Obsessive Compulsive Disorder (17 page)

down in the water so that the wave can flow over you. The child is then asked how pushing thoughts away might be like running away from a wave (i.e. the thoughts keep coming after you). So it is better to let thoughts flow over you while carrying on with life.

Intrusive thoughts can also be compared to a rude guest who visits a house without being asked and says lots of annoying things. The child is asked to think how to deal with a rude guest. They could argue with the guest, push the guest out, or leave the guest alone until they became bored and left. Then the child is asked, ‘What is the best way to deal with intrusive thoughts that come into your mind without being invited?’ (leave thoughts alone and let them come into your mind when they want to).

Intrusive thoughts can be compared to metaphors, such as waves or a rude guest, in order to see that it is better to leave them alone and carry on with life rather than reacting and pushing intrusive thoughts away.

Introducing an alternative explanation

The possibility of an alternative non-threatening explanation for the OCD is then introduced. A simple way is to ask the child to
become a detective
to find out whether OCD is telling the truth or is a liar. Both explanations are written on a piece of paper and the child is asked to rate their belief in each explanation on a scale from 0 to 10 (0 = I do not believe it at all, 10 = I completely believe it). The process of undermining the child’s belief in OCD

and building motivation to carry out experiments can begin by asking the child to compile evidence for both explanations (see Figure 5.3).

Carrying out behavioural experiments

Even quite young children will know about experiments. Young children find them helpful because they demonstrate in a concrete way that they do not have to continue doing what OCD tells them. They are encouraged to think that experiments can find out if OCD is telling the truth or lies. If the child does not understand the concept of experiments it is helpful to describe some. For example, to test a belief like ‘all dogs kill people’ the child and therapist might design a few experiments such as: visit a pet shop with dogs, stand near a friend’s dog, pat a dog, or take a dog for a walk. As soon as the child and therapist have designed some experiments, the child is asked what these experiments could teach someone who believed that ‘all dogs kill’

(e.g. not all dogs kill, dogs can be friendly). When designing experiments for 88

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Figure 5.3

Two explanations

OCD, the therapist needs to have a clear idea about the child’s OCD-related beliefs in order to tailor them to specific beliefs, for example:

• thoughts can make things happen

• bad thoughts mean I am a bad person

• germs will definitely kill me

• I am the only one with this kind of thought

• rituals make me feel better and stop harm

• it is up to me to stop bad things from happening.

Treatment sessions should involve the following:

• identify an unhelpful belief

• set up two opposing explanations (i.e. OCD is telling the truth or OCD

is a liar)

• ask the child to rate their current belief on a scale from 0 to 10

• ask the child to make predictions based on the two explanations

• carry out the experiment

• afterwards, discuss the results.

For example, a child who believes that reciting words in his head keeps his mother safe could be asked how much he believes that this is really true (i.e. rituals stop harm coming to Mum). The strength of the child’s belief could be loosened by asking the child to describe exactly how their rituals
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work and to recall every single time that their mother has been harmed because of their failure to do rituals. The child could also be asked to recall what has happened when they have not carried out their rituals. The usefulness of rituals can be challenged by asking the child what they think a policeman should do if he sees something bad happening: that is, should the policeman (a) carry out rituals and walk away? or (b) do something to help such as protect a child and run after the criminal?

• Experiments allow the young person to become a detective and find out whether OCD is telling the truth or is a liar and demonstrate in a concrete way that the young person does not have to continue doing what OCD tells them.

• When designing experiments, the therapist needs to have a clear idea about the child’s OCD-related beliefs.

Once a child’s belief has been loosened, they may be motivated to carry out experiments. For example, the usefulness of these rituals could be tested by asking the child to carry out the ritual (i.e. recite special words) in the session to prevent their mother getting hurt. The therapist then tells the child that they will throw a pen at their mother’s leg. The child’s task is to prevent their mother being hurt by carrying out the ritual. The child is asked what should happen if OCD is telling the truth about rituals stopping harm (i.e.

the pen should not hurt his mother) and what should happen if OCD is telling lies about rituals stopping harm (i.e. the pen will hurt his mother).

The development of more helpful beliefs can be consolidated by helping the child think through the results by asking questions such as:

• What have you learnt from this experiment?

• If OCD is telling the truth what should have happened?

• Now that you know that OCD is a liar, do you have to do what OCD

tells you to do?

• The next time OCD tells you to do a ritual, what will you tell OCD?

• How much do you believe now that rituals stop harm?

Usually children will cooperate with experiments if they are done swiftly using humour and enthusiasm to reduce anxiety and prevent refusal. Many children are initially reluctant to carry out experiments and this can be managed by the therapist modelling difficult experiments (e.g. for children with contamination fears the therapist touches the bottom of their shoe and then wipes their face) followed by suggesting an easier experiment for the child (e.g. the child touches the phone and the computer). The therapist should avoid stand-offs with the child over experiments. If a child refuses to do an experiment, it may be wise to back down and move on to another experiment. As the child’s confidence increases, the therapist can return to the previously refused experiment.

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Many young children are initially reluctant to carry out experiments and this can be managed by the therapist modelling difficult experiments and carrying them out swiftly, using humour and novelty.

Throughout treatment it is important that the therapist is aware of the possibility that the child may be passing responsibility on to adults while carrying out experiments. This is a problem because it stops the child from discovering that things would have been okay whether or not the therapist and/or their parents were in the room. If a child has shifted responsibility to other adults, the therapist should arrange to have several treatment sessions alone with the child and encourage the child to design and carry out experiments on their own. Examples of different experiments are listed in Appendix E.

