD] and how does it occur?
The most widely held theory is that the cause is related to abnormal levels of one of the brain’s vital chemical messengers – serotonin. While there is no consensus of scientific evidence for such a theory, serotonin plays a role in many biological processes, including mood, aggression, impulse control, sleep, appetite, body temperature and pain. Therefore, it seems logical to suspect that it has something to do with any dysfunction of any of these systems, although what that role is, is not at all clear. In fact, serotonin gets blamed for almost all dysfunctional attitudes concerning fear, sadness and/or anger.
But while serotonin may be the medium of implementation, there are several anomalous areas of concern. The first of which is the cause/effect conundrum. Are the changes in serotonin levels a cause of dysfunctional attitudes or an effect of them. Probably the most common knowledge example for comparison would be adrenaline. Everyone seems to know that when you are frightened or angry the adrenaline level in the body increases preparing the body for action. However, common knowledge would also surmise that the rise in adrenaline is the effect of being frightened and not the cause. It is difficult to imagine that adrenaline causes fear, and if it were so, the question would need to be asked, what causes the increase in adrenaline?
A second area of concern is that we are aware that it is our perception that causes fear. If a stimulus is one which we have learned is dangerous, our perception of the stimulus is likely to heighten our anxiety. Of course, there are some stimuli which are not dangerous, but which we believe are dangerous. How do we know?
Our understanding of what to fear is based on two factors: epigenetic rules and learning. The epigenetic rules, such as the fear of loud noises or falling are inherent genetic predispositions acquired over millions of years and are easily demonstrated with infants. However, we must learn that bears are dangerous. We learn through other people and/or our interpretation of our own experiences. If we run into a bear and it mauls us, we are likely to avoid bears in the future. If we have been taught by others that bears are dangerous, we may still want to test out the other person’s theory, but will probably do so with great caution.
Learning is an ambiguous process. We see how other people behave and interpret the experience. We feel the emotional qualities of other people and may find fear contagious. We experience our own calm/fear in situations and gradually build up a ‘theory of meaning’ about given experiences. Once we have a theory of meaning for bears, we are likely to hold onto that theory quite strongly, seeking out confirmative evidence and ignoring contrary evidence. In fact, if we were to believe that bears were dangerous and searched for supportive evidence, we are likely to ignore each piece of contrary evidence and keep searching. Once we find confirmation, we are likely to stop searching. This is similar to the question “Where do you find a lost item?” The answer, of course, is “In the last place you look”. The reason is that once you find it you no longer search.
OCD is an anxiety disorder. It occurs when an unnatural fear occurs about somewhat normal events. We have all experienced a questioning of ourselves – i.e., did I turn off the lights? Most of us would ruminate on this for a short period of time, and then shrug it off and accept the risk that we didn’t turn them off, but probably did. The reason we are able to shrug off the concern is that we assume that even if we did not turn off the lights, everything will be all right. But what if the supposition that the lights are still on brings on the thought that the house will burn down. What if our belief is that a tragedy could occur? Perhaps we would want to go back to the house and check to see if we had, in fact, turned the lights out. We have all gone back and checked before and some of us, even then, continue to be concerned, to have anxiety that we cannot quite put our finger on. So we might check again.
Somehow, we may get into the habit of checking and rechecking, and once we habituate a thought or action, it becomes automatic. One may say that the loss of consciousness of a predictable event ‘is’ the signal that the event has been learned completely What this means is that we are no longer necessarily aware of the thought or behavior. Like a reflex behavior such as blinking, we can become aware of it, but unless we do, it just continues to occur. Obsessional thinking is learned behavior that has become nonconscious and creates anxiety. We automatically assume that leaving the lights on will burn down the house and every time we leave the house, we have this uncanny feeling that danger exists. Since serotonin is a chemical that is involved with a change in moods, we certainly would expect to have serotonin involved – for we have a thought that affects our mood. We are anxious on a regular basis, and we are anxious because we believe that something harmful will happen.
We have a thought about some simple thing, and for some reason we interpret that thought as an indication of danger. Most of us take action to protect ourselves and our loved ones against harm. The actions we take might include checking [physical] the situation to ensure that we did what we needed to do to avoid the disaster or praying [mental] that no disaster will happen. This is a highly rationale response based on our beliefs about how the world works. The function of the compulsive ritual [behavioral or mental] is to reduce the distress that accompanies an obsessive worry or fear. But the house doesn’t burn down until the house burns down; and the failure of the house to burn down reinforces the belief that the checking and/or praying is working. And since we tend to ignore evidence that disconfirms our beliefs, we continue to check or pray over and over again until that becomes a habit [nonconscious and automatic].
Now one thought may lead to another – if leaving the lights on is a problem, it is probably much worse to have left water running or the gas stove burning. Thus, we may increase either the obsessional thought or the rituals by simply following the rules of social learning and our own theory of meaning. The reinforcement for our rituals occurs because the disaster [burning down of the house] never occurs as long as we continue to perform the rituals.
Having gotten ourselves into this routine, there are only two ways to break out of it. The first is to change the thought – the lights on is not dangerous. This would require a cognitive intervention that would bring the thoughts into consciousness so that the thought can be ‘debugged’. The other approach would be to change the behavior. If the person does not check and the disaster does not happen – what might occur? Most likely there will be a reduction in anxiety.
A review of the literature of effective intervention strategies for anxiety indicates that exposure and response prevention [E/RP] is the one that is most effective. Exposure to a feared object or thought habituates that object or thought and reduces the valuation [emotional content] of that object or thought. Doctors perform autopsies without qualm [emotional content] only after a lot of exposure. In addition, the exposure without the disaster provides experiences that are contrary to the theory of meaning, which requires an adaptation in the theory – thus modifying the thought.
Of course, since the obsessive thoughts and compulsive rituals are somewhat out of the ordinary mainstream way of thinking, other emotional valuations will probably occur. You may think that other people are ‘crazy’ for not seeing the need for the ritual. Others may see you as ‘crazy’ for your behavior. The rituals may interfere with your ability to carry out other functions of living [school, work, relationships]. Other people may try to stop your behavior through persuasion or coercion, or they may have compassion that leads them to participate in your rituals in order to compensate your anxiety. All of these experiences lead to their own problematic potentials.
To intervene effectively, the helper will need to be aware of all of these dimensions of social difficulty. S/he will need to be able to bring significant others to a point where they do not support nor punish the OCD, but do support the person in dealing with the issues. Facing our fear is a difficult task whether or not the fear is ‘real’. Just because the thought is obsessive does not mean there is no danger.
Parents play a part in initiating and maintaining thoughts of all kinds. If what they are maintaining is not helpful, they are probably willing to change. But understanding the role of initiating and maintaining negative thoughts does not mean that that parents are to blame for those thoughts. Parents, by and large, act in ways that they hope and expect will be helpful to their children. When the effort fails, it needs remedy, not blame.
PREVALENCE
In the United States, Obsessive Compulsive Disorder [OCD] is the fourth most common mental diagnosis with a prevalence rate of 2.5%. This means that one out of every forty people, over 6.6 million men, women and children in this country suffer from OCD. As many as one in 200 young people suffer from OCD at any given time. This means that there are three to four youngsters with OCD in the average elementary school and up to 20 to 30 in a large suburban school district. Among children, boys with OCD outnumber girls by about two to one. The onset is usually gradual, although some people have reported a sudden onset. It is not uncommon for OCD to flare up during times of emotional stress.
Obsessive Compulsive Disorder is an anxiety disorder. Although the thoughts associated with OCD are bizarre, they are not at all the focal point of the clinical objective. The essential features of OCD are recurrent obsessions (thoughts) that create an awareness of alarm or threat. (e.g., “I might get AIDS from the germs on that door knob”; “Since I had the thought of killing my baby, I might be capable of doing it”; “If I don’t pick up that Band-Aid someone else might get sick from it, and I would hold myself culpable”; etc.). Persons typically engage in some avoidance or escape response in reaction to the obsessive threat. What appears to be dysfunctional has a functional attribute within the ‘inner logic’ of the disorder. This program will offer a paradoxical intervention to address the disorder. Paradoxical interventions are strategies and tactics in apparent opposition to the acknowledged goals, but actually are designed to achieve them. The goal of the clinical intervention for OCD is to reduce the anxiety, but this is not done through avoidance or escape.
Obsessions take the form of a perceived threat of physical harm to oneself or others or, in some cases, more of a metaphysical or spiritual threat to oneself, others, or perhaps a deity. The response is often to perform certain physical or mental rituals to avoid the danger. In approximately 80% of all OCD cases, persons performing these rituals are painfully aware that their behavior is unreasonable and irrational. However, this insight provides no relief. Therefore, attempting to help sufferers through reassurance or persuasion has no long lasting positive effect.
It is not unusual for people to question whether they might qualify for a diagnosis of OCD given that most of the following examples are not unlike what most of us do to a limited degree on an everyday basis. Everyday examples of OCD-like behavior include using one’s foot to flush a toilet to avoid germs, knocking on wood three times to ward off a bad omen, throwing salt over one’s shoulder for a positive future, or feeling inspired to say ‘God forbid!’ after mentioning the potential death of a living person. Simplistic tests to determine whether these behaviors cross the line into the OCD realm include asking yourself how much money it would take for you not to perform the safe behavior. Persons operating in the non-OCD realm would most likely accept between $10 to $100 to do something that would make them feel uncomfortable. Persons with OCD typically would not accept upwards in the neighborhood of $100,000 to face their feared concern. OCD is a disorder of intensity, not type. We all have some obsessional type thoughts and compulsive type responses, but for most of us these do not get out of hand. This speaks to another criterion involving the degree to life’s disruption. While we all have quirks that take up small bits of the day, people wrestling with OCD very often invest hours of their day avoiding these concerns.
TYPES & FORMS
The most common and well-studied type of OCD is where the undoing response involves some overt behavior. The most common form of OCD involves contamination. Here an awareness of germs, disease, or the mere presence of dirt evokes a sense of threat and an incredible inspiration to reduce the presence of these contaminants. Most commonly the escape ritual involves a cleaning response (e.g., hand washing, chronic cleaning). The next most common form of OCD involves a sense of danger based on something left undone, which evokes the compulsive behavior of checking. Typically, checking involves door locks, light switches, faucets, stoves or items that left unchecked might pose a risk to either one’s well-being or the well-being of others. It is not at all uncommon for persons with this manifestation to check items between 10 to 100 times. The overwhelming impulse to recheck remains, despite the realization that the item is secure, until the person experiences a reduction in tension.
Less common forms of this type of OCD include hoarding, which is the excessive saving of typically worthless items such as junk mail, or excessive purchasing of certain items (e.g., owning hundreds of pairs of shoes). Other typically hoarded items include trash, novelty items, or magazines and newspapers. A common rationale given to justify obsessive-compulsive hoarding behavior is an overriding fear that one day these items might come in handy or be of some value and therefore must not be thrown away. Another subgroup of hoarders involves persons who become emotionally attached to the items or believe these items hold some emotional significance that reflects a particular moment in time. The person believes that relinquishing the item is in some way tantamount to releasing a past experience or association with a significant other.
Ordering is a subcategory of OCD where the person feels compelled to place items in a designated spot or order. This person fears a sense of being overwhelmed and impending anarchy if items are not placed exactly as they are arbitrarily determined. Persons with this condition typically line up items in parallel locations, but the focus is on the concept that each item belongs in a particular place. Another form of OCD is perfectionism, in which persons feel compelled to habitually check for potential mistakes or errors that might reveal their own faults or might jeopardize the person’s stature at work.
Another type is the purely obsessional (Pure-O). The objective of the client here involves the escape or avoidance (through excessive covert mental behavior) of noxious and unwanted thoughts. In its most generic form, persons might have upsetting words or phrases repeated in their head, not unlike what most experience when an unpleasant song is played over and over in our mind without our active choice in it being there. Persons with the Pure-O classification can also experience what seems to them to be threatening ideation involving the potential that they might do harm to others or that merely the idea of having the threatening thought suggests something evil or depraved about their identity, capability, or self worth. This classification periodically also involves persons who engage in a tremendous amount of problem solving (also referred to as ruminating), as a ritual. Endless attempts to answer questions related to one’s own sexual orientation or even something as simplistic as the name of one’s third grade teacher might occupy endless hours of problem solving.
This classification also involves persons with a heightened sense of superstition, in which, for example, certain numbers might take on a great significance related to positive or negative outcomes. Typically, positive numbers or perhaps the number ‘seven’ involve a greater likelihood for safety or permission to proceed with a given task. Other numbers forewarn of something ominous about to happen. These persons typically engage in elaborate touching or counting rituals to ensure that the safe or desirable number is the one upon which the task or thought is to be ended. Superstitiousness need not be limited to numbers. The old quirky childhood games of avoiding cracks or walking under ladders takes on a significance beyond most people’s ability to comprehend.
The last type involves a somewhat more complex and difficult to treat form of OCD. That is Responsibility OC (hyperscrupulosity). Here, the person’s concern is not for themselves, but directed toward the well-being of others. Typically, significant others (although sometimes society at large) are thought of as the predominant focus on which to prevent harm from coming. The responsibility OC might take on a Pure-O form such as getting a noxious thought that some harm might come to someone else. And the person might feel compelled to pray in a way to stave off that harm coming to another. Also the responsibility OC might engage in elaborate cleansing rituals to prevent others from receiving germs or diseases that s/he may be carrying, yet feels no fear for his own well-being. Persons with this form of OC often engage in warning others about possible risks or cleansing their environment of possible risks to others at large. Persons with responsibility OC often engage in excesses for another’s distress or danger, so as not to be held culpable. The reason this form is particularly difficult to treat is the combination of anxiety in association with the risk and guilt at being responsible for adversity happening to others.
More obscure forms of OCD involve body dysmorphia. Body dysmorphia is a condition wherein a person become excessively focused on some body part, which they perceive to be grossly malformed. Typically, the area that a person with body dysmorphia focuses upon would never be thought of as a defect to others in the person’s peer group. Persons with body dysmorphia engage in elaborate checking rituals to try to gain reassurance or assess the severity of their deformity in the mirror or go for repeated plastic surgery or often engage others in the attempt to gain reassurance in the absence of the problem.
Another obscure sub-classification of OCD involves an olfactory obsession in which persons are entrenched in the idea that some part of their body is emitting a noxious aroma. Typically, the areas that the person is convinced emits the noxious smell involve genitalia, breath, feet, or underarms.
A last form of OCD involves a preoccupation with the potential of having some physical malady, typically cancer or some life threatening disease. This condition continues to be referred to as hypochondriasis and exists in the DSM as a separate disorder from OCD. However, like body dysmorphic disorder, the symptoms and endless search for reassurance fall completely under the diagnostic category of OCD.
