Cognitive Therapy for Psychiatric Problems: Hawton, Salkovskis et al

Cognitive Therapy for Psychiatric Problems: Hawton, Salkovskis et al

Contents
Chapter 5 Obsessional Disorders    1
Nature of the problem    1
Content of obsessions    2
Types of compulsive behaviour    2
The psychological model of obsessive compulsive disorder    2
Assessment    2
Factors determining suitability for treatment    2
Detailed behavioural analysis    2
Covert neutralising    3
Avoidance    3
Emotional factors    3
Behaviours    3
Other aspects of assessment    3
Difficulties in assessment    4
Chronicity    4
Treatment of obsessions with over compulsive behaviour    4

Chapter 5 Obsessional Disorders

Nature of the problem

Obsessions are the intrusive thoughts that then provoke unpleasant feelings, standardly anxiety, that are then neutralised by the compulsion. There are standardly some specific situations that trigger the thoughts, although they might be so wide spread the actual originary situation is lost, although there will definitely be modulators.  The neutralising behaviour then gives some temporary relief from the anxiety, although the obsession returns.  Patients also develop avoidant behaviour to avoid trigger situations.

Clinically OCD gets divided into obsessional rumination, which is obsession with covert compulsion and obsessions with overt compulsions (obsessional ritualizing)

Content of obsessions

Usually concerned with something personally repugnant

Types of compulsive behaviour

A theme common to OCD is future harm and a desire to prevent it. Cleaning\checking compulsions more closely resemble phobias and have more avoidant behaviour in them.  When avoidance fails then compulsion is used to neutralise.  In checking obsessions the patient strives to ensure he has not been responsible for harm coming to himself or others.  There is a functional identity between cleaning and checking, making sure I am not responsible for harm. Likewise overt compulsions can be classified into restitution, i.e. putting things right and verification i.e. checking.

The psychological model of obsessive compulsive disorder

Core features of obsessional problems are

1.       Avoidance of object which trigger obsessions

2.       Obsessions

3.       Compulsive behaviours and thought rituals

As the obsessions persist and rituals become extensive patients can present with ritualistic behaviours apparently independent of the obsession when confronted with an obsessional trigger, as the patient neutralises before the obsession occurs.

Obsessions get associated with anxiety, i.e. conditioned, the anxiety would decline naturally but is kept there by the compulsions, which reduce the anxiety temporarily but the client never sees the anxiety dropping so the conditioning remains.  Again avoidance maintains the anxiety as exposure to the thoughts occurs less often.

Assessment

A crucial aspect of assessment is the response to exposure both within session and for homework as once the link between triggers, thoughts, neutralising activities and avoidance are clear then the therapist can implement a treatment plan.

Factors determining suitability for treatment

You need to establish if the OCD is primary or as a reaction to a primary problem, if it’s the primary problem then this should be treated first. The treatment is relatively straightforward once the detailed assessment is complete and consists of exposure and response prevention.  Schizophrenic patients often show OCD symptoms

Find out how the problem has affected them over the last week, i.e. intensity and duration, then move to a specific example of the problem. Look for what triggers the behaviour and look to elucidate any thoughts that there might be, or images.

Detailed behavioural analysis

Move to a specific example, and ask about the trigger situations, go through cognitions, emotions, physiology and behaviour. Then ask about the consequences, so do an ABC analysis.

Things to look for in analysis

1.       Avoidance

2.       Reassurance

3.       Modulators

4.       Forms of obsession, thoughts, images, impulses

5.       Triggers, emotional, cognitive

6.       Emotions, how they change, pre obsession, during compulsion and post compulsion

7.       Development of problem

8.       Degree of impairment due to problem, in various domains

9.       Cost benefit analysis of change

Covert neutralising

If a client’s obsessions are obscured by compulsions, then try to get the client to provoke the obsession, or provoke it for them on an assumption of what it is. Alternatively if there is a trigger situation that forces them to compulsion then get that trigger situation done without the compulsion.

Avoidance

There can be cognitive avoidance, as the client tries not to think about something. This will prevent exposure from working.  If the client doesn’t think their behaviours are senseless or excessive then they are not obsessional, especially if they think the origin of these behaviours are external, e.g. radio waves. When a client sees their behaviour as reasonable but excessive then do a cost benefit, the amount of effort put in for a highly improbable event.

Emotional factors

Check the mood associated with the obsession, the assumption is its anxiety but many patients report it as discomfort, tension, anger or repugnance. To clarify feelings, you can ask, is it like the feeling you get before an exam, when you are fed up

Behaviours

Behavioural assessment is crucial any behaviours that trigger obsessional thoughts.  Prevent exposure to them are crucial to be understood.  Look at active and passive avoidance, so are there things that prevent you having obsessions, are there things you avoid to prevent you having obsessions.  Sometimes covert rituals are used when overt ones are not possible. The behaviours that terminate exposure are reassurance and neutralising behaviours, you should be aware of these before doing any exposure.  Neutralising behaviours can be stored up, so for eight hours you can’t neutralise, then you neutralise furiously. Modulators can be situational, emotional, cognitive or interpersonal.

