Mastery of Obsessive-Compulsive Disorder : A Cognitive-Behavioral Approach Therapist Guide 9780199774968, 9780195186826

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Mastery of Obsessive-Compulsive Disorder A Cognitive-Behavioral Approach

Therapist Guide Michael J. Kozak Edna B. Foa

OXFORD U N I V E R S I T Y PRESS

OXTORD

UNIVERSITY PRESS

Oxford University Press, Inc., publishes works that further Oxford University's objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices Argentina Guatemala South Korea

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Permission is hereby granted to reproduce the forms located in the Appendix in this publication in complete pages, with the copyright notice, for instructional use and not for resale.

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Printed in the United States of America on acid-free paper

Contents

'Section .. Section 1: 1: Description andand Description Assessment of OCA Ass meofntOCD Chapter 1: Symptoms of OCD

3

Introduction Definition of OCD Prevalence Course Associated Disorders

3 4 5 5 6

Chapter 2: Theories ©f OCD

7

Learning Theories Cognitive Theories Neurochemical Theories Neuroanatomical Factors

1 8 10 11

Chapter 3: Assessment of OCD

13

Diagnostic Interview Differential Diagnosis Obsessions Versus Ruminations OCD and Other Anxiety Disorders Hypochondriasis Body Dysmorphic Disorder Tourette's Disorder and Tic Disorder Delusional Disorder

13 15 15 15 16 16 16 17

Section 2: Available Treatement of OCD Ter Chapter 4: Psychosocial Therapy for OCD

21

Cognitive-Behavioral Treatment Exposure Versus Response Prevention Imaginal Versus Actual Exposure Gradual Versus Immediate Exposure Duration of Exposure

21 22 22 23 23 iii

Frequency of Exposure Therapist-Guided Exposure Versus Self-Exposure Ritual Prevention Requests for Assurance Cognitive Therapy

23 24 24 25 26

Chapter 5: Pharmaeotherapy for OCD Serotonergic Medications Combined Treatment by Exposure and Medication

29 29 30

Chapter B: Choice of Treatment Discussion of Treatment Options With the Client Additional Considerations Treatment History Combined Treatments

33 34 38 38 38

-:-• Section 3l Cognitive-Behavioral Treatment Exposure by and Ritual prevention

iv

Chapter 7: Treatment Planning: Understanding and Persuading Understanding the Client Identifying Obsessions Identifying Avoidance Patterns Identifying Rituals The Nature of Obsessions Avoidance and Rituals General Functioning History Development of the Client's Symptoms Previous Treatment General History Depression Persuading the Client Definition of OCD Explanation of Treatment

43 44 44 44 45 45 49 51 51 51 52 53 53 53 53 54

Chapter 8: Treatment Planning: In Vivo Exposure Creating a List of Exposure Situations Guidelines for Selecting Exposure Situations Lines of Inquiry Sample Lists of Exposure Items

59 59 60 60 64

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Sample Exposure Plans Washer Checker Hoarder

66 66 69 70

Chapter 9: Treatment Planning; ImaginaS Exposure Medium of Exposure Problems With Imaginal Exposure Guidelines for Imaginal Exposure Model Introduction to Imaginal Exposure Sample Narrative Script for Imaginal Exposure

75 76 77 78 78 79

Chapter 10: Treatment Planning: Ritual Prevention Introducing the Concept and Persuading the Client Sample Guidelines for Refraining From Rituals Decontamination Rituals Checking Rituals Self-Monitoring of Rituals Guidelines for Self-Monitoring Reviewing the Self-Monitoring

81 81 83 83 84 84 85 86

Chapter 11: Treatment Planning: Social Support Patterns of Collaboration Interpersonal Conflicts

87 87 89

Chapter 12: Reviewing the Plan: Explicating the Contract

93

Chapter 13: Beginning Exposure: Revision and Consent Goals of the Exposure Sessions Revealing Mistaken Beliefs Building Confidence in the Therapist and in the Program The Importance of Consistency Refining the Program A Typical Exposure Session Imaginal Exposure In Vivo Exposure Instructions for Washers Exposure for Checkers Homework Instructions

97 97 97 98 98 99 100 100 102 102 103 105

V

Chapter 14: Middle Exposure: From Bete Noir to Paper Tiger Introducing the Most Difficult Exposures Tactics for Helping the Clients Scheduling Encouragement Courage Risk Taking The Paper Tiger Metaphor Therapist Attitude Alternatives to the Planned Exposure Discontinuing Therapy Intermediate Exercises Crises Unrelated to Exposure

107 108 108 108 109 109 109 110 Ill 112 112 • • . 113 114

Chapter 15: End Exposure: Theme and Variations Repetitions and Generalizations Teaching Normal Patterns of Behavior Rules for "Normal" Behavior

us 115 116 117

Chapter 16: Relapse Prevention: Self-Exposure The Process of Relapse Rules for Self-Exposure Stress-Management Techniques Meeting With Significant Others New Activities and Interests Scheduling Follow-Up Contacts

119 119 120 120 121 121 122

Chapter 17: Resistance and Other Difficulties Concealment of Symptoms Discussing Problems With Client and Support Person First Instance of Concealment Second Instance of Concealment Symptom (Ritual) Substitution Unforbidden Avoidance Incomplete Abstinence From Rituals Handling Arguments Emphasizing the Client's Control Over Treatment Intermediate Tasks Emotional Obstacles

123 123 124 127 127 128 129 129 130 131 131 132

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Chapter 18: Adjustment for Clients With Mental Retardation

133

Diagnosis of OCD Behavioral Stereotypes Versus Rituals Interviewing the Client Other Sources of Information Treatment of OCD Adjustments of Exposure Treatment Pessimism Impaired Discrimination and Distractibility Slower Learning Maintenance of Gains

133 134 134 134 135 135 136 136 137 137

Chapter 19: Adjustment for Children

139

Comorbidity in Pediatric OCD Adjustment of Exposure Treatment Teaching Children and Families About OCD Explanation of OCD as a Psychobiological Disease Explanation of OCD as a Set of Strong Habits Evaluating Parent's Observations Pace of Exposure for Children A Model Treatment Program Assessment and Treatment Planning Ritual Prevention Reframing OCD as the Child's Enemy Family Involvement With Treatment

139 140 141 141 142 142 142 143 144 144 144 145

Chapter 20: Conclusion

147

References

149

Appendix A

165

vii

Series Introduction

The psychosocial treatment program in this Therapist Guide is part of a series of empirically supported treatment programs. The purpose of the series is to disseminate knowledge about specific interventions for which systematic research studies indicate effectiveness. This treatment program, along with others in the series, has been clearly demonstrated to have empirical support for its efficacy in treating the particular condition you are addressing. However, clinicians operate with a wide variety of patients with different characteristics who are treated in different settings. Thus, the manner in which the treatment program is implemented will be the decision of the treating clinician with his or her unparalleled knowledge of the local clinical situation and the particular patient under care. Although some data indicate that allegiance to the treatment protocol produces the best results, only the treating clinician is in a position to judge the degree of flexibility required to achieve optimal results. We sincerely hope that you find the psychosocial treatment program, of which this Therapist Guide forms an integral part, useful in your clinical practice. This Therapist Guide is meant to accompany various clinical materials that you would be prescribing for patients in the implementation of this program. It is designed to assist clinicians in the systematic and sequential administration of the particular treatment program being implemented. As such it highlights relevant, practical information and exercises for the sessions. It also presents typical problems that may arise during specific therapeutic procedures and provides suggestions for solving these problems. Thus, you may want to review the brief individual chapters corresponding to each therapeutic session or intervention before conducting sessions, perhaps while reviewing case notes. Although the Therapist Guide is not a full description of the theoretical approach and empirical work that supports this treatment, references for additional information are provided. We encourage review of these readings for a comprehensive understanding. Please let us know if you have suggestions for improving our systems for helping you deliver effective psychosocial treatments for clients under your care. David H. Barlow, PhD Distinguished Professor

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About the Authors

M

ICHAEL]. KOZAK received his PhD in clinical psychology at the University of Wisconsin-Madison in 1982. Currently he is associate professor of psychiatry at Allegheny University of the Health Sciences and Clinical Director at the Center for the Treatment and Study of Anxiety. He has studied the process and outcome of psychosocial treatment and pharmacotherapy for anxiety disorders, including blood/injury phobia, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), and social anxiety. His expertise in exposure-based treatment for obsessive-compulsive disorder (OCD) has been developed over 14 years of daily clinical practice with OCD patients. His scholarly publications include reports of individual case studies and controlled outcome trials of cognitive-behavior therapy and pharmacotherapy for anxiety disorders, laboratory psychophysiological studies of emotion, theoretical and review articles, and philosophical analyses. He was a member of the Workgroup on Obsessive-Compulsive Disorder for the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition of the American Psychiatric Association.

E

DNA B. FOA, PhD, professor at the Allegheny University of the Health Sciences (formerly Medical College of Pennsylvania and Hahnemann University) and Director of the Center for the Treatment and Study of Anxiety, is an internationally renowned authority on the psychopathology and treatment of anxiety. Her research aiming at delineating etiological frameworks and targeted treatment has been highly influential and she is currently one of the leading experts on obsessive-compulsive disorder and phobias. The program that she has developed for rape victims is considered to be the most effective therapy for posttrauma sequela. More recently she has been investigating the psychopathology and treatment of social phobia. She has published several books and over 100 articles and book chapters, has lectured extensively around the world, and was the chair of the OCD workgroup and cochair of the PTSD workgroup of the DSM-IV. Dr. Foa is the recipient of numerous awards and honors, including the Fulbright Distinguished Professor Award, the Distinguished Scientist Award from the Scientific section of the American Psychological Association, the First Annual Outstanding Research Contribution Award from the Association for the Advancement of Behavior Therapy and the American Psychological Association Award for Distinguished Scientific Contributions to Clinical Psychology. ix

Acknowledgments

In clinical science, we extend our scope by standing on the shoulders of those who have preceded us. We owe much to the work of those who pioneered the application of behavior therapy to OCD, such as Meyer, Marks, and Rachman. Our conceptualization of emotional processing in exposure therapy has been greatly influenced by the bio-informational theory of Peter Lang, another trailblazer. Our many colleagues in research and practice over the years have also contributed to the development of our cognitive-behavioral approach. We are especially indebted to our patients with OCD, whose courage in confronting their obsessive fears has revealed so clearly the potency of exposure treatment, and to the National Institute of Mental Health, which has been supporting our research on OCD for almost 20 years. Our appreciation is extended to various persons at The Psychological Corporation, especially for the support we have received from John Dilworth, President; Joanne Lenke, PhD, Executive Vice President; and Aurelio Prifitera, PhD, Vice President and Director of the Psychological Measurement Group. The expertise contributed by Larry Weiss, PhD, Senior Project Director, has been invaluable in ensuring the high quality of the Therapist Guide. Special thanks are extended to those individuals whose meticulous and diligent efforts were essential in preparing the Therapist Guide for publication. Among this group are John Trent, Research Assistant; Kathy Overstreet, Senior Editor; Cynthia Woerner, Consulting Editor; and Javier Flores, Designer.

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Sectio n1 Description and m

Assessment of OCD

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CHAPTER 1

Symptoms of OCD

Introduction This Therapist Guide is designed to help psychotherapists in assessing and treating obsessive-compulsive disorder (OCD). It is divided into three sections. In the first section, a summary of the symptoms of OCD and methods for assessing the disorder are presented. In the second section, the relative efficacy of the available treatments and how to arrive at treatment recommendations for individuals with OCD who seek treatment are discussed. In the third section, a guide to cognitive-behavioral treatment by exposure and ritual prevention (i.e., refraining from performing rituals) is provided. Also in this section, the components of the treatment procedures whose efficacy has been experimentally documented are described and illustrated, as well as those aspects of their practical application that inhabit experimentally uncharted territory of clinical wisdom and artistry. This treatment program is referred to as cognitive-behavioral therapy because it incorporates techniques aimed at modifying cognitive structures, including unrealistic associations and mistaken beliefs, that underlie obsessions and compulsions. However, use of the term "cognitive behavioral" does not imply, in the Skinnerian tradition, that thoughts are "cognitive behaviors." Throughout the Therapist Guide, the program is interchangeably referred to as "exposure therapy," "cognitive-behavioral therapy," and "exposure and ritual prevention." 3

This Therapist Guide may be used either alone or with the accompanying Client Workbook, available from The Psychological Corporation.

Definition of OCD According to the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV; American Psychiatric Association, 1994), the essential features of OCD are severe recurrent obsessions or compulsions. Obsessions are "persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate, and that cause marked anxiety or distress" (p. 418). Compulsions are "repetitive behaviors . . . or mental acts . . . the goal of which is to prevent or reduce anxiety or distress" (p. 418). The traditional (pre-DSM-/F) definition of OCD reflects three basic ideas: (a) Obsessions are mental events, and compulsions are behavioral events; (b) obsessions and compulsions may either be connected or occur independently; and (c) those with OCD recognize the senselessness of their obsessions. The DSM-IV definition, however, reflects more contemporary views about these issues. In contrast to the traditional idea that obsessions are thoughts and that compulsions are actions, for the past two decades, experts have recognized that compulsions can be either actions or thoughts. Thus, the distinction between an obsession and a compulsion cannot rest solely on the modality of expression, that is, on whether or not the manifestation is a thought or an observable behavior. If one cannot rely on the simple notion that obsessions are thoughts and that compulsions are actions, how can they be distinguished from one another? A current view is that obsessions and compulsions may be defined according to whether they produce or reduce distress (Foa & Tillmanns, 1980). Accordingly, obsessions are thoughts, images, or impulses that produce anxiety or distress, and compulsions are overt (behavioral) or covert (mental) actions that reduce or prevent distress brought on by the obsessions. Behavioral rituals are thus functionally equivalent to mental rituals (such as silently repeating numbers) in that both aim to reduce obsessional distress. Sometimes mental rituals are referred to as "neutralizing thoughts" (Rachman, 1976). In summary, both behavioral and mental rituals may be performed to prevent harm, restore safety, or reduce distress.

4

The second notion found in the Diagnostic and Statistical Manual of Mental Disorders—Third Edition (DSM-III; American Psychiatric Association, 1980) and retained in the DSM-IV is that although most obsessions and compulsions are functionally related in the manner just described, some compulsions are carried out without direct relationship to any obsession. Findings of a study that was designed to address this issue indicate that about 90% of rituals are performed either to reduce or undo an obsession or to reduce an unspecified distress. However, about 10% of compulsions are unrelated to obsessions in the minds of the clients (Foa et al, 1995). The third traditional notion about OCD, which was revised in the DSM-IV, is that individuals with OCD recognize their obsessions and compulsions as senseless or unreasonable. Kozak and Foa (1994) have argued elsewhere that the clinical picture of OCD is more accurately represented by a continuum of "insight" or "strength of belief" than by the dichotomy of presence or absence of insight. Consensus about this issue has grown over the last several years (Foa & Kozak, 1996; Insel & Akiskal, 1986; Lelliott, Noshirvani, Basoglu, Marks, & Monteiro, 1988), and the DSM-IV reflects this by stipulating a subtype of OCD "with poor insight."

Prevalence No longer thought to be a rare disorder, OCD is now estimated to occur in about 2.5% of the population (Karno, Golding, Sorensen, & Burnam, 1988). Slightly more than half of those with OCD are female (Rasmussen & Tsuang, 1986). Age of onset ranges from early adolescence to young adulthood, with earlier onset in males (modal onset at 13-15 years old) than in females (modal onset at 20-24 years old; Rasmussen & Eisen, 1990).

Course Development of OCD is usually gradual, but acute onset has been reported. Chronic waxing and waning of symptoms is typical, but episodic and deteriorating courses have been observed in about 10% of clients (Rasmussen & Eisen, 1989). Many individuals with OCD have the disorder for years before seeking treatment. In one study, individuals first presented for psychiatric treatment over seven years after the onset of significant symptoms (Rasmussen & Tsuang, 1986). OCD is routinely associated with impaired general functioning, such as disruption of 5

gainful employment and of marital and other interpersonal relationships (Emmelkamp, de Haan, & Hoogduin, 1990; Riggs, Hiss, & Foa, 1992).

Associtated Disorders Depression, anxiety, phobic avoidance, and excessive worry often occur along with OCD (Tynes, White, & Steketee, 1990). In a sample of OCD clients, Rasmussen and Tsuang (1986) found that the lifetime incidence of simple phobia was about 30%; social phobia, 20%; and panic disorder, 15%. Approximately 30% of those with OCD also meet criteria for major depression, and sleep disturbances have been found in roughly 40% (Karno et al, 1988). A relationship between OCD and eating disorders has been observed. About 10% of women with OCD have a history of anorexia nervosa (Kasvikis, Tsakiris, Marks, Basoglu, & Noshirvani, 1986), and over 33% of individuals with bulimia have a history of OCD (Hudson, Pope, Yurgelun-Todd, Jonas, & Frankenburg, 1987; Laessle, Kittl, Fichter, Wittchen, & Pirke, 1987). Tourette's disorder and motor tics also appear related to OCD. Of individuals with OCD, 20%-30% report a current or past tics (Pauls, 1989). Estimates of the comorbidity of Tourette's disorder and OCD range from 36% to 52% (Leckman & Chittenden, 1990; Pauls, Towbin, Leckman, Zahner, & Cohen, 1986). Interestingly, whereas the incidence of OCD among individuals with Tourette's disorder is quite high (Pitman, Green, Jenike, & Mesulam, 1987), the converse is not true, with only 5%-7% of those with OCD having comorbid Tourette's disorder (Rasmussen & Eisen, 1989).

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CHAPTER 2

Theories of OCD

Learning Theorise Mowrer's (1939, 1960) two-stage theory for the acquisition and maintenance of fear and avoidance behavior has helped learning theorists to understand OCD. According to this theory, a neutral event comes to elicit fear after being experienced along with an event that itself causes distress, and distress can be conditioned to mental events, such as thoughts and images, as well as to physical events, such as snakes and spiders. Once fear is acquired, escape or avoidance patterns emerge as a means of reducing fear and are maintained when successful. This is the second, or operant stage, of the hypothesized process. Bollard and Miller (1950) adopted Mowrer's theory to understand obsessive-compulsive neurosis. Unlike the foci of simple phobias, obsessions cannot be avoided readily because they often occur spontaneously. Thus, the passive avoidance tactics used by people with phobias are often ineffective against obsessional distress, and active avoidance (i.e., compulsive rituals) is developed to counter the obsessions. Although Mowrer's elegant theory is clearly too simple to account for fear acquisition (Rachman & Wilson, 1980), it maps well onto observations about the maintenance of obsessive-compulsive rituals: Obsessions give rise to anxiety or distress, and compulsions reduce it. Obsessions, as well as confrontation with situations that prompt obsessions, provoke reports 7

of distress and elevated cardiac and electrodermal activity (Boulougouris, Rabavilas, & Stefanis, 1977; Hodgson & Rachman, 1972; Hornsveld, Kraaimaat, & van Dam-Baggen, 1979; Kozak, Foa, & Steketee, 1988; Rabavilas. & Boulougouris, 1974). Furthermore, obsessive distress routinely decreases following the performance of a ritual (Hodgson & Rachman, 1972; Hornsveld et al., 1979; Roper & Rachman, 1976; Roper, Rachman, & Hodgson, 1973).