CLINICAL RESPONSES
Almost all clinical and research evidence indicates that cognitive behavior interventions are the response of choice. This is usually couched in the terms Cognitive Behavior Therapy [CBT] Since it is a social learning approach, training might be a better word for the T.
Most practitioners will also suggest the use of medication – particular selected serotonin reuptake inhibitors [SSRI] as a part of the intervention. We believe that this not only sends the wrong message, but is harmful to the children we serve and will avoid its use in this intervention.
Finally, we want to be sure that the cognitive behavior intervention does not imply cognitive process correction as a major focus as is used for sadness disorders.
Our attempt is to explain how cognitive mechanisms (i.e., style of thinking) and time tested behavioral techniques (i.e., exposure and response prevention), can augment intervention strategies available for OCD. An historical perspective is presented below to familiarize the reader with traditional cognitive-behavioral principles. The main thrust will be to delineate the differences between the client’s conceptual understanding of OCD and the traditional cognitive process correction approach. The client’s understanding of the language and concepts of OCD provides a rationale for specific intervention components. The term we will use is cognitive management to indicate that the process is one of managing the cognitive content and often reframing the perceptions in order to mitigate anxiety and reduce the frequency of disturbing mental prompts.
Cognitive-Behavioral Therapy (CBT) is most often associated with the work of Albert Ellis and Aaron Beck, dating back to the early 1970’s. The basic premise of this approach is founded on the belief that at the heart of emotional difficulty there exist distorted and irrational patterns of thought. These patterns revolve around our automatic reactions toward life circumstances that create upsetting emotional consequences. CBT was developed to assist people to respond rationally to automatic irrational thoughts. Automatic thoughts are defined as reflexive cognitive reactions toward upsetting thoughts that are beyond our conscious control. Research findings strongly suggest that the long-term application of cognitive behavioral principles yield a better outcome than medication. This approach teaches the person to identify the irrationality of his or her reflexive reactions or beliefs (automatic thought), that occur as a consequence of upsetting events (activating event). The intervention challenges the notion that the actual situation is responsible for the periodic upset (emotional consequence) that is experienced. The foundation of CBT is predicated on the philosophy of the ancient Greeks, which stipulates that “Nothing in life is actually bad, lest we perceive it to be so”. Traditional cognitive-behaviorists focus on teaching clients to substitute automatic irrational thoughts with rational thinking through dispute and scripted self talk.
An example that illustrates this premise is a story about Mary and John. It seems that after dating for approximately one year, Mary decided to end her relationship with John (activating event). Following the termination of the relationship, John experienced dramatic periods of depression (emotional consequence). John’s reaction to the break-up in his internal dialogue, (i.e. self-talk (belief)) was something like this: “Now, I’ll never find someone to love…My life will be filled with emptiness.” Traditional cognitive therapists would encourage John to challenge these self talk statements (disputation) by examining the possibility that although this is truly an upsetting experience, one’s future is predicated on the choices one makes. Ultimately, John’s success with future relationships will be determined by the effort he makes. The fullness of his life is determined largely by his hobbies, peer relationships, and occupational participation. The existence of an intimate relationship is not the sum total of his wholeness.
Traditional CBT presumes that all people have irrational thoughts. The interventions are based on the clinician’s faith in the client’s ability to learn how to differentiate between being rational and irrational. At the heart of this model is the belief that we learn to think in dysfunctional and/or irrational ways from such sources as society, family, and culture. The problem posed by OCD is that the vast majority of sufferers are painfully aware that what they are doing is bizarre and irrational. It is common for a person with OCD to say, “It feels so real, yet I know it’s literally impossible for it to be legitimate”. Most can even predict that the risk of danger is infinitesimal, yet they ‘feel’ overwhelmingly compelled to act out some escape response.
This creates a chronic losing battle between the rational self (as represented by an individual’s futile attempts at using reason to combat the disorder) and the brain’s capacity to create unreasonable automatic thoughts accompanied by uncontrolled emotional upheaval. This dichotomy within the sufferer’s mind is best exemplified by examining the frequently reported experience of remaining cognitively aware of the absurdity of the thought of immanent danger while still experiencing a fear that the threat is totally legitimate. The cognitive aspects of traditional CBT for people suffering with OCD is therefore likely to be counter-productive toward achieving a beneficial social outcome. Instead of analyzing or disputing the automatic thoughts in order to help the client understand that they are irrational, the clinician will need to help the client manage his/her thoughts in quite a different manner.
COGNITIVE BEHAVIOR MANAGEMENT
CLINICAL RELATIONSHIP
Consistent findings from studies testing the effectiveness of different clinical interventions strongly suggest that the working alliance (the bond between clinician and client) is paramount in predicting successful outcome. The following interpersonal aspects of intervention play a significant role in fostering an atmosphere of collaboration:
- level of comfort;
- confidence in the clinician; and
- a commitment to the process by the client and clinician.
The relationship is a partnership in the fullest sense of the word. To be successful, both parties need to bring their fullest devotion to the explicit and implicit contract, such that, at the end of each session, both parties come to an agreement as to the upcoming week’s homework challenges and goals. All too often clients say, “You made me touch the door knob” as they review their previous week’s homework assignment. A cognitive behavior management specialist may immediately respond by saying, “The way I remember it, we had an agreement that you would do it.”
It is essential that the client accept the responsibility to willingly participate in his/her own rehabilitation. This may pose a difficulty in working with children. The suffering may not have reached a point where the ‘risk’ of recovery is valued sufficiently to choose to share the challenges of this difficult process even with an experienced partner.
Cognitive principles focus on fostering a sense of independence on the part of the client. Cognitive behavior management specialists teach the client language and concepts, skills, strategies and perspectives for responding to the challenges that life has to offer so that s/he can gain a greater sense of self-efficacy (i.e. developing faith in his/her own abilities to achieve specified goals). Equally as important as knowledge, training, experience, and credentials on the part of the clinician are warmth, understanding, and compassion.
In the final analysis, the clinician will either fulfill for the client a need to finally escape ‘no matter what it takes’ or convince the child that, with the clinician’s trust and support, s/he can take the risk, stand the heat, and harass the demon.
PSYCHOEDUCATION
Despite repeated research suggesting that an academic insight into the dynamics of OCD provides limited to zero benefit to the client in practice, a basic understanding of the language and concepts of the disorder’s design may nevertheless facilitate cognitive behavior management procedures. The design of this diabolical disorder is often misunderstood by clients. Once the client can come to anticipate the structure and rules of OCD, they gain a tremendous emotional edge.
As an adjunct to behavioral techniques, the clinician must provide to the client a perspective that utilizes specific mental actions. These mental actions will be designed to help OCD sufferers respond more effectively to the destructive inner voices that seem to manipulate them so persistently.
Progress can be enhanced by enlightening the client to a number of key principles about the disorder, among them:
- That OCD doesn’t indicate a malfunctioning brain or a lack of reasoning capacity.
- That the disorder is best represented symbolically as a type of bully or demon that can be understood and defeated.
- That recognizing the key warning signs of an OC episode – especially the onset of anxiety – is a necessary prerequisite to addressing the disorder.
- That learning effective responses and attitudes can bring satisfying results.
- That the client’s overall strategy is only effective if accompanied by a resolve to fight as hard as necessary and live with pain as long as necessary – rather than to merely throw hollow words at the disorder. A willingness to harass the demon.
First we will formulate a theoretical foundation on which the primary premise will be based. It is well documented that the great majority of people with OCD are aware that their rituals are meaningless , yet they still experience a tremendous urge or impulse to escape the irrational threat by engaging in these rituals. Recently, it has been established that OCD’s locus in the brain is in the brain stem, specifically the limbic system . This system is found in the primitive part of the brain and is responsible for regulating sleep cycles, appetite, and the ‘fight or flight’ response to anxiety or stress. A person’s ability to reason is located in the brain’s outer surface, the neo-cortex. It is important to understand that the brain does not function as a singular, harmonious unit. Various parts of the brain present different levels of priorities or experiences of urgency. This duplicity of experience explains a key phenomenon: as the primitive part of the brain is firing biologically, the reasonable neo-cortex is confused by the false alarm. No experience carries a greater sense of urgency than a perception of imminent threat to one’s self or to a loved one.
A common example of the multiplicity regarding the brain’s functioning is experienced by the dieter who restricts caloric intake. The goals and aesthetic interests of the individual frequently clash with the body’s craving for a balanced sugar level and nourishment. Similarly, the alcoholic who understands, logically, that drinking will kill him, is still seduced emotionally and physically by the brain to give in to the urges (e.g. “just one drink couldn’t do any harm”).
In the case of OCD sufferers, the primitive brain is reacting to a perceived threat while the rational brain is painfully aware that the threat is only a perceived one and in fact does not exist. In this case, the primitive brain might make an association between toilet seats and the possibility of an AIDS risk, while the rational brain remains aware that the risk is extremely remote. Hence, it is common for a person to say, “I feel as if I’m in danger, even though I know rationally that I’m not.” Conversely, persons with contamination concerns will wash their hands until they ‘feel’ clean, although they have a realization that they may not have been dirty in the first place.
The experience is counter productive since the hand washing provides only minimal comfort for a short period of time, Therefore, repeated washing become necessary. Additionally, as the brain becomes habituated to the washing and still is unable to quiet the perceived threat, the number of washings must be constantly increased before some level of comfort can be reached .
This aspect of the disorder generates the most frustration and confusion for the sufferer. People who generally are accustomed to relying on their superior reasoning ability are completely at a loss to come up with a healthier way of responding to the threat. An analogy is that, “it is as if one were placed in a maze, with an urgent impulse to escape, and all the doors marked exit merely brought you deeper into the labyrinth”.
In early sessions with clients, the clinician will need to spend considerable time teaching them to make a clear distinction between what their primitive brain is telling them and what their rational brain or neo-cortex tells them. Although this understanding has no power over the disorder per se, it provides a basis for understanding and responding more effectively to this dichotomy. Having clients learn that the primitive brain is behind perceived threats can be helpful in formulating a strategy to help them end their continual mental victimization. Such understanding can further assist in alleviating some of the guilt and shame associated with the disorder.
Many clients express a sense of relief when they realize that their basic character (e.g. rational self or neo-cortex) has little if anything to do with the content or theme of their obsessional focus. They’re also relieved to know their brain isn’t malfunctioning. What clients learn is how to make a clear delineation between the neo-cortex (representing genuine ideas and values) and those impulses or urges that are motivated out of anxiety and/or guilt.
It is critically important for the client to be mindful that OCD is a disorder of associations. There are automatic connections between becoming aware of something and having an immediate reflexive thought or impulse in reaction to that awareness. Behaviorists contend that this connection comes about as a result of basic learning and therefore has no underlying meaning reflecting unconscious motives. OCD is not a condition in which a person is actually afraid of germs or killing someone. Instead, the anxiety comes as a result of a reflexive association between two items that the brain links due to past learning.
Because the thoughts involve basic learning and habituation, we have no capacity to prevent their emergence into our consciousness. For this reason, attempting to treat the OCD by logically disputing the irrational nature of the concerns will have no bearing on the overall outcome. Unfortunately, sufferers, supporters and professionals alike become overly focused on providing reassurances, rather than on learning how to cope more effectively with the anxiety and its symptoms. Unknowingly, they merely facilitate the suffering, rather than alleviate it!
Detecting the onset of an OC episode can help in creating an effective response. A willingness to take the risk must begin with the first awareness of the presence of anxiety, which is a key OC barometer. People who use their experience of anxiety to recognize the disorder’s presence can get a jump on their ruminating. Saying to oneself that, “the risk may be real, but I won’t attend to it until I feel minimal anxiety”, can be a powerful mechanism that manipulates the disorder rather than the reverse.
One of the most difficult pills for the OCD sufferer to swallow is to accept taking a risk when confronted with any threat that has a component of anxiety or guilt associated with it. In clinical experience, it is unlikely for a clinician to know a person with OCD to have been ruminating over a threat involving anxiety or guilt, which turned out to have any realistic significance. In conjunction with this, it is never heard that a client wonders whether a concern was actually OCD and have it turn out not to be. So what an OCD client most needs to know is which emotions or thought patterns are clear indications of an OCD episode and which aren’t. The client, once recognizing these, must then take a stance against the OCD.
As clients attempt to implement this perspective, their greatest downfall is generally a result of grasping just the words and not the spirit of the intervention process. A willingness to paradoxically embrace the discomfort is easy to understand, but difficult to implement. Often what happens in the process is that there will be an initial decrease in anxiety as the client faithfully puts the techniques into practice. At this point, realizing that something positive has taken place, the client frantically attempts to repeat the success, but only by parroting the words learned in the clinical sessions. Phrases such as “I’m willing to suffer throughout the day” or “I can live with this discomfort” have a great deal of potential benefit, but only if they are more than just a verbal incantation and reflect a deep (or thorough) emotional commitment .
How, then, does the practitioner go about treating OCD? First, the power of understanding and use of a mental paradox (i.e. encouraging an exaggeration of the problem) in the daily struggle with anxiety cannot be overstated. An example of understanding the application of paradox is reflected in the soldier in battle who is deathly afraid for his/her own and his/her comrades’ lives. The primary instinct is to hide or run away. Yet paradoxically, s/he is safest when s/he and everyone else stands and fights.
So the best approach acknowledges the threats, before embracing and encouraging an even greater level of anxiety.
As part of the cognitive process, the portion of the brain generating the anxiety is externalized and identified as evil. Without any religious connotations, externalizing by conceptualizing the disorder as a demon, separate from one’s own identity, seems to be an apt choice. The designs of both a demon and this disorder can be conceptualized as follows:
- To seduce the client into doing it’s bidding by promising relief just around the corner, often the OC demon will convince the victim that only one more reassurance will resolve the dilemma and provide more than momentary relief.
- To exploit moments of weakness and materialize at the worst possible times in a client’s life (e.g. when it is perceived as absolutely disastrous to become anxious).
- To choke the victim more each time s/he struggles to get away.
Those clients who have genuinely challenged the demon to do its worst, and are perfectly willing to confront and endure tremendous discomfort, even death itself, have made the most dramatic progress. They, in fact, have experienced the least amount of pain while performing exposure exercises. This exemplifies the critical nature of understanding the mental paradox: the more pain one is willing to endure, the less it is experienced.
Although the literal wording to be used in confronting the internal demon at the onset of anxiety will vary from person to person, the following represents a helpful generic phrasing:
“OK demon, I feel the discomfort you’re able to create. I know I’ve felt you many times before, but I’m willing to make room for you and acknowledge your presence without escape. I have the capacity to tolerate an increase in the level of distress you’re creating. I’m willing to concede to you that I haven’t solved your dilemma. I can be reminded of this by you on a frequent basis and I can stand you being with me throughout the day. I’m celebrating your presence, willing to think about you often for a split second each time, and seeing your arrival as a chance for me to hone my skills of living with the demon. Bring it on!”.
