Obsessive Compulsive Disorder (20 page)

While younger children often enjoy developing and drawing out characters to represent these two explanations, adolescents often choose to call them 106

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Figure 6.3

Ellie’s predictions about what will happen if she does not neutralise after having an obsessional thought

‘OCD’ and something like, ‘the opposite of OCD’ or ‘not OCD’. Figure 6.3

shows Ellie’s explanations of what OCD tells her and an alternative way of understanding how the world may work.

• It is helpful to externalise the OCD to help the young person step outside the beliefs and see them in a more objective way.

• The therapist and young person develop two opposing ways of making sense of how the world works (an OCD

explanation and a competing explanation) and these are used to guide discussion and behavioural experiments.

Behavioural experiments

As described in previous chapters, the purpose of behavioural 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 are in danger). As much as possible, the young person needs to be involved in designing experiments and it is crucial that they are always clear about the rationale for the experiment and before carrying it out have made predictions about what they believe will happen and what this would mean.

With all behavioural experiments, it is important to spend time afterwards exploring what happened through guided discovery. This includes finding out what the young person made of what happened and what it told them about how the world works generally:
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• How does it fit in with the young person’s original prediction?

• Was the original prediction correct or incorrect?

• Does this fit best with the idea that the problem is about danger or does it fit better with the idea that the problem is about worry?

• How does this experiment relate to the formulation of the young person’s problem?

• How can this new understanding be carried forward in real life and further experiments?

It is worth taking time to reflect on experiments and to relate it back to the young person’s assumptions and beliefs in order for them to generalise what they have learned. By focusing on how the results of the experiment relate to the bigger picture, this also helps to ensure that the experiment does not end up as a form of reassurance.

Behavioural experiments need to have a clear rationale. Before carrying out an experiment, the young person needs to think about what they would predict will happen. After the experiment is carried out, it is important to reflect on the outcome and relate it back to the young person’s assumptions and beliefs in order for them to generalise what they have learned.

When carrying out behavioural experiments, it is also important to be aware that the therapist or other people’s presence or involvement may have the effect of reducing how the young person sees their personal responsibility. As a result, the young person may feel less anxious and less likely to feel that harm could occur. In general, it is helpful for the young person to become more responsible for experiments through the course of therapy.

This includes designing them and carrying them out increasingly independently. This also has the added benefit of facilitating the young person’s autonomy and self-confidence. With adolescents in particular, it can be helpful to have a discussion about the role of parents and other family members when carrying out experiments between sessions. Although parents are often keen to help and be involved, young people often prefer to carry out experiments independently and report back to the therapist and family in the following session. It is helpful to think this through with the young person early on so that everyone is clear about their role.

Tom was a 14-year-old who developed OCD after being bullied at school.

This began at the start of secondary school, when he was ostracised by a group of friends and bullied verbally. As a result, he moved to another class and his teachers then noticed a number of ‘odd’ behaviours, such as him hovering near doorways, going in and out of doorways more than once and repeating other actions. Although he was able to establish a new group of friends, over time these behaviours increased and by the time he was referred to the clinic he was spending more than ten hours a 108

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day doing compulsions. His obsessional thoughts were mainly around the worry that he would be bullied again, thinking of the people who bullied him, the worry he would lose his friends or that other ‘bad luck’

might happen to him, such as doing badly in a test or getting a detention.

He continued to have problems with repeating (written work if it did not

‘feel right’, walking through doors, up and down stairs, getting up and down from a chair, in and out of the shower) and would do actions holding a ‘good’ thought a certain number of times. ‘Good’ thoughts were thoughts of his friends, things they had enjoyed doing together and happy memories with his family.

Changing beliefs about thoughts

Thought–action fusion, the idea that thinking a thought can increase the chance of the thought coming true, is prevalent in OCD. In Tom’s case, he believed that thinking about the group who bullied him could lead to him being bullied again. His therapist asked him to rate how strongly he held this belief and he rated it as 95 per cent. However, when asked about the mechanism through which this occurred, Tom was unclear. He did not feel that he had any special powers and struggled to account for how it may happen.

However, he was able to describe how he felt that if he were to have a thought and not neutralise then bad luck would happen to him within the next day or so.

Tom and his therapist planned some experiments to investigate this further. They began with an experiment that would not lead to actual harm so that Tom could see what would happen in a less ‘risky’ way and then experiments became increasingly more ‘risky’. These experiments are illustrated in Figure 6.4. To begin with they designed the experiments so they would be able to find out the results straightaway. The therapist modelled more difficult experiments first to encourage Tom to do experiments himself. Whilst doing the experiments, Tom and the therapist had a discussion which covered the following: • The importance of Tom rating his predictions based on his feeling deep down rather than what he knew logically should happen.

• That if they did come true, the mechanism through which this would happen,
i.e.
did he feel he had any special powers? If not, how would it work?

• Could he kill things (like snakes – which his mum was scared of) by thinking about it?

• Could he make good things happen (for example, winning the lottery) as well as bad things – and if not, why not?

• Did he notice any relationship between how worried he was and how likely he felt it was that something bad would happen?