Cognitive Theorise tgjf

Cognitive theories of OCD abound. Carr (1974), for example, noting that obsessions typically involve exaggerated concerns about health, death, welfare of others, sex, religion, and so on, argued that OCD is founded in ideas of exaggerated negative consequences. This view of obsessions as mistaken beliefs that are similar to the those found in generalized anxiety disorder, agoraphobia, and social phobia resembles Beck's (1976) notion that obsessions are mistaken beliefs about harm. McFall and Wollersheim (1979) also observed that individuals with OCD harbor mistaken ideas that lead to erroneous perceptions of threat, associated distress, and ritualized attempts to reduce it. Several difficulties arise with theories that feature mistaken beliefs in a prominent explanatory role in OCD. Not only has the presence of specific ideas common to OCD not been established, but clinical observations also suggest that the sort of pessimistic ideas about outcomes, and about perfectionist criteria for self-worth, are typical of other anxiety disorders, as well as of depression. Curiously, none of the theories addresses the distinctively intrusive character of obsessions that differentiates them from the fearful beliefs of simple phobia. Salkovskis (1985) has offered an elaborate cognitive analysis of OCD. According to this theory, obsessional intrusions are supposed to stimulate certain self-critical beliefs that then cause mood disturbances. Both covert and overt rituals are attempts to reduce this guilt. Furthermore, the frequently occurring thoughts regarding unacceptable actions may be perceived by the individual with OCD as actual performance of the actions themselves. Salkovskis (1985, p. 579) proposed that five assumptions are specifically characteristic of OCD: (a) Thinking of an action is tantamount to its performance; (b) failing to prevent (or failing to try to prevent) harm to self 8

or others is morally equivalent to causing the harm; (c) responsibility for harm is not diminished by extenuating circumstances; (d) failing to ritualize in response to an idea about harm constitutes an intention to harm; and (e) one should exercise control over one's thoughts. An interesting implication of this theory is that whereas the obsessive intrusion may be seen by the client as unacceptable, the mental and overt rituals that it prompts are acceptable. Another implication is that identifying and modifying these mistaken assumptions would result in the reduction of OCD symptoms. Other cognitive theorists have focused not as much on mistaken ideas as on impaired cognitive processes. For example, Reed (1985) hypothesized that OCD is characterized by impairments in the organization and integration of experiences and that certain symptoms (e.g., excessive structuring of activities, strict categorizations) constitute compensatory efforts. Other investigators have found specific memory deficits for actions in compulsive checkers (Sher, Frost, Kushner, Crews, & Alexander, 1989; Sher, Frost, & Otto, 1983) that might play a causal role in OCD. Clients' doubts about having performed an action may not reflect a memory deficit but rather, as suggested by Foa and Kozak (1985; cf. von Domarus, 1944), an impairment in the way inferences are made about danger. Specifically, Foa and Kozak hypothesized that individuals with OCD from the absence of evidence of safety often conclude that a situation is dangerous and fail to make inductive leaps about safety from information about the absence of danger. In other words, someone with OCD might insist on proof that any toilet seat is safe before sitting on it, whereas a person without OCD would sit on any toilet seat unless something about a particular seat indicated danger, such as a splintered edge flecked with blood. Consequently, rituals that are performed to reduce the likelihood of harm can never really provide safety and must be repeated. Regardless of whether cognitive deficits lie in memory processes or in transformational rules, the question of whether such impairments are general or are specific to the processing of threatrelated information remains open. In Foa and Kozak's (1985) cognitive theory of anxiety disorders, specific impairments in emotional memory structures were postulated. Following Lang's (1979) bioinformational theory, Foa and Kozak construed anxiety as founded in an information structure in memory that represents fear stimuli, responses, and their meanings. Accordingly, disordered fear memories are characterized by erroneous estimates of threat, high negative 9

valence for the feared event, and excessive response elements preparatory to escape or avoidance. Foa and Kozak (1985) hypothesized that several types of fear structures occur in individuals with OCD. Associations between the stimuli (e.g., toilet seats) and meaning (e.g., a high probability of contracting a venereal disease) are evident in the client with unrealistic fears of public rest rooms. For others with OCD, certain harmless stimuli are strongly associated with distress, without regard to harm. For example, some clients reduce distress about disarray by rearranging objects but do not anticipate any harmful consequences of the disorganization, except that it "just doesn't feel right."

Neurochemical Theories The prevailing biological account of OCD hypothesizes that abnormal serotonin metabolism is expressed in OCD symptoms. The efficacy of serotonin reuptake inhibitors (SRIs) with OCD has provided the primary impetus for this hypothesis. SRIs have been found more potent with OCD than have placebos and several other antidepressant medications, such as imipramine, nortriptyline, and amitriptyline (Zohar & Insel, 1987a). Significant correlations between clomipramine (CMI) plasma levels and improvement of OCD symptoms have led researchers to suggest that the serotonin function mediates OCD symptoms and lend further support to the serotonin hypothesis (Insel, Murphy, et al., 1983; Stern, Marks, Wright, & Luscombe, 1980). Direct investigations of serotonin functioning in individuals with OCD have been inconclusive (Joffe & Swinson, 1991). High correlations between improvement in OCD symptoms and a decrease in the serotonin metabolite 5-hydroxy indoleacetic acid (5-HIAA) were reported in two studies (Flament et al., 1985; Thoren, Asberg, Bertilsson, et al., 1980). These results are consistent with the hypothesis that the antiobsessional effects of CMI are mediated by the serotonergic system. Lucey, Butcher, Clare, and Dinan (1993) found responses to a serotonin agent, d-fenfluramine, significantly attenuated in individuals with OCD, whereas pituitary response to hypothalamic stimulation (protirelin challenge) was normal. These results point to central serotonergic dysfunction rather than to pituitary hyperactivity in individuals with OCD.

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On the other hand, the literature on serotonin involvement in OCD reveals some troubling inconsistencies. Studies of serotonin platelet uptake have failed to differentiate obsessive compulsives from controls (Insel, Mueller, Alterman, Linnoila, & Murphy, 1985; Weizman et al., 1985). In two studies, Zohar and his colleagues (Zohar & Insel, 1987b; Zohar, Mueller, Insel, Zohar-Kaduch, & Murphy, 1987) found an increase in obsessive-compulsive symptoms following the oral administration of the serotonin agonist metachlorophenylpoprazine (mCPP), which disappeared after treatment with CMI. However, intravenous administration of mCPP did not produce an increase in OCD symptoms (Charney et al., 1988).

Neurochemical Factors Several studies suggest neuroanatomical abnormalities in individuals with OCD. Some neuropsychological results have pointed to frontal lobe abnormalities (Behar et al., 1984; Cox, Fedio, & Rapoport, 1989; Head, Bolton, & Hymas, 1989), but there have also been inconsistent neuropsychological findings (Insel, Donnelly, Lalakea, Alterman, & Murphy, 1983). The reported success of capsulotomy and cingulotomy in clients with OCD also hints at frontal lobe involvement (Ballantine, Bouckoms, Thomas, & Giriunas, 1987). However, no well-controlled studies on the efficacy of these treatments have been conducted. Additional evidence for neurobiological abnormalities comes from several positron-emission tomographic studies of cerebral metabolism that have revealed elevated metabolic rates in the prefrontal cortex in clients with OCD (e.g., Rauch et al., 1994). Also suggestive is the association of OCD symptoms with disorders that stem from basal ganglia problems: encephalitis lethargica (Schilder, 1938), Sydenham's Chorea (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989), and Tourette's disorder (Rapoport & Wise, 1988).

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CHAPTER 3 Assessmentof OCD

Diagnostic Interview The foundation of a satisfactory assessment is a thorough diagnostic interview to ascertain the presence of OCD and any comorbid disorders. Clinicians will find the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon, & First, 1990) useful, although time consuming, for ensuring a thorough survey of symptoms. In addition to establishing diagnoses, it is important for the therapist to quantify the severity of OCD symptoms via a reliable and valid instrument. A commonly used interview tool for assessing the symptoms of OCD and their severity is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischman, et al., 1989). It is a semistructured interview consisting of a symptom checklist and a severity-rating scale. The severity-rating scale has five items about obsessions and five about compulsions, each rated on a 5-point scale ranging from 0 (no symptoms) to 4 (severe symptoms). Overall severity is rated according to time spent on obsessions and compulsions, interference with functioning, distress associated with OCD symptoms, resistance to the symptoms, and control over the symptoms. The Y-BOCS has satisfactory interrater reliability, internal consistency, and validity (Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure,

13

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Fleischman, et al., 1989) and has been found sensitive to treatment effects in many studies of OCD. At the Center for the Treatment and Study of Anxiety (CTSA), three target symptom ratings are used in addition to the Y-BOCS. Each instrument is an 8-point Likert-type rating scale for a specific area: anxiety/distress, avoidance, and rituals. On the basis of the information gathered in an initial interview, the clinician identifies three primary target situations that provoke obsessional distress and rates the severity of this distress. When rating a client's anxiety or distress, the clinician takes into account the client distress when confronted with the situation or object, including both frequency and intensity of the distress. For example, if a client is concerned with contamination, the clinician identifies the three main contaminating stimuli (objects or situations) and rates each separately. Next, the clinician assesses the degree to which the client avoids situations related to the stimuli identified as main distressing stimulus. For example, if the main contaminant is feces, the avoidance item selected for rating might be public restrooms. Third, the clinician evaluates the severity of the three primary rituals. The severity of rituals is based on both the frequency and the duration of the compulsion. Although researchers have used these and similar target symptom ratings in studies of OCD (e.g., Foa, Grayson, & Steketee, 1982; Foa et al., 1983; Marks et al., 1988; O'Sullivan, Noshirvani, Marks, Monteiro, & Lelliott, 1991), information about their psychometrics is scarce. The scales appear to have adequate interrater agreement when completed by two independent assessors (Foa, Ilai, McCarthy, Shoyer, & Murdock, 1993), but there is less agreement between the ratings completed by the therapist and those completed by the client (Foa, Steketee, Kozak, & Dugger, 1987). The attractiveness of these rating scales is derived mainly from their face validity and demonstrated sensitivity to therapeutic change. Moreover, the clinician can readily use these scales to plan the therapy program and to assess progress on specific symptoms. Questionnaire measures of OCD symptoms are also available but have some disadvantages: They target only certain forms of obsessive-compulsive behavior, include items unrelated to OCD symptoms, or both (Compulsive Activity Checklist [Freund, Steketee, & Foa, 1987], Leyton Obsessional Inventory [LOI; Kazarian, Evans, & Lefave, 1977], Lynfield Obsessional-Compulsive Questionnaire [LOCQ Allen & Tune, 1975], Maudsley Obsessive-Compulsive Inventory [MOCI; Hodgson & Rachman, 1977]). Recently the staff of the CTSA have collaborated with researchers 14

at Oxford University to develop a brief self-report measure for assessing seven common obsessions and compulsions (MCP-Oxford OCD Inventory). This instrument is reliable and easy to administer, but its sensitivity to treatment effects is unknown.

Differential Diagnosis The high comorbidity of OCD with other disorders sometimes leaves difficult diagnostic questions. Obsessions Versus

Ruminations

The frequent co-occurrence of depression with OCD gives rise to questions about depressive rumination versus obsessions. Ruminations are common in individuals with depression and their confounding presence can make the evaluation of the severity of obsessive intrusions difficult. Distinctions can be made according to the content of the thoughts and the client's resistance. Depressive ruminations are pessimistic ideas about the self or the world and, in contrast to obsessions, are not characterized by attempts to ignore or suppress them.

OCD and Other Anxiety D i s o r d e r s The high rate of comorbidity of OCD with other anxiety disorders can sometimes pose complications for the diagnostic process. For example, the excessive worries that are characteristic of generalized anxiety disorder (GAD) bear strong formal resemblance to obsessions. However, unlike obsessions, worries are excessive concerns about real-life circumstances and are perceived by the individual as appropriate. In contrast, obsessive thinking is more likely to be unrealistic or magical and obsessions are usually perceived by the individual as inappropriate. This algorithm does not obviate all ambiguity however, for in some cases, an obsession involves a realistic threat but with a greatly exaggerated likelihood estimate. Fortunately, the problem of distinguishing obsessions from worries assumes diagnostic significance primarily when there are no accompanying compulsions, and individuals with obsessions and no compulsions have been found to be quite rare (Foa et al., 1995). An analogous situation arises with the symptom of phobic avoidance, which, in the absence of rituals, can give the diagnostic impression of a phobia. For example, excessive fear of germs can lead to avoidance of animals. However, unlike an individual with OCD, a person with a phobia 15

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of dogs can successfully avoid dogs altogether or escape them readily and is no longer distressed. In contrast, the individual with OCD who is obsessed with dog contamination continues to feel contaminated even after the dog is gone. This continued reaction prompts rituals that are the hallmark of most OCD. Thus, the individual who is obsessive-compulsive but not the phobic will exhibit ritualistic behavior.

Hypochondriasis The health concerns that characterize hypochondriasis are formally similar to obsessions of OCD. Some researchers have suggested that clients with obsessive concerns about their health who also exhibit somatic checking or excessive physician visits should be diagnosed with OCD and treated accordingly (Rasmussen & Eisen, 1989; Rasmussen & Tsuang, 1986). Thus, a useful way of differentiating the two disorders is by the presence or absence of compulsions; obsessions about illness combined with rituals such as excessive handwashing or checking would indicate OCD, whereas preoccupation about health without ritualistic behavior would indicate hypochondriasis.

Body Dysmorphic Disorder A related diagnostic issue arises with body dysmorphic disorder (BDD). The essential features of BDD are excessive concern about an imagined physical defect and strong belief that the defect exists. This preoccupation is sometimes coupled with compulsive checking behavior; thus, there is much formal similarity between BDD and OCD. Two aspects may help to differentiate the two disorders. First, clinical observations suggest that individuals with BDD are generally more strongly convinced of the validity of their fears than are individuals with OCD. Although strength of belief occurs on a continuum in both populations (Hollander, 1989; Kozak & Foa, 1994), only a minority of individuals with OCD express very strong conviction that their obsessions and compulsions are realistic. Second, most individuals with BDD are singly obsessed with some aspect of the body, whereas most individuals with OCD have multiple obsessions.

Tourette's Disorder and Tic Disorder It can sometimes be difficult to differentiate the stereotyped motor behaviors that characterize Tourette's disorder and tic disorder from compulsions. The behaviors of Tourette's disorder and tic disorder can usually be distinguished from compulsions in that they are generally experienced as involuntary and are not aimed at neutralizing distress 16

brought about by an obsession. There is no conventional way of differentiating them from "pure" compulsions, but fortunately, OCD with pure compulsions is rarely diagnosed (Foa et al., 1995).

Delusional Disorder Individuals with OCD may present with obsessions that are of a delusional intensity (see Kozak & Foa, 1994, for a review). About 5% of clients with OCD report complete conviction that their obsessions and compulsions are realistic and an additional 20% report strong conviction. Therefore, it is important not to discount a diagnosis of OCD simply because of strong obsessional beliefs. Indeed, the DSM-IV recognizes that obsessions can be of a delusional intensity as reflected in the DSM-IV by the addition of a subtype of OCD "with poor insight." Like the differentiation of hypochondriasis from OCD, the differentiation of delusional disorder from OCD can depend on the presence of compulsions in OCD. In OCD, obsessions of delusional intensity are accompanied by compulsions. It is important to recognize that the content of obsessions in OCD may be quite bizarre, as are the delusions of schizophrenia, but the degree of bizarreness does not in itself counterindicate a diagnosis of OCD. In schizophrenia, other symptoms of formal thought disorder must also be present, such as loose associations, hallucinations, flat or grossly inappropriate affect, and thought insertion or projection. A dual diagnosis is appropriate when an individual meets criteria for both OCD and schizophrenia.

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SECTION 2

Available Treatments of OCD

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CHAPTER 4

Psychosocial Therapy for OCD

For a long time, OCD was considered unresponsive to treatment. Neither psychotherapy nor a variety of pharmacotherapies was helpful in the treatment of the disorder (Black, 1974; Perse, 1988). In the last three decades, however, two treatments have emerged as being effective for OCD: (a) cognitive-behavioral therapy by exposure and ritual prevention and (b) pharmacotherapy with serotonin reuptake inhibitors (SRIs). This chapter summarizes the studies of the efficacy of cognitive-behavioral therapy with OCD.

Cognitive-Behavioral Treatment Despite early claims of the usefulness of systematic desensitization with OCD, results of case studies indicated that only about 30% of clients profited from this narrow form of cognitive-behavioral treatment (Beech & Vaughn, 1978; Cooper, Gelder, & Marks, 1965). A number of other exposure-oriented procedures, such as paradoxical intention, imaginal flooding, satiation, and aversion relief, have also been found relatively unsuccessful with OCD. Procedures aimed at blocking or punishing obsessions and compulsions, such as thought stopping, aversion therapy, and covert sensitization, have also been relatively unsuccessful with OCD (Emmelkamp & Kwee, 1977; Kenny, Mowbray, & Lalani, 1978; Kenny, Solyom, & Solyom, 1973; Stern, 1978; Stern, Lipsedge, & Marks, 1973). 21

Conversely, Victor Meyer and his colleagues treated clients with OCD with prolonged exposure to situations or objects that evoked obsessional distress and prevention of rituals. This treatment program was very successful in 10 of 15 cases and partly effective in the. remainder; only 2 clients relapsed after 5 years (Meyer, 1966; Meyer & Levy, 1973; Meyer, Levy, & Schnurer, 1974). Uncontrolled and controlled studies of exposure and response prevention have been strikingly consistent: about 75% of clients are responders at follow-up (Foa & Kozak, 1996). The treatment involves .repeated, prolonged (from 45 minutes to 2 hours) confrontation with situations that provoke distress. In addition, the client must abstain from rituals, despite strong urges to ritualize. Exposure can be conducted in reality, for example, asking the client who fears contamination from germs to sit on the floor. This type of exposure is called actual or in vivo exposure. The client can also be asked to imagine sitting on the floor; this type of exposure is called imaginal exposure. Exposure is usually gradual, with the client confronting situations that provoke moderate distress before confronting more upsetting ones. Substantial additional exposures between treatment sessions are also required.

Exposure Versus Response Prevention The separate effects of exposure and response prevention for OCD have been examined in several studies. Clients were treated by prolonged exposure without response prevention, by response prevention without exposure, and by their combination. Treatment that combined both exposure and response prevention was found to be more effective, both at immediate posttreatment and at follow-up than were the two singlecomponent treatments. Moreover, the two components affected symptoms differently: Exposure mostly reduced obsessional distress, whereas response prevention mostly reduced rituals (Foa, Steketee, Grayson, Turner, & Latimer, 1984;- Foa, Steketee, & Milby, 1980; Steketee, Foa, & Grayson, 1982).

imaginai Versus Actual Exposure Less information is available about the differential efficacy of imaginai and actual exposure; moreover, immediately after treatment, the combination of imaginai exposure and in vivo exposure does not appear to be more effective than in vivo exposure alone. However, at follow-up, there may be somewhat less relapse after the combined procedure (Foa, Steketee, Turner, & Fischer, 1980). 22

Should imaginal exposure constitute part of exposure therapy? In addition to the single finding that combining imaginal and actual exposure inhibited relapse, other considerations suggest a role for imaginal exposure in the treatment of OCD. At times, it may be impractical to address the feared catastrophes that characterize some obsessions via actual exposure, and imagery is a useful alternative approach. Also, adding imagery to in vivo exposure might circumvent the counterproductive defensive tactics of clients who try to avoid thinking about what they are doing during the exposure exercise. Therefore, although imaginal exposure is not essential for a successful outcome, it is often a useful adjunct to in vivo exercises.

Gradual Versus Immediate Exposure Clients who confront their most distressing situations at the start of therapy respond as favorably as do clients who confront less distressing situations first (Hodgson, Rachman, & Marks, 1972). However, most clients prefer a gradual approach. Typically, situations of moderate difficulty are confronted first and followed by several intermediate steps before the most distressing exposures are accomplished. If a client has underestimated the difficulty of a situation, additional intermediate steps can be interpolated. It is important, however, not to delay the most difficult exposures until the very end of the treatment, because the client will not have sufficient time to get used to the most distressing situations.

Duration of Exposure Duration of exposure is important for a successful outcome: Prolonged, continuous exposure is better than short, interrupted exposure (Rabavilas, Boulougouris, & Stefanis, 1976). How much time is enough? Exposure should continue until the client notices a decrease in the obsessional distress. Indeed, reduction in anxiety within the exposure session and reduction in peak anxiety across sessions predicts good outcome (Kozak et al, 1988). There is no fast rule about required exposure duration for the treatment of OCD, but 90 minutes is a useful rule-of-thumb (Foa & Chambless, 1978; Rachman, DeSilva, & Roper, 1976).

Frequency of Exposure Optimal frequency of exposure sessions is unknown. The intensive exposure therapy programs that have achieved the most impressive results typically involve daily sessions, but favorable outcomes have also been achieved with more widely spaced sessions. Weekly sessions may suffice for clients who have mild OCD symptoms and who readily understand

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the importance of regular daily exposure tasks. For severely symptomatic clients and for those who have difficulty completing their homework, daily sessions will probably prove more effective.

Therapist-Guided Exposure Versys Self-Exposure The extent of the therapist's contribution to treatment outcome is ambiguous. Evaluations of the presence of a therapist during exposure have yielded inconsistent results. Although clients appear more willing to confront feared situations in the presence of the therapist, particularly if the therapist confronts the situation first, therapist modeling of the exposure exercises has not been demonstrated to help (Rachman, Marks, & Hodgson, 1973). In one study, clients who received therapist-aided exposure fared better immediately after treatment than did a group who received clomipramine and self-exposure, but this advantage disappeared at the one-year follow-up (Marks et al., 1988). The report of this study did not make clear, however, how much additional treatment with a therapist the clients received during the period prior to the follow-up assessment. In another study, no immediate posttreatment differences were found between the effects of self-exposure and those of 10 sessions of in vivo exposure conducted by a therapist, but the presence of a therapist was quite minimal (Emmelkamp & Kraanen, 1977). In one study, single 3-hour exposure sessions with and without a therapist were compared; results indicated that the therapist's presence enhanced treatment efficacy for specific phobia (Ost, 1989). Because specific phobias are on the whole less debilitating and easier to treat than OCD, one might suppose that therapist presence could also enhance exposure treatment of OGD.