The general paradoxical strategy is to allow the unresolved conflict into the consciousness and acknowledge a willingness to suffer for as long as the brain is able to generate discomfort. If the anxiety subsides, the sufferer may even re-ignite discomfort as a further test of his/her own power over the demon.
There are many instances in which the demon’s threat involves one’s own death or the death of a loved one. Unless the client is prepared for these events to come to fruition, the disorder will always have the upper hand. Merely saying “I’m ready to die” is meaningless without an associated internal preparedness. Although these ideas are profoundly philosophical, they have a very pragmatic and basic application. One must be willing to suffer the elephants to risk not waving the arms.
Unfortunately, after initial success, some clients often use these responses in a very laborious and circumscribed manner. Often this response pattern can become part of the ritualizing process and takes as much, if not more, time to engage in as performing the escape ritual itself. Instead, genuinely saying to your own brain, “OK, I’m ready to die so do your worst”, cuts out a lot of time.
People with Responsibility OC will often say that they are willing to die, but they are not willing to be involved in the risk of harming others or having others remain at risk without taking action to reduce the threat. Unfortunately, unless one is willing to face the worst possible scenario, the disorder will always have the upper hand. It is important to remember that, in treating this disorder, when legitimate danger is present, anxiety is not the experience. Instead, a client experiences healthy concern for an individual.
Remember that anxiety and guilt aren’t the only OC warning signs. Among the other indicators are:
- Thinking you’re foolish for not completing the ritual.
- Worry that the demon won’t let you relax until the ritual is performed.
- Ruminating over whether or not the problem is real or OCD.
The primary objective of cognitive behavior management for OCD is to starve the demon of its nourishment (i.e. avoid any thoughts or behaviors that are reassuring, avoidant, or escapist in nature). One does not kill the disorder directly and, therefore, these procedures do not have immediate relief effects. Impatience for the anxiety to go away is the demon’s greatest ally. Choosing to embark on the long path of eliminating this disorder requires realizing that the goal of starving an enemy to death takes time. Most successful clients have taken at least four months to eliminate as much as 80% of their ritualizing time, while the average course lasts between one to two years. So it is extremely important for the client and his/her family to be patient.
If one’s overriding concern is to feel better and attain immediate relief, then clients are at risk for sabotaging any benefit they might otherwise derive. The overriding objective of any cognitive behavioral approach concerning anxiety is to manage discomfort in an effective way. Being focused on symptom relief will inadvertently perpetuate the power of the anxiety. In other words, the more important it becomes to escape something, the more the brain needs to become sensitized either to be on the watch for future symptoms or to escalate the symptoms currently being perceived.
One of the most common pitfalls of people in the recovery process is to covet the periods of symptom relief. Often clients report that when they become aware the disorder is not present, that awareness itself will paradoxically trigger an association and thereby create a new threat. In the scheme of things, this pattern makes perfect sense due to the tremendous importance placed on maintaining the period of relief. A highly recommended response when one becomes aware of symptom relief is to create a willingness for the peacefulness to end. As an analogy, if your disorder were a bear sleeping in a cave, it would be important not to tiptoe across the entrance praying the bear doesn’t awake, but instead to throw a rock into the cave and call out for the tyrant – this perspective is equivalent to ‘jousting with the devil’. Rather than have the demon harass you; you want to harass the demon.
Making an attitude adjustment while going through the rigors of this paradoxical process is critical in relation to relapse prevention. Researchers in the area of OCD are well aware that the two primary concerns to the clinician are symptom reduction and maintenance of progress. The path to achieving the first goal is fairly well established, while the latter goal remains somewhat elusive. Those people who have maintained their progress for over one year have adopted the following perspective shifts:
- They see being challenged by their disorder as an opportunity to test their efforts rather than a signal that they will never completely recover.
- Being uncomfortable is viewed as an experience to be tolerated and celebrated rather than one from which to escape.
- Since the body and brain can periodically misfire and create unexplained feelings of peril, coping with and accepting these emotional events is more important than ensuring that they do not return or attempting to escape from them.
We have attempted to lay out a cognitive and attitudinal perspective that can greatly facilitate the often purely structural aspects of the intervention. Experience has consistently demonstrated that creating a willingness to be challenged and an emotional preparedness to embrace the disquieting aspects of OCD significantly contributes to rapid symptom relief. Sustaining these attitudes will enhance resistance to relapse. Understanding the design of this disorder has provided many people with the competitive edge that they have used in overcoming their emotional imprisonment.
Using traditional CBT techniques to treat OCD, the sequence of therapy would go something like this: activating event => “The thought of killing my daughter while changing her diaper” occurred; automatic thought (belief) => “This means I’m a horrible parent and may actually be putting my child at risk by being alone with her;” emotional reaction => anxiety/guilt; rational responses=> “The chance of harming her is minimal.” What evidence do I have that I would ever harm any child, let alone my own? Cognitive error correction may provide temporary relief for the anxiety that plagues the person. However, obsessions will inevitably focus on other elements of uncertainty that concern the person and will cause the anxiety to resurface. “Excuse me, all that makes sense but I did enjoy killing ants when I was a child and I heard a news report about a guy who went crazy and killed his children and himself shortly after hearing voices telling him the world is coming to an end”. This CBT strategy presumes that the client is not aware of the irrational nature of the thoughts and can, therefore, be frustrating and alienating to those who suffer from them. OCD is less a manifestation of people who have irrational thoughts than it is an anxiety disorder in which people respond instinctually to the fear of being in grave jeopardy. Devoting a significant amount of time in an attempt to explain the irrational nature of the thought content misses the underlying characteristics of the disorder.
Individuals who have OCD often report that they had these same ideas in their life before OCD, but were able to disregard them, much like anyone else would. There is no evidence that people who develop anxiety disorders change their basic thought patterns. What does appear to change is the intensity of the experience associated with what is perceived to be threatening thoughts. There is a small sub-sample of people with OCD who possess what is referred to as ‘overvalued ideation’ in which they lose the ability to discern the irrational nature of their thoughts. However, the majority of people with OCD are aware of the excessiveness and absurdity of their thoughts and perceptions. Nevertheless, they continue to experience a great deal of distress from the thoughts. Therefore, helping OCD sufferers to see the irrational nature of the thought content is counterproductive.
IMPLEMENTATION STRATEGIES
The cognitive behavior management strategy for OCD is the application of cognitive conceptualization and paradoxical intention to help the client to develop a sound response-set to this anxiety disorder.
Psychoeducation focuses on removing the sense of culpability, shame and guilt that is pervasive among OCD sufferers. Understanding the language and concepts of OCD allows for a greater sense of commitment to engaging in the difficult and seemingly contradictory suggestions. Accessing the ideas and philosophy of cognitive-conceptualization in the midst of a challenge would be ill advised since it would tend to be reassurance oriented. The hands on tactics of cognitive management is instructive in helping people respond effectively to the cognitive prompt or physiological experience of the perceived danger. When the least resistance is applied to this prompt the principles of habituation are most apt to take effect.
Externalization
It is important to note that one’s thought content and one’s genuine beliefs can be very different. People are not responsible for the ideas that occur to them through automatic cognitive processes . Helping people to separate themselves (i.e. their ‘genuine’ identity) from the emotional and/or moral implications of what this disorder seems to represent is a major portion of cognitive conceptualization. Many of those who suffer from either the purely obsessional form of this condition and/or responsibility OC (hyper-scrupulosity) experience tremendous amounts of guilt and shame. This shame is a consequence of having these thoughts and believing oneself to be responsible for the well being of others. Dr. Phillipson highlights the importance of accepting the brain’s ability to produce horribly upsetting thoughts, without concluding that these thoughts are evidence of our being evil. The presence of shame and/or guilt would preclude intrinsic evil.
Surveys consistently show that approximately 80% of the population experiences violent and upsetting thoughts. These thoughts are most likely due to the automatic associations produced by the brain. In other words, there is no reflection on one’s character for having a brain which produces these thoughts. This idea is in stark contrast with a traditional notion that the unconscious mind possesses deep-seated evil intentions. Given that intrusive thoughts are common even among a non-clinical population, it would be unreasonable to have someone strive for an absence of these thoughts. The horrible ideas of the person suffering from OCD are differentiated from the thoughts of the person without OCD by the experience of tremendous anxiety that accompanies the OCD sufferer’s thoughts. It is not the experience of these thoughts, but the client’s interpretation of the experience that is the problem.
Brain mapping studies seem to suggest that when OCD sufferers are confronted with feared stressors, it is the amygdala that is most active. With this in mind, it may be comforting (not therapeutic) for the child to know that the content of one’s obsessions does not characterize one’s true identity. For instance, the spike “Oh my God, I may be gay,” is only meaningful because its interpretation brings on an accompanying anxiety. It does not imply that the person is actually homophobic or having a sexual orientation crisis. [Do not use this information in response to a spike. Such use will only serve as reassurance and the intervention process is to ‘handle’ the anxiety; not to relieve it. Remember that paradoxically we will want to heighten the threat, not reduce it.]
The rationale for this seemingly counterintuitive strategy is also a facet of cognitive conceptualization. When one gives in to the performance of a ritual, the brain’s sensitivity to the perceived threat is increased. Understanding that giving in to a ritual can have negative consequences is instrumental in fostering a sense of determination in the avoidance of relief-seeking behaviors. On the other hand, gaining insight into this clinical rationale does very little in regard to responding more effectively to the experience of imminent jeopardy. This is particularly true when the intensity is high and the threat feels very real. The amygdala is not a thinking part of the brain. It only transmits experience and therefore academic learning has no effect on it. No matter how many times a person learns that AIDS is in not likely to be transmitted by doorknobs, the anxiety caused by the perception of threat can only be reduced by exposure: taking on the potential risk through contradictory repetitive acts. For example, the person may repeatedly touch public doorknobs and then resist the impulse to hand-wash.
Choice
Cognitive conceptualization also involves empowering clients by helping them discover their ability to make their own choices. For example, such a choice could involve differentiating between surrendering to a ritual or embracing the risk of the obsession. Taking full responsibility for making choices enhances a person’s sense of self-efficacy. Self-efficacy is the degree of confidence that the person has in his or her ability to achieve a desired outcome.
Statements such as, “I had to wash because I couldn’t stand the anxiety”, are frequently heard in the initial phases of clinical involvement. This serves to distance the person from considering what options are available in the moment of being challenged. Acknowledging the availability of a choice provides an opportunity to access resources that can be used to effectively manage the situation. Conceptualizing the overwhelming urge to ritualize as having no choice but to yield to the anxiety limits the faith one has in his or her capacity to change his or her life. Within the statements, “I HAVE TO” or “I CAN’T STAND THE ANXIETY”, a person gives up the opportunity to examine his or her available resources in making a healthy choice.
Reframing the ritualizing based on a conceptual understanding of choice is important. The reframing process might conclude “I chose to wash my hands because the doorknob might have had AIDS on it, therefore, I was not willing to live with that possibility!” This statement contrasts with the belief that performing rituals in the face of threat is obligatory. It is common for people to experience a diminution in the urgency to perform a ritual once they accept their willing collaboration and make the active choice to give in. Studies measuring pain tolerance have shown that our ability to tolerate pain is greatly increased after we realize that we have the power to decide whether we wish to seek relief or withstand the discomfort. In general, the greater our perceived sense of control over pain is, the more we are able to tolerate discomfort. Undoubtedly, it is important for people to understand that they can have a significant impact on the psychological outcome. This cognitive aspect is critical.
Challenge
It is essential that one’s method of generating cognitive responses not be pre-programmed, rote, reflexive reactions. The more one infuses a genuine emotional emphasis into the responses, the more they will enhance the potency and efficacy of the intervention. “There may be AIDS on the doorknob. I’ll choose to TAKE THE RISK and touch it anyway.” Within this exposure response set there will be a greater degree of benefit when the infinitesimal chance of danger is actually considered. Making the decision to live with the uncertainty and truly accepting all possibilities is, therefore, most beneficial. Exposure exercises using loop tapes to repeatedly expose oneself to the unsettling nature of a noxious thought might not be the best form of exposure. The passive nature of just listening over and over again may not prompt the mind to be fully engaged in the acceptance of the thought. By deliberately creating the thought the person has the opportunity to really ‘get into it’. Being purposefully emphatic about the nature of the upsetting thought contributes to greater levels of habituation.
“Yes, I might be gay, but for now I’ll kiss my girlfriend anyway and probably not enjoy the experience”. It is critical that the child realize the choices available to them and not make choices based on their thought content. If someone has obsessions related to their sexual orientation, there would be a tremendous amount of anxiety regarding the pleasure derived from engaging in intimate acts with significant others. Since anxiety and sexual arousal are mutually exclusive events, they can’t occur together. If someone with OCD were to base the decision to make sexual advances on his/her level of inspiration, all sexual activity would come to a halt. Paradoxically, this decrease in sexual activity will ultimately fuel the justification for the fear that one might actually be gay.
Paradox
As a result of yielding to the urge to ritualize many people feel a tremendous amount of guilt and regard themselves as being emotionally weak. It is critical to understand that relief-seeking is actually a biologically programmed response characteristic of human beings. It is instinctive to look for a solution to a dangerous situation when the anxiety center (amygdala) of the brain is activated. The guidelines offered are actually counter-intuitive. The clinical response flies in the face of an overwhelming urge to obtain comfort and seek relief. Within the fabric of each human being lies a basic drive to resolve emotional conflict when it reaches a heightened level. The recommended strategy requires a diametrically opposite response; a paradoxical intention.
In an apparent emergency, the paradoxical option is represented by the door labeled DO NOT ENTER. The door labeled EMERGENCY EXIT is of course the one that gets the child deeper into the quagmire. While encountering a highly charged feeling of jeopardy, in the moment in which the bullets are flying, making the choice not to give in to relief-seeking requires a leap of faith toward these principles. Engaging in the recommended paradoxical guidelines is actually a very brave act. Few people make the effort to give themselves credit for avoiding the emergency exit and going deliberately through the “do not enter’ door by touching a toilet seat or accepting the possibility that they may be of harm to their own children.
Among the general population there is a pervasive misunderstanding that these seemingly ‘normal’ events (i.e., touching a doorknob), are natural. Therefore, why ‘should’ the person make a big deal over being able to confront these anxiety-evoking events? The reason for the child to praise him/herself for these acts of courage is that it would be tantamount for the non-OCD sufferer to be asked to lie down on train tracks and experience the feeling of being in danger without getting up. Remember that the part of the brain responsible for anxiety is not a thinking part, but only understands the experience of danger.
