Obsessive Compulsive Disorder (23 page)

• to provide different family members with alternative, less threatening explanations which they can then be encouraged to test out.

This represents a fundamental shift from a more didactic, instructional model which urges family members, for example, to ‘stop providing reassurance’ or ‘stop engaging in checking rituals on your child’s behalf’. This is likely to lead to greater engagement in the therapeutic process, and a better likelihood that family members will test out new strategies. It enables therapists to avoid labelling family members as ‘resistant’, and normalises the beliefs of other family members, which are often different from the key threat appraisals of the young person, whilst highlighting different ways of dealing with the problem. The following case example illustrates these points.

Simon is a 12-year-old boy who has always performed well at school.

Recently his teacher expressed concerns that he had been having difficulty concentrating in class, and that his school performance had deteriorated. He was referred to a colleague for an assessment after he disclosed that he was being bothered by thoughts that he didn’t wish to disclose. Discussion with Simon revealed that shortly after his mother Dawn had separated from his father Marco approximately two years ago, he had begun to worry what would happen to him if his mother were to die. Shortly thereafter he started to experience intrusive images of his mother lying dead in a coffin. The images were extremely upsetting to him and he started to engage in a number of rituals to try to prevent his mother from dying. These rituals included saying prayers in his head, trying to suppress the images and counting to ‘lucky’ numbers. The more Simon performed the rituals, the more convinced he became that they were preventing serious harm from occurring to his mother.

Dawn felt extremely guilty about the difficulties which Simon was experiencing, partly as the worries centred on her, but also because she attributed Simon’s difficulties to her separation from Marco. She had also had OCD as a child. In order to assuage her guilt, and to help 126

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Simon, once she became aware of the problem she started to provide him with reassurance whenever he had the images. Unfortunately this developed into a pattern whereby Simon began to repeatedly ask her the same questions each night
e.g.
‘You’re okay, aren’t you Mum?’

Marco, who lived separately in the same town and had a new partner, looked after Simon on alternating weekends. Simon’s therapist requested that he attend some of the initial sessions, as Dawn described his approach as being inconsistent with her approach to the problem.

Marco reluctantly agreed to attend after being contacted by the therapist.

• A modified version of the Salkovskis (1985) model may be used as a formulatory template to guide questions.

• Different family members will have different threat appraisals, even if these lead to the same consequences in terms of similar safety-seeking behaviours.

• This model represents a shift from a didactic, instructional model to a more inquiring, collaborative way of working.

Formulating when working with an individual

The therapist began by formulating a recent typical example with Simon.

Simon explained how he was staying at his father’s home on Saturday evening when he suddenly had an image of the lid of a coffin being closed over his mother’s face (intrusive image). The meaning of this image for Simon was the belief that this image could cause his mother to die (threat appraisal). This in turn led to him becoming extremely anxious (emotional response). He tried to count to his lucky number seven in his head and keep the seven stuck in his head (neutralising); he prayed that his mother would be all right (neutralising), tried to push the image out of his head (thought suppression) and phoned her to check that she was okay (checking ritual).

All of these responses, including the anxiety, served to reinforce his belief that having these images meant that he could be responsible for causing serious harm to his mother, thereby reinforcing the threat appraisal and maintaining the OCD.

At some point in this process, the therapist may choose to complete another formulation – this time, based on the beliefs of a family member, rather than the young person. The therapist may choose to do this informally, using cognitive therapy discussion techniques to identify and challenge unhelpful beliefs and offer alternative, more helpful ways of seeing the problem. Alternatively, where an initial formulation has been done with the young person and found to be helpful, the therapist may choose to formally write up one or several more formulations that described the beliefs of
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different family members, and the way in which these beliefs affect their involvement in the problem. In this case, the trigger which activates the family member’s threat appraisal is likely to be the young person’s compulsive behaviour, rather than an intrusive thought. The family member’s threat appraisal may be similar to, or differ significantly from, the young person’s threat appraisal. Nonetheless, although the threat appraisals may differ, the emotional, physical and cognitive responses to the appraisals may be very similar to those of the young person and may also serve to reinforce or maintain the problem.

• The therapist may choose to complete another formulation

– this time based on the beliefs of a family member, rather than the young person.

• The trigger activating the threat appraisal is likely to be the OCD, although the family member’s threat appraisal may differ significantly from that of the young person.

• However, the emotional, physical and cognitive responses to the appraisals may be very similar to those of the young person and may also maintain the problem.

Formulating from the perspective of family members
Having done some work with Simon in terms of formulating the problem and setting homework tasks, the therapist decided to see his parents individually to clarify their beliefs. It became apparent that Dawn felt guilty about the separation from Marco and partially believed that she had let Simon down by insisting on the separation. Within the formulation, the therapist identified the separation from Marco as a critical event which reinforced some longstanding beliefs which Dawn had about herself. Her son’s compulsive behaviour was the trigger which then fed into two main threat appraisals: that Simon’s OCD was her fault and that her son would no longer be able to function if he became too anxious. These appraisals led her to feel guilty and anxious. They also led her to provide her son with reassurance whenever possible, and to do everything in her power to try to help him to reduce all of his anxiety levels, including encouraging him to stay at home.

Careful use of normalising and empathy was used by the therapist to illustrate how these responses were completely understandable, particularly within the context of her life history and the separation from Marco.

However, the responses were only helpful if the beliefs were true. If they were untrue, and Dawn was a good mother to her son, who was not at risk of ceasing to function even if he became more anxious as a consequence of going out, then a different set of strategies was needed. The present ones 128

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were reinforcing these worrying beliefs, and possibly even contributing to Simon’s obsessional problem, even though this was the last thing that Dawn wanted (see Figure 7.2).