Other aspects of assessment

Check family members aren’t helping to maintain their behaviours.  Do a cost benefit analysis, if you didn’t have this behaviour how would your life be different.

Behavioural tests

Get client to enter the compulsion provoking situation without doing the compulsion and to note down what they’re thinking and what they’re feeling without doing the compulsion. Often because clients have become so used to their behaviour they omit salient details, so if you can do something in session that is a trigger situation for them and then to see what they do then that would be ideal for collecting all the information.

Difficulties in assessment

Obsessional thoughts are repugnant to the client and they fear they will be rejected if people know they have them. Some patients may think talking about their obsessional fears may make them worse. There can also be shame and embarrassment about the compulsions.

Chronicity

A very chronic problem might lead to the client not wanting to talk about their thoughts, through fear they may get locked up, seen as bad etc. Here look at what the effect of having the thought is, I don’t want to be locked up, then show how because you try to stop the thought because its repugnant shows you won’t act on it, and also how thought suppression leads to the enhancement and rebound effect.

Treatment of obsessions with overt compulsive behaviour

Presenting the rational

So you can use the dogs example, i.e. little boy gets scared of dogs and as an adult crosses the road, does this help, what should we do? When clients fear that the anxiety will not decline, then to say it will be fine is counterproductive, rather use it to do another behavioural experiment.

Introduction to exposure

Clients are willing to endure high levels of distress if they think the treatment will be effective. One of the things about exposure is that it will produce anxiety but actually this is a good thing as you may well find it goes down more rapidly than you thought between 20 -60 mins.  The other thing you will find is after repeating the same exposure the anxiety will reduce more quickly

Modelling is a useful way to show the client there is no problem with doing what you are asking.  It can often help if the therapist goes beyond what they are asking the client to do. Modelling should be used only at the start of treatment but should be phased out as it can be used as a reassurance technique by the client.

If responsibility is an issue in terms of the client always seeking reassurance that they have done the task right, then get them to set their own homework, without telling the therapist, and get them to do a homework review the next week.

Reassurance

Reassurance seeking is a common aspect of obsessions. Reassurance seeking looks to ensure that harm hasn’t happened and has the effect of passing the responsibility onto someone else.  If the client does reassurance seeking in session then do an ABC on it and see how much relief it provides, then look to see what the long term picture is, does it actually maintain the anxiety.  So to get the client to think about this, then ask the client how much reassurance they would need to make the problem go away for a month, if this doesn’t work then its ineffective.  Reassurance prevents confronting and extinguishing the anxiety that’s arisen about being responsible for harm.  If relatives have problems with this then they can say hospital instructions are that I don’t answer such questions.

Difficulties encountered in the course of treatment

Habituation does not occur in session.

If you get stuck with the client, then “There are two problems we could be having, one that you are having problems with germs and need to be obsessional with it, or two you are having obsessional problems which are kept going by your compulsions, how do you think we could decide between these possibilities.

Treatment of obsessions without overt compulsive behaviour

Covert compulsive behaviours are quite difficult to gain access to and to control.  However all that needs to happen to the standard model is to recognise mental neutralising behaviour. Indeed then the exposure is the repugnant thought, and the response prevention is

Assessment

Discriminating between the obsessional thought and the compulsive thought is critical.  Intrusive involuntary thoughts need to be discriminated from neutralising thoughts which are deliberately evoked. . There also might be covert avoidance behaviour, such as thought suppression.

Treatment procedure

Habituation procedure

IN habituation training then you repeat predictably to elicit thoughts to get anxiety reduction whilst preventing any neutralising behaviours. The key here is predictable, so if there are certain triggers that get the thoughts reliably created use these. From this point then move on to unpredictable events.

Before any ERP is started though, the client must fully understand the treatment rationale, the function of their compulsions and avoidance.

To get the predictable thought then you can get the patient to say the thought to themselves or to have a tape loop with their voice on it.  Get them to listen to the tape for 10 times without any neutralising behaviours, rate anxiety and urge to neutralise. Repeat this every day for a week and see how the anxiety changes

Thought stopping

I’m not sure about this one, this seems like it could turn into a safety behaviour but still…What you do is to get the client to describe a pleasant scene or thought, then elicit a distressing thought for the client and then shout stop and  then get them to think the more pleasant thought, I guess the sense of surprise will make them change, then get them to say it to themselves. The thought stopping needs to be practised in non-stressful situations until it can be used in stressful situations.

First you direct proceedings then you get them to do it. I guess one thing with thought stopping is the novelty of it wears off after a while, so I guess some ingenuity should be used to make it still seem novel.

Alternative treatments

Behavioural treatment, is the treatment of choice.  Psychotherapy is seen to be effective for people with obsessional traits and not OCD. Learning as an in-patient can lead to difficulties in generalisation when they leave hospital.

OCD a guide for professionals:Wilhelm and Steketee

OCD a guide for professionals:Wilhelm and Steketee

Contents
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

. 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