Cognitive conceptualization assists the child in developing a healthy and informed understanding of how the mechanisms of OCD operate. It also provides a rationale for the efficacy of this very powerful paradoxical treatment.
The second step of intervention – cognitive management, involves teaching sufferers to respond effectively to obsessive threats in the moment of being challenged. Cognitive management also focuses on the importance of one’s disposition while engaging in exposure exercises. The child is on the front line of a battle and bullets are flying. What do you do? (Hint: Put away the training manual). For the purposes of our battle with OCD it is generally a good idea to respond in such a way that there is little to no ‘conflict’ in response to being spiked by anxiety. The main objective is to reduce/eliminate the fruitless efforts of mentally escaping the threat, in formulating a response to the upsetting thought (i.e. spike). When your brain sees that you are no longer running from the feared topics, a long-term consequence is that it will generally not bother transmitting the warning. Like a computer program that says “do not show this warning again”, the brain is reprogrammed. This is, once again, the basic principle of extinction.
COGNITIVE MANAGEMENT
Externalization
The process begins by helping the child to externalize the problem. With younger children, they may give the OCD a nasty nickname. By always using a disparaging name to refer to OCD, the child and the clinician ‘externalize’ the disorder that may have been associated with previous punishment experiences. Adolescents frequently find the nickname procedure silly, and prefer to refer to the problem as OCD, but the principle of externalizing the disorder remains the same. Adolescents and parents ordinarily appreciate a more through discussion of the construct of ODC and are able to find abstract concepts that help in the externalizing process.
The externalization identifies an ‘enemy’ and prepares the child mentally for a ‘fight’ with an outcome expectation of ‘winning’. This sets the stage for the paradox of ‘taking the enemy’s best punch’ and continuing to thrive.
Cognitive Training
Goals of the training include increasing a sense of personal efficacy, predictability, controllability, choice and self-attributed likelihood of a positive outcome for the exposure tasks. Targets include reinforcing accurate information about ‘harassing the demon’ and self-administered positive reinforcement and encouragement through self talk. To increase the child’s sense of predictability and controllability, the clinician should explicitly frame the exposure and response prevention as the strategy and the clinician, parents [and sometimes teacher or friends] as the allies in the child’s ‘battle’ against the demon. Constructive self talk and the use of positive coping strategies provide the child with a cognitive ‘tool kit’ to use during exposure and response prevention tasks which in turn facilitates fulfillment.
Mapping
This process includes the mapping of specific obsessions, compulsions, triggers, avoidance behaviors and consequences in the child’s experience. In behavioral terms, this process generates a ‘stimulus hierarchy’ within a narrative context. The clinician can use mapping metaphors to illustrate where the child is free from OCD, where OCD and the child each ‘win’ some of the time, and where the child feels helpless against OCD. Identify the central region where the child already has some success in resisting OCD as the transition [or work] zone. In practice, the transition zone is usually defined by the lower end of the stimulus hierarchy. ‘Standing’ with the child on territory free from OCD allows us to strengthen the twin belief that we are, first, on his/her side in the struggle, and second, that we are interested in him/her as a person who wants desperately to write OCD out of the story. The clinician teaches the child to recognize and use the transition zone, thereby providing a reliable guide to graded exposure throughout the process.
Engagement
This step implements the core technique for anxiety disorders including clinician assisted imaginal and in vivo [in life] exposure practice linked to weekly homework assignments. Exposure and response prevention is the process of engaging the demon in battle. ‘Exposure’ occurs when the child exposes him/herself to the feared object, action or thought. ‘Response prevention’ is the process of blocking rituals and/or minimizing avoidance behaviors. Response prevention takes place when the child refuses to perform the usual anxiety driven compulsion such as washing hands or using a tissue to grasp a door knob.
As in a contest, OCD is framed as the adversary and all parties remain intransigent against it. This attitude explicitly requires that the child use his/her allies [the clinician, parents or friends, and new strategies: cognitive training and exposure/response prevention] thereby preventing the intervention from becoming an excuse to avoid exposure. However, since only the child can do the actual combat [E/RP], s/he necessarily remains in charge of choosing targets from the transition or work zone.
Extinction
The principles of extinction and habituation are the basic foundation of cognitive management for OCD. Extinction is the process whereby variables that reinforce the repetition of a behavior are removed. This means that events tend to stop occurring when we take away the rewards for their ongoing nature. Behaviors and/or thoughts that are not reinforced will tend to decrease in frequency. An example would be ignoring a child during a tantrum. By not consistently giving in to the child’s demands, the tendency for the child to throw tantrums will decrease. In a behavioral treatment for OCD, not washing one’s hands after touching the floor repeatedly will reduce the brain’s sensitivity to the dirtiness of the floor. By consistently not seeking an answer to the question, “Am I a danger to my own child if I touch him without washing my hands?,” eventually the brain will reduce its need for resolution.
Habituation
Habituation is the biological tendency for the brain not to focus on information that is continually present. Individuals who live close to a train track tend not to be aware of the passing train’s presence until a visiting friend mentions the surprising loudness of the passing train’s sound. Habituation is represented in behavioral treatment for OCD by purposefully repeating in one’s head the nature of the spike. The ‘purposeful’ repetition of the upsetting thought will communicate the irrelevant nature of the spike’s theme to the brain . This repetition will also reduce the brain’s sensitivity to the emotional intensity of the spike. After you touch the bottom of your shoe, find out how difficult it would be to purposefully remind yourself, every five seconds for a five minute period, that you are now going to get sick and spread disease.
The following scenario is an example of extinction and habituation. While changing her daughter’s diaper, the mother has an automatic thought (spike) that she ‘should’ suffocate her child with a pillow. A paradoxical acceptance response would entail having the mother say, “OK, maybe I’ll kill my daughter, so let’s do it now”. This response is based on the premise that through acceptance, the mind will reduce its sensitivity to these ideas (e.g. extinction). Escape or intolerance regarding the feared stimulus (spike) tends to perpetuate its strength. Having this mother purposefully create the thought (approximately 15 times) while changing a diaper would act as a purposeful exposure (e.g. habituation) and also further reduce the mind’s sensitivity to these topics.
Exposure and Response Prevention
The most basic element of cognitive management involves the procedures known as Exposure and Response Prevention (E/RP). Exposure and response prevention are the definitive non-medical interventions of choice. The general guidelines of this procedure involve having the child purposefully expose him/herself to stressors without engaging in a ritual. These exposure exercises may entail having the client rub his hands on a sidewalk and not washing, or purposely creating the thought, “God is a jerk!” and then not praying for forgiveness. By purposefully choosing to come in contact with items or thoughts that are anxiety provoking, the brain tends to send back a less intense signal of fear because it habituates to the anxiety of the stressor. Choosing to expose oneself to the feared item without the escape response is the most critical component of the recommended intervention. A second and almost equally important aspect involves not giving in to it inadvertently. Rather than just saying “NO! I won’t give in,” it is advisable to allow for the possibility that there is an actual risk.
The behavioral contribution requires people to come in contact with the feared items. There are basically two means of being spiked: having the environment or your own mind create it by accident (inadvertent) or going after it by choice (purposeful). Whether mentally or physically, an exposure exercise attempts to purposefully reproduce the elements of the inadvertent spike. The cognitive element of the intervention (i.e., self talk), which facilitates the impact of the exposure exercise and produces more resilience to relapse, involves making purposeful mental statements about the possibility of an actual risk being present. The thought that “there’s AIDS on the doorknob” or the statement, “Stay away from knives as you might be a risk to others”, illustrates how inadvertent spikes can cause people to become hypervigilant about their surroundings. The exposure exercise would entail having the client purposefully grab a knife and take it to bed saying, “Tonight I make sushi out of my husband… I hope I have enough rice to go with it”. Humor counts! The more you laugh at the OCD, the more disrespect you give it. Hence, the less power it has.
There are two opposite cognitive processes to approach negative thoughts: self defense and acceptance. In self defense, you use logic or evidence to disprove the negative thoughts. Once seeing that the negative thoughts are distorted and untrue, the subject usually feels better. However, the negative thoughts connected with OCD are already understood as distorted and can be handled far more effectively with acceptance. If the child can do this with inner peace, self-esteem and a little humor, the results can often be spectacular. The child can practice his/her acceptance of the threat by taking the role of Negative Thoughts and having a dialogue similar to Externalizing. The child, instead of disputing the danger, accepts each negative thought, accepts the fact that s/he may be in danger, accepts these shortcomings with honesty and inner peace. The surprising result is that the child can gain invulnerability when s/he makes herself completely vulnerable and defenseless.
Merely utilizing cognitive responses such as, “I’ll take the risk and accept the possibility that the danger may be real”, without embracing a genuine acceptance of that risk, is a rote exercise and therapeutically useless. Another aspect of cognitive management entails purposefully creating the awareness and accepting the nature of the risk while engaging in the exposure exercise. This strategy enhances the impact of an exposure exercise by combining the behavior of touching a toilet seat with self-talk: “OK, maybe I will now get AIDS, so death come and get me”. Choosing to accept the risk by eliciting physical discomfort and cognitive warning, shuts down the brain’s natural tendency to warn its host that s/he should feel horrible until the danger is removed. For the purely obsessional client, it is encouraged that, along with creating the spike (“today I’m going to push ten people in front of a train”), one would also remind him/herself that in the end, “one never knows what evil lurks in the hearts of men”. Attempts at reassurance inspire the brain to automatically scan for any possible exceptions. “The clinician says that people with OCD NEVER actually act out their fear. Thank God, now I don’t have to worry about harming my daughter” or “Gee s/he [the clinician] has only known me for three months. I wonder if s/he can actually be sure that I have OCD and that I am not actually a psychopath. After all, didn’t Jeffery Dahmer claim to have OCD?”
Seeking out the risks on purpose (i.e. rubbing one’s hands on the floor and then eating a sandwich), armed with the disposition of ‘come and get me’, is by far the greatest facilitator of daily therapeutic gains! Without a doubt, the more aggressive one is in confronting the disorder, the less distress it will cause. Developing an aggressive disposition toward being challenged is tremendously advantageous toward a successful recovery. Aggressiveness is defined as actively seeking out anxiety provoking challenges (touching toilet seats, creating the thought of jumping in front of an oncoming train). Paradoxically, when a person seeks out anxiety-provoking challenges, there tends to be a greater likelihood that levels of anxiety will be reduced through habituation. Thus, as we turn the tide of the condition’s momentum from endless escape to approach, we aggressively seek challenges and decrease the likelihood of finding them.
The recommended paradoxical intervention process also involves facilitating greater levels of tolerance toward anxiety by making space for the discomfort and looking upon it as something to be managed effectively. An important aspect of this process is to not wait for the anxiety to subside. The reduction in anxiety will happen naturally and spontaneously, once the person genuinely accepts the initial increase in anxiety. When the client feels anxious it is important to:
- rate the level of discomfort on a scale from 1 – 10;
- describe the anxiety in terms of what is actually going on in your body (rapid heart rate, sweaty palms etc.);
- assess your willingness to allow for the anxiety to be there at this level (i.e. “Hey its only a 5, no problem I’ve successfully dealt with 7’s”); and
- assess your willingness to have this amount of anxiety dwell for a specified time period (i.e., “At this level I’m sure I can allow it to be there for at least thirty [30] minutes. At 3:30 I’ll reassess my tolerance”).
By engaging in this process one rises above the experience, creating a more manageable distance and less discomfort. Paradoxically, the chances of obtaining relief is increased the less one seeks it out.
The quest to eliminate the spike is probably the greatest cognitive misconception that people bring to the clinical process. Ultimately the goal of traditional cognitive therapy for OCD is to manage the spike (i.e. mental risk) effectively not to focus on its existence or disappearance. Thus, relief seeking increases the person’s vigilance toward his or her anxiety. In contrary fashion, tolerating anxiety focuses on creating room for the experience. Making room for its presence allows the brain to focus on other information. “Anxiety not focused on, is anxiety minimally experienced.”
The importance of self-talk in invalidating and effectively mediating the seemingly endless cycle of fear/escape within OCD cannot be underestimated. A critical aspect of this paradoxical intention focuses on the premise that the responses to the disorder are not designed to make it ‘go away’. Rather, by perpetuating the condition this perspective allows the anxiety to burn itself out due to lack of reinforcement (removal of the escape response). The idea is that the less one avoids the bully the greater the likelihood that the bully will find someone else to pick on.
Often clients will state that the intensity of their anxiety makes it difficult to discern the legitimacy of the threat. “It feels so real!” is the calling card that seduces a person to be tempted to give in to the ritual. Clearly, reassurances are of no value in dispelling an OCD sufferers concerns. “Within the question lies the answer.” Many OCD sufferers have found that accepting this premise on faith is a powerful guideline that helps people realize that they have the ability to resist performing the rituals. This statement encourages people to make a choice toward ‘risk taking’ when the nature of one’s spike leaves ‘any doubt’ about its legitimacy.
This perspective can be of benefit when people are confronted with what appears to be a genuine risk. Focusing on the awareness that there is doubt (i.e., “Am I really in danger?”), then making the determination to accept the risk (i.e., “Maybe I am in danger, but I’m going to accept the risk and not undo the danger.”), will eliminate a tremendous amount of problem solving. For example, a woman suffered greatly from hypochondriacal OC revolving around the possibility of having breast cancer. She used the model in the following manner. During a breast self-exam she would regularly come across possible lumps that may not have been there at her previous exam. She would use the experience of the extreme doubt as a signal that it would be worth taking the risk and accepting the ambiguity of having this fatal disease. Rather than repeatedly running to her doctor for reassurance, she was willing to stick to her annual appointments. Each lump presented itself as a question about its legitimacy and sameness. She chose to accept the risk and ambiguity that actual tumors would probably not activate a never-ending search for an answer. When dealing with the ‘real thing’ people tend not to question it.
As previously mentioned, the cognitive behavior management intervention for OCD has two primary applications:
- psychoeducation to help people understand the guidelines of an anxiety disorder’s overall design (i.e. mental mechanisms); and
- cognitive management to provide specific suggestions in the face of challenge.
For those with OCD, the purpose of being challenged refers to the awareness that there is some imminent danger. The specific application of cognitive principles as a management strategy is paramount. Cognitive principles to help sufferers develop a healthier disposition toward their anxiety disorder is critical. These two foci will most likely facilitate progress when they are integrated in the clinical process.
