Obsessive Compulsive Disorder (14 page)

Therapist:
It sounds as if OCD has been telling you that he knows how the world works and that if you don’t do a habit or tell your mum, certain things are going to happen. Is that right?

Jack:

Yes.

Therapist:
Let’s draw this out. Can you draw two columns and in the first one we’ll write all the things that OCD says will happen if you don’t do habits.

Jack:

Okay, OCD says that I’ll be a bad brother and that I could end up hurting Charlie by squashing him.

Therapist:
And if you don’t do what OCD says, what will happen to how worried you get?

Jack:

It will go up and up and won’t come down.

Therapist:
No wonder you’ve been feeling so bad. Is there anything else OCD would predict?

Jack:

I don’t think so.

Therapist:
Okay, so let’s now think about a different way of thinking about this. This is the total opposite of what OCD says. What shall we call this?

Jack:

Let’s call this one ‘Football King’!

Therapist:
Okay, so what would Football King say would happen if you don’t do a habit?

Jack:

He would say OCD is a great big liar and that I’m a nice brother and that I’m not going to hurt Charlie. He would say you don’t need to do habits and that you might be quite worried but after a while your worry would just disappear.

Therapist:
Okay, so OCD says, ‘Jack, if you don’t do all these things, it means that you are a bad brother, you might hurt Charlie and that your worries will go up and up.’ Is OCD saying that the 70

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problem here is danger and that if you don’t do these things lots of bad stuff is going to happen?

Jack:

Yes.

Therapist:
But Football King says, ‘OCD is a great big liar and that actually if you don’t do a habit or tell your mum, you are not a bad brother and nothing will happen and actually your worry will go down.’

Jack:

Yes.

Therapist:
So, Football King says, ‘You know what Jack, this isn’t a problem about danger, this is actually a problem about worry.’ [Pause.] Is that a new way of thinking about it, that the problem might actually be about worry rather than bad stuff happening?

Jack:

Yes.

Therapist:
And what would it mean if OCD is right?

Jack:

I need to do habits.

Therapist:
And if Football King is right?

Jack:

Habits are a waste of time – maybe I should be having fun instead.

Therapist:
What do you think about that idea?

Jack:

That would be good.

Therapist:
So how do we find out if OCD is right or if Football King is right?

Jack:

I could not do a habit and see what happens.

Therapist:
That sounds like a good place to start.

It is useful at this point to ask the young person to rate their belief in each explanation on a scale from 0 to 100 (with 0 being ‘I do not believe it at all’

and 100 being ‘I completely believe this’). Throughout treatment the therapist can then ask the young person to re-rate their beliefs. The next stage in treatment involves building on this belief by asking the young person to consider all possible evidence to support both explanations. It is often easier to start collecting evidence in favour of the problem being danger.

However, it is not uncommon for a young person to struggle to find any evidence at all. This realisation can help loosen their belief about the world being a dangerous place, while simultaneously building the belief that their problem might be about worry. In doing so, it is very important to make sure that all evidence is considered, no matter how small or unlikely (e.g.

forgetting to pray one night and falling ill the next day or a loved one being in an accident or having a strong emotional feeling that the danger is real).

All of this evidence provides a focus for treatment and an opportunity to consider alternative explanations (for example, challenging a young person’s belief that they are responsible for the accident to their family member).

Once a clear list of evidence for their problem being danger has been collected, it is helpful to move on to evidence for the idea that their problem is about worry. Useful questions to pose to the young person include:
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• Have there been times when you did not carry out a ritual and nothing happened?

• Have you ever had a thought about harm followed by nothing happening?

• Has your worry become better or worse since carrying out rituals?

• What was your worry like before you had OCD?

• Have you ever noticed that in the long term the OCD gets worse when you do the things it wants?

• Have you ever carried out a ritual and it did not work?

Introducing an alternative view of the problem as being around ‘worry’

rather than ‘danger’ can be helpful in giving the young person a different way of making sense of what is going on.

Behavioural experiments

By this stage in treatment, belief in the problem being danger should be loosening, and the belief in the problem being worry should be growing.

This loosening of belief in danger can increase the motivation required to move from discussion-focused therapy toward real-life experiments. These experiments are designed to provide stronger evidence within the heart (i.e.

at an emotional level) supporting the notion that the problem is worry rather than real danger. Thus, the purpose of carrying out experiments is to help the young person build up a body of evidence to support a new way of thinking about their problem (i.e. that they worry too much about danger) while decreasing evidence for their previously held interpretation of the problem (i.e. that they truly are in danger and responsible for causing or preventing this danger). When introducing experiments, it is useful to describe them as a way of finding out how the world really works, rather than how they think it works. Stories and imagery can be a useful method to get this idea across. For example, you can compare carrying out experiments to a scientist trying to find out how the world really works by doing experiments in their lab instead of simply relying on what other people say. This can then be presented to the young person as an image of a courtroom with evidence for and against being presented and examined. It can be useful to use role play to bring this idea to life, especially when working with younger children.