Ritual Prevention In Meyer's (1966) original treatment program, staff members actually prevented clients from performing rituals (e.g., they turned off the water supply in the client room). However, contemporary outpatient and inpatient treatment largely relies on the client's choosing not to perform rituals. Thus, "response prevention" typically entails the kind of voluntary abstinence from rituals that characterizes outpatient exposure therapy programs for OCD. Even with the daily 2-hour sessions that typify intensive outpatient programs, there remain many hours per day during which the client must voluntarily abstain from rituals. Thus, it is essential for the therapist to persuade clients of the necessity of abstaining from rituals, because clients must be highly motivated for this part of the treatment if they are to resist strong urges to ritualize. 24

As we noted earlier, although exposure reduces obsessional distress, it is not as effective in reducing compulsions. To reduce the urges to ritualize, clients must refrain from rituals. Self-monitoring of both the urges to ritualize and the violations of the abstinence rules can help clients prevent themselves from ritualizing. In addition, a designated friend or family member can encourage the client to resist ritualizing by offering reminders of the rationale and importance of resistance. The importance of ritual prevention (abstinence from rituals) has been demonstrated, but procedures have differed from study to study, ranging from normal washing without supervision to complete abstinence from washing for several days under continuous supervision. The level of supervision does not seem to affect treatment outcome, but the strictness of the rules themselves may matter. Therapists at the CTSA have observed that clients more readily comply with strict instructions that minimize demands to decide if a particular action is normal or ritualized than with vague instructions that require the client to make fine judgments or that allow partial ritualizing. Mental rituals can be harder to overcome than overt rituals if the client has difficulty distinguishing between two related mental events: the obsession and the mental ritual. For example, one CTSA client became distressed each time he thought about chicken soup. The idea of chicken soup triggered a sense of being contaminated as if he had actually touched chicken soup. To neutralize the contamination he thought of the word Palmolive. Thus, the idea of chicken soup was an obsessive intrusion whereas thinking the word Palmolive was a mental ritual. For treatment to be successful, the client had to discriminate between the obsession and the ritual, because obsessions are countered by prolonged exposure and mental rituals, like behavioral rituals, are countered by ritual prevention. Therapists can help clients distinguish obsessional intrusions from mental rituals, which are aimed at relieving obsessions. Once this distinction is clear to the client, he or she can refrain from the mental rituals. As just noted, this distinction is important because exposure therapy requires deliberate provocation of obsessions but the systematic avoidance of rituals.

Requests for Assurance Compulsive requests for assurance about safety frequently occur in OCD but may not be recognized as rituals because not every inquiry is 25

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compulsive. When repeated questions by the client yield no new information and are motivated by obsessional fear, they are indeed compulsions and must be proscribed along with all other rituals. In such cases, the therapist should enjoin the client not to seek assurance and ask the people in the client's social environment who usually provide such assurances to refrain from giving assurance. Refusal by friends and relatives to answer compulsive questions, although therapeutic, routinely prompts anxiety, anger, or both in the client. The therapist must prepare the client, friends, and relatives for such reactions by rehearsal of these refusals.

Cognitive Therapy Case reports of successful outcomes have suggested the efficacy of cognitive procedures used in conjunction with exposure techniques for OCD (O'Conner & Robillard, 1995; Salkovskis & Warwick, 1985). Emmelkamp and colleagues found that the effects of six sessions of cognitive therapy based on A. Ellis's (1962) ABC techniques did not differ from those of self-controlled exposure and response prevention (Emmelkamp & Beens, 1991; Emmelkamp, Visser, & Hoekstra, 1988) and that the combination of exposure and response prevention was not enhanced by the addition of cognitive therapy (Emmelkamp & Beens, 1991). In another study (van Oppen et al., 1995), cognitive therapy based on the cognitive approaches of Beck, Emery, and Greenberg (1985) and Salkovskis (1985) was compared to exposure and response prevention. Findings of this study also indicated that cognitive therapy alone was as effective as exposure therapy. The interpretation of the results of all three studies just mentioned as indicating equivalent success for the two types of treatment is questionable for two reasons. First, in all three studies, the treatments yielded minimal improvement. For example, although van Oppen et al. (1995) found that six weekly 45-minute sessions of cognitive restructuring produced improvement similar to that from six weekly 45-minute sessions of exposure treatment, the improvement from both of these sixsession treatments was weak (cognitive M = 20% severity reduction; exposure M = 24% reduction). Both groups remained quite symptomatic. From these results one might therefore conclude that the efficacy of the cognitive procedure alone was similar to that of a substandard exposure procedure alone. Second, only when the cognitive procedure was supplemented by 10 additional weekly sessions of exposure did symptom

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reduction approach that of adequate exposure treatment. The cognitiveplus-exposure procedure appeared slightly superior to the exposure-alone procedure, but the difference did not achieve statistical significance (cognitive + exposure M = 45% severity reduction; exposure alone M = 32% reduction). Why did exposure produce a poorer outcome in the van Oppen et al.(1995) study than would be expected from the results of other available studies of exposure treatment? (For a review, see Foa & Kozak, 1996.) Perhaps the relatively short (45-minute) and infrequent (weekly) sessions reduced effectiveness. Also, perhaps because this would have been considered a "cognitive" procedure, clients were not taught about the functional relationship between obsessions and compulsions. Regardless of the reasons for the unusually poor results of the exposure procedure, it would be premature to conclude much about the extent to which the particular cognitive procedure used in the van Oppen et al. (1995) study contributed to the reduced OCD symptoms. The efficacy of exposure treatment is certainly believed to be related to changes in the cognitions of the client and this hypothesis has been argued extensively elsewhere (Foa & Kozak, 1986). However, further studies are needed to ascertain whether conventional cognitive therapy procedures (identifying automatic thoughts and their triggers, rational challenge of automatic thoughts) can contribute significantly to the treatment of OCD. Unfortunately, published descriptions (including our own) of exposure procedures for OCD often fail to explicate "cognitive" elements in the procedures that could be contributing to outcome. For example, clients must be persuaded to do exposure therapy, but the informal techniques of persuasion are afforded little attention in studies of exposure based treatment. These techniques involve both cultivating a trusting interpersonal relationship, and discussing various fear-related ideas. During exposure treatment conducted at the CTSA, the staff routinely discuss the importance of risk-taking, the cost of avoidance and ritualizing, and the futility of attempts to obtain fail-safe guarantees. Such rational persuasions render the exposure treatment procedurally "impure" (as do the routine instructions to clients in methods of relapse prevention and conferences with family). Thus, there is ample justification for construing much of the exposure-based therapy as cognitive-behavioral. Although we strongly suspect that discussions of fear-related ideas can be important elements in exposure-based treatment of OCD, it is not at all clear whether the discussion of ideas per se or the formal procedures of traditional cognitive therapy have much effect on OCD. 27

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CHAPTER 5

Pharmacotherapy for OCD

Serotonergic Medications Pharmacotherapy by serotonin reuptake inhibitors (SRIs) is an established treatment of OCD, The trycyclic antidepressant clomipramine (Anafranil®) was the first FDA-approved compound with an indication for OCD, and its usefulness has been documented in a number of doubleblind, controlled trials (DeVeaugh-Geiss, Landau, & Katz, 1989; Marks, Stern, Mawson, Cobb, & McDonald, 1980; Thoren, Asberg, Cronholm, Jornestedt, &.Traskman, 1980; Zohar & Insel, 1987a). More recently, fluoxetine (Prozac®) has also been established as an effective antiobsessive agent (Fontaine & Chouinard, 1985; Jenike, Buttolph, Baer, Ricciardi, & Holland, 1989; Montgomery et al, 1993). Another SRI, fluvoxamine (Luvox®), has also been found effective (Montgomery & Manceaux, 1992; Perse, Greist, Jefferson, Rosenfeld, & Dar, 1987; Price, Goodman, Charney, Rasmussen, & Heninger, 1987). The various studies of SRIs have indicated responding rates of up to approximately 60%, but, on average, symptom reductions are quite modest, ranging from 5 to 8 points on the severity section of the YaleBrown Obsessive Compulsive Scale (Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischman, 1989). Conclusions about the relative efficacy of the different SRIs are difficult in the absence of direct comparisons. However, Greist, Jefferson, Kobak, Katzelnick, and Serlin (1995) conducted a meta-analysis of the 29

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available large-scale, double-blind, controlled studies that suggests that clomipramine is superior to fluoxetine, fluvoxamine, and sertraline, and that the latter three do not differ from one another in efficacy. Long-term improvement with SRIs seems to depend heavily on continuation of the pharmacotherapy and relapse occurs after discontinuation (Thoren, Asberg, Cronholm, et al., 1980). Of a group who had improved with clomipramine, 90% relapsed within a few weeks after a drug withdrawal (Pato, Zohar-Kadouch, Zohar, & Murphy, 1988). Notwithstanding the somewhat lower relapse (23%) that has been found after withdrawal from fluoxetine (Fontaine & Chouinard, 1989; Mallya, White, Waternaux, & Quay, 1992), the problem is substantial for this compound as well.

Combined Treatment by Exposure and Medication The availability of two treatments that are partially effective individually has prompted a few studies of their combined efficacy. Substantial improvement with exposure therapy with a small additive effect of clomipramine was found in 40 individuals with OCD immediately after treatment by Marks et al. (1980). However, the drug-only period was too short (4 weeks) to allow optimal assessment of the individual effect of clomipramine. In a later comparison of clomipramine and exposure in a sample of 49 clients with OCD, Marks et al. (1988) found that adjunctive medication had a small, transitory (8-week) additive effect: Again, exposure was more effective than clomipramine. Although the design of the study did not allow evaluation of the long-term effects of exposure therapy, a 6-year follow-up of 34 of the clients included in the study revealed no long-term drug effects. Interestingly, long-term improvement was associated with better client compliance during exposure treatment (O'Sullivan et al., 1991). Fluvoxamine and exposure therapy have been found to produce comparable reductions in OCD symptoms immediately after treatment and at 6-months follow-up, and exposure therapy plus fluvoxamine produced slightly more improvement in depression than did exposure therapy alone (Cottraux et al., 1990). The post-treatment superiority of the combined treatment for depression, however, did not persist at follow-up.

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In an uncontrolled study at the Medical College of Pennsylvania, the long-term effects (mean 1.5 years posttreatment) of intensive exposure therapy and fluvoxamine or clomipramine in 62 clients with OCD were studied (Hembree, Cohen, Riggs, Kozak, & Foa, 1993). Clients were treated with serotonergic drugs, intensive exposure therapy, or exposure therapy plus one of the two medications. Clients who were taking medication at follow-up (N = 25) did equally well regardless of whether they had received medication alone or exposure therapy in addition to medication. However, clients who were medication-free at follow up (N - 37) showed a different pattern: Those who had received exposure therapy alone or exposure therapy plus medication were less symptomatic than those who had received only medication. Thus, clients who received exposure therapy maintained their gains more than did clients treated with serotonergic medication that was subsequently discontinued.

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CHAPTER 6

Choice of of Treatment

How should a client choose among the available treatments? Prolonged exposure and SRIs are the only established treatments, so the reasonable choice appears to be between either of these or their combination. No therapy is effective with all clients and no useful predictors of individual outcome with the different therapies are available. Uncontrolled comparisons of exposure and SRIs suggest stronger and more durable effects for behavior therapy (Hembree et al, 1993), but definitive controlled trials have not been published. Preliminary findings of a controlled, doubleblind, multicenter comparison of clomipramine, exposure therapy, and their combination indicate that exposure therapy has stronger effects than clomipramine, and that both procedures instigated simultaneously are equivalent to exposure therapy alone (Foa et al., 1993). Pretreatment with clomipramine, followed by exposure and ritual prevention therapy, has been found marginally superior to exposure therapy alone (Marks et al., 1980, 1988), but because pretreatment medication periods were short, the additive contribution of initial pharmacotherapy might have been underestimated. On the basis of the effectiveness alone, monotherapy with exposure therapy is preferable to pharmacotherapy alone. It remains unclear whether a combination of exposure and SRIs yields generally superior outcomes to that of exposure alone. As previously mentioned, for clients with serious depression, pretreatment with an established SRI should be considered.

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Discussion of Treatent Options With the Client Of course, the choice of any treatment is a decision made with the client. The following discussion is a suggested introduction to the client of the available choices. The purpose of our interview is for me to five you the results of your evaluation and to help you decide what, if arty, treatment you will receive. It is clear that the difficulties you are having fit into the category of obsessive-compulsive disorder, or OCD for short. You might have already been aware of that, but our first task is to discover whether the problems you are having match the treatments in which we specialize, so that we know how to advise you. Your OCD is of (mild, moderate, severe) intensity, compared to that of others we have evaluated. It is considered (mild, moderate, severe) because (specify details of comparative distress and impairment). Your future experience with OCD, if it is not treated, is difficult to predict, because there is almost no evidence about spontaneous recovery over the long term. We do know that in the short term, there is very little spontaneous recovery—probably about 5%. Some people who come for treatment have described a gradual worsening of OCD symptoms over years, and many have said that their symptoms are variable—getting worse or better from time to time, particularly depending on stressful events in their lives. It is probably reasonable to assume that unless you receive treatment, you will continue to have problems with your OCD. Because your OCD symptoms impair your functioning and decrease your quality of life, I recommend that you seriously consider receiving treatment for your OCD. Many people would like to know how they developed OCD. There are a number of guesses, some better than others, about why some people get OCD, but there is no satisfactory theory of its development. Fortunately, despite our lack of knowledge about the development of OCD, there is good information available about treatment. There are two types of treatment that have been found helpful for OCD: cognitive-behavioral therapy and pharmacotherapy. Both have been studied extensively with hundreds of patients in centers in different parts of the world, and both are established treatments for OCD.

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What treatment is right for you? There are advantages and disadvantages to both types of treatments. I'll describe each treatment to you, along with its advantages and disadvantages, to help you make a choice. ! said that pharmacotherapy—treatment with medication—has been found helpful, it is important to note that not just any drug is helpful. Particular drugs called serotonin reuptake inhibitors are a class of antidepressant drugs that are useful with OCD. It is not clear why they work, but it is clear that they do indeed often help to reduce OCD symptoms. The idea is that these drugs act on a chemical in the brain called serotonin, and when pharmacotherapy is successful, obsessional distress decreases, urges to ritualize decrease, and along with these, rituals and avoidance also decrease, The frequency and persistence of obsessive intrusions also decrease as well, although most patients say that they still have some obsessive intrusions even after successful drug treatment. There are several drugs that fall into the class of SRIs that have been found helpful for OCD, but I'll focus only on the ones that are approved by the FDA with an indication for OCD. Depending on the particular drug, the evidence is more or less strong for its helpfulness. The most well established drug is domipramine, whose brand name is Anafranil®. it has been studied with hundreds of clients and it has been found that about half of those who take it do welt with it. OCD symptoms are reduced by an average of about 40%. Thus, you can see that domipramine is a good drug: Half those who take it improve enough that they say it makes an important difference in their lives. Other FDA-approved drugs for OCD are fluoxetine (brand name Proiae®), fluvoxamine (Liivox®), sertraline (Zoloft®), and paroxetine (Paxil®). They are more recently available than domipramine, but have been studied very extensively and have been established as helpful with OCD. it is hard to say with confidence which of the SRIs is best for OCD, but it seems like they are similar in effectiveness, although it appears that domipramine may produce more improvements. The drugs have the dear benefit that they are helpful for many people. They also have an advantage that they do not require much effort to fake. After a few visits with a psychiatrist and once you have worked up to an effective dosage of the drug, you meet with your psychiatrist only occasionally for monitoring. Of course these are averages, and in choosing a treatment, you are betting on averages. You could do much better than the average or could not improve at all with the drug. We don't know how to predict who will d@ well with a particular treatment and who will not. What are the disadvantages of the drug therapy? Well, even though many people do well with pharmaeotherapy, about half ©f those who take medication do not 35

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improve, and of those who do improve, most still experience noticeable OCD symptoms. In addition, drugs do not usually do only what you want them to do: decrease OCD symptoms. They usually also have some unwanted side effects. These are readily tolerated by many people, but can sometimes be unpleasant or intolerable. For example, side effects from clomipramine can include dry mouth, sleep changes, weight gain, and sexual dysfunction. Although you would probably have some side effects, it is difficult to predict how tolerable they will be for you. There is another disadvantage of the medications. Although you will probably continue to do well as long as you take them, most people who withdraw from them have a return of OCD symptoms. Many people are not concerned about taking a medication for a long period, but some people prefer not to do this. (Women who wish to become pregnant are generally advised to withdraw from their medication because so little is known about it effects on pregnancy.) The other established treatment for OCD is a form of cognitive-behavioral therapy called exposure therapy. This has also been studied very extensively with hundreds of clients in different countries and has been found very helpful. The idea behind exposure therapy is different from that behind drug therapy. With drug therapy, you ingest a chemical, it gets into your brain and changes your neurochemistry, and your experience improves. Cognitive-behavioral therapy is based on the idea that obsessive intrusions, distress, and rituals are habitual ways of reacting, and that as habits, they can be weakened. Exposure therapy is a learning-based therapy that consists of a series of exercises designed to weaken certain thinking habits, feeling habits, and behavior habits. The exercises are called prolonged exposure and response prevention, which actually means abstaining from, or not doing, the rituals. Exposure means that you purposely confront situations that prompt obsessions, distress, and urges to ritualize, and that you stay in the situation for a long period of time until the symptoms decrease spontaneously. Abstaining from rituals means that you give up using rituals as a way to reduce obsessions and distress. We have found excellent results with an intensive cognitive-behavioral therapy program, with daily, 90-minute sessions, for a month, including guided exposure practice with the therapist at your home. This is important because OCD habits are often especially strong in the home, In addition, this program involves daily homework practice with the exposure exercises and concentration on abstaining from rituals. There are some clear advantages to exposure therapy. First, it has been found to be more helpful than drugs for individuals who complete it. About 75% of 36

clients who complete cognitive-behavioral therapy do well both immediately after treatment and in the long run, and show lasting improvement of about 65% fewer symptoms on average. Also, you need not concern yourself with medication side-effects from exposure therapy. There are some drawbacks to cognitive-behavioral therapy that you should aiso know about First of all, just as with medication, there is no guarantee of improvement. Even though it is an excellent treatment, about 1 person in 4 who receive it do not benefit. Furthermore, even those who do benefit are not usually completely symptom free. They do, however, say that the therapy made an important difference in their experience. Second, although one doesn't usually think of psychotherapy as having side effects, there is one unpleasant side effect of exposure therapy. This is the distress that occurs when you confront situations that provoke your obsessions. Typically, when a person first confronts a feared situation, he or she reacts with distress, but this then decreases spontaneously over the course of a session. The next time you confront the situation, you experience less distress, and so on with repeated exposure practice until the situation prompts little distress. The distress is a kind of side effect in that the goal of the therapy is really to reduce distress, but during the exposure practice, distress increases temporarily, and is not something you want to experience from the therapy, if you choose the cognitive-behavioral therapy, you should expect to experience distress during the exposure exercises, ft is difficult to predict how uncomfortable you will feel: Some people are intensely distressed, and others experience very little distress. A third thing to consider about the cognitive-behavioral therapy is that it requires substantial effort on your part. Unlike the drug treatment, where a chemical does most of the work, in exposure therapy, you do most of the work, practicing exposure both in sessions with the therapist, and on your own for "homework." Thus, for exposure therapy to work as well as it does, you must dedicate enough time and energy to practice. The payoff from this therapy depends heavily on your investment of time and effort in the program. This cost in your own time and effort can be seen as a disadvantage of exposure therapy, compared to drug therapy. So, there are two good treatments for OC0. Cognitive-behavioral therapy seems to produce more improvements than medication, and these improvements are more lasting after treatment is stopped. Medication therapy takes less time and effort in the short run than exposure therapy, but would probably have to be continued indefinitely if you are to keep your improvements. Exposure therapy is usually emotionally challenging and requires your 37

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determination to continue even when the exposure is distressing. Medication therapy requires your willingness to tolerate various medication side-effects. On the whole, exposure therapy would seem to be the preferred option, both because it produces more improvement and because the improvement is more lasting. Therefore, I recommend that you seriously consider this treatment as your first choice. A second-choice recommendation wouid be one of the FDAapproved serotonergic drugs. If you choose pharmacotherapy, the specific drug choice would be decided by you and your psychiatrist.

