Obsessive Compulsive Disorder (22 page)

• Clinicians may use the formulation to determine whether involving family members in treatment may be appropriate in these instances.

Issues confronting therapists

Cognitive behavioural and family systems therapy approaches to the treatment of OCD are not easily reconciled. These two approaches can differ 118

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fundamentally on core issues of aetiology, therapist role, focus on symptomatology, means of intervention – even before considering the fact that many different schools of family therapy exist. The CBT approach has the advantage of being an empirically validated, focused approach with explicit models which describe how individuals develop and maintain anxiety-based problems. A key advantage of the CBT approach is its focus on the specific problem. On the other hand, whilst good CBT normalises problems and emphasises the importance of working collaboratively, systemic therapy approaches may consider broader contextual issues involved in maintaining and overcoming the problem, rather than focusing predominantly on the young person. Family and systemic therapies also have well-developed techniques for including family members within therapy sessions.

Strapping CBT techniques on to a family therapy intervention for OCD runs the risk of diluting the CBT. If the main focus is systemic work, important facets of CBT such as goal setting, reviewing homework and setting up behavioural experiments may be neglected. Similarly, including family members in CBT without working systemically or using the specific techniques of family therapy runs the risk of people feeling blamed, not addressing the beliefs and behaviours of family members which may be maintaining the problem or which may increase the likelihood of relapse, and neglecting effective, well-established therapeutic techniques. Further, simply asking family members to attend therapy sessions may not necessarily add to a reduction in the problem. MacFarlane (2001) notes that marital and family involvement in the treatment of OCD may be positive, but does not seem to reduce OCD symptomatology. The importance which is placed in individual CBT on working collaboratively and using Socratic techniques is at risk of being ignored if we regard parents and family members as potential co-therapists who need to be educated and then told how to carry out exposure tasks with young people, rather than exploring their beliefs and behaviours in more detail in an attempt to understand how the problem has developed.

CBT with families with OCD is currently an under-researched area. As discussed above, adding CBT interventions to family therapy sessions is unlikely to achieve optimal symptom reduction. Similarly, involving family members in CBT sessions in an ad hoc manner may not significantly reduce the OCD symptomatology either. This argues for the incorporation of current CBT skills beyond psychoeducation and exposure work when working with parents. Idiosyncratic, cognition-driven formulations of parental beliefs and behaviours with regard to the maintenance of the OCD should be developed and shared. These idiosyncratic formulations should then guide treatment and subsequent behavioural experiments, as well as the systems involved in the therapy sessions. The inclusion of family members in this way, using current cognitive therapy skills to make sense of why family members may be maintaining a problem, rather than prescribing exposure-based tasks, makes intuitive sense. Further research in this area is needed to determine whether this intuitively appealing strategy can be empirically validated. It may also be helpful to develop measures in addition to those 120

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measuring the young person’s OCD symptomatology in order to determine the effect of these interventions, as family involvement in treatment may prove to have benefits that extend beyond the reduction of obsessional symptomatology.

• Cognitive behavioural and family systems therapy approaches to the treatment of OCD are not easily reconciled; a key advantage of the CBT approach is its specificity; family therapies also have well-developed techniques for including family members.

• Simply asking family members to attend therapy sessions may not necessarily add to a reduction in the problem.

• Idiosyncratic, cognition-driven formulations should be developed and shared; they should guide treatment, as well as which systems to work with.

The family life cycle and OCD

Many young people with OCD report that their symptoms either began or worsened at significant points in their lives, such as moving to secondary school or moving out of home for the first time. Stobie
et al.
(2007) examined the course of OCD in people who failed to respond to CBT for OCD and found that respondents reported an average age of OCD symptom onset of 16 years, which might have been associated with going to college or leaving school. This finding is compatible with the cognitive model of OCD

(Salkovskis, 1985) which highlights the importance of responsibility in the development and maintenance of OCD. Young people may become vulnerable to developing OCD at life cycle points where they change their environments and experience a significant change in the level of responsibility which they are accorded. If the problem persists or worsens, that individual may fail to negotiate the life cycle targets appropriate to their developmental stage. In severe cases of OCD, individuals often appear to be stuck at the particular developmental stage where the OCD first began to significantly interfere with their lives. For example, if the OCD worsened in their teenage years, they might not achieve the developmental task of establishing autonomy traditionally associated with successfully negotiating this life cycle stage.

From a family perspective, disruption to an individual within the family system is likely to have repercussions on other members of the system, so that the fulfilment of the age-appropriate life cycle goals of other individuals within the system may be delayed or even disrupted completely. An example of this might be where a young person with OCD is unable to attend school and one of their parents has to give up work to be at home with them.

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• Young people may become vulnerable to developing OCD

at life cycle points where they change their environments and experience a shift in responsibility.

• OCD may prevent an individual from achieving appropriate life cycle targets.

• Fulfilment of the age-appropriate life cycle goals of other family members may also be delayed.

Who is the client?