In summary, the intervention process involves providing clients with specific responses to the spikes. There is also a psychoeducational (language and concepts) component. This involves helping sufferers understand that the content of their OCD concerns are separate from and do not reflect their basic human nature or character. Intervention also provides an opportunity to highlight generalized strategies, which facilitate anxiety management. Providing reassurances and educating the OCD sufferer about how unlikely their risks actually are can be counterproductive and alienating. Cognitive process correction strategies are ineffective substitutes for the behavioral assignments (i.e. exposure and response prevention), which are paramount in bringing about benefits. The immediate goal is not to eliminate the spikes or to feel better. The techniques are designed to manage anxiety and to stop the endless cycle of ritualizing. The long-term indirect dividends of these strategies are to reduce the spike frequency and to reduce the frequency and intensity of the associated anxiety.
Primarily the cognitive behavior management protocol includes exposure with response prevention, cognitive rehabilitation, relaxation training, social skills training, and stress management. Individualized homework challenges are an essential component of the process. Typically persons have to be willing to commit a total of 15 to 20 minutes per day toward their between session practice. The exercises are generally based on a graded hierarchy from least to most challenging exposures.
THE ROLE OF PARENTS
Parents are an important part of the process both in what the are expected to do and not do. Parents have an instinctual desire to help their children avoid pain and suffering. Yet the process of recovery requires an increase in pain and suffering at least at the beginning. The acceptance that a) the child can do it, and b) they will conceptually ‘hold the child’s hands to the fire’ in a supportive manner is counterintuitive. Yet this is the expectation. Parents are a stringent coach, who demands the best that the athlete can give. The coach seeks mastery – incremental improvements over yesterday’s best performance. The coach is always at the same time demanding and supportive. The self fulfilling prophecy of the coach is “I know you can do it!”, while continuing to accept failure as growth producing.
This can be a difficult role for parents who want to protect their child and who may, in the past, have provided avoidance reinforcement – “It’s okay to do the rituals if it will ease the distress”. Along with participation in the Psychoeducational component, it can be helpful for the parents to have a support group.
Family Coping Skills Group
The initiation of a coping skills group for families and significant others of people with obsessive-compulsive disorder may be a helpful support. Watching a loved one struggle with OCD can be quite overwhelming for family members who do not know how to effectively manage the emotional pain. A family’s lack of understanding about the feelings of helplessness, guilt, frustration, or intolerance, may incite negative or rejecting reactions to the paradoxical intention which can further exacerbate obsessions and compulsions.
In addition to the various instrumental responsibilities of the family members, their troubled loved ones often rely on them for emotional and informational support in their daily struggle with OCD. The pathological doubting, so commonly associated with OCD, causes people to doubt their senses (i.e. what they see, hear or touch) and can profoundly impair their daily performance. Thus, they may rely on relatives to offer them constant reassurance or may request that the family participate in their ritualistic behaviors to assure them that they indeed have completed a task or performed it correctly. In order to alleviate a child’s fear and anxiety, families may become overly involved in his/her avoidance behaviors, decision making and daily responsibilities, further fostering the dependence and insecurities that are characteristic of this disorder. The coping skills group will help family members and significant others to clarify the dubious boundaries between a healthy involvement and a maladaptive one that acts to reinforce the symptoms.
Furthermore, the coping skills group can educate families about the benefits of the cognitive behavior management approach and will assist them in helping their loved ones recognize the need for clinical intervention if they are not already involved. Family members can assume an active role in the behavioral intervention by encouraging their child to participate in and comply with treatment. Families will learn how to expose their children to anxiety-provoking stimuli in a step-by-step fashion, gradually habituating them to the stressors. Relatives may be asked to participate in the response prevention exercises by supervising and monitoring the time and frequency the child engages in certain ritualistic behaviors. The more stringent and detailed the response-prevention instructions are for the child, the fewer decisions the child has to make with regard to what is normal and what is ritualized, ultimately resulting in better participation in the recovery process.
In addition to encouraging active family participation in exposure and response prevention exercises, the coping skills group will offer an open forum for questions, discussions and concerns about obsessive compulsive disorder. The group will allow for people to share their experiences, and confide in others who have family members with OCD. The group will strive to minimize the daily stressors that families of people with OCD often experience. Moreover, the group will educate the family members about beneficial support methods, helpful coping mechanisms, and better ways to communicate their feelings and frustrations. Through the support and guidance of weekly group sessions, families will learn how to provide their loved ones with a greater sense of self-confidence and self-efficacy.
PSYCHOLOGICAL TESTING
Within recent years obsessive-compulsive disorder has been classified as a handicapping condition. Therefore, persons who qualify for this diagnosis may have special privileges available to them pertaining to standardized testing procedures. Tests such as the SAT, GRE, LSAT, and MCAT have special testing conditions available to those with handicapping conditions, whereby these tests might be read to the subject, or special time extensions may be granted.
IMPLEMENTATION TACTICS
ASSESSMENT & EVALUATION
Assessment
Ideally, a structured interview, such as the Anxiety Disorders Interview Schedule for Children [ADIS; Silverman & Eisen, 1992], should be a part of every diagnostic assessment. Since implementation requires a lengthy separate interview of the child and at least one parent this is a time consuming effort, which can be supported by data from the following rating scales to confirm the findings.
The Yale-Brown Obsessive-Compulsive Scale [YBOCS] is a questionnaire used to help target obsessive compulsive symptoms and assess their severity. There is a children version of this scale. Other assessment tools include the Compulsive Activity Checklist [CAC], the Leyton Obsessional Inventory [LOI], the Maudsley Obsessive Compulsive Inventory [MOCI], the Padua Inventory [PI] and the NIMH Global Obsessive-Compulsive Scale [NIMH global OC].
Based on the nature, length and frequency of the symptoms presented, a psychiatrist will differentiate OCD from medical diseases with similar symptoms. A physical examination may be ordered to rule out other causes.
Evaluation
The clinician will need to use the symptom hierarchies and feeling thermometer ratings to assess within exposure anxiety in response to specific targets. The NIMH global OC Scale and the CGI scales as modified, take less than a minute to fill out and can be used weekly.
The most detailed instrument for assessing the outcome of intervention is the YBOCS, which assesses obsessions and compulsions separately in terms of time consumed, distress, interference, degree of resistance and control. The YBOCS is a clinician rated instrument that merges data from clinical observation with data from the parent and child reports, the cutoffs that are generally used in evaluating the YBOCS scores are:
- 10 – 18: Mild OCD that causes distress but not necessarily dysfunction; help from others is usually not required to get through the day.
- 18 – 29: Moderate OCD that causes both distress and functional impairment.
- 30 and above: Severe OCD that causes serious functional impairment requiring significant help from others.
The goal of intervention is to reach a score indicating a subclinical level of symptoms, which is generally considered to be in the range below 10. The clinician should obtain ratings of the YBOCS every three [03] to four [04] weeks during the process and at the end of the process. The results should be graphed so that the child/family can watch the scores come down as a reinforcement for engagement.
PSYCHOEDUCATION
The first responsibility is for the clinician to engage the child in a trust relationship which can be enhanced by giving the child information about OCD and his/her participation in it. Basic concepts include:
Obsessions are persistent impulses, ideas, images or thoughts that intrude into a person’s thinking and cause excessive worry and anxiety.
Compulsions are mental acts or repetitive behaviors performed in response to obsessions to relieve or prevent worry and/or anxiety. They often have the intent of magically preventing or avoiding some dreaded event such as death, illness or some perceived misfortune.
Reinforcement is a process of reward which influences the continuation of a thought or behavior. If the thought/behavior is rewarded it is likely to increase in frequency. If it is ignored, it is likely to disappear.
Compulsions reinforce obsessions. They do this by helping the individual deal with the anxiety of the threat which is therefore never resolved.
A man is sitting on the park bench incessantly waving his arms. When asked why he is doing this, he states that he is keeping the elephants away. When it is pointed out that there are no elephants in the park, he responds: “See it works!”.
Help the child understand that ‘it works’ only in the man’s mind. If he risked not waving his arms, he may find that there are no elephants anyway. It is in this same manner that the compulsion works for him/her.
Is s/he willing to risk the elephants?
Choice
Along with the provision of the language and concepts already addressed, an important part of the discussion with the child will be to explore choice: alternative solutions. At base, two choices exist for the child: 1) avoid the threat or 2) embrace the threat. There may be other options that the child wants to explore as well. The clinician should be prepared to help the child identify the potential consequences of these options in order to help the child make an informed choice to ‘harass the demon’. If the child is unable or unwilling to make that choice, s/he probably is not ready to accept recovery. The clinician has the option of 1) continuing to provide additional information to enable the child to make a better choice, 2) providing some ameliorative consultation, or 3) ending the clinical relationship with an open invitation to return to the process when the child is ready.
Preparing For Change
Part of the preparation for change is to identify the concerns that the client child holds that may hinder the process. Using the Fear of Change Questionaire – CBP#04-001, ask the child to place a check mark next to the concerns that apply to him/her. Note that s/he may have additional fears and concerns and s/he should write them down in the space provided.
- “If I don’t do my rituals, what will I do to feel safe?” _____
- “If I confront my fear of dirt, germs, etc., how can I be guaranteed that the catastrophe I fear [getting sick, losing a loved one, hurting others] won’t happen?” _____
- “Since there is no cure for OCD, why bother?” _____ _____
- “It sounds too easy. I know I’ll fail. I’ve failed at everything else.” _____
- “I’ve already done behavior therapy, and it didn’t work for me.” _____
- “I’d rather just take medicine ….this is too hard.” _____
- “My rituals are necessary to ward off the dangers I feel” _____
- “I’m afraid I will go crazy (get sick, harm others, etc.) if I’m prevented from doing my rituals.” _____
- “My thoughts are so bad it must mean I have an ‘evil seed’ inside me. I don’t deserve to get better.” _____
- “If I get better or feel happy, then something bad surely has to happen. I don’t want to take a chance.” _____
- Other ______________________________________ _____
These are the issues that you will need to address in the psychoeducation phase using the material that has introduced OCD. Obviously, some people will choose to continue to be victims, rather than to ’harass the demon’. This may be particularly true for children who have not experienced the suffering for long enough to be exhausted and ‘ready to try anything’. The best that can be hoped for if this is the case with the child you are working with is that s/he can learn about the process and become engaged sufficiently with you to trust trying it out.
Commitment to Change
Once having addressed the fears of change sufficiently, it is time for the child to make a commitment to change. The child should understand that s/he will need to:
- Set aside a period of between four to eight weeks during which time s/he will make the change protocol the most important priority in his/her life.
- Be prepared to spend a minimum of two to three hours per day – every day – doing Exposure/ Response Prevention techniques.
- Tell others [family and friends] what you are starting and, if s/he can, get them to provide support. S/he may need to invite these natural support people to a meeting to learn about OCD and how to avoid enabling its procedures.
- Identify a specific supportive person in his/her environment who would be a willing ‘coach’ and be a confidante.
Natural Supports
You and/or the child, will need to ensure that these natural supports understand the following guidelines:
- the child does not choose to have OCD and is committed to change
- the decision to change is the child’s and cannot be forced
- do not criticize the child if/when s/he fails to meet your expectations
- encourage, guide, monitor, help and support
- expect relapses – restrain the tendency to become discouraged and help the child avoid this as well
- reward progress, no matter how small
- don’t blame yourself for the child’s OCD
- expect the OCD symptoms not to make sense and to be inconsistent
- agree to hold the line against giving help with rituals when asked by the child [don’t wash clothes, etc.]
- repeat the child’s self sufficient mantra whenever the child indicates discouragement
COGNITIVE TRAINING
The goal is to train the child or adolescent in cognitive tactics for resisting OCD [as distinct from response prevention for mental rituals]. Objectives include increasing a sense of personal efficacy, predictability, controllability and self attributed likelihood of a positive outcome for the E/RP tasks. Targets include reinforcing accurate information regarding OCD and the process of intervention, cognitive resistance [harassing the demon] and self administered positive reinforcement and encouragement.
It is important to explicitly frame E/RP as the strategy and the clinician, family and sometimes teachers and friends, as allies in the child’s ‘battle’. Constructive self-talk (‘bossing back’ OCD) and the use of positive coping strategies provide the child with a cognitive ‘tool kit’ to use during exposure and response prevention tasks.
Mapping
Another part of the symbolism of the protocol is to develop a ’battle field’ metaphor by indicating how much territory is controlled by the OCD and how much is controlled by the child. A battle strategy will then be developed to take over more and more of the OCD territory. The process of mapping is done through the assessment of the individual child’s problem using first the OCD Symptoms Assessment – CBP#04-002.
OBSESSIONS
Contamination Obsessions
Excessive fear or disgust, and preoccupation with avoiding:
_____ bodily waste or secretions – urine, feces, saliva, blood
_____ dirt or germs
_____ sticky substances or residues
_____ household cleansing agents or chemicals
_____ environmental contaminants – radon, asbestos, radiation, toxic waste
_____ touching animals
_____ insects
_____ becoming ill from contamination
_____ making others ill by contaminating them
_____ diseases – AIDS, hepatitis, sexually transmitted diseases
Hoarding, Saving And Collecting Obsessions
_____ worry about throwing things away, even seemingly useless items
_____ urge to collect useless things
_____ urge to pick up items from the ground
_____ uncomfortable with empty space – feel need to fill it
Ordering Obsessions
_____ preoccupation with symmetry, exactness or order
_____ excessive concern that handwriting be perfect or ‘just so’
_____ concern with aligning papers, books and other items in a certain ‘perfect’ way
Religious Obsessions, Scrupulosity
Excessive fear, worry and preoccupation with:
_____ having blasphemous thoughts or saying bad things
_____ being punished for blasphemous thoughts
_____ concern with religious beliefs
_____ issues of right and wrong, morality
_____ dwelling on religious images or thoughts
Somatic Obsessions
Excessive fear, worry and preoccupation with:
_____ having an illness
_____ negative reactions of others to one’s appearance
Aggressive Obsessions
Preoccupation and excessive, illogical fear of:
_____ harming yourself
_____ harming others
_____ acting on unwanted impulse – e.g., run someone over, stab someone
_____ harming others through your own carelessness
_____ responsibility for some terrible accident – or fire, burglary – especially from personal carelessness
_____ blurting out insults or obscenities
_____ doing something embarrassing or looking foolish
_____ violent or horrific images in your mind causing you to do harm to others
Sexual Obsessions
Unwanted, worrisome and intrusive
_____ sexual thoughts, images or impulses
_____ thoughts about molesting children
_____ thoughts about being or becoming a homosexual
_____ thoughts or images of violent sexual behavior toward others
Miscellaneous Obsessions
_____ urge to know or remember certain things – slogans, license plate numbers, names, words, events of the past
_____ fear of saying something wrong, not saying something just right or leaving out details
_____ worry about losing things
_____ worry about making mistakes
_____ easily bothered by certain sounds and noises – clocks ticking, loud noises, buzzing
_____ easily bothered by feel of clothing, textures on skin
_____ intrusive nonsense sounds, music, words
_____ fear of saying certain words because of superstitious beliefs about those words
_____ fear of using certain colors for superstitious reasons
_____ excessive superstitious fears with rigid adherence to them
_____ excessive concern with lucky and unlucky numbers with rigid adherence to them
COMPULSIONS
Cleaning and Washing Compulsions
Excessive, illogical and uncontrollable
_____ hand washing, often performed in a ritualistic way
_____ showering or bathing often performed in a ritualistic way
_____ ritualistic tooth brushing, grooming, shaving
_____ cleaning of the house, certain rooms, yard, sidewalk, car
_____ cleaning of objects, household items
_____ use of special cleaners or cleaning techniques
_____ avoidance of objects considered ‘contaminated’
_____ avoidance of specific places – cities, towns, buildings – considered contaminated
_____ concern with wearing gloves or other protection to avoid ‘contamination’
Checking Compulsions
Checking over and over (despite repeated confirmations)
_____ that you did not harm others without knowing it
_____ that you did not harm yourself
_____ that others did not harm you
_____ that you did not make a mistake
_____ that nothing terrible happened
_____ that you did not do something that could cause future harm
_____ some aspect of physical conditions, health – pulse, blood pressure, appearance
_____ physical surroundings – locks, windows, appliances, stoves
_____ that jars are closed by excessive tightening
_____ that doors are closed by excessive, repeated shutting, closing
Hoarding, Saving And Collecting Compulsions
_____ saving, collecting, seemingly useless items
_____ pick up useless items from the ground
_____ difficulty throwing seemingly useless items away: “Someday I may make use of this…”
Repeating, Counting, Ordering
_____ reading and rereading things, sometimes for hours
_____ excessive worrying that you didn’t understand something you read
_____ excessive writing and rewriting things
_____ repeating routine activities – going in and out of doorways, repeated crossing of thresholds, getting up and down from a chair, combing hair, tying shoes, dressing and undressing over and over
_____ doing certain activities a particular number of times
_____ counting items – books on a shelf, ceiling tiles, cars going by
_____ counting during compulsive activities, such as checking and washing
_____ arranging items in a certain order – books, pencils, cupboards
Miscellaneous Compulsions
_____ mental rituals – prayers, repeating ‘good’ thoughts to counteract ‘bad’ thoughts
NOTE: Unlike obsessions, these mental rituals are performed with the intention of reducing or neutralizing anxiety.