Additional Considerations Treatment History The model presentation is idealized because it assumes that the clients has had no prior experience with any of the treatments and because it does not mention combination treatments. Prior response or no response to one of the treatments would complicate the recommendation, as would a history of relevant medication allergies or other physical conditions that would counterindicate a particular pharmacotherapy. Women of childbearing potential must consider that medication withdrawal is generally recommended before pregnancy.

Combined Treatments The long-term efficacy of combined treatment by exposure therapy and medication is yet unclear. Therefore, we are hesitant to offer any strong recommendations about such combined treatment. Because antidepressants have been found not to compromise exposure therapy, clients need not withdraw from such medication, particularly after relief from depressive symptoms. Furthermore, as previously mentioned, clients with severe depression are advised to consider premedication with an effective antidepressant before starting exposure therapy. Some clients are motivated to maximize their treatment outcome by simultaneous treatment with both an SRI and exposure therapy. Because definitive results on such augmentation strategies are unavailable, the decision about whether to pursue this approach is somewhat arbitrary. In most cases, we do not favor starting or stopping medication immediately before, immediately after, or during cognitive-behavioral therapy, because the salutary or adverse effects of such changes are confounded with those of exposure therapy. Thus, decisions about modifying either 38

the exposure therapy procedures or medication regimens become more difficult. Clients who have had an adequate trial of a medication to which they have not responded usually should be withdrawn from it before cognitive-behavioral therapy begins, so that any physical and emotional consequences of medication withdrawal do not compromise the exposure therapy.

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SECTION 3

Cognitive-Behavioral Treatment by Exposure and Ritual Prevention

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CHAPTER 7

Treatment Planning: Understanding and and persuasion

Once the client has elected to pursue exposure and ritual prevention therapy, treatment planning is the next step in the treatment sequence. There are two important aspects to planning exposure-based treatment. One is to create a good plan, that is, a plan derived from a thorough and accurate understanding of the client's obsessions and compulsions and a plan well matched to the client's symptoms. The second aspect is communicating that plan to the client in a way that persuades the client to make good use of the plan and of your expertise. Forms are provided in Appendix A to assist in this process of information gathering and treatment planning. You may photocopy the forms as needed. Additionally, the client receives a pad of "Self-Monitoring of Rituals" forms and a binder in which to keep completed ones. As summarized in Chapter 4, substantial research has indicated that the essentials of a good plan are prolonged exposure and ritual prevention. However, the development of a plan that is well suited to a particular client is not logically derived from some particular set of algorithms. Rather, it requires creative application of the basic techniques of exposure and response prevention. The research literature provides considerably less guidance about how to communicate a plan to the client in a way that optimizes outcome. Successful persuasion probably depends heavily on your credibility, and such credibility depends extensively on your ability to demonstrate a clear understanding of OCD as it is experienced by the client. If so, then 43

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apparently an early demonstration of such competence, that is, during the assessment and planning stages, would be quite important later in persuading the client to act courageously in the face of exposure to feared situations.

Understanding the Client A first step in developing a good plan is to evaluate the client's obsessive-compulsive symptoms in detail. Useful guidelines for this evaluation are provided in the following sections. Indicate to the client that you, as the therapist, need a detailed description of the symptoms so that you can individualize the exposure exercises and other therapy procedures for the client. Use the form "Information Gathering: First Session" (in Appendix A) to record this information.

Identifying Obsessions Identify the objects or situations that are sources of distress, such as urine, pesticides, locking a door, driving over bumps, and so on. Identify the thoughts, images, or impulses that provoke anxiety, shame or disgust, such as sacrilegious images, unlucky numbers, unacceptable impulses, thoughts of being contaminated, thoughts of negligence, and so on. Inquire about disturbing bodily sensations, such as tachycardia, pains, or swallowing. Identify the threatening nature of obsessional ideas, especially disastrous consequences that are anticipated if the client does not take some protective action, for example, disease from touching a contaminated object, burglary if a door is not properly locked, condemnation if a blasphemous thought is not neutralized, or choking if the sensation in the throat is not cleared.

Identifying Avoidance Patterns Identify situations or objects that are avoided, for example, using public bathrooms, stepping on wet spots on the sidewalk, using a kitchen knife when a child is in the room, or driving. Attend to subtle avoidance, for example, touching doorknobs on the least used surface, or driving only on nonbusy streets. 44

Identifying Rituals Identify rituals, including washing, cleaning, and checking; repeating actions; ordering objects and actions; requesting assurances; and mental rituals (such as praying, "good" phrases or numbers). Attend to subtle rituals such as the use of hand lotion as a sterilizer, rinsing, and dry wiping. Ask the client about habits that she or he finds unusual or troublesome.

The Nature of ObsessionsRituals Obsessional distress may be provoked either by physical events in the client's external environment or by mental events (thoughts, images, or impulses that the person experiences). Both avoidance and rituals are both aimed at minimizing distress associated with the threatening events, and both may be overt or covert (i.e., cognitive avoidance or rituals) and thus not directly observable. For many clients with OCD, identifiable physical events (objects, persons, or situations) evoke obsessional distress. The specifics of the precipitant, however, differ among clients. For example, two individuals who fear HIV infection may have different perceptions of danger. One client may primarily fear contact with individuals perceived as high risk for HIV, whereas another may fear all surfaces touched by those with uncertain HIV status. Alternatively, two clients may be afraid of causing automobile accidents, whereas only one of them may be obsessively concerned with hitting children. Identifying any perceived threat associated with obsessional cues is important. Otherwise, the exposure exercises might not adequately address the obsessional fear. Confronting situations that actually evoke obsessional fear is essential for successful exposure treatment of OCD, and understanding the threat underlying the obsessional content permits the development of corrective exposure exercises. If mistaken perceptions of danger are not corrected during treatment, the client is probably at elevated risk for relapse, because such perceptions will engender distress that will motivate avoidance and rituals. For example, a client whose fear of daytime city driving decreases during practice with the therapist may relapse after returning home, where he or she must drive on dark, country roads. The opposite situation may hold for the client who practices driving on uncrowded suburban streets and returns fearfully to busy,urban congestion.

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These examples illustrate the importance of ascertaining what the person perceives as dangerous about driving: Is it crowds of pedestrians or dark deserted roads? The answer has implications for planning the exposure exercises. .

Certain unacceptable thoughts, images, or impulses can themselves provoke obsessional fear, shame, or disgust. Examples include impulses to harm a loved one, thoughts of accidental injury to a loved one, or images of blasphemous sexual activity with sacred personages. Of course, such mental events may be prompted by the client's environment, but the unacceptability of the thought governs the distress. Interoceptive events may also prompt obsessive distress. For example, a headache can evoke the idea of going insane, along with urges to seek assurances about sanity. Sometimes a person hesitates to describe an obsession because of concern that describing it, or even simply thinking about it, is itself harmful. You may find it useful to tell the client that many people with and without OCD have unwanted thoughts (as many as 85% of individuals without OCD do so; Rachman & DeSilva, 1978) and to state clearly that merely having an abhorrent thought is not dangerous and is not tantamount to acting according to the thought. Without accurate descriptions of the . obsessions, relevant exposure exercises cannot be developed. The following interchange illustrates an inquiry designed to encourage a client to disclose unacceptable thoughts.

Describe the idea that is so distressing to you. I would feel terrible, it would be wrong to say it. It is important for me to understand enough about what is bothering you so I can suggest something for you to do about it. If you don't tell me what it is, I won't be able to help with it. Try to tell me generally what it is about. I don't even want to think about it. It's too wrong to think about. It's morally wrong.

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Does it have something to do with religious beliefs? Yes, it would be a sin to say it. Does it have something to do with praying or churchgoing? I can't go to church anymore. Do you avoid going to church because of the obsessions?

Yes. Some people with obsessions have intrusive thoughts when they are praying or are in church. They hate to have the thoughts because they are sacrilegious, but they don't know how to stop them. Then they feel very ashamed of having the thoughts. Do you experience anything like that?

Yes. Does it have to do with praying? No, it's just thoughts that I have if I'm around a church or holy pictures or anything like that. If you can tell me what the thoughts are like, I might be able to help you with them. I won't say the whole thought, but you know, I sometimes think of a bad word when I shouldn't, like when I'm in church or even if I drive by a church. What sort of a bad word? Since we're not in a church now, maybe you can tell me an example of a bad word that you think.

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Well, it begins with s. Is it "shit"? (nods assent)

In this model dialogue, the therapist coaxes the client to clarify the content of the unacceptable thought by offering descriptions that the client can endorse or deny without actually having to say the unacceptable word. Sometimes the unacceptable thoughts involve blasphemous intrusions related to praying, such as a vulgar or obscene word in a prayer, or the thought of praying for some bad event to occur. Other sacrilegious intrusions may involve Satan or unacceptable sexual activity with religious figures. If the individual has strong religious beliefs, it can be important for you to offer assurances that nothing about the therapy.is designed to turn the person against religion. Such assurances can be especially important if the exposure exercises involve having the unacceptable sacrilegious images. Only if the client has an appreciation of the seemingly paradoxical effect of exposure (i.e., that having the unacceptable thoughts on purpose reduces the intrusions in the long run) will exposure exercises that seem morally questionable be palatable. Sometimes enlisting a clergy member who is trusted by the client to support the treatment can be helpful. This cooperative effort first involves obtaining the client's permission to explain her or his OCD symptoms and the mechanisms of exposure treatment to the clergy member, and then all meeting together to discuss the clergy member's role. The idea that harm will ensue from exposure to feared situations, or from failure to perform rituals, is often an important component of the obsession. Individuals who perform washing compulsions often have ideas of illness, disability, or death. Individuals who check excessively have ideas of harm that will follow acts of omission or commission. However, not all individuals with OCD articulate clear ideas of harmful consequences associated with their obsessions. Some report only vague notions of harm, or they are mainly concerned that their own anxiety will harm them. Others completely deny ideas of harm and are puzzled about why they are so intensely distressed by what they themselves view as clearly harmless situations. 48

You must ascertain whether or not the client believes that some harm will occur unless rituals are performed. If a person harbors such a belief, exposure situations that do not address the idea about harm will not be very useful. For example, if a client is concerned about running over children but not adults while driving, imagining automobile accidents with adults will not be beneficial. Thus, in addition to matching details of an actual exposure situation to the client's obsession, you must match the imaginal exposure situation to the client's anticipated disasters. Such matching sometimes involves apparently small but important details. For example, asking the client to imagine that he or she contracts a disease from contaminants would not be very helpful if the client is concerned primarily with communicating a disease to others. Traditionally, individuals with OCD were believed to recognize their obsessions and compulsions as unreasonable or excessive, but some clients with OCD do not regard their symptoms as such. Insight into the senselessness of obsessions varies across clients and within the individual client. Some readily acknowledge that their obsessional beliefs are irrational, but nevertheless distressing, whereas others firmly believe that their obsessions and compulsions are rational. In most clients, though, the strength of belief fluctuates across situations; this variance complicates the assessment. For example, the client who fears contracting a disease from public toilets may recognize the fear as unreasonable while discussing it in the therapist's office; when actually using a public toilet, however, the client may consider the fear quite reasonable.

Avoidance and Rituals Because avoidance and rituals sustain obsessive fear, they must be carefully listed and eliminated. Because your inquiry will not likely elicit every avoidance or ritual that the client performs, you must help the client understand his or her function in maintaining fear and encourage the client to notice specific instances and to report them to you spontaneously. If the client can confront a situation he or she usually avoids without distress, the avoidance is probably irrelevant to the OCD and need not be addressed further in therapy. The more strongly a client protests such an experiment, the more likely the avoided situation is related to obsessional fear and the more important is confronting it during treatment. Many forms of fearful avoidance are readily understood by both the client and the therapist (e.g., squatting over a toilet seat or avoiding public toilets completely, avoiding driving, avoiding the use of sharp objects). However, subtle avoidance is also common and must be

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addressed as well. For example, a client may limit the length of his or her excursions from home according to how long it takes to develop a full bladder, because she or he will only use the toilet at home. Tab-top beverage cans may be avoided in favor of capped bottles, and dented cans or marred boxes in supermarkets may be taboo. Socks may be avoided in favor of loose slippers only, because donning socks requires touching the feet. Even astute observation by the therapist will not reveal every subtle avoidance, so training the client in self-observation to recognize such avoidance can be an important part of the assessment and planning stages of treatment. As with avoidance, you must identify both blatant and subtle rituals. For example, a client with contamination obsessions may not handwash excessively but may, instead, just wipe them repeatedly. Detection of mental rituals relies primarily on the client's self-observation. Therefore, you must teach the client to recognize and report them, so that they can be addressed during treatment. Many clients with OCD exhibit some mental rituals, and their assessment should be a routine component of treatment planning. Sometimes clients find ritualizing to be distressing rather than anxiety reducing. The consequences can be paradoxical if the client avoids certain situations or actions in order to avoid "getting stuck" in distressing rituals. For example, a person who is obsessed with cleanliness may live in filthy surroundings because ritualized cleaning is an ordeal that is avoided, despite the distressing consequences. Someone who is concerned with neatness might leave belongings in a clutter of unpacked boxes because the perfectionistic unpacking, sorting, and arranging of the items would be too distressing. Because of the aversiveness of some rituals, avoidance may expand to the point that the client falsely appears to be agoraphobic. When feelings of contamination lead to 3-hour showers, sterilization or discarding of clothing, and painstaking cleaning of all surfaces in the home, the client sometimes just gives up venturing outside to avoid contamination. These avoidances should be noted and addressed during treatment. In some cases, new rituals emerge to replace those that have been eliminated, thus calling to mind the psychodynamic hypothesis of symptom substitution. For example, a client who stops sterilizing items with alcohol might substitute the alcohol with bleach. A subtler exchange is illustrated by the client who fears running over people while driving. The client gives up checking for accidents in the rearview mirror and 50

replaces this activity with monitoring of news programs for reports of hitand-run accidents or with systematic attention to a passenger's silence to obtain indirect assurance that no accident has occurred ("if the passenger does not ask about an accident, there must not have been any accident").

General Functioning OCD symptoms may disrupt routine activities and thus impair general functioning. Such disruptions should be assessed. Exposure exercises targeted at symptoms that cause such impairments can be coupled with instructions to resume adaptive functioning in the previously disrupted area. For example, Mr. C experienced difficulties making sales calls because of the necessity of retracing his path when driving; he had therefore avoided sales assignments in favor of office work. Treatment included driving practice, and he was instructed to resume making sales calls. Self-maintenance tasks, and tasks involved in the care of children, such as laundry, cooking, and shopping, can also be practiced in conjunction with exposure exercises. Simulation of occupational performance can be a less satisfactory but useful therapy technique when actual job duties cannot be realized during the treatment period. Assessment should include an evaluation of how others cooperate in the maintenance of the client's symptoms. The client's demands of assurance of safety from others or cooperation in avoidance or rituals (e.g., family members must remove their shoes before entering the house or check locks or appliances for the client) must be addressed.

History Development of the Client's Symptoms Inquire about the circumstances surrounding the onset of symptoms, about the course of the problem and about any previous psychiatric treatment for the obsessive-compulsive symptoms (note the provider, the type, the duration, and the outcome of the treatment). If prior treatment was unsuccessful, discuss with the client explanations for this failure and anticipate how the planned treatment will differ in ways that can be expected to yield a more successful outcome. Clients often cannot describe the circumstances surrounding the onset of their OCD symptoms, either because onset was so gradual that there was no obvious starting point or because they began so long ago that the memory has since faded. Obtaining detailed information about the onset of OCD symptoms is not prerequisite to successful treatment by 51

cognitive-behavioral therapy. However, such information may lead to hypotheses about the nature of the client's obsessions and thus point to exposure exercises that may be useful.

Previous Treatment The history of a client's OCD also includes information about previous pharmacotherapy and psychotherapy. Some clients might have received inadequate treatments, such as medications that have not been found useful with OCD or insufficient dosages or durations of SRIs. Communicate with the treating physician to ascertain the rationale and outcome of previous treatments and to help the client understand his or her treatment options. Clients who underwent psychodynamic psychotherapy might have been told by their psychotherapist that their OCD stems from internal conflicts dating from childhood and that working through their conflicts is a preferred therapeutic technique. Inform your client that there is no evidence that OCD is caused by internal conflicts or that working on such conflicts is a satisfactory treatment for OCD. If the client has received cognitive-behavioral therapy, ascertain what techniques were used. Cognitive-behavioral therapy is inadequate unless it involves the client's prolonged exposure to her or his most feared situations and abstinence from rituals. Examples of inadequate therapy include weekly exposure sessions between which the client returns to avoidance and rituals, exposure regimens that do not address the most feared situations (e.g., practice in discarding junk mail without discarding amassed hoards of other junk), and ritual prevention that does not include mental rituals. A good working hypothesis about the failure of any previous cognitive-behavioral therapy can help minimize duplication of the same inadequacies in re-treatment. Inquire about the client's previous difficulties so that you can devise ways to help the client avoid the same problems. Thus, if the client did not comply with previous instructions for ritual prevention, explore the reasons and devise a corrective procedure with the client. If the client dutifully performed assigned exposure exercises but did not achieve relief, explore the possible explanations for this failure and develop more effective exercises. In some cases, an adequate prior treatment has yielded a partial response, and the client is seeking additional relief. This is often the experience of 52

clients treated successfully with SRIs, the best of which typically produce symptom reductions of about 35%-40%. Such clients frequently seek cognitive-behavioral treatment either to augment the gains achieved with the medication or to discontinue the medication and to eliminate side effects. Some simply prefer not to continue taking the medication indefinitely. Genera! History The client's history also includes a general life history, with attention to how OCD symptoms have impinged on general functioning. Obtain information about the client's medical history, psychiatric history, education, employment, relationships, financial history, relationships with friends, and dating and sexual history. Depression Although some research has suggested that depression may limit the efficacy of cognitive-behavioral therapy for OCD, other findings have indicated that clients with moderate depression respond well to this therapy. Clients who are seriously depressed can be expected to have difficulty adhering to a challenging regimen, and premedication with an established antidepressant, particularly one of the SRIs with demonstrated antiobsessive effects, is usually advisable.

Persuading the Client Definition of OCD Introduce a concept of OCD that will lead the client to an understanding of the exposure and ritual prevention treatment. The following is a model explanation of OCD: One way of thinking about OCD is as a set of habits of thinking, feeling, and acting that are extremely unpleasant, wasteful, and difficult to get rid of on your own. Usually, these involve thoughts, images, or impulses, often about something threatening, that habitually come to mind even though you don't want them. Along with the ideas come distressing feelings and strong urges to do something to reduce the threat and the distress. People also develop habits of doing certain thoughts or actions that we call rituals to try to help themselves feel better. Unfortunately, doing these rituals doesn't work all that well, and the distress only decreases for a short time at best. Often, you find yourself doing more rituals that don't work that well to take care of the

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problem. Soon, you are putting so much time and energy into rituals that other areas of your life get disrupted. For example, you , . . [give examples of client's obsessions and compulsions].