The above highlights another issue for the therapist to consider prior to the sessions starting – namely, who is their client and what are the factors which have motivated different family members to attend? This may also be reviewed over the course of the sessions, but being explicit about this and establishing the expectations of the different family members from the outset is likely to reduce confusion and increase collaboration. Family members may attend for the following reasons: • to complain about the young person, or separate from them, or blame them for the development of the problem or other problems in the family

• one family member may wish to be confirmed as having a better approach to tackling the obsessional problem than other members

• to learn more about obsessional problems and how to help the young person to deal with them

• to check whether they are doing the right thing

• to seek emotional support or assistance, or a combination of these points.

In some cases family members may be in broad agreement about wanting to tackle the obsessional problem. In others, certain family members (sometimes the young person) may not believe that the obsessional problem exists, or is the main problem which needs to be addressed within the family. The greater the level of agreement between family members, the easier the therapist’s task becomes. It is very easy to become distracted from focusing on overcoming obsessional problems even when working with individuals.

When working with families, therapists can easily become distracted by other issues. One way of staying on track is to set clear goals at the start of therapy and to review these regularly over the course of the sessions.

Establishing the expectations of family members from the outset is likely to reduce confusion and increase collaboration.

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Goal setting

A potential starting point in drawing up goals with the family is discussion about the effect of the OCD on the family as a whole and on individual family members separately. Who has had to sacrifice what in response to the OCD, and what do they wish to do about this? What are the goals of the various family members – how do they differ and how do they link to the life cycle stages of these family members? As usual, it is helpful to construct SMART goals (Specific, Measurable, Attainable, Realistic, Timely) and to break these into short, medium and long-term goals. The therapist should also ask which family members will be responsible for ensuring which of the goals are carried out.

In instances where a family member has had OCD for many years, family members may be pessimistic about what can be achieved. These beliefs can have a very negative effect on the progress of the therapy sessions. Therapists need to respect what the family has to say about the problem and what needs to be done to overcome it, but also not buy into unhelpful beliefs and collaborate in the setting of goals which will not be sufficient to make lasting improvements. Where the goals of family members conflict substantially, this suggests the need for further discussion and later review of the goals, possibly after formulating. Should substantial differences remain, the therapist may need to consider who they are representing and who it will be helpful to include in the sessions. Where goals significantly differ between family members, the therapist should use a combination of education, formulation and discussion techniques in order to address the most significant points of difference. If this has been done and the family members continue to have wildly divergent goals, the therapist will need to continue based on an understanding of who their client is. It may be necessary not to continue with all of the family members if no agreement can be reached.

• The therapist should begin by discussing the effect of the OCD on the family as a whole and on individual members separately.

• Goals should be SMART and broken down into short, medium and long-term.

• If family members continue to have wildly divergent goals, it may be necessary to stop working with some family members.

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Education

A significant difference between this form of CBT and some of the other manualised treatment approaches (e.g. March and Mulle, 1998) with regard to education is that the present approach does not stress biological factors in educating family members about OCD. The advantage of stressing biological and genetic components to OCD may be that it can lead clients to feel less to blame for their symptoms, which is obviously potentially very helpful. However, stressing biological mechanisms as underpinning OCD

can be disempowering and promote pessimism about the ability to change the problem fundamentally. It can result in OCD being viewed as a longstanding problem which can be managed but never fully treated. Further, it may lead them to regard themselves as having something fundamentally wrong with them. This would conflict with the core thread of normalising and making sense of the problem which runs through the cognitive conceptualisation of OCD.

The present approach does not stress biological factors in educating family members about OCD, as this may make young people pessimistic about their ability to change the problem. This could also conflict with the core thread of normalising which runs through the cognitive conceptualisation of OCD.

Applying a modified version of the Salkovskis model to working
with families

Having dispensed useful information to the family regarding OCD and how it works, the therapist may then proceed to ask for a recent example of the problem, in order to formulate how it works and how the different family members respond to the problem. When working with a young person presenting with OCD, where a therapist suspects that family members may be involved in the maintenance of the problem, it may be helpful to construct several different formulations for different family members, and to consider how these feed into the OCD. A slightly modified version of the Salkovskis (1985) model might be useful for therapists to bear in mind as a formulatory template to guide questions (see Figure 7.1).

The therapist should first formulate a recent typical example provided by the young person. Once a clear understanding of the problem has been obtained, the discussion can then move on to explore a different family member’s response to the obsessional problem. In this case, instead of an intrusive thought, image, urge or doubt, the trigger is likely to be the young person’s compulsions or urge to engage in compulsions. The threat appraisal remains central to the formulation, but may be entirely different to the 124

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Figure 7.1

A modification of the Salkovskis model of OCD for use with family members

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young person’s threat appraisal. The family member’s threat appraisal may be what they fear will happen if they do not agree to provide reassurance or engage in checking or other rituals. Their threat appraisal is likely to lead to shifts in mood (which may be an increase in anxiety, but also possibly guilt, anger, sadness, etc.), avoidance, rituals, neutralising and the provision of reassurance. All of these responses feed back into that family member’s threat appraisal and are also likely to reinforce the young person’s threat appraisal. The key advantage to doing several formulations with different family members is that they allow therapists: • to understand how different family members will have different threat appraisals, even if these lead to the same consequences in terms of similar safety-seeking behaviours being adopted and the OCD being maintained