• Did this fit in more with the idea that this is really dangerous (OCD) or that he was worrying too much about it being dangerous (the opposite of OCD)?

Over the following week, both Tom and the therapist continued with
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Figure 6.4

Tom’s thinking experiments

thinking experiments to see if either or them could make good or bad things happen. By the following week, Tom decided to try to put the thought of the bullies into his head without doing a mental ritual afterwards, to test out his original belief that thinking about them would cause something bad to happen the following day. By repeating these experiments a number of times, this allowed him to develop a less threatening interpretation, which was that thoughts were actually not that important, but he had been worrying too much about it.

Estimating threat

One of the central beliefs in OCD is around the overestimation of threat, in that the estimation of the probability and/or severity of harm is exaggerated.

Theoretically, threat estimation (and inflated responsibility) is most strongly linked to thoughts of contamination and harming others (OCCWG, 2001; Salkovskis, 1985).

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Once Ellie and her therapist developed an understanding of her problem around germs, Ellie was encouraged to think about whether the problem fitted more with the idea that the world is dangerous or with the idea that she is worrying too much about the world being dangerous. So far she had been thinking about the problem as being around germs and so her therapist carried out a behavioural experiment to start to test out what the problem was really about. Ellie was asked what she thought would happen if the therapist licked the bottom of her shoe. Ellie predicted that there was a 90

per cent chance that the therapist would get a stomach bug as she could have trodden in dirt, mud or dog mess. The therapist then licked the bottom of her shoe so that Ellie could see and the following week reported back the results of the experiment. The following session, the therapist suggested that she do another over-the-top experiment again to learn more about how Ellie had been estimating the likelihood of harm. She and Ellie went into the bathroom and the therapist touched the objects that Ellie felt were contaminated, such as the taps, toilet flush and seat and then licked her hands afterwards. Prior to this, the therapist made sure that Ellie was clear about the purpose of this experiment and got her to make some predictions that they could test out. By modelling more extreme experiments, this allowed Ellie to see that the therapist was willing to take risks and also that she herself could cope with the anxiety this entailed. It also meant that she felt more willing to carry out some experiments herself.

Ellie found it helpful to find out that she had been overestimating the likelihood of harm in experiments carried out by the therapist. She described how this had led her to feel in her head that germs were not as dangerous as she had thought, but in her heart she still felt that if she were to touch something she (and then other people) would get ill. She felt that the next step would be to find out what would happen if she were to touch something she felt was germy and then not do a compulsion. She and the therapist came up with an experiment where she touched a door handle and then immediately ate a sweet without washing her hands first (see Figure 6.5). The results of this experiment enabled her to see that it worked in the same way as the therapist’s more extreme experiments and that the problem appeared to be more related to worry than actual harm.

Dealing with uncertainty and perfectionism

The belief that it is necessary to be certain and that it will be impossible to cope without complete certainty can be a problem in OCD. In particular, young people with checking compulsions often describe the aim as being to achieve certainty. Behavioural experiments can be helpful to test this out.

One of Jacob’s worries was around the idea that if he did not check text messages before he sent them, he may have written an insult without realising. As a result, he checked text messages again and again before sending them. He and his therapist carried out an experiment to see if checking led to greater certainty. They designed an experiment where he wrote a text to his friend and then behaved in a completely OCD way by checking it
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Figure 6.5

Ellie’s experiment

multiple times. He then wrote another text and then did the opposite of what OCD would tell him to do, by sending it without checking it first. He predicted that on the second occasion, he would feel more uncertain and worried about it. Interestingly, after checking each text he felt uncertain and was worried that by pressing the keys on his mobile phone to check it he may actually be changing the text. He also learned that he was actually more certain when he did not check the text and soon after sending it he actually forgot about it. The following week, he reported back that he had spoken to the friend that evening and felt confident that although he had not checked the second text, this had not caused him to insult his friend. As a result he concluded that this experiment fitted in more with the idea that the problem was about worrying too much rather than the risk of something bad happening.

Experiments are essential in exploring beliefs around thought–action fusion, threat estimation and dealing with uncertainty and perfectionism.

Discussion techniques

Changing beliefs about personal responsibility

An exaggerated belief by the young person that they have the power to bring about or prevent bad things happening is common in OCD. This results in 112

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feeling obliged to take every possible action to make sure the bad thing does not happen or to make sure that nothing they have done or not done could have a negative impact. Discussion and techniques, such as pie charts, can be useful in modifying the young person’s negative beliefs. In particular, the aim is for the young person to find out that they tend to overestimate their personal responsibility in relation to their obsessions and to learn that it is difficult to partition overall responsibility because of many interacting contributory factors.

This technique was used with Ellie to explore her belief that she was 90 per cent responsible for causing her father’s heart attack. To begin with, she was asked to make a list of all the things that may have contributed to him dying, however slight. She began with her belief that she had caused his heart attack by thinking about him dying some weeks before the event. She then identified all the other factors that may have been involved: 1

Her thinking of her dad dying.

2

Smoking.

3

In his genes.