OCD a guide for professionals:Wilhelm and Steketee
Chapter 1 Cognitive Features, Theories and treatments for OCD 3
Symptoms and characteristics of OCD 3
Types of OCD Symptom 3
Normalising & Etiology 3
Cognitive models of OCD 4
Types of belief in OCD 4
Over importance of thoughts 4
Control of thoughts 4
Overestimation of danger 4
Desire for certainty 4
Responsibility 4
Perfectionism 4
Consequences of anxiety 4
Fear of positive experiences 5
Moods and beliefs 5
Summary of the cognitive model of OCD 5
Treatments for OCD 6
Cognitive Therapy 6
Chapter 2 Structure and application of cognitive therapy 6
Diagnosis and comorbidity 6
Selecting cognitive therapy modules 6
Summary of CT Method 6
Therapist Style 6
Treatment goals 6
Treatment 6
Chapter 3 Summary of Cognitive Therapy Techniques 6
Chapter 4 Assessment and Education 7
Session 2 8
Rationale for CT 8
Describe rituals and coping strategies 8
Cognitive triangle 8
Session 3 9
Types of OCD Belief 9
Cognitive Errors 9
Session 4 9
Chapter 5 Overimportance of thoughts 10
Cognitive Therapy Techniques 10
Wise Mind=Rational + emotional thinking 10
Psychoeducation 10
Metaphors and Stories 10
Patient as Scientist or detective 10
Courtroom technique 10
Downward arrow 11
Behavioural experiments 11
Double standard technique 11
Continuum technique 11
Advantages and disadvantages of the belief 11
Assign homework 11
Chapter 6 Control of Thoughts 11
Thought expression experiment 11
Metaphors 11
Chapter 7 Overestimation of danger 11
Cognitive Therapy Techniques 11
Downward Arrow 11
Calculating the probability of harm 12
Conducting a survey 12
Chapter 8 Desire for certainty 12
Cognitive therapy techniques 12
Downward arrow 12
Identifying cognitive errors 12
Advantages and disadvantages 12
Conducting a survey 12
Continuum Technique 12
Behavioural experiments 12
Fill in the blanks 12
Chapter 9 Responsibility 12
Cognitive therapy techniques 12
Chapter 10 Perfectionism 13
Chapter 12 Fear of positive experience 14
Chapter 13 Modifying Core beliefs 14
Modifying Core beliefs 14
Chapter 14 Relapse Prevention 15
Cognitive therapy techniques 15
Summary 15
Chapter 1 Cognitive Features, Theories and treatments for OCD
Symptoms and characteristics of OCD
Obsessions are intrusive and repetitive, thoughts, images or
impulses and lead people to do compulsive physical actions in order to reduce
the distress. Compulsions can be external, e.g. hand washing or internal saying
hail Marys. Compulsions are neutralising behaviour attempting to reduce the
distress.
Many obsessions, e.g. contamination have an aspect of
truth\fear about them, although the client’s response to them is excessive.
OCD is an anxiety disorder and also carries with it emotions
of guilt and shame.
Types of OCD Symptom
·
Harming, religious and sexual obsessions
·
Contamination
·
Symmetry
·
Checking
·
Hoarding
Hoarding is less responsive to standard OCD treatments and
there is specialised treatment, see Steketee for this.
Normalising & Etiology
In a study over 80% of people had similar intrusive thoughts
as OCD sufferers at some time. The intrusions were more frequent when anxious
or depressed or the client tried to resist them. OCD patients experienced
intrusions for longer periods, felt more upset about them and found them harder
to dismiss.
Stress provides a pathway to intrusive thoughts, when
anxious or depressed intrusive thoughts are more prevalent. Pregnancy,
childbirth or increased responsibility can be seen as precipitants for OCD,
where the thoughts are seen to be indicators that they are bad parents, or
incompetent. Rigid rules and conduct at school or early responsibility can
again be harbingers of OCD.
Cognitive models of OCD
People with strong positive core beliefs usually aren’t
troubled by intrusive thoughts, so an intrusive thought can take hold of
someone when it highlights a feared core belief.
Salkovskis argues that distorted beliefs about personal
responsibility for preventing harm is a major mechanism through which intrusive
thoughts provoke anxiety. OCD, overly high levels of personal responsibility
and perfectionism are all seen together.