_____ excessive need to repetitively ask others for reassurance when ample assurance is evident to others and has already been provided by those around you
_____ need to confess wrong behavior, even the slightest insignificant infractions of behavior toward others
_____ superstitious behavior that takes excessive amounts of time
_____ need to touch, tap, or rub certain items or people
_____ measures, other than checking, to prevent harm to self or others – for example, avoidance of certain objects or extreme precautions to prevent highly unlikely harm or danger
_____ eating ritualistically according to specific ‘rules’ – arranging food or utensils, eating at certain times, eating foods in a particularly order
RELATED SYMPTOMS
_____ pulling own hair – from scalp, eyebrows, eyelashes, pubic area
_____ acts of self damage or self mutilation – picking skin
_____ compulsive shopping
NOTE: compulsive shopping is often related to hoarding – buying a number of things for fear of running out, for example.
After the child has completed the Symptom Assessment, you will need to discuss these elements and help the child use his/her responses to focus the change process. Using the Symptom Intensity Rating Form – CBP#04-003, have the child write the symptoms down on the Form under ‘Symptoms’ in the appropriate section. S/he should indicate whether each symptom is a past or current one by placing a check in the appropriate box. Then, using the guidelines below, indicate how much of a problem each symptom is presently causing by marking a 1, 2 or 3 on the blank line below “Disruption rating’. Have the child do a disruption rating only on current symptoms.
Past = symptom bothered you in the past
Current = symptom bothers you now
Disruption Rating [of current symptoms]
1 = mild symptoms, just a slight nuisance or problem
2 = a moderate symptom, causes some anxiety and disruption in daily life
3 = a severe symptom, causes much anxiety and great disruption in daily life
OBSESSIONS
Contamination Obsessions [these are the excessive fear or disgust and/or preoccupation with the avoidance of dirt, germs, contaminants of any kind]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Hoarding, Saving and Collecting Obsessions [these are the acquisition of and failure to discard possessions that appear to be useless or of very limited value]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Ordering Compulsions [these are an excessive preoccupation with symmetry, exactness or order]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Religious Obsessions, Scrupulosity [these are excessive fear, worry and preoccupation with violating moral and religious laws and rules, such as the fear of being punished for blasphemous thoughts]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Somatic Obsessions [these involve a preoccupation with the appearance of specific parts of the body or the possibility of having an illness or incurable disease]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Aggressive Obsessions [these involve having excessive thoughts of causing harm to yourself or to others]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Sexual Obsessions [these are frequent unwanted, worrisome and intrusive sexual thoughts, images or impulses]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Miscellaneous Obsessions [these are obsessions that don’t fit into any of the descriptive categories above]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
COMPULSIONS
Cleaning and Washing Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Checking Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Hoarding, Saving and Collecting Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Repeating, Counting and Ordering Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________________________________
Next, you will want to have the child identify his/her avoidance symptoms. Using the Avoidance Symptom Form – CBP#04-004, have the child list all of the situations, persons, places or things that s/he avoids because of his/her OCD. These can also include recurring horrible or disturbing thoughts that s/he tries to avoid. Indicate the degree to which s/he avoids each situation on a scale of 0 – 100.
0 = I never avoid it
50 = I avoid it about one half the time
75 = I avoid it most of the time
100 = I completely avoid this at all costs
Avoided Situations, Persons, Places, Things or Thoughts Degree of
Avoidance
1. _____________________________________ ________
2. _____________________________________ ________
3. _____________________________________ ________
4. _____________________________________ ________
5. _____________________________________ ________
6. _____________________________________ ________
7. _____________________________________ ________
8. _____________________________________ ________
9. _____________________________________ ________
____________________________________________________
TARGETING SYMPTOMS
The next step will be to target symptoms for intervention on the Target Symptom Form – CBP#04-005. The initial target is to list all of the symptoms that were rated a 3 on the Symptom Intensity Chart – CBP#04-003. As you list them, try to sort them in order of degree of disruption, with the most disruptive as number 1 and the least disruptive at the bottom. You should also note the avoidance symptoms. These main obsessions, compulsions and avoidances will be the initial target symptoms of the protocol.
Target Symptom Form – CBP#04-005
Obsessions Compulsions
1. _____________________ 1. _____________________
2. _____________________ 2. _____________________
3. _____________________ 3. _____________________
4. _____________________ 4. _____________________
5. _____________________ 5. _____________________
6. _____________________ 6. _____________________
7, _____________________ 7. _____________________
8. _____________________ 8. _____________________
9. _____________________ 9. _____________________
10. ____________________ 10. ____________________
Next you will want the child to fill out a form indicating the top five avoidance symptoms that are interfering with his/her life.
Target Avoidance Form – CBP#04-006
Based on the Avoidance Symptom Form – CBP#04-004, select the five most critical avoidances that disrupt your life.
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________
____________________________________________________
People with OCD often have symptoms in more than one area. The targeting process is to identify those symptoms that are most disturbing and to order their negative impact on the child’s life. Eventually, all of these disturbing symptoms will be addressed.
The process of mapping is to develop a picture of what the road to recovery is going to look like, what territory the child will need to pass through, and what territory s/he already controls.
INTERVENTION STRATEGY
The intervention form is called an Anxiety/Exposure List – CBP#04-007. It is simply a list of situations that the child fears and avoids, listed in order of the levels of fear that they provoke. Like a road map, the Anxiety/Exposure List shows where to start and where to finish, and the pathway in between. The unit of measurement used to convey and describe the anxiety aroused in various fear provoking situations is called the SUDS scale. This stands for:
S ubjective
U nits of
D istress
S cale
The SUDS is a rating system designed to measure the amount of anxiety a person feels. It was invented in the ‘70s by Edward Wolpe, a professor at Temple University. The SUDS will be used in designing an Anxiety/Exposure List for the child. It is a 100 point scale with 100 equaling the most anxiety provoking situation that the child has ever experienced in his/her life. Zero [0] equals neutral or no anxiety whatsoever. A 50 SUDS is neither very high nor very low anxiety. It indicates just medium anxiety.
CALIBRATING THE SCALE
Have the child think about a few situations which s/he has experienced that caused the most anxiety and fear that s/he has ever experienced. Or have the child think of a very scary situation s/he hopes s/he will never have to deal with. If s/he finds him/herself not wanting to think much about this, that’s okay. Situations that elicit these kinds of strong feelings of anxiety will earn a 100 on the child’s SUDScale.
Now, have the child think of a few situations that s/he has experienced that have caused only a moderate level of anxiety – not too much and not too little.
Finally, have the child think of a very neutral or pleasant situation. These situations would be a zero on the SUDScale.
Remember that every person is different as to the specific situations they consider as low, medium or high on the SUDScale.
CREATING THE ROAD MAP
Using the variety of forms and charts that have helped the child think about and document his/her fears and anxieties, you are now ready to help the child create a ‘road map’ for working on and defeating OCD.
Tips for Creating the Child’s Anxiety/Exposure List
- for each trigger situation, the child should rate the SUDS level based upon what s/he thinks s/he would feel if s/he were faced with the fearful situation and s/he is unable or prevented from carrying out the compulsion s/he would typically use in that situation.
- the list should include 10 to 15 specific situations that trigger different levels of fear and anxiety. The most useful place to start may be with the list of Target Avoidance compiled earlier.
- the situations or triggers in the list should differ from each other by about 5 to 10 SUDS points each
- begin the list [#1] with situations or triggers that provoke about 20 to 40 SUDS points, or low to medium anxiety. Then list situations [#2, #3, etc,] that trigger higher and higher levels of SUDS.
- the last item on the list should be the situation that triggers the child’s highest level of anxiety and fear
- from the master list, you can make one or more ‘mini-lists’ that address one situation, trigger or avoidance behavior. You may list the triggers differing only in their degree of proximity to the feared object or situation.
Anxiety/Exposure Mini-List – CBP#04-008
AN EXAMPLE:
A ‘mini-list’ concerning fear of hospitals.
Trigger SUDS
- Walking into a hospital known to treat AIDS patients, 40 standing for one minute, and then leaving
- Walking into the hospital, standing in the waiting 55 room
- Sitting in a chair in the hospital waiting room 60
- Touching a chair in the a patient’s room 70
- Standing in a patient’s room 80
- Sitting in a chair in a patient’s room 90
- Touching a patient 100
By expanding the degrees of fear and anxiety for each individual trigger, the child is able to create gradual ramps for overcoming and dealing with each individual situation.
‘Grist for the mill’
If the child has developed fifteen situations that evoke fear and anxiety and is able to expand each situation into seven to ten levels of fear and anxiety, you have developed anywhere from 105 to 150 fear and anxiety variables that can be worked with.
NOTE: blank CBP#04-007 & CBP#04-008 are available in the Appendix and can be copied for use in this process.
STEPS TO EXPOSURE AND RITUAL PREVENTION
Exposure consists of using situations from the list to create opportunities to change the way the child typically responds to these anxiety arousing situations. Step by step, the child will confront his/her personal anxiety arousing situations, facing the easiest first and then based on that confidence building up the experience and confidence to address more powerful issues.
Exposure can be done either imaginal [visualization] or in vivo [in real life]. This is a clinical decision and you may wish to review Techniques #08, #09 & #11 for more information on these procedures.
STEP 1. Choose a mini-list and start with the items that provoke at least a moderate amount of anxiety.
If the child does not feel any fear or anxiety when doing an exposure, move on to the next situation or trigger on the list. This is done to provide the child with firsthand experience of the process of habituation. ‘No pain, no gain.’
STEP 2. Allow the discomfort to rise, stay with it and do not avoid it!
This is the time for the child to ‘harass the demon’. S/he will need to adopt the attitude that s/he will endure and beat the demon at its own game. The more s/he is able to prolong the anxiety, the less it will affect him/her. The more SUDS the better. Too much SUDS is better than too little! Try to help the child accept the discomfort. Over time, s/he will notice that the SUDS level begins to diminish. This is a sign that habituation is taking place. This can take a few minutes or hours.
If the child’s SUDS is not high enough, explore for blocking techniques.
- the child is purposively becoming ‘numb’ to the experience by dulling him/herself instead of remaining alert and connected to the fear feelings.
- the child is relying upon a ‘safety signal’ such as you or a friend who excessively reassures while practicing an exposure. Be careful of who ‘coaches’ an exposure since the desire to protect others from fear and anxiety is a powerful one.
- the child is ritualizing privately by counting, praying or otherwise neutralizing the anxiety or discomfort.
- the child is dissociating from the experience – for example, thinking: ‘It’s not me doing this, but someone else’. This is a form of ‘magical’ thinking that people with OCD may resort to for handling their discomfort during the exposure.
STEP 3. Practice ritual prevention while doing the exposure
Ritual prevention is the voluntary blocking of compulsive rituals and it is one of the keys to progress. Doing ritual prevention is like refraining from scratching an itch, knowing that if you give in and scratch it, it will only become itchier. If the child is successful in refraining from scratching, the itch has a chance to go away on its own.
- if the exposure is in vivo and a family member or friend is to ‘coach’, they must be instructed to stop the child from violating the rules of ritual prevention
- if the child has the urge to ritualize and is afraid that s/he can’t resist, s/he should be instructed to talk to the coach and work together to delay, if not eliminate, the ritual
- as a general rule, no one with OCD should be physically restrained from doing rituals. There are, however, certain situations where such restraint may be appropriate:
- the rituals are causing life-threatening harm
- the person has agreed prior to starting the exposure to a specific plan of having the ‘coach’ physically restrain them
FEARED CONSEQUENCES OF NOT DOING RITUALS
Typical fears for not doing rituals include dying, hurting others, failing to prevent harm to someone else, going crazy, causing someone you care about to get sick, being held guilty for something bad happening, going to jail and losing one’s job.
For form CBP#04-009, you can have the child list the consequences s/he fears might happen if s/he did not do the rituals using the SUDS scale. Then s/he can rate how strongly s/he believes that the feared consequence will really happen on a scale of 0-100 using the following guidelines:
Rate the degree of belief in the third column using the following scale:
0% = not likely at all, I know it is completely senseless and I have no doubt about that
25% = I don’t believe it will really happen, but I don’t want to take any chances
50% = I somewhat believe it will really happen, and I don’t want to take any chances
75% = I strongly believe it will really happen, and I don’t want to take any chances
100% = I am completely certain this will happen, I have no doubt whatsoever.