Explanation of Treatment After defining OCD, provide a general explanation of treatment: The therapy we are going to do is designed to weaken your obsessive-compulsive habits to the point that they no longer interfere with your activities. As with all habits, the obsessions and compulsions cart be weakened through practice. To weaken the obsessive-compulsive patterns, you will practice two types of exercises: exposure and ritual prevention. Exposure is confronting situations that give rise to your obsessions and staying in the situation for a long period of time until your distress decreases. Ritual prevention means that you must stop yourself from doing anything to get rid of the obsession except staying in the situation, in other words, you must abstain from any of the rituals that you are accustomed to doing when you are bothered by an obsession. The exposure exercises are designed to weaken mental connections between the situations and the distress that you have in them. [Use specific information you have collected from the client as examples: When you touch anything related to bathrooms you feel contaminated and anxious; we will design exposure exercises to weaken your mental connection between bathrooms, contamination, and anxiety.] When you practice not giving in to your urges to ritualize, you weaken the mental connection between ritualizing and temporarily feeling better. In other words, after you carry out your rituals [specify the identified rituals], you temporarily feel a little better. Therefore, you keep trying to get relief from obsessions by doing rituals. By practicing not doing the rituals, you will weaken the mental connection between the rituals and temporary relief, and then the compulsive urges themselves will decrease. Exposure and ritual prevention help people with OCD realise that the ideas they had all along are mistaken. First, you will learn that anxiety and distress do not stay forever even if you do not ritualize or avoid situations that trigger your urge to ritualize. Second, you will learn that the bad things that you were afraid would happen if you did not ritualize, do not happen. You will realize that you do not need to ritualize to protect yourself or others. Most people with DCD can temporarily stop their avoidance and rituals, but it is very uncomfortable, and they don't see why anyone would go through this. Why do we want you to expose yourself to these situations that you have worked so hard to avoid? We know that when people confront feared 54

situations for a prolonged period, anxiety gradually declines. This usually happens, however, only if you confront the situation for a rather long time. You must let the distress decrease gradually on its own, withoyt trying to get relief by leaving the situation or doing rituals. Otherwise, you will not weaken the OCB pattern, and the exposure will have been painful without being helpful. it is true that for this program, you must decide to stop avoiding and ritualizing, but you will do it in a way that has been found to reduce the obsessions and compulsions. Not just any kind of exposure works. Certainly you have had occasions when you accidentally or purposely confronted feared situations, but this did not get rid of your OCD habits. You must do well-designed exercises, and do them correctly; otherwise, the exposure will not work. In this treatment, you and I will develop a set of exposure exercises that are well designed to get you the relief that you want, and f will coach you through them as you are doing the practices. You can see that what you get out of treatment depends very heavily on what you put into it. it also depends on my coming up with an exposure plan that fits your particular OCD habits. A useful analogy is that of an athlete who gets help from an expert coach. Suppose that a baseball player is in a batting slump and does not know how to get out of it. An expert coach will watch the batter and figure out what has to be done differently. Then practice exercises will be assigned to correct the problem. If the coach is not very knowledgeable and does not analyze the athlete's problem correctly or provide useful exercises, no amount of practicing the wrong exercises by the batter will correct the problem. On the other hand, if the coach prescribes just the right exercises, but the batter rejects the coach's instructions, the coaching won't be useful. Also, even if the batter agrees with what the coach says but doesn't practice or changes the exercises around to make them easier, the expert coaching will be useless. Exposure and ritual prevention therapy is much the same. If I give you essential exercises to do, but you decide that you know better than I do what you have to do and reject the exercises or change them to make them "better" or easier, it won't matter how much expertise I have, because you won't be taking advantage of it. Also, even if you accept the exercises, but you don't practice as much as you should, you will not get the relief that you want. Sometimes an exercise that! prescribe may seem unreasonable or not very related to what you want to get out of the treatment, but it will be important for you to practice it anyway. If you want to hit home runs, a coach might give you a weight-lifting schedule and a diet. Neither of these exercises took much 55

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like homerun hitting, but if your muscles are weak and you are malnourished, your hitting wil! not be very good. In this exposure program, 1 will probably give you some exercises that seem a bit odd and different from what you would do in your day-to-day routine. It's important that you do them anyway, if you are to get the relief from OCD symptoms that you want. For example, I sometimes instruct people not to wash even when they are dirty or not to check things that other people ordinarily check. The exposure exercises are not simply supposed to mimic what other people do, so don't expect them to be like that. Instead, they are especially designed to reduce your obsessions and compulsions. If you complain that a certain exposure exercise just isn't normal or isn't something that a normal person would ever do, you are missing the point. The exposure exercises are not supposed to be normal practices. They are supposed to be special exercises designed to relieve you from obsessive-compulsive habits. Try to remember this if you start wondering whether a normal person would do the exposure exercise that you are doing. The exercises are not designed to be normal; they are designed to reduce your OCD symptoms. Conclude this explanation of the treatment plan by describing the general practice routine the client will follow on a daily basis. During the next session, I will continue to find out more about your obsessions and compulsions so we can identify the various situations and thoughts that bother you. We will make a list of them and order them according to how difficult each one is for you. We will use a scale from 0 to 100, where 9 means no distress or difficulty and 100 means maximum distress or difficulty. Sometimes people call these ratings SUOs ratings. S-U-D stands for subjective unit of distress. The exposure exercises will be drawn from this list. You will gradually confront the situations and thoughts that are difficult for you, until you have faced even the most difficult ones on the list. In addition, as you are working through the list of exposure exercises, it will be essential that you also practice abstaining from rituals. If you confront all of the difficult situations but continue to do your rituals, you will not get rid of your obsessive-compulsive habits. This point is extremely important: You must do all the exposure exercises and refrain from rituals if the program is to work well for you. You may not skip difficult exposure exercises or maintain certain rituals. Each day, beginning with the first treatment session, I will ask you to practice on your own the exposure exercises that you did during that day's session. You will confront the situations we faced during the treatment session. I'll ask you to do this for a period of two hours, and it is best if you do it all at one time rather than splitting it into segments. Sometimes, however, there may be 56

situations to which you can't continually expose yourself for two-hour periods because of special circumstances. Even in those cases, however, it will be important that you practice for a long enough period for you to notice a decrease in obsessional distress, Sometimes, I may ask you to do an exposure exercise that we do not do in the office, either because of practical limitations or because you must do it alone to reduce your fear. [Offer an example, such as touching fixed objects at home or driving alone.]

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CHAPTER 8 Treatment Planning:

In Vivo Exposure

During the second session, you and the client will work together to create a list of exposure situations to be confronted during treatment. This chapter provides guidelines for selecting those situations, lines of inquiry to elicit feared situations from the client, sample lists, and example exposure plans.

Creating a List of Exposure Situations Drawing from what you have learned about the details of the client's obsessions and compulsions, work with the client to compile a list of exposure situations the client must confront during the treatment program. Together, choose from 10 to 20 situations encompassing major areas of the client's obsessive distress. More important than the number of situations is their representation of the main difficulties targeted for treatment and the inclusion of particularly distressing situations. Ask the client to estimate how distressing each situation will be, using the SUDs 0-100 rating scale. You can help the client by suggesting several exposure items, requesting ratings, and then asking the client to add other situations to the list. Use the form "Information Gathering: Second Session" to record the information.

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Guidelines for Selecting Exposure Situations Items chosen for exposure (i.e., items or situations or thoughts evoking distress and urges to ritualize) are selected according to the client's report of their fearfulness. Items are to be confronted in ascending order of difficulty, beginning with situations that are moderately difficult. That is, if the top item evokes 100 SUDs, a 50-SUDs item is a desirable starting point. The most disturbing item should be confronted during a predesignated day that is well before the planned end of treatment. A typical schedule for intensive therapy would have 15 exposure sessions over 3 weeks, with the most difficult confrontation planned for one third of the way through the schedule, that is, on Day 6 of exposure. After the most difficult item has been confronted, subsequent exposure sessions should involve repetition of the most difficult exposure, and variations on this exercise. If new items are identified after the initial planning sessions, they will be incorporated in the remaining sessions. Exposure to an item may be omitted when it evokes minimal or no distress for two successive days. The level of detail in the list of exposure items initially explicated by the client is somewhat arbitrary. Specifying in advance every specific exposure variation that will be practiced is less important than having a clear agreement with the client on the items that represent the core elements of the obsessional fear and the client's commitment to confront each of the items as scheduled. Overspecificity can be somewhat wasteful of therapy time during the planning period. It can also introduce inflexibility if you or the client takes a rigid or perfectionistic view of an overly specified schedule of exposure tasks. The initial list should be sufficiently specific so the client is well aware of the difficulty of the exposure tasks but also knows that the tasks will be varied according to what is needed. Because needed variations on the initial exposure list usually become evident only after you have observed the client performing various activities, it is important to preserve this option contractually with the client during the treatment planning period.

Linesof Inqylry The following lines of inquiry may help you and the client develop a list of situations to be confronted during exposure.

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Examples Inquire about fearful ideas. Ask about both thoughts and images and about circumstances surrounding their evocation. What worries you about washing dishes in the kitchen? When I'm washing dishes in the kitchen, I am afraid that I'll bump two glasses together and a chip of glass will get into the food my family eats. This can cut up their insides. What bothers you about going to church? I get this picture in my head of Jesus having sex with the devil whenever I'm in church. Inquire about fearful physical sensations. I* «,•J-" L ,

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What worries you about having a bowel movement? I can feel something in there and so I know I'm not finished getting everything out, so I have to sit there and squeeze hard until I can't feel anything left in there.

Inquire about harmful consequences anticipated by the client if he or she refrains from avoidance or rituals. What will happen if you don't get every last bit of feces out .when you have a bowel movement? I've heard you can get intestinal cancer that way. I just won't feel clean, and cleanliness is next to Godliness, you know. What will happen if you don't wash after using the toilet?

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I am afraid that if I don't wash, I will get more and more anxious until I'll go crazy. I'm afraid that if I don't wash, I'll spread disease to innocent people. These examples of anticipated consequences illustrate how a ritual, like washing, can be variously motivated. Identifying the motivation for the ritual can be useful if that motivation is to be altered by a specific treatment procedure. For example, for a client concerned about spreading disease to others, practice in touching items that others will touch is relevant; for a client whose primary concern is going crazy from anxiety, this "spreading" exercise is not relevant. Inquire about day-to-day situations that the client avoids because they would give rise to obsessional intrusions and distress or to disruptive rituals. "-,

I'm going to ask you to tell me about situations that you avoid because of your obsessive concerns. By avoidance I mean not only staying completely away from the situation but also procrastinating, or putting off, confronting the situation and doing little things to get around the situation. Let me give you some examples. A person who is concerned about germs might try to avoid public toilets in different ways. This might involve not going out to eat or not going on long trips, because both of these activities could require using a public toilet. Another type of avoidance might be to try to tolerate a full bladder much longer than you would like to, so that you would not have to use a public toilet. What do you do to avoid obsessional distress? I always carry my own toilet paper. That way if I get stuck having to use a public toilet, I won't have to use the paper there. If I didn't have my own paper, I just wouldn't use any paper at all. I don't wear any socks, because you have to touch your feet to get them on and off.

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Also, I wear slippers or loafers. I won't wear shoeswith laces because you have to touch them. With loafers you can just put the heel of the shoe against something and get it off. They can't be too tight though, or else when you put them on, the heel part bends over and you have to touch it to get it on. I never buy shoes that are the right size. If I get them a little big, I can slip them on and off without touching them. Inquire about rituals. Ask the client to describe in detail the routine surrounding problematic activity and to perform the activity to discover directly any unnecessary or excessive components. Ask the client about these components so that you can discover whether they are related to obsessional distress or are simply adventitious. 15

You told me that you had trouble shaving in the morning, so I asked you to bring your shaving materials so that I could watch how you shave. Describe your trouble with shaving to me, and then you can show me what you do.

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Well, it starts when I get up in the morning and I first use the toilet. I clean the toilet and every place around it, just in case some water splashed. I then wash my hands thoroughly, up to the elbows. Then I clean the shower and the faucets so I can take a shower in a clean bathroom. I have to be completely clean before I shave. Then I wash the soap and make sure there aren't any spots on it or hairs or anything. Then I rub the soap until I get some lather and I rub it on my face. Then I take my razor out of the plastic bag and rinse it under the hottest water, and I have to keep rinsing it while I'm shaving. I shave real slow so that I don't cut myself. If I cut myself, I have to put alcohol on the cut right away. Usually I don't cut myself, but it takes a long time to be so careful. When I'm done, I put alcohol on my face just in case there are any little cuts that I didn't notice. Then I put some alcohol on the razor and rinse out the plastic 63

bag with alcohol and put the razor back in the bag and seal it. Then I can get out of the shower. I use an electric razor. That's because it gives a better shave than a blade. I go over each spot 10 times, then I check if it's smooth enough. If it isn't, then I go over it another 10 times. When I get one spot smooth enough, then I have to clean out the razor. I turn it off and open it up and tap it 10 times with my hand, over the sink. Then I blow on it 10 times, then 10 more taps. Then I check to see if it's clean enough. If it's okay, then I close it up and do the next part of my face.

Sample List of Exposure Items The following examples illustrate the items that might be listed for three different fears. For each, the exposure items are presented in the approximate order of increasing difficulty.

•Fear .of, Co^ttamitiittioii 1. touch top of shoe 2. touch bottom of shoe 3. sit on floor of office 4. touch spigots on sink in clinic 5. touch handle of door to clinic toilet 6. touch latch on stall in clinic toilet 7. sit on floor in public bathroom 8. touch flush knob on clinic toilet 9. touch toilet paper roll in toilet stall 10. touch toilet seat cover of clinic toilet 11. touch porcelain toilet hopper 12. sit on toilet seat at clinic with clothes on

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13. sit on clinic toilet to urinate, use toilet paper, flush toilet with hand 14. sit on restaurant toilet to urinate, use toilet paper, flush toilet with hand 15. sit on airport toilet to urinate, use toilet paper, flush toilet with hand 16. touch dog feces on sidewalk with shoe 17. touch shoe after having kicked dog feces on sidewalk 18. touch doorknobs and other surfaces in clinic after having touched shoe contaminated with dog feces 19. shake hands with street person 20. handle produce at public market after having shaken hands with street person

' ;. ,. • \- '.-. fear of Sttpermatmtai,Harm. .

•/ ' •

1. think of the words "bad luck" 2. say aloud the words "bad luck" 3. write the words "bad luck" on paper 4. write the words "bad luck" on back of hand 5. think of the number "13" 6. say aloud the number "13" 7. write the number "13" on paper 8. write the number "13" on the back of hand 9. think of a blasphemous word 10. say aloud the blasphemous word 11. write the blasphemous word on an index card and carry it at all times 12. view the film "The Exorcist" 13. use an Ouija board to predict the future Severe cases may require the use of more distressing exposure content (e.g., occultic symbols, such as the number 666 or pentagrams).

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H

Additional items may be created as clinically indicated to treat the client's particular obsessive pathology.

Fear, of Causing Ha»m to Self and' Others'. , , - ' ' • • by Aets of.'Negligence, . . '. • 1. leave plastic bag from dry cleaners in trash can 2. put kettle on range and leave kitchen area 3. touch glass bowls together while preparing food 4. cut bread in kitchen with sharp knife while infant sits in highchair 5. put kettle on range and walk outside of house 6. leave piece of broken glass in bottom of dishwasher 7. put piece of broken glass on sink counter while preparing food 8. put can of drain cleaner on sink counter while preparing food 9. hold child while holding bread knife 10. touch dull edge of bread knife to infant

Sample Exposure Plans The following examples of exposure plans illustrate the application of the guidelines presented in this chapter.

Washer The client feared contamination by feces, urine, sweat, and contact with others. He feared contracting a serious disease and spreading disease to other individuals. The client's feared situations were linked in their capacity to cause disease, and, based on the client's SUDs ratings of those situations, the following hierarchy was developed. Each treatment session included exposure exercises based on this hierarchy.

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: ,;. .'. JearM Sifngtiomis Wtfb-.S^ps Ratings; Washer. Street person

100

Sweat

75

Feces

100

Newspapers

60

Urine

100

Doorknobs

50

Public toilet seats

'••

80

- ExfiosiireL EierGisfes/bf Sesstent Washer

Session 1—The client walked with the therapist through the building touching doorknobs, including those of the public lavatories. He then rubbed his hands together; touched his clothing, face, and hair; shook hands, first with the therapist and then with other people in the building. He held newspapers left behind by people in the waiting room and then touched his hands to other parts of himself and to other people, as he had done after touching the doorknobs. Session 2—The client touched newspapers and doorknobs. He then touched other parts of himself and shook hands with others. Contact with sweat was introduced by having the client place one hand under his arm and the other inside his shoe. Session 3 —Within the first 10 minutes of the exposure part of the session, the client repeated exposure to doorknobs, newspapers, and sweat as in Sessions 1 and 2. The new exposure task was for the client. to stand by the stall in the clinic lavatory and to touch the toilet seat cover with his index finger. First, the therapist demonstrated the procedure to the client. Then the client touched the seat. For the next step, the client closed his hand so that his index finger touched other parts of his hand. Then, the client touched both hands together and then touched the therapist's hand. The therapist modeled touching the face and clothes and instructed the client to do the same. The process was repeated. Then the client was instructed to touch the toilet seat with his whole hand, including the palm, and to repeat the entire process, Session 4—Exposure began with repetition of the toilet-seat-touching task from Session 3. Then the therapist demonstrated sitting on the toilet seat, with clothes on, and instructed the client to do the same, Next, the therapist instructed the client to close the stall door, to sit on the seat unclothed, as if to actually use the toilet, and to do so

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without any further inspection of the seat surface. Then the therapist went outside the stall, and the client sat on the toilet. Session 5—The client was instructed to sit on the toilet seat as in Session 4 and to put a few drops of urine on a paper towel and return to the therapist's office with the towel in hand. The therapist took the towel from the client, touched the spot where the urine was, and instructed the client to do the same. Hands were then touched together and to clothes, face, and hair. The towel was retained by the client for subsequent exposure practice. Session 6—The session began with repetition of the client's sitting on the toilet seat as was done at the Session 5. However, during Session 6, the client was instructed to touch a paper towel to the anal area to obtain some fecal contamination, and to return with the towel to the therapist's office. The therapist touched the contaminated spot on the towel and then touched clothes, face, and hair. The client did the same. The client retained the towel for subsequent exposure practice. Session 7—The exposure to fecal contamination of the previous day was repeated, with the client using the paper towel he had retained. The therapist then accompanied the client to an area frequented by homeless street dwellers. Some dollar bills were exchanged for coins at a nearby store. The client then practiced exposure to homeless people by approaching several who were asking for money, offering each a quarter, touching their hands as they accepted the coins, and shaking their hands afterward if they permitted this. After each contact, the client touched the therapist's hand and touched his own clothes, face, and hair. Sessions 8-15—Variations of the exposure tasks completed during Sessions 1-7 were developed and practiced incidentally. The client visited and touched public toilets outside of the clinic (e.g., toilets in restaurants and shopping areas). He repeated contact with homeless people at a different location. On one occasion the therapist visited the client home and coached the client in touching the two prepared "contamination" towels to items in the home, including furniture, kitchen counters and utensils, clean clothing stored in drawers and closets, and the inside surfaces of the clothes dryer and dishwasher. In the development and practice of variations on the basic exposure exercises, attention was directed especially to areas about which some distress persisted.

B

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Checker The client feared harming others when driving his car and when using appliances, locks, lights, and other items at home. He was especially worried about his 4-year-old daughter, fearing that he would drop her on a concrete floor or that she would fall downstairs. To prevent these catastrophes, he checked a variety of situations repeatedly, including the area surrounding his car (both directly and with the mirrors), his daughter's whereabouts and condition, and the condition of appliances, locks, and lights at home. Based on the client's list of exposure items and SUDs ratings, the following hierarchy of feared situations and schedule of exposure exercises were developed.

-."v JPett^-Staftttomlltoto SUDs Mutings: Checker' • Driving on highways

100

Carrying daughter over concrete

85

Daughter's playing near open stair gate

75

Flushing toilet with cover closed

70

Opening doors and windows

60

Using lights and stove

50

Exposure Exefcises by .'Session: Checker/ . • Session 1—The client turned the lights on and off once, turned the stove on and off once, and opened and closed doors and windows once. After each action, he left the room immediately and focused on having not checked these objects. This procedure was repeated throughout the session with different switches, appliances, and windows. Each exposure exercise was performed in a different area of the house so that "accidental" checking of completed tasks would not occur. Session 2—The client repeated exposure to the situations from Session 1 but without the therapist's presence in the same room when each task was performed. In this way, the client would not consider the therapist's acquiescence as indicating that the client had indeed done nothing harmful.

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Session 3—The previous session's exercises were repeated. In addition, the client allowed his 4-year-old daughter to play near the stair gate without his supervision. Session 4—The previous session's exercises were repeated. In addition, the client held and then carried his daughter over the concrete floor. Session 5—The previous session's exercises were repeated. Then, accompanied by the therapist, the client drove on the highway and returned by a different route so that he could not incidentally check for accidents. The center-mounted rearview mirror was displaced so that it was not focused on the area behind the automobile, and door-mounted rearview mirrors were used only for lane changes. Session 6—The client drove on the highway as in Session 5, but without the therapist. He returned to the clinic after the drive to describe his performance and experience during the exercise. Sessions 7-15—Exposure to all of the previous situations under various conditions was continued with particular emphasis on the most difficult items. Variations of the driving task included driving at night, driving in rainy weather, driving in areas crowded with pedestrians, and driving in areas crowded with children.