OCD may also develop in people who overestimate the
probability of harm. Doubting of one’s
personal experience is a hallmark of OCD. They can doubt their decisions due to
a combination of perfectionism and an assumption that there is danger unless
they can be absolutely certain there isn’t.
Types of belief in OCD
Over importance of thoughts
Thought action fusion.
Control of thoughts
Clients think that they can control their thoughts
Overestimation of danger
Clients overestimate danger and require certainty to show
them that there is none. A situation is seen as dangerous unless proven safe,
which is a difficult\impossible thing to do.
Desire for certainty
There is thought that key to OCD is an uncertainty and
ambiguity intolerance and that the drive for certainty is the other side of
this.
Responsibility
People with OCD see themselves as being responsible for
preventing danger.
Perfectionism
Early experiences of rigid standards might lead people to
perfectionism and a fear of failing.
Consequences of anxiety
Clients have irrational beliefs about being able to tolerate
anxiety and that feeling anxious may lead them to going crazy.
Fear of positive experiences
Clients may feel they do not deserve positive experiences,
or that they will always turn into bad experiences.
Moods and beliefs
A person with OCD unlike a phobia are continually bombarded
with intrusions that they have to neutralise with compulsive behaviour. They
try to resist their thoughts which creates anxiety which then gets associated
with that which they fear, i.e. their obsessions. Not being able to control
their thoughts also leads to a feeling of helplessness and depression
Summary of the cognitive model of OCD
People have certain upbringing that gives them high levels
of responsibility and perfectionist attitudes, they develop beliefs about
thought, it’s over importance, its controllability, they have a desire for
certainty and have certain negative core beliefs. Then there is a trigger of a thought
or an event which is intrusive, then there is an interpretation which creates
certain emotions which then their safety behaviours respond to. The safety
behaviours exacerbate the levels of anxiety which makes the intrusion worse and
increases the safety behaviours.
Bit wobbly!!
Treatments for OCD
Clomipramine has been shown to be the most effective drug,
they do not work better than ERP. ERP is highly effective
Cognitive Therapy
CT is as effective as ERP, but CT and ERP is the gold
standard.
Chapter 2 Structure and application of cognitive therapy
Diagnosis and comorbidity
Check for any physical habits such as tics that would
indicate a physical substrate. If the person acts on their obsessional thoughts
or finds them pleasurable they are not OCD. The ideal OCD patient is one whom
the OCD is their main presenting problem. Assess the severity of the OCD with
Yale Brown or the OCSRS
Selecting cognitive therapy modules
Of the following modules pick what is appropriate for the
client and do those first, spend 2-4 sessions on them until you see
improvement.
Summary of CT Method
The overall treatment method is to identify domains of
cognitive interpretations and beliefs about intrusive thoughts and to teach
patients to modify these interpretations
Therapist Style
Some OCD patients can become dependent on their therapist,
so get the patient to think as independently as possible.
Treatment goals
Beware of unrealistic goals driven by perfectionist
standards. Also beware of clients who have been urged to get treatment by
spouses do a pros and cons of treating OCD.
Treatment
Be careful that DTRs or Socratic questioning doesn’t get
elevated to a compulsion, so a client starts repeating them to themselves to
ward of anxiety
Chapter 3 Summary of Cognitive Therapy Techniques
One difference between healthy and unhealthy core beliefs is
the latter are global and absolute, e.g. I’m stupid as opposed to sometimes I’m
clever. With global core beliefs then this leads to selective abstraction, to
only recalling memories that accord to this belief. In other words the absolute
nature of them means that perception and cognition gets skewed in favour of the
core belief to support it. When there is a non-absolute core belief then there
is still a sense of engagement with the world as it could be one thing or
another.
Socratic questioning is useful as a technique for changing
interpretations and intermediate beliefs, as there is the thought that people
change more quickly, more permanently if they discover the problems with the old
belief themselves .
Using a metaphor, story or analogy about a client’s distress
can help the client step back and become an observer on their problems. Doing
this encourages the sense of scientist practitioner that CBT is aiming to
evoke.
Downward arrow questions=so if that happened, what would
that mean to you? What does that mean about you? What’s the worst about that?
Conducting a survey=useful when an OCD sufferer forgets what
normal behaviour is
Fill in the blanks=when a client has a need for certainty,
then get them to see that all their obsessions are variants on the same theme.