Rituals Consequences Form – CBP#04-010
Feared Consequences of Not doing ritual(s) SUDS Degree
of belief
Example: ‘Some will get sick’ 100 50%
1. _______________________________ _____ ______
2. _______________________________ _____ ______
3. _______________________________ _____ ______
4. _______________________________ _____ ______
5. _______________________________ _____ ______
6. _______________________________ _____ ______
7. _______________________________ _____ ______
8. _______________________________ _____ ______
_________________________________________________________
STEP 4. Repeat the exposure task over and over until the SUDS rating goes down to 20 or less. Then move on to the next item on the list.
The process of habituation requires extensive and prolonged contact with the situations, places and objects that provoke anxiety.
STEP 5. The process should be tracked for progress in order to help the child see that s/he is, in fact, improving.
Using the Daily Exposure Practice Form – CBP#04-011 [in appendix], have the child track all E/RP interventions, both done with you and those done as homework with ‘coaches’. It is important for the clinician to review the Form regularly and note any discrepancies such as differences between practices with you and at home, failure to reduce SUDS over the course of the practice, or failure to practice. Each discrepancy will need to be addressed if the child is to progress. The clinician will also want to use the positive aspect of progress to help bolster the child in the face of the next step up the ladder of fear and anxiety.
IMAGINAL EXPOSURE
People with OCD are afflicted by the presence of powerful images of possible future dangers. The images are often triggered in relatively harmless situations, yet are often highly charged and frightening. This imagery about future disastrous events fuels obsessive worry and compulsive rituals. The object of doing E/RP is to free the mind from needless worry about possible dangers and disasters. In vivo exposure involves confronting the situations that are feared in real life, so the child can learn that what s/he fears will happen, is highly unlikely to happen. There are situations, however, that are either impossible or just too impractical to re-create in real life for the purpose of exposure and ritual prevention. This is where imaginal exposure can be very useful.
Imaginal exposure, or visualization, will enable the child to think uncomfortable, fear provoking thoughts and hold them in mind without excessive discomfort. Since the mind does not separate imagined events from real events, substantial anxiety or fear can be generated, but they can also be stopped almost immediately. The control is in the purview of the child. The goal of imaginal exposure is to provide opportunities to become habituated to your own thoughts.
STEP 1.
Have the child write [or write for him/her using her dictation] a three to five minute narrative in the first person, present tense [‘I am…’], describing the feared situation that would arise if s/he were not to check or carry out a compulsive ritual or behavior. Write it as though describing a scene from a movie, frame by frame. Make it as vivid as possible. S/he can even enlarge the scene and his/her fear triggers to the point of absurdity.
Like exposure in vivo, the imaginal exposure should create an initially high SUDS level. The higher the SUDS the child can tolerate in the narrative, the better the overall effect. However, some images [the death of a loved one, for example] may seem much too scary to include in the narrative, especially in the beginning. In this case, describe a situation that provokes medium levels of fear – 60 to 75 SUDS points. When the child has habituated to that situation, do another narrative with more frightening images – in the 80 to 90 SUDS point range.
STEP 2.
Record the narrative on a cassette tape and have the child listen to it over and over for a minimum of forty five [45] minutes a day, for one week. An endless loop tape works best. It is helpful to have the child monitor the SUDS level after each replay of the narrative using the Imaginal Exposure Monitoring Form – CBP#04-012. The goal is to play the narrative over and over until the SUDS lowers to twenty [20] or fewer points. This indicates that the situation is probably habituated and the images will no longer evoke excessive discomfort. At this point you can repeat step 1 with a higher SUDS level event.
IMAGINAL EXPOSURE MONITORING FORM – CBP#04-0012
Use a separate form for each Exposure experience. Rate the SUDS [0 to 100] after each repetition of the narrative.
Date ____________________ Total Exposure Time ________________
1. _____________ 7. ________________ 13. _____________
2. _____________ 8. ________________ 14. _____________
3. _____________ 9. ________________ 15. _____________
4. _____________ 8. ________________ 16. _____________
5. _____________ 10. ________________ 17. _____________
6. _____________ 11. ________________ 18. _____________
Average SUDS level for this session [total SUDS divided by the number of exposures to tape] = ______________
__________________________________________________________
CAUTION: there are some people who should not try imaginal exposure without the supervision of a qualified clinician. These include people who have severe OCD combined with having a strong belief that their obsessive thoughts are real and make sense [‘overvalued ideas’], a history of psychosis or borderline personality disorder.
If the child cannot tolerate the anxiety level of the imaginal exposure.
Make the narrative shorter and less anxiety provoking. Have the imaginal exposure start with a lower SUDS level. Make the imaginal narrative absurd or even ridiculous to take the edge off.
If the imaginal exposure doesn’t arouse much anxiety.
The narrative may be too generalized. Make it more vivid and include specific disturbing images of situations that are feared. For example, if the child fears being ill in the future, describe a specific image of being in a hospital hooked up to IVs and breathing machine, or of being left alone and unable to call for the nurse, etc.
Also, check to ensure that the child is not blocking the full emotional impact of the experience while listening.
If just imagining the scary scene is not enough to provoke anxiety.
Some people are just not imaginative and they have difficulty imagining scenes vividly. They simply must experience ‘the real thing’ to arouse an appropriate level of anxiety. If this is the case, move to in vivo exposure and ritual prevention.
SPECIAL CASES
WASHERS
Fast Track Method [Total Water Block]
This method, although at first appearing to be the most frightening, if followed rigorously, will produce rapid results for washers within a three [03] week period.
- for a period of at least three weeks, except for the procedures listed below, the child must commit to severely limiting or blocking this use of water on his/her body – limited hand washing, no excessive rinsing, no use of wet towels or pre-moistened towelettes and no swimming.
- showering will consist of one ten minute shower every three days. This includes hair washing.
- use a time to limit his/her shower. Repetitive or ritualistic washing of specific areas of the body – such as the genitals and hair – should be limited as much as possible
- the use of creams and other toiletry articles [bath powder, deodorant, etc.] is okay, except where the use of these items reduces ‘contamination’. Do not use antibacterial creams, soaps or other toiletry items.
- shaving is done by electric shaver, not with water.
- water can be drunk or used to brush teeth. Care must be taken not to get water on the face and hands.
- restrict hand washing to the following: before meals; after toileting and after handling greasy or visibly dirty things.
- Do not exceed six [06] hand washings per day.
- clients with excessive cleaning rituals, for example, those who use bleaches or other unnecessarily strong detergents to clean their bodies, should remove those cleaning items from the home entirely.
For washers, the goal of the ritual prevention program is to ‘recalibrate’ the brain’s relationship to water and the function of cleaning and washing. In OCD-driven cleaning and washing, water, soap and detergents are misused as anxiety regulation tools to eliminate ‘contamination’. In contrast, the goal of normal cleaning and washing is merely to achieve the feeling of being fresh and clean.
Gradual Method [Ritual Delay]
Phase I
During this phase which can last a few days to a week, the child will work on trying to become more comfortable with the idea of delaying the washing rituals while at the same time actually shortening the duration of the ritual.
- Have the child choose a ‘contaminated’ object or situation from the Anxiety/Exposure List of situations that typically trigger hand washing and/or showering. Then, decide upon a length of time to refrain from washing that would trigger an anxiety level of around 50 – 60 SUDS. It may be one, five, ten, twenty or more minutes. It is up to the child.
- Have the child touch the object until s/he feels sufficiently ‘contaminated’ [50 to 60 SUDS]. Using a timer or other timing instrument, wait until the selected amount of time has passed without washing or showering. The child should experience the anxiety without blocking it.
- At the end of the predetermined waiting period, have the child wash, shower and reduce anxiety as s/he usually does. But this time, s/he should reduce the length of the washing by one-half. Each time, work on reducing the washing time by seconds, minutes or hours, depending upon the baseline level of washing before you started the procedure. Repeat this exposure three times per day, or as many times as the child can handle, until s/he gets the idea of delaying and reducing washing.
- Record the progress on the Ritual Delay Worksheet – CBP#04-013 as shown in the Appendix.
Phase II
After about a week, the child should be getting used to touching objects and being in places s/he considers contaminated and then delaying his/her rituals by several minutes or longer. Hopefully, s/he has also reduced the total number and length of hand washes and showers. If s/he hasn’t by now, s/he will.
Now you will have the child add one more component to the practices: delay doing the rituals for as long as it takes for the SUDS level to go down to less than 20 points. This requires more time, more staying power and the ability to withstand some uncomfortable feelings for longer periods of time. The child is still permitted to wash, but only after the SUDS level has been reduced low enough. The message to the brain is “If I only wait, the discomfort will go down on its own”. The child still has the ‘crutch’ of knowing that a wash is soon to come.
Repeat the exposure several times per day until the child has managed to reduce the initial SUDS level significantly. Each day as the child masters situations that formerly caused discomfort, introduce new items from the Anxiety/Exposure List while s/he continues to reduce rituals.
Phase III
By the third week, the child should be realizing that although certain situations still cause anxiety, s/he has the capacity to withstand the discomfort until the feeling passes on its own.
During this Phase the emphasis is on exposure to situations that provoke the most fear, with the goal of reducing washing to normal levels [In the Appendix CBP#04-014 provides these ‘rules’]. The child may notice at this point, that normal washing may leave him/her with a feeling of being ‘not quite clean’. This is to be expected and will probably persist for some time until the brain adapts to this new ‘normal’ feeling. Emphasize that the child is giving up OCD rules for ‘Normal’ rules.
Additional Procedures for Washers
- it is a good idea to create a ‘contamination’ towel that will be used as a tool for doing exposures to feared objects such as doorknobs or toilet seats. With it you would have the child lightly touch a small edge of a small hand towel to the feared object and then touch the towel to objects s/he lives with daily in home and school. It is only necessary to ‘contaminate’ the tiniest edge of the towel for the child to feel fully ‘contaminated’. While doing exposure with the towel, the child may find that after some time [a few minutes to a few hours] the towel no longer feels ‘contaminated’ [this means that s/he is becoming habituated to the towel. It is therefore necessary to ‘recharge’ the towel by retouching the original ‘contaminated’ object.
- should the child slip up and wash when s/he was not supposed to, have him/her ‘recontaminate’ him/herself with the ‘contaminated towel’ immediately after washing.
- Often people with contamination OCD do not distinguish between ‘unpleasant’ and ‘dangerous’. They worry excessively about touching an object merely because it is unpleasant to do so. By going ahead and touching an ‘unpleasant’ object, the fearful feelings associated with the object will eventually subside to manageable levels.
Self-Monitoring Method
If the child is just too fearful of doing any type of exposure whatsoever, try this method.
- make a copy of the Daily Washing Monitoring Chart – CBP#04-015 and have the child keep it in a journal. Use it to keep track of how many times s/he washes his/her hands every day.
- each time s/he washes his/her hands, she is instructed to mark it down on the chart immediately. Include baths and showers as well. Even if the washing is for a valid reason, s/he should mark it down – no exceptions.
- to wean the child from soap and water, you may begin to temporarily-substitute nonalcohol baby wipes or wet wipes, these are much less harsh and avoid towel rubbing, which irritates the hands.
- mark a wet wipe washing on the chart as a hand washing as well, using the code letter. The first goal is to have as few total marks as possible. The second goal is to have as few ‘soap and water’ washings as possible. Emphasize to the child that s/he cannot cheat – the OCD demon knows when s/he is lying and feeds off it.
- have the child use a dry napkin to clean his/her hands after a meal rather than washing them.
- schedule activities that will get the child’s hands dirty close together, then wash at the end of the last activity, rather than after each activity.
CHECKERS
When doing E/RP for checking, work toward the goal of checking only once. Work to refrain from checking items where they are not normally checked.
Strict ritual prevention for checking is very challenging. Try to use the following procedure to help strengthen the child’s efforts to deal with the powerful urges to check.
- Instead of checking over and over, check it once; then plan to check it once every five minutes for an hour. This ‘overcorrection’ makes the checking more cumbersome and thus may inhibit it.
- Use procrastination as part of the ritual prevention. Make a ‘deal’ with the child to check it later. Often, by the time ‘later’ comes, the urge to check will have passed.
- the urge to ritualize during ritual prevention is powerful. It is like a strong magnet that tries to pull the child back to the area not checked. Coach the child to ‘resist the magnet’ by taking his/her mind off the urge. Have the child focus on another activity. Do a chore, make a phone call or do vigorous physical exercise.
You may also want to consider exploring the Calm Technique #26, as a means of helping the child to train his/her mind to focus as a means of resistance.
- Because checking often involves fears and images of catastrophic future events and consequences, use imaginal exposure.
- Help the child fight the urge to check by using self-talk techniques [See Self Verbalization Technique #21].
OBSESSIONAL SLOWNESS
This common feature of OCD involves taking an extremely long time to complete the most basic daily tasks such as dressing, bathing and grooming. Obsessional slowness is a by-product of perfectionism and intolerance for not doing a task ‘just right’. Usually the person becomes so absorbed in the ritual activity that s/he loses sight of the time involved.
Slowness is often made worse by ‘trying harder’. The more pressure you put on the child to speed up the worse the slowness tend to become. People with slowness sometimes benefit from the procedure of tracking the length of time it takes to do various tasks. By committing to consciousness a ‘typical’ length of time an activity should take and then simply monitoring the length of time it does take, the person is taking conscious control of their own slowness. Gradually with the help of a timer or a ‘coach’ s/he may then be able to shave the time by concentrating on the task, gaining two to five minutes at a time.
The Activity Monitoring Form – CBP#04-016 [in the appendix] can be used to chart the time and this is a good activity for a friend or family member to act as a ‘coach’ to help the person focus on the time. The role, however, is not to urge quickness, but simply to bring to the child’s consciousness the time process.
CONCLUSIONS
Addressing OCD takes courage and training. As with athletes, the goal is mastery, not competitive performance. What this means is that you want to help the child improve his/her personal performance in each event. Just as the runner trains to improve his/her speed in the 100 meter dash incrementally, so the child with OCD will seek to improve his/her time in each exposure. Once the hard training is done and mastery is developed, they will be able to take on the competition.
The role of the friend or family ‘coach’ is an important one that will need to be addressed. If the person is too close, they may be a part of the problem and therefore find it difficult to be a part of the solution. The clinical staff will have to make decisions about whether the person has the qualities to be a good coach and then to help the coach understand clearly the role. Incremental gain may be the most important concept for the coach to learn. Just as superior athletes may have difficulty tolerating the level of performance of developing athletes and therefore be poor coaches, so too a parent who sees stopping these thoughts and rituals as a simple matter of will may have a difficult time being a coach.
There is a process of training to go through and as the child learns each of the procedures, s/he is learning how to cope with both the present and future anxieties of life.