Hoarder Designing an exposure program for hoarders sometimes presents special problems. First, you must be able to conceptualize adequately the symptom pattern of the client. Relatively few hoarders actually spend much time on ritualized gathering of material to hoard. Intact, many seem to spend little or no time on ritualizing, and their difficulty appears mainly to be avoidance of discarding. For these individuals, it is tempting to construe the problem as a practical one—one of simply arranging the logistics of discarding a great volume of hoarded material. For those hoarders who seem to have few rituals, there may be an unexplicated problem of perfectionistic sorting. Accordingly, these individuals are concerned about making sorting or discarding mistakes: They are afraid that they might discard something important or that something might be useful in some unanticipated way in the indefinite future. Because the perfectionistic sorting is such an ordeal, these individuals often just avoid discarding. By this avoidance, they do not risk inadvertently discarding something important. 70

Other hoarders have magical ideas about discarding material. For example, a person might not want to discard fingernail clippings or hair for fear that doing so would cause harm in some way. Some hoarding is related to moral scrupulosity, that is, perfectionistic avoidance of wasting anything. For many hoarders, a practical program involves two components: (a) discarding a large volume of material and (b) practice in nonperfectionistic sorting. These are related but somewhat different tasks, and their practical separation can be important. Suppose that a hoarder has accumulated 2,500 pounds of material to be discarded and that the material occupies two or three 8' x 12' rooms. Sorting through all the material would not be practical because of the time required. Instead, the goal is to discard as much junk as possible, as fast as possible, with minimal sorting into "save" and "discard" categories. Enlisting the help of others may be necessary because of the sheer magnitude of the discard task. Rental of a truck or dumpster might be required in order to haul away the discarded material. This discard task is actually a series of exposure practices: The client risks loosing something important each time he or she discards a box or bag or pile of material without ritualized, perfectionistic inspection. If a mass discard of the sort just described is done without sorting, the client may still require practice in "normal" sorting and discarding, and an exposure program must often also include such practice. For this purpose, small amounts of material are quickly sorted and discarded, and only material that will be useful in the near future is retained. Separating practice in routine sorting and discarding from the extraordinary task of discarding the mass of junk helps keep the client from becoming overwhelmed and demoralized about the required activity. The following exposure plan was developed for a client who was concerned about inadvertently discarding items that might be useful at some time in the future and had accumulated large amounts of newspapers, magazines, old clothing, mail, store receipts, and used packaging material. The client had stored the hoarded material in her apartment, in rented storage bins at another location, and in her car. In addition, her refrigerator was packed tightly with stale food items so that there was no room for edible food. The following hierarchy of feared items and schedule of exercises were developed.

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Feared Situations With-SUDs Rattings: Hoarder Emptying junk rooms at home and discarding contents

95

Emptying storage bins and discarding contents

95

Emptying refrigerator and discarding all food without sorting

90

Discarding junk stored in car

85

Sorting new mail and discarding most

75

Sorting box of receipts and discarding most

75

Discarding items of used clothing

60

Discarding old packaging material

57

Discarding old magazines in office

55

Discarding old newspapers in office

50

Exposure Exercises.by Pay; Hoarder , . - , . . , Day 1—Client brings box of old newspapers and magazines to therapist's office. Together, therapist and client dump all items into trash bin. Therapist demonstrates how to discard quickly and without careful inspection of each item. Cursory inspection is allowed; that is, the client is permitted to look at the item while it is being discarded. Valuable items may be retained, but none are identified in the box of newspapers and magazines. For homework, the client chooses one box of newspapers and magazines at home and discards them in the same manner as was done with the therapist at the office. The client is to bring another box of material as well as a large bag of old wrapping material for Day 2. Day 2—The client discards a box of magazines and newspapers, with therapist supervision. The client similarly discards the large bag of old wrapping material. The therapist accompanies the client to the location of one of the rented storage bins, inspects the contents, and chooses with client one box of junk to discard immediately. For homework, client discards one more box of newspapers and magazines as well as one box of used packing material at home. She selects two boxes of old clothing and a box of store receipts to take to the office on Day 3. 72

Day 3—Client discards two boxes of old clothing with therapist supervision. Therapist demonstrates sorting of store receipts for discard. All receipts are discarded except those for costly appliances that are under warranty. If the receipt is for less than $50.00, it is discarded immediately. The decision for each receipt is made instantly: No prolonged inspection or deliberation is permitted. If there is any doubt about whether to retain a particular receipt, it is discarded. Only receipts that are clearly important are retained. About 2 pounds of receipts are discarded, and none is retained. For homework, the client repeats the discard homework from Days 1 and 2 and also discards one box of old clothing and a small box of receipts. Day 4—The client brings any new mail received since Day 1 of treatment and a checkbook. The therapist demonstrates sorting and discarding of recently received mail. Advertising items are discarded without opening them (e.g., an envelope labeled "valuable coupons inside" and a booklet of advertisements for a local supermarket). Other items are opened quickly, scanned for 5 seconds, and discarded unless they are bills, checks, or personal letters. One utility bill is discovered, and a check is immediately written and the payment is mailed during the session. Other than the notation in the checkbook, no record of the bill payment is retained. The therapist accompanies the client to her car, and both drive to a nearby trash bin belonging to the hospital. The therapist demonstrates rapid discarding of old newspapers, bottles, aluminum cans, magazines, old clothing, and food wrappers from the trunk and seating areas of the car. The client then discards about 75% of the junk stored in the car, quickly and without sorting. For homework, the client discards the remaining 25% of junk stored in the car. In addition, the client purchases a box of heavy-duty garbage bags for the next session. Any new mail that is received at home is immediately sorted and discarded or answered. Day 5—The therapist meets the client at her home. Together, client and therapist empty 75% of contents of refrigerator into plastic bags and carry them to the dumpster of the apartment building. For homework, client rents hand truck and brings to apartment for use during subsequent sessions. Day 6—Therapist meets the client at her home. Together, they load the hand truck with boxes and bags of newspapers, magazines, and other junk, and cart it to the dumpster of the apartment building. No detailed inspection or sorting of the contents of the bags and 73

boxes is permitted. If a box or bag contains clothing, it is retained for subsequent sorting. Approximately 5% of the stored junk is discarded during this session. For homework, client is to spend one additional hour hauling junk out to the dumpster. Days 7-15—The exercises performed on Days 1-6 are continued and elaborated. Most of the remaining time is spent on daily discard of large quantities of hoarded material from the apartment and the rented storage bins. The therapist visits the client at home and at the storage bins on some days. On other days, meetings take place at the therapist's office, where the previous day's homework and next day's homework are discussed. On some days, the client arranges for friends to visit her at home and at the storage bins to help haul items. Approximately 10% of the stored material is discarded daily, so that by Day 15 almost all of the junk has been discarded. Remaining junk is discarded by the client after the 15 scheduled daily sessions.

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CHAPTER 9

Treatment Planning: Imaginal Exposure

Imaginal exposure alone is not generally a preferred treatment for OCD (see Chapter 4). However, some experimental evidence indicates that, when used in conjunction with in vivo exposure, imaginal exposure promotes maintenance of gains achieved during treatment. Another reason to include imaginal exposure is that it permits exercises that are not practical to conduct in vivo. For example, a person who is afraid of blurting out obscenities during a church service can imagine this situation for an extended period in the therapist's office. An in vivo exercise of this sort, however, would surely offend other churchgoers. For the most part, the principles underlying imaginal exposure mirror those for in vivo exposure. The client confronts material that provokes obsessional distress and does not try to reduce the distress by withdrawing from the situation or by performing rituals. For imaginal exposure, the information that evokes the obsession, however, is not usually contained in a situation that the client encounters in day-to-day life. Rather, it is evoked by some medium, such as narrative scripts, slides, or audiovisuals. The choice of evocative medium is always subsidiary to the fundamental goal: to evoke the obsessive distress and allow it to decrease spontaneously. As with an in vivo exercise, if an imaginal exposure exercise does not both activate fear and allow it to decrease, it is unlikely to be therapeutic.

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Therefore, important tasks for the therapist are: 8 to develop evocative material that prompts obsessional distress, •

to present the material in an evocative manner,

M

to help the client understand how the imagery works, and

HI to encourage the client to tolerate the distress until it decreases. Achieving these goals depends on many factors, some of the more obvious of which are summarized in this chapter.

Medium of Exposure Evocative material is what is presented to the client to prompt an image. This material can be a spoken or written description; a still visual display, such as a photo or slide; a dynamic visual display, such as a videotaped scene; or some emerging media technique, such as a computer-generated interactive audiovisual display. As previously mentioned, the medium is not of primary importance. What is important is that, regardless of its medium of presentation, the evocative material matches the client's obsessional concerns. So, the first principle of imaginal exposure is to develop evocative material that constitutes a good match for the client's fear. This point may seem obvious, but it is so fundamentally important that it merits emphasis. Achieving a good match between evocative material and obsessional concerns depends on a good understanding of the client's fears. This understanding is derived largely from the extended assessment done in the pretreatment planning phase. It is during this phase that you develop a set of evocative materials and schedule their use into the treatment plan, which is discussed with the client. The most practical medium for imaginal exposure is the scripted narrative, spoken by you during the session. This medium is extremely flexible: The content of the narrative is unlimited and can be changed in an instant as needed, stopped and restarted, and audiotaped for use by the client in homework exposure practice. Although other media for imaginal exposure have certain advantages, they can also be cumbersome. Whereas a good slide, videotape, or computer-generated presentation can be especially evocative, an appropriate slide set, videotape collection, or virtualreality routine for a particular client can be practically difficult and time 76

consuming to gather and requires equipment for practice. Thus, scripted narratives are often a first choice for imaginal exposure. Although a more detailed description of the environmental "picture" is traditionally believed to evoke a more vivid image, just how much detail is optimal is unknown. Because the efficacy of imaginal exposure hinges on the client's generating emotional images, inclusion in a script of a detail that has particular emotional significance to the client is essential. For example, a script that uses some of the client's own words might be especially evocative if these words are part of that client's obsessional intrusion and reliably evoke the obsessional distress. On the other hand, the inclusion of details that are inconsistent with the client's obsessional content and that interfere with the formation of an emotional image can be detrimental. Some evidence suggests that incorporating descriptions of physical responses (e.g., heart rate, sweating) in the script enhances the client's emotional engagement. Therefore, including physical reactions that the client has reported experiencing when having obsessional distress is. recommended. A model schedule for intensive imaginal exposure might be as follows. Six situations of gradually increasing distress-evoking potential are identified in advance of treatment, and a script describing each situation is developed. Each script depicts the situation in a way that readily evokes obsessional concerns for the client. More severe concerns and feared consequences are included in scripts to be presented later in the sequence.

Problem With Imaginal Exposure If a client claims not to have had a vivid image or denies distress during imagery, you should probably change the imagery procedure. A script might be changed if you have omitted an important detail or included a distracting discrepancy. Another problem with using imagery exposure lies in the client's attitude. Some clients purposely avoid including certain scripted material in images or distract themselves during the image to reduce distress. You can question clients about the details of their imagery and remind them that the imagery must be a distressing reflection of their target obsessive concerns if it is to be useful.

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Having the client describe the imagery can reveal discrepancies between your script and the client's image. If the script contains material that is incongruent with the client's obsession or contains significant omissions, modify the script. If the client is compromising the exposure by "softening" the image in some way, encourage the client to let the image be more distressing. Your task is to help the client access the obsession, not simply to follow some prearranged script in a rote fashion. Some clients can produce fear images better without an ongoing spoken narrative. For such clients the narrative is actually distracting and impedes the emotional engagement.

Guidelines for Imaginal Exposure Evocative materials of gradually increasing distress are prepared. The inclusion of feared disastrous consequences in narrative descriptions gives an opportunity for reduction of anticipatory fear of those potential consequences. Evocative material matches the obsessional concerns of the client. Obsessional distress evoked by imaginal exposure predicts improvement of OCD symptoms. If the client consistently denies distress during imaginal exposure, the procedure should be modified or abandoned.

Model Introduction to Imaginal Exposure There are different ways to do exposure exercises. One method is imaginal exposure. This means that instead of confronting a situation that provokes your obsessions in real life, you can do it in your imagination. The technique is similar to the actual exposure exercises that you wiil do. You will imagine confronting difficult situations without doing rituals, even though it is uncomfortable, and you will keep imagining being in that situation until you notice a decrease in distress. An advantage of the imagery exercises is that you can confront situations in your imagination that are impractical to confront in reality. For example, you can imagine the disastrous consequences that you fear until they don't bother you as much, but it wouldn't be practical t© produce those bad consequences in real life. As we are planning the therapy, we will develop some scenes that you will use for your imagery exercises. Then, when we start the practice, I'll guide you through the imagery in the 78

session. Then, you will practice it at home, with the help of a tape of what we did in the session. When you do the imagery, 1'SI ask you to close your eyes so that you won't be distracted. The imagery will be useful only if you can form an image of the situation that is realistic enough to make you feel some of the distress that you would feel if the situation were actually happening to you. So when you are doing the imagery, it is important to let yourself fee! the way you do when you are having an obsessive concern. However, I will ask you to refrain from any rituals in the image, even if that is what you would be tempted to do if the situation in the image actually occurred. After you maintain the image for a while,! will ask you to describe aloud what you are seeing, thinking, feeling, and doing in the image. Also, I'll ask you from time to time to say how uncomfortable you feel.

Sample Narrative Script for Imaginal Exposure You are sitting here in the chair, and I am with you. You are already starting to feel a little anxious because you know what we are going to be doing today, You know that we will be touching many things that you usually avoid, and you know that you are going to get contaminated. I'll tell you that it is time to start and that the first exercise is to sit down on the floor, You tense up immediately and feel your heart racing as you look down at the floor. You can see that the carpet is not very clean. There are little bits of lint and sortie dark stains on the floor. You realize that people walk on very dirty surfaces and then track the dirt onto the carpet. The carpet is full ©f germs from people's shoes. You figure they must have walked on streets and sidewalks and grass where dogs have urinated and defecated. You know that people aren't that careful where they walk and don't wipe their feet carefully when they enter the building. You stand up but hesitate to sit on the dirty floor, You really don't want to do it, but you know it is important to do so that you can get relief from the OCD symptoms. Finally, you just sit down on the floor. You don't want to touch it with your hands, but you put one hand on the floor for balance as you sit down, and it feels pretty gritty. You look at the palm of your hand and see some hair stuck to it You know that your hand and your clothes are dirty now. You're wondering if you got germs from feces on you from touching the floor. You think that they must be there because so many people have walked on this floor and you can tell that it has not been carefully cleaned. You break out in a sweat as you realise that you are not going to wash after having touched the floor. You feel like getting up and washing your hands, but you aren't going to do it, and you feel very uncomfortable about this. You figure that you're going to get sick from the germs.

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As previously mentioned, narrative scripts are not the only types of evocative material that can be useful for exposure. Commercial films depicting satanic possession, impulsive harm to others, unacceptable sexual activity, and so on, can also be highly evocative of obsessional distress and, thus, quite useful for exposure.

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CHAPTER 10

Treatment Planning: Ritual Prevention Introducing the Concept and persuading the Clint EES?

As we argued in Chapter 4, refraining from rituals, or ritual prevention, is an important component of cognitive-behavioral treatment for OCD. It is, however, a frequently misunderstood component of the treatment, and its implementation often requires some artistry. The conventional term response prevention is itself a source of confusion. It seems to imply that, during treatment, some agent other than the client will interfere with the client's ritualizing. This implication may frighten prospective clients if they suspect that their therapy will be coercive in some way. The term might also suggest to clients that, in the face of an urge to ritualize, they may not have much choice in the matter. These implications, however, misrepresent much current practice of cognitive-behavioral therapy for OCD. In current practice, as with the exposure component of cognitive-behavioral therapy for OCD, the response prevention component is generally self-governed. That is to say, clients are persuaded of the rationale and importance, indeed, of the very necessity of refraining from rituals and are coached in self-control tactics. It is important to begin this process in a way that prospective clients immediately understand that you will not 81

be a coercive agent and that they, the clients, can exercise a good deal of control over ritualizing. Persuading clients that your role is one of coach rather than one of bully can be handled simply enough by early explanation and your own subsequent behavior that is thoroughly consistent with this ideal. Such consistency sometimes requires effortful self-discipline on your part, particularly in the face of client noncompliance with your instructions, but it is not particularly complicated. The issue of client choice about refraining from rituals, however, is more conceptually complex and practically difficult to manage. One problem with telling clients that they must choose to stop ritualizing as part of their cognitive-behavioral therapy, is that they often do not perceive their doing so as humanly possible. Some individuals become quite angry at first hearing about this component of treatment, supposing that "if I could stop ritualizing I wouldn't need to come for treatment." Many might have been influenced by the all-too-common simplification that "OCD is a brain disease." They see no choice in the face of a neurobiological destiny that cannot be changed except by chemicals or psychosurgery. For some, a long-suffering history of unsuccessful attempts to overcome their rituals has led to despair about any further endeavors. Many clients readily admit to being able to refrain from rituals. Others believe that they have no choice but to ritualize, so instructions to refrain from rituals will fail. Therefore, persuading skeptical clients about the importance and possibility of ritual prevention is practically essential before they are instructed to stop ritualizing. For clients who have decided that OCD is a physical rather than a mental disorder, a couple of arguments may be helpful. First, you can argue that biological and psychological explanations are different ways of understanding OCD, or "different angles on the same problem," and that both can be useful. You can persuasively illustrate this point by citing the documented efficacy of both exposure therapy and pharmacotherapy. Second, you can give examples of the role of practice in both physical and cognitive rehabilitation after physical injuries (e.g., strokes, athletic injuries) to make the point that identifying a problem as a physical one does not mean that practicing certain cognitive behaviors cannot be extremely powerful. Citing the finding that positron emission tomography (PET) patterns in clients with OCD change similarly after both cognitive-behavioral therapy and medication may be helpful. 82

For individuals whose skepticism about their capacity to choose does not rest on issues of the mind-body relationship, other approaches may be more helpful. For example, a detailed analysis of the temporal pattern of a client's rituals can reveal instances when the client delayed rituals because their performance would be embarrassing or particularly inconvenient. Such revelations can persuade some clients that they do indeed exercise a degree of choice about ritualizing. For some clients, rituals have become "automatic" in that they are performed unintentionally, and they thus seem unsusceptible to voluntary control. In such cases, you can explain that choice requires awareness and that you can teach the client ways to enhance awareness and thereby enhance his or her capacity for choice. Illustrative examples are overlearned habits, such as tying shoelaces or shifting gears in a particular pattern on a manual automobile transmission. A person must direct special attention to these activities in order to change the strong habits ingrained through long practice. The specifics of refraining from rituals should be outlined during treatment planning, and reviewed frequently during treatment. Sample guidelines for washing and checking rituals are given in the following sections. The client should receive a copy of the instructions tailored to his or her specific rituals. Sample client instructions for washing and checking rituals are provided in Appendix A.

Sample Guidelines for Refraining From Rituals Decontamination Rituals During the ritual prevention period, the client must restrict the use of water on the body; that is, no hand washing, no rinsing, no wet towels or wash cloths are permitted. The client may use creams and other toiletry articles (bath powder, deodorant, etc.) except when their use reduces contamination. The client may shave with an electric shaver. The client may drink water or use it to brush teeth, being careful not to get it on the face or hands. The client may take supervised showers, including hair washing, every three days for 10 minutes each. Supervision usually requires that a designated person monitor the length of the shower and notify the client to stop when the 10 minutes are over. Ritualistic washing of specific areas of the body (e.g., genitals, hair) is prohibited. Exceptions may be made for unusual circumstances (e.g., medical conditions necessitating cleansing).

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At home, a designated relative or friend should be available to the client if she or he has difficulty controlling a strong urge to wash. The client must report any such concern to the supervisor, who will remain with the client until the urge decreases to a manageable level. The supervisor alerts the client of any observed violations of ritual prevention and reminds the client to report them to you. To help the client stop doing a ritual, the supervisor may remind the client about the importance of ritual prevention in treating OCD but should not argue with the client or use physical force. In some cases, if the client agrees, the supply valves to readily available water faucets can be turned off (as a form of stimuluscontrol) to reduce "temptation." Showers may be self-timed or timed by the support person but it is not customary for this person to observe showering directly.

Checking Rituals Beginning with the first session of exposure and response prevention, the client is enjoined from all ritualistic behavior. Only normal checking is permitted (e.g., one check of door locks). Checking is prohibited for items ordinarily not checked. At home, a designated relative or friend may help the client by being available at the client's request whenever an urge to check is difficult to resist and by staying with the client until the urge decreases to a manageable level.