So create a template that represents their fear, e.g. I think I have seen a
______ that might be a ___________and I might be held accountable for not
saving_________and I would feel guilty forever
Pie chart=use this to understand levels of responsibility
for something
Switch Roles=get the client to be the therapist and tell
them how importantly it is do everything perfectly
Making extreme contrasts: so with certainty then put
something you must be certain about on one end and something you don’t need to
be certain about on the other and compare, e.g. names of family members, name
of a pet
Chapter 4 Assessment and Education
Session 1
Agenda (Including)
1.
Welcome and check on recent OCD symptoms and
mood
2.
Provide patient with Personal session form and
notebook
3.
Define and discuss OCD
4.
Gather information using the OCD assessment form
5.
Discuss treatment goals
6.
Assign homework to read of what is OCD
At the start of every session give your patient a personal
session form
Defining OCD= ask client their understanding of the obsessions
and compulsions, ask what they think their compulsions do for them in the short
term and in the long run
The personal session form will be used at the end of the
sessions as a relapse prevention tool.
Session 2
1.
Agenda (Including)
2.
Discuss the cognitive triangle
3.
Develop the cognitive model of OCD
Rationale for CT
·
Intrusions are normal, OCD sufferers attach a
higher importance to this than people who don’t suffer from this
·
Trying to stop thinking about it adds fuel to
the fire
Describe rituals and coping strategies
Give your client the Ritual and Neutralisation strategies
document and show the type of things people do to neutralise the anxiety caused
by their intrusion. Show how the
neutralisation works in the short term but not in the long term as it doesn’t
dispute the base fear and how it enhances the levels of fear as you are
thinking about it all the time.
Cognitive triangle
Introduce the cognitive triangle of thoughts feelings and
behaviours. Thoughts are what you say to yourself, some can be automatic, some
deliberate, most thoughts are not under your control. Thoughts, behaviours and
emotions are all related so change one you will change the others.
Develop the cognitive model
Use the patients OCD and apply to the model, so show how
their interpretation, leads to their emotions and their behaviour. Ask what influences the interpretation, so
childhood events, media etc.
When the intrusion develops high emotions you probably want
to avoid that situation, these strategies only partly work so you use neutralisation,
but you can’t control thoughts but this provokes more thoughts and reinforces
the notion that these thoughts are bad.
However how would your emotional response be if you thought, oh I
thought that because of something I saw in a movie?
Discuss how these interpretations are affected by mood, and
understand the patient’s modulators, use this to show that there is no fact
about the interpretation rather it is emotionally dependent.
Describe the treatment process
First the client needs to become a good observer of what is
going on. So when they start any avoidance or neutralisation behaviour they
need to take note of their thoughts and emotions.
OCD has some biological aspect as we know that genetics
plays some role in certain parts of the brain that are associated with
excessive activity when OCD is present.
The goal of therapy is to reduce but not eliminate intrusive thoughts,
the main aim is to reduce the malign interpretations of these intrusions which
in turn will reduce the frequency of these thoughts.
Session 2 homework: complete a personalised version of the
cognitive model as it applies to their OCD
Session 3
Agenda (includes)
·
Discuss types of OCD beliefs
·
Discuss list of cognitive errors
·
Explain DTR
Types of OCD Belief
Hand the client the types of belief hand-out and see which
ones are pertinent to them. We will use
the types of belief that are identified to target them in therapy
Cognitive Errors
Provide your client with the cognitive errors hand-out
Introduce the 5 column thought record
Show how the DTR can challenge the thoughts that we have.
Homework: get client to fill out a 5 column thought record,
get the client to identify any cognitive errors
Session 4
·
Evaluate interpretations with Socratic
questioning
Explain to the client how certain beliefs will lead to
negative interpretations. So if you believe you can control your thoughts, that
you are responsible for them then having a certain thought means you don’t
want, means you are a bad person and that you are imminent danger of losing
control.
Explain the 7 column thought record
Then do some Socratic questioning, is this
thought\interpretation helpful to you, what is the evidence for and against
this interpretation, what would a friend say.
Homework give a 7 column thought record
Select the next cognitive domain.
On the basis of their answers to the above cognitive
domains, then select the next modules to be completed.