When setting up the first experiment with the young person it is important to help them choose something that is likely to be successful and something that can be tested immediately (e.g. testing whether they can make something happen in the room by thinking it to test out the idea that thinking things implies they have control over what will actually happen). It may be necessary for the therapist to model the experiment (or something more anxiety provoking) to the young person first if they are finding it difficult to 72

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engage in the experiment. The therapist should bear in mind that any experiments they carry out should be designed to model that they are trying to gain new information and that this may produce some degree of anxiety, but the anxiety is manageable and decreases over time. The therapist should try to model that they do experience some anxiety. Thought should therefore be given to choosing an experiment that does in fact produce some anxiety for the therapist (e.g. thinking about a loved one dying or rubbing an item of food on the bottom of their shoe before eating it). When setting up experiments it is also important that the young person is clear about the purpose of the experiment. Prior to conducting the experiment the therapist should ask the young person what it is they are trying to test out, what their predictions are and what the results would indicate about OCD if their predictions were found to be true or not true. Consideration should also be given to what future action the potential findings would suggest the young person takes.

‘I can’t let you do this until I know for sure that you understand why we are doing it. It is not to punish or torture you, but to help us find out how this problem really works. That is, to find out if the problem is worry rather than danger. Can you tell me in your own words why you are about to do this and what it might tell you about OCD and the way forward?’

As treatment progresses it is important to encourage the young person to come up with their own experiments. Not only can this build motivation and engagement, but it also helps to ensure that the young person is not obtain-ing reassurance from the therapist by shifting responsibility for danger away from themselves (e.g. ‘If something goes wrong it is not my fault because my therapist told me to do it.’). Consequently, it is important that over time the young person takes on increasing amounts of responsibility. The following structure can be a useful starting point in terms of carrying out experiments and gradually shifting responsibility toward the young person: 1

The therapist comes up with an idea and also carries it out. The young person copies this.

2

The therapist comes up with an idea, but does not carry it out. The young person does this.

3

The young person comes up with an idea and carries it out in front of the therapist.

4

The young person comes up with an idea, does not tell the therapist, and carries it out.

5

The young person comes up with an idea, does not tell the therapist, and only discusses the results.

Experiments should only be carried out if they fit the needs of the young person according to their beliefs. For example, a young person who believes that thoughts can cause harm would benefit from experiments focusing on thought–action fusion. For example, to see if thinking something can make
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it happen, the young person could think of the therapist being hit by a car as the therapist goes outside and walks around the car park. However, such an experiment would be of little value to a young person who does not believe that thoughts can cause harm. Examples of various experiments are set out in Appendix E. However, it is important to remember that they are a guide only and that many great experiments have been thought of in the midst of a difficult treatment session.

• Behavioural experiments are an essential part of treatment and are designed to provide evidence to support a new way of thinking about the problem.

• Experiments must always clearly relate to the specific beliefs of the young person.

Common obstacles to treatment

Helping the young person to engage with a different understanding of their OCD and to start to engage with experiments can be an issue that arises early on in treatment. It is important to try and identify the young person’s individual reasons for not wanting to engage in treatment and then help them to move forward on these issues. For example, if the young person feels that their OCD is not really a problem for them, the therapist should help them consider the pros and cons of their OCD, making sure they give enough time to the pros before moving on to the cons and then reviewing the evidence for the perceived pros.

Engagement can also be hindered if the young person appears to resent being offered help. If this appears to be the case it can be helpful to find out what it means to them to receive help (e.g. they are weak, stupid, or unable to sort things out for themselves) and to challenge this with questions such as: ‘What do you think it means if you need some help?’ ‘Do you think you are the only one that needs help with something?’ ‘Can you think of a time when someone in your family or a friend needed help with something?’ If after the reason for not wanting to engage has been identified and challenged the young person is still reluctant to begin treatment, it can be useful to review whether they feel their way of handling the OCD has been working. Try and gain minimal engagement (e.g. for a short period of time or for one area or ritual) to see if there may be a better way of handling things. The therapist can assure the young person that if they are not happy with the other way of dealing with things, they will put all their effort into helping the young person go back to doing it the obsessional way again.

One of the most common difficulties encountered in treatment is when the young person refuses to give experiments a go. It is vital that the therapist 74

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does not take an authoritarian stance and try to push the young person to do the experiment as this may threaten their engagement. Instead it is important to identify collaboratively what it is that is feeling so difficult and then try to problem-solve or get the young person to review the evidence for their worry. It is vital that the young person feels they are in control of what is going on within treatment. However, the challenge for the therapist is to allow this to occur whilst also encouraging the young person to step slightly outside their comfort zone to gain new information. Thus, the most common reason for not wanting to take part in an experiment is because it feels too scary or too great a leap for the young person to take.

If this is the case, the therapist and young person should consider taking a step back and think about carrying out an experiment that is less anxiety provoking.

However, it is also important that the therapist is not overly cautious as young people with OCD are often ready and able to make some huge leaps and therefore gain invaluable new evidence. It can be helpful to use natural opportunities whenever they arise. For example, if a young person spon-taneously suggests an experiment, then briefly review the reason for carrying it out and go with it immediately. It can also be helpful to remind the young person that it is sometimes better to do something you are scared of straightaway rather than think it through too much and have them find examples of this in their own life to build motivation. Similarly, it is helpful to highlight the nature of anxiety and the fact that things often are not as bad as they initially seem and to encourage the young person to identify previous non-OCD examples of times when they have been really worried about something but it has actually turned out to be manageable. Where possible, the therapist should try to make experiments fun, for example, if a young person enjoys tennis then incorporate this into experiments. If you are carrying out an experiment showing that focusing on body symptoms increases their salience, you may want to alternate between focusing on body symptoms and asking the young person to give you a quick verbal tennis lesson. Finally, if it becomes apparent that the experiment was too difficult for the young person, it is important that the therapist takes responsibility for the situation that has arisen to avoid the young person losing motivation.