Self-Monitoring of Rituals Self-monitoring has a two-fold purpose in the treatment of OCD. It promotes the client's awareness of the events targeted for monitoring and provides you more accurate information about these events than can be gathered from informal recollection. People generally find self-monitoring burdensome, so it is important to explain and emphasize its importance. Otherwise, clients will be insufficiently motivated to maintain the discipline of the monitoring procedure. Prepare the client for self-monitoring with the following introduction. It is important to obtain accurate information about the frequency and duration of your obsessions and compulsions. This monitoring is actually a powerful treatment procedure in itseff, so it will be important for you to take full advantage of its benefits. Self-monitoring has actually been found to help 84

people exercise self-control probably because it helps them to be very aware of what they are trying to control. Another benefit of self-monitoring is that we can use it to monitor your progress and to adjust the treatment exercises accordingly. It can be difficult to monitor your obsessions and compulsions, especially if you have very many of them ©r if you are not used to paying attention to when they occur. You'll spend some time now and in the next session learning how t© self-monitor. Here are some forms to help you with self-monitoring. Use them to record your obsessions and compulsions.

Provide the pad of "Self-Monitoring of Rituals" forms and the binder in which to keep completed ones.

Guidelines for Self-Monitoring Go over the self-monitoring form with the client and provide the following instructions. Do not guess the length of time spent ritualizing. Use a watch to determine the time spent. Note the time before you start the ritual and then again when you stop the ritual. Keep the monitoring form with you during all waking hours. Immediately record on your monitoring form each time you engage in a ritual, rather than trying to remember it later. Do not save the recording to the end of the day or the beginning of the next day. If you do not do the monitoring at the time that you actually ritualize, the monitoring will not be of much benefit to you and will be a waste of time and effort. Write in just a few words the trigger for ritualizing. The trigger can be a thought, an action, or an environmental event. Do not write long paragraphs on each of the triggers because the self-monitoring task involves self-ratings of distress. These ratings are the same ones used for the exposure exercises. We called them SUDs.

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If is convenient to describe the degree of distress by using a number on a rating scale from 0 to 100, where 0 means that you feel no distress whatsoever and 100 indicates that you are extremely upset, the most you've ever felt. Let's try it. How much distress do you feel now? Have you ever experienced 0 distress? When? 100 distress? When? (Assist the client in establishing anchor points for 0, 50, and 100 SUDs.)

Reviewing the Self-Monitoring At the beginning of each session after self-monitoring has been assigned, the therapist will review with the client the self-monitoring homework. This review early in each session communicates to the client the importance of the self-monitoring task. It also communicates the idea that assigned homework should be taken very seriously and will be considered thoroughly at the next session. The review of self-monitoring homework consists of your inspecting the completed self-monitoring forms and discussing the client's descriptions of triggers and notes about rituals. At this time, reinstruct the client in how to do the self-monitoring, as needed. The daily review of self-monitoring may be construed as a shaping procedure designed to train clients to monitor their symptoms in a useful way. Your inattention to the self-monitoring homework may promote parallel inattention by the client. Accompany this daily inspection of the selfmonitoring with a discussion of the symptoms themselves, particularly as violations of the proscription of ritualizing.

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CHAPTER 11

Treatment Planning: Social Support

Although there is little scientific knowledge about the social contributions to the development, maintenance, and remission of OCD, clinical experience does suggest that social factors are important considerations in the development of a treatment plan. Two general issues may be considered: (a) historical patterns of collaboration in OCD avoidance and rituals in the social environment and (b) interpersonal conflicts in the client's social environment.

Patterns of Collaboration The first issue concerns how the client's social milieu has accommodated itself to the OCD. One common way that family and friends react to the client's obsessive concerns is to also adopt the avoidance and rituals that the client uses to cope with obsessive distress. For example, a male client who is concerned about contamination may insist that his wife and children change their clothes in the basement upon entering the house or refuse to allow his children's friends to enter the house because they are not participants in the patterns of avoidance and rituals. Such collaboration is an extension of the client's own avoidance and rituals and must be discontinued on a schedule that parallels the client's own schedule of exposure and ritual prevention.

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Inquire whether such collaboration occurs. If so, schedule a meeting with the client's significant others to coordinate their withdrawal of this collaboration with the client as part of the exposure exercises. Withdrawal may be difficult for some friends and family members, who may continue to try to protect the client from upsetting situations. Years of accommodation to the client's peculiar requests might have established habits that are difficult to weaken. Coaching family members in specific exercises may be useful. For example, the husband who has grown accustomed to entering his home through the basement and immediately removing his clothes and showering for his wife's sake should be instructed to enter through the front door and to toss his overcoat on the couch. Similarly, family members may find themselves continuing to perform a variety of household activities that they have come to regard as their responsibility because the client wishes to avoid feared contexts. Because such familiar patterns may hinder progress in treatment, you should inquire about such habits from both the client and family members and prescribe appropriate alternative behaviors that maximize the client's exposure and minimize avoidance. Changes in avoidance and rituals in the social milieu must not occur before the client has confronted the relevant feared situations. Otherwise, the client may think that you and the family are colluding to take away control of situations that are perceived as highly threatening. For example, suppose that a family discontinues all avoidance of contamination abruptly on the first day of treatment. Specifically, someone in the family sits on the lawn outside and then sits on the couch without first changing clothes. The client has not yet practiced sitting on lawns, or touching dog feces that is feared to be on lawns, and is not scheduled to touch dog feces until the second week of exposure practice. In this case, abrupt changes in the family's behavior then violates the schedule of exposures that you have arranged with the client. Such a violation can lead to loss of trust in you and the family. This distrust can, in turn, undermine the client's willingness to comply with the treatment program. Therefore, your actions and those of the family should be predetermined so that no surprises are sprung on the client. If the client feels betrayed by your instructions to the family, he or she will be unlikely to cooperate in the therapy. To preclude a problem of this type, have the client enjoin friends and family from specific avoidances rituals and also inform both the client and family about the importance of matching the client's schedule of exposures to the family's schedule for adopting nonavoidant patterns. In a meeting with the client and friends and family members, you can explain the rationale for what on 00

must be done, and the client can solicit an agreement from the friends or family members to refuse to cooperate in avoidance and rituals. Accordingly, the family agrees not to change an avoidance or class of avoidances until specifically instructed to do so by the client. Inquire daily about what avoidance or rituals the client has instructed the family to abandon. Sometimes, friends or family members have their own superstitions that reinforce the obsessive-compulsive patterns of the client. If a superstitious pattern of family behavior developed somewhat independently of the client's OCD symptoms, the situation can be difficult. For example, if a client's concern about contamination is shared by significant others (although to a much less disruptive extent), the client might encounter opposition to some of the exposure exercises. Particularly difficult are situations where there is strong cultural support for ritualistic behavior relevant to the client's OCD, as in the religious observance of dietary rules. For example, a Jewish client who was highly concerned about obeying the rule of not mixing milk and meat in her cooking spent hours wiping the kitchen counter top. Although her family members were also religious, they recognized that her behavior was highly exaggerated. In such a case, conferences with a clergyman trusted by the client may help in devising exposure exercises that will be religiously acceptable to the client and the family.

Interpersonal Conflicts The second issue, interpersonal conflicts that occur during the course of a cognitive-behavioral therapy program, may also be important to address. Interference in the exposure therapy, including distraction from therapy, demoralization, and even exacerbation of OCD symptoms, can stem from conflicts with friends and family. Because family members have often had a history of intense affect surrounding the client's OCD, such affect frequently emerges in family interactions during the course of the therapy, and it can distract the client from following the treatment program. It is important for you to caution both the client and interested family members or friends to minimize such distraction. Sometimes a family member is so motivated by the prospect of relief from hardships caused by the client's OCD symptoms that fear, frustration, or anger pervade that individual's approach to the client. Alternatively, intense commitment to the client's welfare motivates some family members toward counterproductive attempts 89

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at control. Your alertness to these processes, and appropriate interventions on their discovery, can help to circumvent interpersonal obstacles to progress. Because friends and family members have often experienced long-term frustration with the client's OCD symptoms, it is not surprising that some are overly motivated, desire improvement to occur smoothly ("like clockwork") and expect treatment to result in complete elimination of all OCD symptoms. Disappointment and anger may result when these expectations are not realized. You must prepare significant others for the often uneven progress that occurs during exposure therapy. Significant others should understand that occasionally strong anxiety reactions are to be expected with exposure and do not reflect failure, and that a matter-of-fact attitude toward this eventuality can be encouraging to the client. Also, you should inform both the client and significant others that treatment is unlikely to eliminate the symptoms completely. Rather, the goal is to reduce the severity of the symptoms to a point that the client can considerably decrease distress and increase general functioning. Failure to clarify this point will result in disappointment and frustration. Moral misconceptions by significant others about the client or treatment are another potential source of disruptive interpersonal conflict. Some people believe that the OCD symptoms are simply ways that the client manipulates his or her environment and that the client should be able to stop the avoidance and rituals without effort, difficulty, or assistance from anyone. Another potential source of interpersonal conflict is unremitting negative judgment. Both attitudes might seriously demoralize the client, and their potentially compromising effects on treatment should be anticipated and addressed. If these potentially destructive attitudes do not readily yield to instruction, consider the alternative tactic of having the client minimize social contact with the problematic individuals during the course of treatment. Clinical observations suggest that a variety of stressors, including interpersonal conflicts, can exacerbate OCD symptoms. Thus, one type of social support is the minimizing of interpersonal conflicts during the course of cognitive-behavioral therapy. One form of such support is strict avoidance of discussing topics that routinely provoke conflict. For example, if political discussions typically end in angry arguments, such discussions should be deferred until the therapy has been completed. Arguments about finances, children, household responsibilities, in-laws, and so on might best be "tabled" until therapy has been completed. If focus on day-to-day interpersonal problems distracts the client B 90

from the important tasks of therapy, its efficacy is likely to be compromised. Thus, one type of social support can be construed quite concretely: systematic minimizing of interpersonal conflicts during the intensive treatment period.

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CHAPTER 12 Reviewing the Plan: the Contract Explicating the

Planning of the treatment usually occurs over several sessions and takes 4-6 hours. Elaborated assessment, treatment planning, and persuasion are intermingled during this period, and should be mutually augmentative. Once the various aspects of the treatment have been planned and the client understands their necessity, reiterate the treatment plan with the client, highlighting the essential details. The client's repeated, explicit agreement to the plan enhances commitment to the program. The following example summarizes and explicates the treatment for the client. So far, we have spent our time mapping out the details of your obsessions and compulsions so that we both understand what they are. We have also discussed the nature of OCD and how the behavioral treatment is supposed to work. In addition, we have developed a specific plan of exposure and refraining from rituals that you are going to follow. Now, 1 want to review these things with you so that we are both clear about what your goafs are and how you are going to achieve them. Yoyr obsessions are (enumerate primary obsessions). You have coped with the distress that obsessive intrusions elicit by doing rituals (enumerate primary rituals) and by avoidance (enumerate primary avoidances). Your way of coping with the obsessions, that is, with avoidance and rituals, has not worked very well. In fact, avoidance and rituals have contributed to the 93

trouble you are having because they are a great burden and because they actually strengthen, father than weaken, the obsessions, in the long run, You have not been able to rid yourself of the OCD on your own. My goal is to help you to eliminate the rituals and avoidance and to greatly reduce the frequency, persistence, and distress of the obsessions. I will help you by teaching you how to accomplish these things, by helping you develop a plan of effective exercises, and by coaching you in doing the exercises correctly. The techniques I am teaching you are very powerful, but only if you use them correctly. Many peopl© have achieved substantial relief from their OCD symptoms from a program of exposure and refraining from ritualizing. I know how to help people do these exercises correctly. I'll be your coach. If you follow my instructions and do the exercises with energy and diligence, you are likely to achieve what you want. If you reject my expertise and spend your energy arguing about what exercises you need to do and don't need to do, refuse to do certain exercises, "cheat" on your homework, or simply don't do some or all of it, you very probably won't improve with this program. If you are not committed to trying as hard as you can to do the prescribed exercises, it would be better for us not to start the exercises, because the program probably won't work for you. There are two essential parts to your program. First, you will systematically confront things that provoke your obsessions, even though this will be distressing for you. The distress that you experience is an important indicator that you are doing useful exercises. Sf you do not experience any distress when you first do an exposure exercise, something is wrong either with the exercise or with the way you are doing it. We have developed a list of situations that you will confront for your therapy. You will start with situations that you rated as moderately difficult and get to the most difficult situations on the list on day (specify day, typically the 6th day of a 15-day intensive exposure series). You will stay in each situation until your distress decreases noticeably, and you can count on that happening. As you repeatedly confront that situation day after day, it will bother you less, until eventually, it hardly bothers you at all. As you start to get used to each situation on the list, you will add a new situation to confront, while continuing to practice exposure to the situations that you have already done. This is the list of situations that you will confront, in the order that we have planned for you to do them (read items ordered according to increasing difficulty). You are scheduled to (specify most difficult item) on (specify day). Each day, for homework, you will practice, outside of the session, the exposure exercises that you have done in the session. You will do yp to several hours of homework each day throughout the program. On days that we do not meet, you will still do the exposure homework. There are no "days off," that is, days that you may choose to return to the ©Id habits of avoidance and ritualiiing.

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The second essential part of your program is stopping the rituals. This means that you agree to stop all rituals completely on the first day of the program. Unlike the gradual way that you wilt do the exposure exercises, with stopping your rituals, you try as hard as you can to do this all at once, "cold turkey" so to speak. This means that you will stop (enumerate main rituals) as well as any minor rituals. SI you continue to ritualhe, you will undermine the effects of the exposure exercises, so that the distress you suffer during the exposures will be for nothing. There's little point to doing an exposure exercise if you undo it afterward by ritualizing. I'll expect you to resist even strong urges to ritualize and if you are afraid of giving in, you must contact your support person or me immediately, before you carry out a compulsive act, so we can help you resist the urges. Occasionally, people make mistakes and find that they engaged in a ritual without thinking about it because it is such an automatic habit. If your habit of ritualiiing is so strong that you could not resist, you should immediately record what happened on the self-monitoring form so we can discuss ways to help you better resist the urge. Do not wait to record this instance until the end of the day or until Just before coming to the session because you may not remember exactly what happened. After recording the ritual on your selfmonitoring form, you should reexpose yourself immediately to the situation or thought that provoked the rituals, but without ritualizing. During treatment, in order to maximize the effects of exposure, you will not be permitted to do some things that other people normally do, like washing (or checking) that other people do. For instance, most people do ... (give example of client's compulsive act, e.g., take a shower every day), but you won't be allowed to do so. This is because refraining from actions associated with your OCD is a powerful way to weaken your OCD patterns. (If social support arrangements have been made) It is important that during the treatment period, family members or friends will be available to stay with you and support you. I will speak with them at the beginning of treatment, and occasionally during the treatment period, to coach them on how to be helpful and to explain things that they should not be doing. Two key elements in being supportive are that they should not collaborate in your avoidance and rituals and that they should minimize interpersonal conflicts with you during the treatment period. My job is to be a coach, not a guard or a parent. 1 will definitely not try to force you to do any parts of the program. I will try not to surprise you with any exposures. I think that I know enough about your OCD now that 1 won't inadvertently expose you to something that you fear. Unfortunately, this does

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happen sometimes, but if it does, it is an accident. If you make mistakes or fail at some practice, f will try to figure out a way to help you do better. If you do not tell me when you've failed in some way because you think that I'll be angry and punish you, then you won't be able to make the best use of my expertise. Please notice if you are starting to feel afraid of me and talk to me about it. The last thing you need is to be afraid of your therapist in addition to your OCD problems. If you are not willing to comply with the program, we should discuss this openly and discontinue the therapy rather than continue working against one another. You and 1 should be working together against th@ OCD, instead of you working together with the OCD against me. If you find yourself protecting your OCD, we should consider discontinuing the program. To summarize what I've said—during exposure sessions—i will ask you to confront the situations we planned in advance for that day. 1 will be as supportive as I can when you become uncomfortable and try to help you to continue, ft is important that you do the imaginat and in vivo exposures willingly and without argument or efforts to delay them. You will stop your rituals as we have planned and if you get overwhelming urges, you will contact your supervisor @r m@ before you ritualize, not after. You will do the homework assigned and record it on the form. Do you agree to this plan? Answer any questions that the client has about the treatment plan. Do not proceed until an agreement is obtained. When the client has reaffirmed agreement to the treatment plan, the days and times for sessions should be scheduled, or reviewed if they had been scheduled previously. A typical out-client intensive treatment program occupies 15 sessions of 90-120 minutes each, scheduled daily Monday through Friday for over a 3-week period.

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CHAPTER 13

Beginning Exposure: Revision and Consent

Although the two basic components, exposure and ritual prevention, are common throughout the program, the focus of therapy usually differs from time to time during treatment. Therefore, it is useful to divide the program conceptually into three parts: the beginning, middle, and end stages of the exposure regimen. In this chapter we describe the core exposure procedures, with particular attention to elements of particular relevance to the early part of an exposure program.

Goals of theExposure sessions The primary goals of all exposure sessions, including those at the beginning of treatment, (e.g., Sessions 1-5 of a 15-session intensive program) are, of course, for the therapist to generate situations that deliberately provoke obsessional distress and for the client to realize the spontaneous decrease of the distress and the urge to ritualize within each session. In addition, the client will realize that the intensity of the distress decreases further with each successive session. These processes, decrease of distress within and between exposure sessions, are thought to indicate that the treatment is succeeding.

Revealing Mistaken Beliefs During these sessions, the client realizes the falsity of certain ideas that support obsessive distress. For example, most clients believe that if they 97

do not ritualize, the obsessional distress will remain forever. The decreasing distress experienced with exposure contradicts this belief. As mentioned earlier, many clients believe that if they do not ritualize, something terrible will happen to them or to others. Systematic, repeated exposure to situations that are believed to forebode disaster help the clients realize that their ideas were mistaken.

Building Confidence in the Therapist and in the Program There are other important goals for the early sessions: (a) to strengthen the client's confidence in you and in the procedure so the client is ready to confront the most difficult situations in the middle part of the program and (b) to promote satisfactory therapy "work habits" in the client that carry over to the remainder of the treatment. There is no established formula for achieving these latter goals, but clinical observations lead to some potentially useful heuristics. As suggested earlier in Chapter 7, a good method of strengthening the client's confidence in the therapy is for you to express confidence in the program and to demonstrate competence with the therapy procedures. In the assessment and planning phases of treatment, your demonstration of extensive knowledge about OCD, sensitivity to the client's particular symptoms, and clarity about treatment procedures help build confidence. In the beginning exposure sessions, however, other factors are likely to come into play. The most obvious factor is whether the experience of exposure closely resembles your initial description for the client. Is the therapy what you said it would be? The experience of exposure is colored by whether your behavior is consistent with how you promised to behave. Are you really acting like an expert coach or like a coercive guard or a punitive parent? Unfortunately, it is easy to slip into the latter role. You must remain firm while explicitly acknowledging the client's suffering.

The Importance of Consistency Another potentially important element is consistency on your part. Being conceptually consistent and interpersonally strong, without being rigid and authoritarian, is an artful endeavor. For example, if you describe a procedure as essential for the therapy but the client elects not to do the procedure, then you must address this difficulty immediately and persist until you have found a satisfactory resolution. To do otherwise is to invite confusion about the procedure, skepticism about your competence, 98

and noncompliance with instructions. On the other hand, if you prescribe an exercise that does not work well, and you fail to take seriously the client's claim of difficulty with the exercise, simply insisting that the plan ought to work, you might also damage your credibility and the relationship with the client. For example, the client could infer either that you do not really understand important parts of the client's experience or that you simply do not care enough about the client. Either shortcoming—waffling or rigidity—can damage the prospects for successful completion of the treatment program.

Refining the Program It is difficult, even after several sessions of assessment and treatment planning, to ascertain all the important details about the client's OCD experience and to anticipate with exquisite precision the responsiveness of a particular client to a given exercise. Therefore, the first sessions of the exposure program should be a blend of progress through the planned schedule of exercises and the continuing assessment and revision of the plan according to what is discovered as the therapy unfolds. This dialectic is particularly prominent early in the exposure schedule, when you first observe how the client functions during exposure and train the client to offer increasingly useful experiential self-observations. Thus, you must strike a balance between rudimentary consistency with the contracted treatment plan and ongoing, midcourse corrections of the plan, with the consent of the client. The following examples of how the best laid plans are subject to revision early on illustrate the balance between consistency and flexibility. Consider a client who, when the program is being planned, estimates that touching the office floor will be moderately difficult, say at 55 SUDs. When this exercise is confronted during exposure in Session 1, the client says that it is much easier to do than anticipated and gives the exercise an actual rating of 35 SUDs, which declines within 5 minutes to 10 SUDs. Should the entire 90-minute exposure period still be devoted, as planned, to touching the floor, just because this was the agreed-upon schedule? Such a discovery calls for modifications in the program. If inquiry reveals that the client is not doing any subtle avoidance or ritual to subvert the exercise, you might comment on the lower-than-anticipated difficulty with the scheduled item and suggest either modifying the scheduled item to make it a bit more challenging (and, thus, more productive)

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or proceeding straightway to the next item on the list. In such circumstances, most clients would readily assent to such a slight revision of the schedule, and the remaining time can be devoted to moving ahead. Perhaps touching the hands to the clothes or face, after the client has touched the floor, might be a workable next step. If this exercise provokes no greater distress than simply touching the floor, an alternative situation can be chosen or developed.