Chapter 5 Overimportance of thoughts
Agenda (Including)
·
Wise mind=rational + emotional thinking
·
Patient as scientist
·
Courtroom technique
·
Downward arrow
·
Behavioural experiments
·
Consulting an expert
·
Double standard technique
Review the thought record and if
the rational response isn’t reducing the belief in the dysfunctional thought,
then use a Socratic method to attend to this. Failure to do homework can show a
problem with motivation and needs to be immediately addressed.
Cognitive Therapy Techniques
·
Challenge
o
Thought action fusion
o
Having the thought means it’s important
o
Thinking something is as bad as doing something
Wise Mind=Rational + emotional thinking
Draw the two circles and the intersect, get the client to
give examples of each type of thinking when it’s all rational, or emotional and
an example of the intersect, then get them to plot where they see their OCD thinking
Psychoeducation
You can normalise about intrusive thoughts. In general
people develop OCD in the area that bothers them most. People have OCD around intrusions that
support a core belief that they are fighting against, e.g. I’m a bad person.
Metaphors and Stories
Thoughts don’t have to be true to have an effect on us, give
the example of making pasta
Patient as Scientist or detective
If you were a detective how would you examine the evidence
for or against
Courtroom technique
Get client to play the prosecuting attorney, then play the
defence attorney and then get them to sum up as the judge. When the attorney
speaks pretend he is talking to the judge, pretend the therapist is the
accused.
Downward arrow
Um, not much to say I know this, but it can also highlight
catastrophic beliefs, and when you ask what’s the worst you will hit a plateau where you can ask is this the
worst.
Behavioural experiments
For people with TAF, then get them to think your finger is
going to break
Double standard technique
Would the client expect another to behave the same as
themselves, if not why not
Continuum technique
For people who think they are dangerous because they think
thoughts use the continuum technique. Get the patient to put themselves on the
line, then find out other types of people and put them on the line, which
should alter their initial position.
Advantages and disadvantages of the belief
When the advantages are listed then use Socratic questioning
to challenge them!
Assign homework
·
7 column thought record
·
Downward arrow form
Chapter 6 Control of Thoughts
Agenda (including)
·
Thought suppression experiment
Thought expression experiment
Do the white bear and explain the enhancement and rebound
affect.
Metaphors
Leaves on a stream
Chapter 7 Overestimation of danger
Unlike the overimportance of thoughts module in this module
you do work with the content of thought.
Agenda (Including)
·
Conduct a survey
·
Betting money
·
Consult an expert
Cognitive Therapy Techniques
Downward Arrow
Use this for overestimations of the severity of harm, to
find any underlying beliefs.
Calculating the probability of harm
Conducting a survey
Chapter 8 Desire for certainty
Patients might need to know with certainty that something is
safe to preclude danger, they might feel they need to completely control their
thoughts otherwise this is a sign of a problem.
They might have difficulty making decisions to ensure they take the
correct one, in some ways OCD is the doubting disease.
Cognitive therapy techniques
With issues around certainty don’t go into the content of
thought but rather look at how certain do you have to be to know nothing bad
will happen.
Downward arrow
This provides a number of opportunities for interventions at
each level down the arrow.
Identifying cognitive errors
Look to get the student to pull out cognitive errors and
give alternative explanations
Advantages and disadvantages
Do advantages and disadvantages of striving for certainty
Conducting a survey
Ask how they see need for absolute certainty as an important
goal
Continuum Technique
Put down those things that need absolute certainty and those
that require little certainty.
Behavioural experiments
When you do this rate both the anxiety, uncertainty and
degree of belief in the statement being tested.
Rate the uncertainty on both an intellectual and emotional level, i.e.
gut level.
Fill in the blanks
OCD patients can have an image or thought that something
dreadful has happened then seek reassurance that it hasn’t, the dreadful
something will change in shape over time, the client should be encouraged to
think of this as the same intrusion so create a template with blanks to let
them fill in the detail. This will help the
client feel more in control.
Chapter 9 Responsibility
Cognitive therapy techniques
Risk=Probability* Consequence…. A low probability can still be high risk if
the consequence is very high.
Responsibility is a combination of the amount of responsibility
felt and the consequences if one is not responsible.
Percentage pie charts are good for responsibility, assign
the persons responsibility last.
Courtroom technique, only use empirical arguments, those
that could stand up in a court of law, this disallows emotional reasoning.,
disallow conjecture and possibility rather stick to the facts.