The therapist should not feel limited to carrying out experiments in the office. Field trips can address problems that are not readily available in the office and help generalise treatment gains to other settings. Field trips can take place wherever OCD causes problems, including the child’s home, school, public toilets, cafeterias, public transport, swimming pools, dirty places and busy streets. During home visits the child can show the therapist around their house and point out where OCD bothers them. The child is then asked to act as if OCD is their best friend and to do everything that OCD tells them to do. When this has been completed, the child is asked to re-enact the day as if they hate OCD and to refuse to do anything that OCD

wants them to do. The aim of this task is to help the child to realise:

• that it feels better to act normally rather than doing rituals

• that it is easier to stand up to OCD than previously thought

• that they do not have to do rituals to feel okay

• that OCD is a liar because nothing bad happens when they stop doing rituals.

Field trips can address problems that are not readily available in the office and generalise treatment gains to other settings.

Voicing intrusive thoughts

Once the child understands that it is normal to have intrusive thoughts, they are encouraged to repeat intrusive thoughts out loud. The rationale for this is to help the child discover that it really is okay to have these thoughts and that having them on purpose might even make them disappear more quickly.

For example, while the child is repeating obsessional thoughts the therapist may ask the child to let them know when another thought already wants to
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take its place (e.g. a thought about what they want for dinner tonight or how bored they are or if they feel a muscle ache). The child is then encouraged to consider what it means if another thought just pops in and takes over the original intrusive thoughts (e.g. you don’t need to control your thoughts because they eventually disappear and are replaced by new thoughts).

Finding out whether arguing with OCD works

Mental arguing occurs when a young person tries to think their way out of a worry by arguing mentally with the worry. For example, Samia tried to cope with her worry by constantly arguing ‘for’ and ‘against’ the possibility of touching her sister in sexual ways. Mental arguing is unhelpful because it increases intrusive thoughts and doubts and intensifies beliefs about danger.

This can be illustrated by comparing an argument in your mind to arguing with a three-year-old child who wants something from you and will not listen to anything you say (e.g. they really want your shoes). The child is asked what they should do if a little child argues with them and does not listen. Some children realise that it is best to ignore the three-year-old, whereas other children think that they should argue back. The child is asked to consider what would happen if they argue back, which can be investigated via role play. The therapist pretends to be a three-year-old toddler who wants the child’s shoes. The child is asked to argue with this three-year-old as much as possible about not getting the shoes. Throughout the role play, the therapist always argues back with reasons why the child should give them their shoes. After a few minutes of arguing, the therapist asks the child questions to elicit the conclusion that arguing is unhelpful. These questions might include: • What happened when you argued with me about the shoes?

• When you continued to argue with me, did the argument get bigger or smaller?

• What sort of things were you thinking about when you argued with me, thoughts about shoes or normal thoughts about life?

The child is then asked how arguing with a child might be similar to arguing with OCD (e.g. OCD always argues back, OCD doesn’t care if you have good reasons, OCD just wants to win, OCD doesn’t fight fair, the more you argue with the OCD the more OCD tries to scare you with other thoughts).

Once the child realises that they cannot win an argument against OCD, the therapist can ask:

• If you can never win an argument with OCD, should you bother arguing at all?

• What should you do instead of arguing (e.g. ignore OCD as if he were a little child, and carry on with what you were doing before OCD

interrupted you)?

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Finding out what happens if you look out for harm

If a child engages in selective attention (e.g. looking for dirt, looking for things that are not symmetrical, focusing on bodily sensations for signs of harm), they should be helped to consider the impact of this unhelpful behaviour. The goal is for the child to realise that looking for danger is counterproductive because: • it makes danger appear more common than it really is

• selectively focusing on the body can intensify physical sensations.

The unhelpfulness of ‘looking for harm’ can be illustrated by asking the child to look for harm related to OCD for a few minutes. For example, for fear of contamination, ask the child to look for dirt and germs. If the child is bothered by asymmetry, ask them to look for things that are uneven. If the child fears choking, then focus on swallowing. The therapist then asks the child what happened when they started to look for danger on purpose.

Most children are able to report that they had lots of worrying thoughts, that they felt scared and that they noticed lots of scary things. Without prior warning, the therapist engages the child in an enjoyable game for a few minutes and then asks the child what happened to their thoughts and feelings about danger when they carried on with life and had some fun. Most children report that their thoughts and worry about harm disappeared. The child is then asked what made them feel better – looking for danger or carrying on with life. As soon the child understands that ‘looking for danger’

makes their belief about danger grow bigger and also triggers more worrying thoughts, the child is asked to draw an arrow from ‘looking for harm’ back to their ‘beliefs’ and ‘intrusive thoughts’ in bright red ink. The child is then asked to explain in their own words what this arrow means.

‘Pushing it’ experiments

As new healthy beliefs develop (e.g. rituals don’t work, rituals make me worry more and it is okay to have intrusive thoughts), it is not uncommon for a child to display reluctance to push OCD any further. This reluctance may be due to a concern that OCD will come back if pushed too far.

However, the child needs to go as far as possible in order to find out that OCD really is a liar. The therapist continues to explain that the only way to totally get rid of OCD is to do ‘
pushing it
’ experiments. The child is told that there are three ways to deal with OCD: • They can give in to OCD and make the problem worse