Appendix
Fear Of Change Questionairre CBP#04-001
Ask the child to place a check mark next to the concerns that apply to him/her. Note that s/he may have additional fears and concerns and s/he should write them down in the space provided.
- “If I don’t do my rituals, what will I do to feel safe?” _____
- “If I confront my fear of dirt, germs, etc., how can I be guaranteed that the catastrophe I fear [getting sick, losing a loved one, hurting others] won’t happen?” _____
- “Since there is no cure for OCD, why bother?” _____
- “It sounds too easy. I know I’ll fail. I’ve failed at everything else.” _____
- “I’ve already done behavior therapy, and it didn’t work for me.” _____
- “I’d rather just take medicine ….this is too hard.” _____
- “My rituals are necessary to ward off the dangers I feel” _____
- “I’m afraid I will go crazy (get sick, harm others, etc.) if I’m prevented from doing my rituals.” _____
- “My thoughts are so bad it must mean I have an ‘evil seed’ inside me. I don’t deserve to get better.” _____
- “If I get better or feel happy, then something bad surely has to happen. I don’t want to take a chance.” _____
- Other ______________________________________ _____
- Other ______________________________________ _____
- Other ______________________________________ _____
OCD Symptoms Assessment – CBP#04-002
OBSESSIONS
Contamination Obsessions
Excessive fear or disgust, and preoccupation with avoiding:
_____ bodily waste or secretions – urine, feces, saliva, blood
_____ dirt or germs
_____ sticky substances or residues
_____ household cleansing agents or chemicals
_____ environmental contaminants – radon, asbestos, radiation, toxic waste
_____ touching animals
_____ insects
_____ becoming ill from contamination
_____ making others ill by contaminating them
_____ diseases – AIDS, hepatitis, sexually transmitted diseases
Hoarding, Saving And Collecting Obsessions
_____ worry about throwing things away, even seemingly useless items
_____ urge to collect useless things
_____ urge to pick up items from the ground
_____ uncomfortable with empty space – feel need to fill it
Ordering Obsessions
_____ preoccupation with symmetry, exactness or order
_____ excessive concern that handwriting be perfect or ‘just so’
_____ concern with aligning papers, books and other items in a certain ‘perfect’ way
CBP#04-002 – page 2
Religious Obsessions, Scrupulosity
Excessive fear, worry and preoccupation with:
_____ having blasphemous thoughts or saying bad things
_____ being punished for blasphemous thoughts
_____ concern with religious beliefs
_____ issues of right and wrong, morality
_____ dwelling on religious images or thoughts
Somatic Obsessions
Excessive fear, worry and preoccupation with:
_____ having an illness
_____ negative reactions of others to one’s appearance
Aggressive Obsessions
Preoccupation and excessive, illogical fear of:
_____ harming yourself
_____ harming others
_____ acting on unwanted impulse – e.g., run someone over, stab someone
_____ harming others through your own carelessness
_____ responsibility for some terrible accident – or fire, burglary – especially from personal carelessness
_____ blurting out insults or obscenities
_____ doing something embarrassing or looking foolish
_____ violent or horrific images in your mind causing you to do harm to others
CBP#04-002 – page 3
Sexual Obsessions
Unwanted, worrisome and intrusive
_____ sexual thoughts, images or impulses
_____ thoughts about molesting children
_____ thoughts about being or becoming a homosexual
_____ thoughts or images of violent sexual behavior toward others
Miscellaneous Obsessions
_____ urge to know or remember certain things – slogans, license plate numbers, names, words, events of the past
_____ fear of saying something wrong, not saying something just right or leaving out details
_____ worry about losing things
_____ worry about making mistakes
_____ easily bothered by certain sounds and noises – clocks ticking, loud noises, buzzing
_____ easily bothered by feel of clothing, textures on skin
_____ intrusive nonsense sounds, music, words
_____ fear of saying certain words because of superstitious beliefs about those words
_____ fear of using certain colors for superstitious reasons
_____ excessive superstitious fears with rigid adherence to them
_____ excessive concern with lucky and unlucky numbers with rigid adherence to them
CBP#04-002 – page 4
COMPULSIONS
Cleaning and Washing Compulsions
Excessive, illogical and uncontrollable
_____ hand washing, often performed in a ritualistic way
_____ showering or bathing often performed in a ritualistic way
_____ ritualistic tooth brushing, grooming, shaving
_____ cleaning of the house, certain rooms, yard, sidewalk, car
_____ cleaning of objects, household items
_____ use of special cleaners or cleaning techniques
_____ avoidance of objects considered ‘contaminated’
_____ avoidance of specific places – cities, towns, buildings – considered contaminated
_____ concern with wearing gloves or other protection to avoid ‘contamination’
Checking Compulsions
Checking over and over (despite repeated confirmations)
_____ that you did not harm others without knowing it
_____ that you did not harm yourself
_____ that others did not harm you
_____ that you did not make a mistake
_____ that nothing terrible happened
_____ that you did not do something that could cause future harm
_____ some aspect of physical conditions, health – pulse, blood pressure, appearance
_____ physical surroundings – locks, windows, appliances, stoves
_____ that jars are closed by excessive tightening
_____ that doors are closed by excessive, repeated shutting, closing
CBP#04-002 – page 5
Hoarding, Saving And Collecting Compulsions
_____ saving and collecting seemingly useless items
_____ pick up useless items from the ground
_____ difficulty throwing seemingly useless items away: “Someday I may make use of this…”
Repeating, Counting, Ordering
_____ reading and rereading things, sometimes for hours
_____ excessive worrying that you didn’t understand something you read
_____ excessive writing and rewriting things
_____ repeating routine activities – going in and out of doorways, repeated crossing of thresholds, getting up and down from a chair, combing hair, tying shoes, dressing and undressing over and over
_____ doing certain activities a particular number of times
_____ counting items – books on a shelf, ceiling tiles, cars going by
_____ counting during compulsive activities, such as checking and washing
_____ arranging items in a certain order – books, pencils, cupboards
Miscellaneous Compulsions
_____ mental rituals – prayers, repeating ‘good’ thoughts to counteract ‘bad’ thoughts
NOTE: Unlike obsessions, these mental rituals are performed with the intention of reducing or neutralizing anxiety.
_____ excessive need to repetitively ask others for reassurance when ample assurance is evident to others and has already been provided by those around you
_____ need to confess wrong behavior, even the slightest insignificant infractions of behavior toward others
_____ superstitious behavior that takes excessive amounts of time
_____ need to touch, tap, or rub certain items or people
CBP#04-002 – page 6
_____ measures, other than checking, to prevent harm to self or others – for example, avoidance of certain objects or extreme precautions to prevent highly unlikely harm or danger
_____ eating ritualistically according to specific ‘rules’ – arranging food or utensils, eating at certain times, eating foods in a particularly order
RELATED SYMPTOMS
_____ pulling own hair – from scalp, eyebrows, eyelashes, pubic area
_____ acts of self damage or self mutilation – picking skin
_____ compulsive shopping
NOTE: compulsive shopping is often related to hoarding – buying a number of things for fear of running out, for example.
Symptom Intensity Rating Form – CBP#04-003
Have the child write the symptoms down on the Form under ‘Symptoms’ in the appropriate section. S/he should indicate whether each symptom is a past or current one by placing a check in the appropriate box. Then, using the guidelines below, indicate how much of a problem each symptom is presently causing by marking a 1, 2 or 3 on the blank line below “Disruption rating’. Have the child do a disruption rating only on current symptoms.
Past = symptom bothered you in the past
Current = symptom bothers you now
Disruption Rating [of current symptoms]
1 = mild symptoms, just a slight nuisance or problem
2 = a moderate symptom, causes some anxiety and disruption in daily life
3 = a severe symptom, causes much anxiety and great disruption in daily life
OBSESSIONS
Contamination Obsessions [these are the excessive fear or disgust and/or preoccupation with the avoidance of dirt, germs, contaminants of any kind]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
CBP#04-003 – 2
Hoarding, Saving and Collecting Obsessions [these are the acquisition of and failure to discard possessions that appear to be useless or of very limited value]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Ordering Compulsions [these are an excessive preoccupation with symmetry, exactness or order]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Religious Obsessions, Scrupulosity [these are excessive fear, worry and preoccupation with violating moral and religious laws and rules, such as the fear of being punished for blasphemous thoughts]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
CBP#04-003 – 3
Somatic Obsessions [these involve a preoccupation with the appearance of specific parts of the body or the possibility of having an illness or incurable disease]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Aggressive Obsessions [these involve having excessive thoughts of causing harm to yourself or to others]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
sexual Obsessions [these are frequent unwanted, worrisome and intrusive sexual thoughts, images or impulses]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
CBP#04-003 – 4
Miscellaneous Obsessions [these are obsessions that don’t fit into any of the descriptive categories above]
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
COMPULSIONS
Cleaning and Washing Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Checking Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
CBP#04-003 – 5
Hoarding, Saving and Collecting Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Repeating, Counting And Ordering Compulsions
Symptom Past Current Disruption
Rating
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
____________________________ ______ _______ ________
Avoidance Symptom Form – CBP#04-004
Have the child list all of the situations, persons, places or things that s/he avoids because of his/her OCD, these can also include recurring horrible or disturbing thoughts that s/he tries to avoid. Indicate the degree to which s/he avoids each situation on a scale of 0 – 100.
0 = I never avoid it
50 = I avoid it about one half the time
75 = I avoid it most of the time
100 = I completely avoid this at all costs
Avoided Situations, Persons, Places, Things or Thoughts Degree of
Avoidance
1. _____________________________________ ________
2. _____________________________________ ________
3. _____________________________________ ________
4. _____________________________________ ________
5. _____________________________________ ________
6. _____________________________________ ________
7. _____________________________________ ________
8. _____________________________________ ________
9. _____________________________________ ________
Target Symptom Form – CBP#04-005
Obsessions Compulsions
1. _____________________ 1. _____________________
2. _____________________ 2. _____________________
3. _____________________ 3. _____________________
4. _____________________ 4. _____________________
5. _____________________ 5. _____________________
6. _____________________ 6. _____________________
7, _____________________ 7. _____________________
8. _____________________ 8. _____________________
9. _____________________ 9. _____________________
10. ____________________ 10. ____________________
11. _____________________ 11. ____________________
12. _____________________ 12. ____________________
13. _____________________ 13. ____________________
14. _____________________ 14. ____________________
15. _____________________ 15. ____________________
Target Avoidance Form – CBP#04-006
Based on the Avoidance Symptom Form – CBP#04-004, select the five most critical avoidances that disrupt your life.
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________
ANXIETY/EXPOSURE LIST – CBT#34-007
Trigger Situations SUDS
1. _____________________________________ ______
2. _____________________________________ ______
3. _____________________________________ ______
4. _____________________________________ ______
5. _____________________________________ ______
6. _____________________________________ ______
7. _____________________________________ ______
8. _____________________________________ ______
9. _____________________________________ ______
10. _____________________________________ ______
11. _____________________________________ ______
12. _____________________________________ ______
13. _____________________________________ ______
14. _____________________________________ ______
15. _____________________________________ ______
ANXIETY/EXPOSURE MINI-LIST – CBP#04-008
Anxiety/Exposure List for _____________________ SUDS
1. _____________________________________ ______
2. _____________________________________ ______
3. _____________________________________ ______
4. _____________________________________ ______
5. _____________________________________ ______
6. _____________________________________ ______
7. _____________________________________ ______
8. _____________________________________ ______
9. _____________________________________ ______
10. _____________________________________ ______
RITUAL CONSEQUENCES FORM – CBP#04-010
Feared Consequences of Not doing ritual(s) SUDS Degree
of belief
Example: ‘Someone will get sick’ 100 50%
1. _______________________________ _____ ______
2. _______________________________ _____ ______
3. _______________________________ _____ ______
4. _______________________________ _____ ______
5. _______________________________ _____ ______
6. _______________________________ _____ ______
7. _______________________________ _____ ______
8. _______________________________ _____ ______
DAILY EXPOSURE PRACTICE FORM – CBP#04-011
Exposure Task: _____________________________________________
Ritual Prevention: ___________________________________________
Initial SUDS [before starting E/RP] _______________________________
Goal SUDS level [after E/RP] ____________________________________
Goal: Length of Time [minutes/hours] per exposure _________________
Frequency of Exposures [days/weeks] ___________________________
Length of Time SUDS (0-100)
Day/Date Start Stop Beginning End Comments
IMAGINAL EXPOSURE MONITORING FORM – CBP#04-0012
Use a separate form for each Exposure experience. Rate the SUDS [0 to 100] after each repetition of the narrative.
Date ____________________ Total Exposure Time ________________
1. _____________ 7. ________________ 13. _____________
2. _____________ 8. ________________ 14. _____________
3. _____________ 9. ________________ 15. _____________
4. _____________ 8. ________________ 16. _____________
5. _____________ 10. ________________ 17. _____________
6. _____________ 11. ________________ 18. _____________
Average SUDS level for this session [total SUDS divided by the number of exposures to tape] = ______________
RITUAL DELAY WORKSHEET – CBP#04-0013
Day Object Touched Initial
SUDS Ritual Delay
[min/hrs] Length of Washing
% Reduction Total # Washing
% Reduction
Sample 1. ‘Dirty’ mail 92% 5 min 60 min 33% 40
10%
RULES FOR ‘NORMAL’ WASHING – CBP#04-014
For purposes of exposure and ritual prevention, normal washing consists of the following:
- One hand wash [less than thirty seconds] just prior to eating a meal and one hand wash [less than thirty seconds] after meals.
- One hand wash [less than thirty seconds] after toileting.
- One hand wash [less than thirty seconds] after changing a diaper, emptying a cat litter box, taking out the garbage or doing the laundry.
- One hand wash [less than thirty seconds] after handling greasy or visibly dirty things.
- One shower per day, ten minutes only.
- No rituals whatsoever are to be performed during showering.
- After vigorous activity, brief hand washing and showering [using the above guidelines] is okay.
- In general, other than at times prescribed above, hand washing should be done only if there are visible signs of dirt on hands.
- Be aware that OCD is tricky! It can create the sensations on your body of being dirty even if you are not. Be as honest with yourself as possible regarding the presence of dirt. When in doubt, don’t wash.
- Do not use anything to clean hands other than plain soap such as Ivory, Dial or other plain commercial soap. Do not use any ‘antibacterial’ soaps.
- when ill, proper hygiene should always be observed.
DAILY WASHING MONITORING CHART – CBP#04-015
Codes:
S = hand wash with soap and water
Sh = shower
W = hand wash with wet wipes
B = bath
Date Washing Code Number
Total:
ACTIVITY MONITORING FORM – CBP#04-016
Target Activity: ___________________
Baseline Time: ___________________
Goal Time: ___________________
Date Start Time End Time Total Time +/-