The client should start off with being the prosecutor and
the judge is the therapist.
You can do both the double standard technique and continuum
technique, and then after that use advantages and disadvantages of holding
double standards, so i.e. doing the initial techniques show that you have an
overinflated sense of responsibility and the pros and cons work will start to
challenge whether or not this is helpful.
Chapter 10 Perfectionism
Perfectionism is even minor mistakes have major
consequences. The therapist needs to be flexible here as you can’t
challenge perfectionism whilst demanding it yourself. You can also use failures within therapy to
see whether or not this ruins total therapy. Perfectionism also occurs in the
domain of the need for certainty , the need for control and excessive
responsibility.
Downward arrow technique
Perfectionists often have black and white thinking. Perfectionism might be a coping strategy for
fear of failure.
Taking another perspective
You can also loosen up their thinking by getting them to think of what they would ask of their
child or their best friend when doing a task, what standards would you have for
them in that situation.
Behavioural experiments
You can ask your client to make small mistakes and see what
the outcome is
Continuum technique works well with people who have
dichotomous thinking.
Chapter 11 Consequences of anxiety
People can engage in many strategies to avoid anxiety due to
fear of what might happen, or to the fear of the feeling itself. They may have beliefs such as anxiety is bad
and needs to be controlled, anxiety stops me from functioning.
It can often be useful to pair downward arrow techniques
with Socratic questioning, so if the downward arrow shows that the belief that
anxiety is going to prevent me from functioning, then you can ask about previous experiences of
being anxious and functioning. If a
client thinks that their performance with be lessened then you can ask about
needing to perform at your best all the time.
When someone says something is really unpleasant compare it
to slamming your finger in the door.
Making extreme contrasts
So when someone says they fear they are going crazy or lose
control and on the verge of going crazy, then ask them what they would see if
someone lost control and went crazy. Then ask them if they have ever done that
and if they felt they were on the verge of doing that.
Retrospective review of evidence
How many times have you been afraid of going crazy before,
and how many times have you gone crazy?
Chapter 12 Fear of positive experience
This module is appropriate if you client doesn’t feel they
deserve positive experiences or they have intrusive thoughts that they might
ruin them. Some patients avoid
pleasurable experiences through moral reasons.
For people who think they jinx their enjoyment, Socratic
questioning can be used to find times that they have had pleasure without it
going wrong, and when it does find out if there’s another reason apart from
them jinxing it.
Again you can use the double standard technique, does the
patient think that someone else in their position deserves to be happy, the
difference can then be seen to be that they have some core beliefs that prevent
their ability to allow themselves pleasure, e.g. I am bad.
You can also role play this, where the therapist has OCD and
the patient needs to suggest good reasons as to why you should improve and why
you deserve to improve
Chapter 13 Modifying Core beliefs
Socratic questioning can often highlight rules and
assumptions as can downward arrow, but the latter is more likely to generate core
beliefs.
Generally positive core beliefs have some moderation, I am
good at everything, whereas negative core beliefs are absolute, I am bad, I am unlovable.
Modifying Core beliefs
Core belief filter
When a core belief is activated then this acts as a mental
filter only processing information that is consistent with it. It can be useful
to educate clients about this. A Core belief rating sheet can be useful for
this, which is like a DTR but just for core beliefs
Socratic questioning is used to show how faulty thinking was
used to come to their conclusion.
Continuum technique, use this and then make extreme
contrasts with people, e.g. Hannibal lecter..
With core beliefs it can also be helpful to find out when
they were first learnt, then do some Socratic questioning to find out how just
before they got that label how they acted and how they would describe
themselves now, so if dad told me I was stupid, was I really at the time, am I
now?
Chapter 14 Relapse Prevention
You need to address client concerns about termination and address
them.
Cognitive therapy techniques
So review CT model, theories and techniques that have been
relevant and identify thinking errors. Review techniques that have worked.
Look at potential stressors, look at how progress and
setbacks are par for the course, and how a lapse isn’t a relapse. Teach problem solving skills. Find out how they can use the extra time freed
up from ocd. Get the patient to book in
a self therapy slot during the time when they came to see you and ask them what
they will do in it.
Summary
Um didn’t find it easy work going through this book, a lot
of repeated techniques. Useful I guess to dip into for specific areas rather than
to read cover to cover
No comments :
Post a Comment