The therapist also spent some time working separately with Simon’s father Marco, who seemed to be the family member who was most resistant to Simon attending the therapy sessions. Marco’s comments to Simon when he had tried to discuss the problem with his father were apparently dismissive. The therapist thought that using a formulatory approach might be helpful in gaining an understanding of why Marco, who was obviously very fond of his son, was seemingly not very supportive of him over the OCD.

Marco began the session by stating how angry he was with Dawn, as he was aware that that she had been spending a lot of time reassuring Simon, and he had read that reassurance only feeds the problem. He also believed that Dawn was using the obsessional problem to prevent Simon from seeing him on weekends, as Simon had become increasingly reluctant to stay over-night as he was worried about an accident befalling his mother whilst he was away. Marco was clearly very reluctant to believe that Simon had an obsessional problem. He stated that Simon’s problems were ‘a passing phase that all kids go through’, citing how he used to play the game ‘Step on a crack, break your mother’s back’ as a child. He believed the sessions were reinforcing the problem by ‘making a big issue of it’. He also explained that his initial reluctance to attend the therapy sessions was due to the fear that he would be blamed for the problem.

Allowing Marco to express his concerns about Simon and the therapy sessions freed him up enough to allow the therapist to formulate a recent example illustrating his response to the obsessional problem. Marco cited an incident which had occurred the previous Saturday. He had hired
Shaun of
the Dead
to watch with Simon. Unfortunately this spoof zombie movie had scared Simon and seemed to trigger his obsessional thoughts about harm coming to his mother. Simon began to experience intrusive images of his mother dying and turning into a zombie. He begged his father to take him home and started to engage in his neutralising rituals. Marco believed at this time that Simon was engaging in attention-seeking behaviour, which irri-tated him. He tried to rationalise with Simon and persuade him that nothing bad could possibly happen to his mother. When this failed to placate Simon, he encouraged him to try to suppress the thoughts and distract himself, which he had read was helpful (and the therapist explained was not). On seeing the level of distress that Simon was experiencing, Marco became increasingly upset and admitted that he feared his son was ‘starting to lose it’. This was identified as Marco’s main feared threat appraisal/belief, which caused him to feel anxious and guilty. Because this belief was so distressing and he did not know how to respond to it, he decided to take Simon back to Dawn. He also admitted to worrying constantly about his son, and that he had recently begun to avoid spending time with Simon as he found the obsessional problem very distressing to have to deal with.

The therapist discussed how Marco’s responses to his beliefs about how Simon’s behaviour was (a) attention-seeking and fostered by Dawn and (b) a
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Figure 7.2

Dawn’s formulation

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sign of mental illness contradicted each other, and were also neither true nor helpful. She also helped him to see that although he had been trying hard to help Simon, his responses to these beliefs (encouraging suppression, distrac-tion and rationalising, as well as becoming angry, returning Simon, and avoiding contact with him) were reinforcing his own beliefs and possibly also contributing to the obsessional problem, although this was the very last thing that he wanted.

The therapist used these formulations to wed her understanding of obsessional problems with the parents’ beliefs about obsessional problems and their son, in order to make sense of the problem and their roles in it. The increased understanding which the formulations yielded the therapist and the family also led to a better rapport and greater consistency, and paved the foundations of further cognitive work, including theory A/B, revisiting goals and setting up specific behavioural experiments for family members based on their idiosyncratic concerns.

Theory A/B

The therapist worked with Simon, Marco and Dawn to contrast Simon’s belief which was driving his compulsive behaviour with an alternative, less threatening explanation. The therapist argued that two possibilities existed and only one could be right – the problem was either
Theory A: having the
images could cause his mother to die
(unless he neutralised them), or
Theory
B: the problem was worry
(whatever thoughts or images he had couldn’t cause his mother to die, whether he neutralised them or not). The therapist discussed, with family members present, how these two ways of looking at the problem are completely different. In the first, theory A, Simon was a potentially dangerous person with magical powers. In the second, theory B, he was a kind, caring son who worries too much about his thoughts and his parents. From here the therapist asked the family what evidence existed for both theories. She then challenged some of this evidence by encouraging Simon and his parents to have a discussion about what evidence would be admissible in a court of law (to separate spurious ‘evidence’ from real evidence). She then asked what action needed to be taken if each of the theories was true. If A were true, the family would need to help Simon to use all of their safety-seeking behaviours, avoidance, neutralising and reassurance-seeking rituals. If B were true, the family would need to encourage Simon to do the opposite, that is, to engage in day-to-day activities without avoidance, to take chances, to allow the thoughts to come and go freely,
etc.

(See Figure 7.3.)

The therapist worked separately with Dawn to establish her own theory A / theory B. In Dawn’s case, theory A read ‘The problem is I
am
a bad, uncaring mother who’s caused Simon to have OCD’ and theory B read ‘The problem is I
worry
I’m a bad, uncaring mother who’s caused Simon to have OCD – but actually I’m a really good mum who loves her son very much.’

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Figure 7.3

Simon’s theory A and theory B

The second part of this sentence was deliberately added by the therapist to help Dawn separate these two ways of perceiving herself, as her low self-esteem made this difficult for her to do. Evidence was then gathered and critically assessed for both theories. Dawn was also asked what she needed to do if A were true and if B were true, for herself and for Simon. She concluded that if A were true, she would need to constantly apologise to Simon and give him reassurance. She should doubt herself and her abilities and ruminate about this extensively and she should spend all her time with Simon worrying about him. If B were true, she should stop spending her time feeling guilty and ruminating and she should make more time for herself. The time spent with Simon should be ‘quality time’, unhampered by worry and doubt, which she could model for him by encouraging him to go out more and visit friends. Dawn was asked to draw up a similar theory A/B