A Typical Exposure Session This section provides an example of a typical exposure session, with specific examples of imaginal and in vivo exposure exercises and homework assignments. First, inquire about the client's affect and progress with the homework assigned at the previous session. Ideally, discussion of the homework is completed within the first 20 minutes of a 2-hour session, leaving time for two 45-minute exposure periods plus 10 minutes at the end to review the session and assign homework exposure exercises. When you have thoroughly considered the previous homework, proceed to the exposure exercises. Remind the client of the exercises that have been planned for that day's session and describe what he or she will be doing.

Imaginal Exposure If imaginal exposure has been scheduled, start it early in the session. During imaginal exposure, the client sits quietly in a comfortable chair. Start the exercise with the following introduction. Today you will be imagining . . , (describe scene). You will close your eyes so that you won't be distracted during the image. Please try to imagine this situation as vividly as possible. For the purpose of this exercise, a vivid image means that you experience the situation as if it were really happening to you right now. It will not be very useful for you just to get a clear picture of the situation in your mind, if y©y don't feel emotionally involved during the image. When you imagine the situation, you should put yourself in the situation, looking around, seeing, hearing, and feeling what is happening as if it were actually occurring right now. Because the situation has some unpleasant aspects, you are likely to feel some distress during the image. For the imaginal exercise to be helpful to you, it is important that when you feel this distress during the imagery, you continue to B 100

stay in the situation, and not do anything to reduce the distress, like changing the action of the image or doing a ritual within the image. Every so often, I will ask you to rate your distress on the 0 to 100 scale that we discussed. Sometimes I will also ask you to rate the vividness of the images on a scale from 0 to 100, with 0 being no image at all and 100 being "just like the situation were really happening." Please answer quickly and stay in the imagined situation when you give your rating. During the session, record the narrative on a audiotape to be given to the client for use in homework imagery exercises. Then, describe the situation to be imagined for about 5 minutes and request a rating. Continue this process for about 45 minutes or until there is considerable reduction in the SUDs ratings. Consider the first exposure sessions as opportunities to teach the client what is to be done. Most have never done such exercises, and many require extensive coaching, or "shaping." Thus, especially early in the imaginal exposure exercises, it is important to ascertain what the client is doing and to offer instruction as appropriate. One obvious way to get information about the imagery is from the client's ratings of distress and vividness. Another way is to inquire about the image after the exposure exercise. If the client does not become distressed at all, you should interrupt the exercise and inquire. Another method of evaluating the quality of an imaginal exposure is to have the client describe the situation aloud during the imagery itself, rather than having the client silently imagining while you read a narrative. Clients can alternately imagine silently for 5 minutes and describe the image aloud for 5 minutes. This method allows you to estimate the correspondence between the client's image and the description you are reading. For some clients, describing the image aloud is distracting and thus diminishes the vividness. For others, describing the image aloud helps them to focus on the imagery and thus enhances the vividness. For some clients, the continuing narrative is a detractor, and they would do best to imagine silently, once you have "set up" the scene. On the basis of the client's response, you can vary the ratio of the client's silent imagining to description aloud. Assessing the client's functioning during the imagery exercise and modifying either the content of the planned script or the details of the imagery procedure can make the difference between a successful and an unsuccessful exercise. Even with the benefit of an extensive treatment

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planning period, predicting exactly what content and procedure will be most suitable for a particular client is difficult, and proceeding with a stereotyped procedure on the assumption that it will be effective for all is a mistake. The available evidence suggests that imagery exposure is effective only if it evokes distress and if the distress declines during the exercise. Your task is to craft imagery exercises for the client that will •achieve these processes. If it appears that the imagery method is not triggering obsessive distress or that this distress is not decreasing during exposure, then stop the planned imagery sequence and take the time to get it right. Do not adhere rigidly to some preplanned, manualized procedures that do not seem to be helpful. Thus, you must apply the theoretical guidelines of imagery exposure with consistency but also implement them with flexibility. Because a good first impression of the exposure process may play a part in motivating clients to continue with the therapy, promptly detecting and correcting problems with an exercise should constitute a particular focus in the beginning stage of exposure treatment. If you keep pushing a failing exercise, you may push the client right out of therapy. Either you will appear incompetent and lose credibility, or the client will feel bad about failing and will withdraw from treatment. When the imaginal exposure exercise has been completed, advance to the in vivo exercises that have been planned for the day, having allowed about 45 minutes for this part of the exposure.

In Vivo0Exposure Instructions for Washers Start the in vivo exposure with the following introduction. Today, you will confront... (specify items). You may begin by touching it with your fingers, just to get started, but then you will touch it with your whole hand, not just with the fingers, and then to touch it to your face and hair and clothing, so that no part of you has avoided contamination. Then, you'll sit and hold it, occasionally touching it to your face, hair, and clothes during the rest of the session. I know that it is likely to be distressing but remember that distress is an indicator that the exercise is useful and that the anxiety will eventually decrease if you persist with the practice. I also want you to remember that you won't be washing or cleaning after this exercise. I am sorry that this treatment has to be distressing but it is a very powerful treatment. The relief from OCD symptoms that it produces makes the exercise • 102

worthwhile for most people who do it. You can expect the exercise to get easier as time goes on. Okay, here it is, go ahead and touch it.

Present the item and then ask the client to touch it. Inquire about the client's experience. Ask for an estimate of distress (SUDs rating). If the item is a situation rather than an object, approach the situation with the client and ask him or her to enter it. After the client has confronted the item and the distress has decreased noticeably, help the client elaborate the exposure. For example, touch "contaminated" hands to the face, hair, and clothing. Contact with the contaminant should continue throughout the session. Touching the face, hair, and so on, may be repeated frequently (e.g., every 5 minutes) throughout the 45-minute session or until the focus is changed to a new exposure item. If the original item becomes minimally distressing for a client early in the session, even with elaborated exposure, you may advance to the next item on the list. However, if it is late in the session, do not advance to more difficult items because the client may not have sufficient time to habituate to the fear within the session. A client sent out of the session very distressed about an item just confronted will likely use rituals to reduce the distress. Exposure for Checkers For checkers, the exposure items are typically more complex than touching a set of discrete objects. Their distress and urges to check are usually provoked by situations where they perceive a risk of harmful acts of commission or omission. These encompass a vast range of situations, such as driving an automobile (hitting someone), using various appliances (fire, electrocution), handling sharp objects (cutting, stabbing), closing doors (crushing, leaving unlocked), cooking (poisoning, foreign objects), writing and speaking (unacceptable words, mistakes), or reading (mistakes). Thus, exposure instructions must be adapted for each class of situation to be confronted by the client. The following example illustrates instructions to clients to confront a variety of situations that prompt obsessive distress and urges to check: Today, your exposure tasks are to write out your checks to pay your monthly bills without looking at them after you've finished. Just put them in the envelope, and then we'll mail them right away without checking even once after you've done it. Then we will go on and do (specify exercise, e.g., drive on a bumpy road without looking in the rearview mirror) in the same way. 103

Note that achieving long, continuing exposure with a checker is not as straightforward as it is with someone who fears contamination from discrete objects. If the client keeps the contaminant at hand and focuses on it frequently, long exposure is achieved. However, checking situations are often brief by their very nature. Mailing a couple of checks properly only takes a few minutes and is then finished. Locking a door or closing a water tap takes only a few seconds, and no more activity is needed. If a checker remains in the feared situation for a long period of time, it can defeat the purpose of the exercise by affording opportunities for automatic or implicit checking. Often, simply staying in the situation for an extended period while no harm ensues (yet!) can constitute a de facto check that seriously compromises the exposure exercise. Only if the client leaves the situation, without checking, will the obsessional distress be fully triggered. Therefore, with checkers, several methods of prolonging exposure are used. First, a session usually includes a number of exposure situations that the client enters and leaves promptly, without returning to them for an extended period of time, if ever. Second, the client is repeatedly reminded by you of the risks that were taken in the exposure exercises already completed during that session. This constant reminding effectively prolongs the exposure period without your having to return to the situations themselves. Third, if the feared act of commission or omission is actually very low risk, such acts can be performed purposely as exposure exercises. The following examples of purposeful low-risk acts are illustrative of the general technique that you can use with some checkers. An individual who fears the oven can practice turning on the oven and leaving the house for a brief period, say an hour. Modern ovens are constructed for such use safely and are even equipped with timers so that users may roast an item over several hours without checking. Similarly, a client who fears leaving on lights or other electrical appliances can safely leave on certain electrical appliances, like radios, televisions, and lamps, for extended periods without monitoring. Such appliances are routinely and safely operated by timers when people are away from home. A person who fears that broken glass has fallen to the bottom of the dishwasher can place a broken dish into the bottom of the dishwasher and then wash a load of dishes. A person who fears miswriting a check can purposely leave one letter out of the payee's name or out of the signature. A person who fears making mistakes in conversations can purposely "misspeak" without correcting the mistakes. More generally, a person who fears performing actions imperfectly can purposefully build minor "imperfections" into every act during a designated exposure period. These are but a few 104

examples of the type of purposeful low-risk activities that can constitute useful exposure exercises for checkers.

Homework Instructions At the end of the session, assign homework, which usually includes exposure practice, abstinence from rituals, and self-monitoring. Present the homework with the following instructions. As we discussed, your homework is to practice what we did here in the session at home, This means that you expose yourself to ... and . , , just as we did today in the session. We did both imaginal and actual exposure, and you are to practice both exercises at home. Also, you must not do any rituals after you leave the session. This is also a very important part of your homework. For your imagery practice, you should try to do the imagery that you did here with me. You can use the tape we made of today's imaginal exposure to time yourself and to keep yourself focused on the imagery. Remember, your task is to imagine, not just to listen to the tape. This means that you must find a quiet place, free from interruptions, and focus on the imagery. If you play the tape while you are driving home, eating dinner, and so on, do not expect the exercise to be useful. During the homework practice, you must devote your full attention to imagining the situation as if it were real. You must engage yourself emotionally with the image and continue with it when you become distressed, if you do not become distressed, the imagery practice probably will not be very helpful. Practice the imagery ail the way through, without interruptions. It should take about 45 minutes to do this. If you become uncomfortable during the imagery, and this distress does not decrease within 45 minutes, you may try continuing the imagery until the distress decreases noticeably, up to another 45 minutes. For your actual (in vivo) exposure, you should repeat at home what we did here in the session. That means long exposures, without any rituals. A useful guideline is that each situation should be done for about an hour, or until you notice that the distress has decreased some. It is not very helpful to confront the situation and then leave it before you have noticed that you feel at least a little better. The situations you are to practice are (specify situations), If you have any problems or comments about the homework, you can write a brief note here so you are reminded to discuss them with me. Do you have any questions?

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CHAPTER 14

Middle Exposure:

From Bete Noir to Paper Tiger

The second, or middle, phase of the exposure treatment involves the client's confronting the most difficult situations. It is during this part of the treatment that the most dramatic fear reduction is usually experienced. It is also during this middle phase that the client is likely to balk at a scheduled exposure exercise. (Of course, this resistance can occur in the beginning period of treatment but becomes more likely as the most distressing exposure exercises are anticipated.) Only when the client has realized prolonged exposure to the most difficult items on the list, without ritualizing, will those items lose their power to evoke obsessional distress. This confrontation must occur sooner or later if the exposure treatment is to be successful, and there are advantages to doing it relatively early in the sequence of exposure exercises. An obvious advantage of confronting the most distressing situations relatively early in the treatment is that you will have ample time to help the client with these situations. You may be tempted to put off the most difficult .challenges until the last days of treatment, to acquiesce in the interests of encouraging the fearful client to confront the situation at all. However, cooperating with the client's inclination to procrastinate as long as possible in approaching the feared situation may be counterproductive. First, such a delay prevents the opportunity for ample time to practice with the most difficult situation. Second, scheduling the most difficult exposures for the end of treatment may seem to confirm the client's perception that the feared situation contains an actual threat. 107

Third, a delay in introducing the most feared situation supports a pattern of avoidance that the client has maintained prior to entering treatment. For some clients, the most distressing situations are surprisingly easy to overcome, for others, they are strikingly difficult. For most individuals with OCD, this part of the treatment is the most difficult and calls for ingenuity on your part. In this chapter, we present suggestions for introducing the exposure and for resolving potential problems.

Introducting the Most Difficult Exposures Many clients express concern about or protest the anticipated difficult exposure. A matter-of-fact attitude on your part will probably help in the face of such distress. Acknowledge the distress and indicate that it is common among individuals with OCD who have advanced to this point in the treatment. At the same time, indicate that avoiding the exposure exercise is not permitted, that avoiding it can jeopardize the therapy. Your discussion should include three chief persuasive elements. First, it is extremely important for the client to get relief from the OCD symptoms. Second, the client simply must do the exercise if she or he expects to get relief through this particular type of therapy. Third, overcoming OCD depends on the client's choosing to act courageously at this point by confronting the most feared object.

Tactics for Helping the clint Scheduling One tactic that may help clients confront their most feared situations according to schedule is the combination of prescheduling of exposure tasks and adherence to the schedule from the beginning of treatment. As early as the treatment planning phase, you and the client have agreed on the items to be confronted and when each will be done. Clear explication of the target date for confronting the most difficult items institutes an expectation that the task will be accomplished on schedule. Communicate clearly that adherence to the schedule is expected and required, if the therapy is to proceed successfully. Construe procrastination for the B 108

client as a form of avoidance, and, thus, as a continuance of the OCD patterns.

Encouragement If a client recoils from a planned exposure or attempts to reduce the intensity of exposure, acknowledge the distress, inquire about the reasons for the hesitation, and encourage him or her to proceed. If this approach fails, remind the client, gently, of the treatment contract. For example, say I'm sorry to see that yoy are having trouble choosing to do this. Remember that it is essential that you confront this situation even though it is very distressing. If you are to obtain relief with this therapy, you have t© do the exercise, f can understand how you would not want to feel this way. Based ®n my experience with other people with OCD, 1 believe that you can choose to confront this, and that the distress will decrease. I'll stay with you here while y@u are doing it, and we can talk about how you feel while you are doing it. It is important not t© put off the exercise because this might interfere with your progress in ridding yourself ©f the OCD symptoms. This is the next step we agreed on, and I would be doing you a disservice to suggest that it isn't necessary for your progress. On the other hand, it is truly your choice, and I don't mean to try to force you to do something you are unwilling to do, f want to find a way to help you confront this, rather than have you choose not t© make progress. Is there anything I can do to encourage y0« to try?

Coyrage Sometimes an explanation of courage helps clients who believe that fear should be avoided at all costs. Describe courage as necessary in the face of fear. Accordingly, there can be no courage without fear. Offer examples of situations calling for courageous action and portray the exposure exercise as an exercise in courage. In this manner, you acknowledge, rather than discount, the fear that the client experiences in anticipation of confronting the exposure item, but maintain the necessity of confronting the item anyway, because of the important consequences of this choice.

iisk Taking With many clients, a discussion of risk taking may encourage them to confront situations that trigger obsessive fears. This discussion is particularly relevant when the client seeks absolute guarantees of safety, often with an unconventional epistemology in which danger is assumed in the absence of evidence of safety, rather than vice versa. Discuss the 109

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importance of taking small risks as a matter of course and in the context of the exhausting cost of pursuing absolute safety. Sometimes analogies, as in the following example, can help the client to understand the need to take risks. Suppose you were a farmer who was concerned about flooding from a nearby river, because a flood could damage your crops and cause you financial problems. In order to be safe, you spend two months digging a ditch between the river and your fields, so that a river flood flows into the ditch and around your farm. You still fee! that your fields are not absolutely safe, and even though you have not planted any crops because you are busy with the ditch, you decide to build a wall between the ditch and your fields just in case the water overflows the ditch. You spend three months, and much of your savings, building the wall. You still do not feel safe, so you decide to build another ditch and wall on the other side of the wall, and install pumps in between, just in case the water comes over the first wali. By the time you have built all the protections, the growing season has passed, and you have not planted crops. You cannot pay your debts and you lose the farm. The point here is that even though there is a risk of flooding, there is a cost to protecting yourself. Sometimes people spend much more on protection than they can afford, and it defeats the original purpose. When you insist on taking every possible measure to be absolutely safe, you will not be able to do much else. The cost is extremely high. Most people choose to accept small risks because doing so is more practical than trying to eliminate all risks. Confronting the feared situations involves very small risk. They are what would generally be considered safe situations. However, they are not absolutely safe: There is n© absolute guarantee of safety. You must decide to accept the small risk of the exposure practices, unless you are prepared to accept the very high cost of continued obsessive distress, avoidance, and rituals.

The Paper Tiger Metaphor A useful approach for helping the client confront the most distressing situations is the use of the paper tiger metaphor. The paper tiger is a terrifying beast, one that convincingly appears quite dangerous and that cannot be recognized as harmless until it is touched. Then it collapses, insubstantial. As long as the client delays in confronting the most distressing situations, those situations will retain their power to evoke fear. Only by facing the beast will the client learn that it is harmless.

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Therapist Attitude It is important for you not to feel threatened by the client's difficulty with exposure. If you do feel threatened and become either anxious or angry, the client will likely perceive your reactions and become distracted from the necessary tasks. If you are unaccustomed to evoking intense anxiety during treatment, you may be tempted to renege on the treatment plan in order to reduce the client's and, thus, your own anxiety. The client might deduce that the treatment plan was ill-formed and lose confidence in your competence. The client might also interpret your attitude as evidence that the exposure task is indeed high-risk and cannot be confronted safely. Alternatively, the client could learn that distress is indeed something to be avoided at all costs, even at the high cost of maintaining the OCD symptoms. Such inconsistencies on your part can certainly compromise the therapy. If you are unaccustomed to exposure treatment, you may not appreciate the meaning of courage or may discount the intensity of the client's distress about the anticipated exposure exercise because the perceived threat is so clearly unrealistic. If you become frustrated or angry, the client might believe that you do not really understand his or her experience and lose confidence in you and in the procedure. If you consistently show understanding of and respect for the challenge of acting courageously in the face of intense fear, you are less likely to become angry when a client is strongly inclined to avoid a harmless situation. Do not struggle with the client about what a client will and will not do during treatment. Both of you are expected to adhere to the contract agreed on at the beginning of treatment. If you try to coerce the client into confronting feared situations, you, too, can become threatening and an object of fear or anger. You might be tempted to argue rationally with the fearfully balking client about the nature of the risk inherent in the exposure task. Our experience is that such arguments do not work very well. Most clients have been subjected to a myriad of such arguments in the past, and the arguments have not shaken the OCD. State clearly that you will not pursue such arguments, because the nature of OCD is such that they do not help. Clients usually recognize the truth of this claim readily. Instead, it is more productive to remind the client that it is doing the exposure exercise that helps. 111

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As we previously noted, clients sometimes demand a guarantee of safety before confronting the most difficult items. Succumbing to such demands by offering rational analyses of risk is tantamount to engaging in the sort of arguing just discussed. Instead, point out that although the situation is low risk, absolute guarantees are not to be had, and that insisting on guarantees constitutes an important difficulty to overcome in OCD. Also, explain to the client the importance of taking a chance in low-risk situations. Offer examples of other low-risk situations where the client does take chances in the absence of guarantees and suggest that part of the problem in OCD is making exceptions for the feared situations. That is, the client requires certainty only in that particular class of situations before confronting them.

Alternatives to the Planned Exposure Discontinuing Therapy If the client continues to refuse to do the exercise, you may offer the option of discontinuing treatment. Note that this option can itself be threatening to clients, but it is a less unattractive alternative than engaging in a prolonged struggle with the client, and respects the client's capacity to choose. Discontinuation can be threatening because the client perceives it (correctly) as failure and disappointment about obtaining relief. However, it can also be perceived as a punishing rejection. If you propose discontinuation, do so only with a clearly understandable apology that anticipates these potential client perceptions and so that it is not perceived as a punitive manipulation. tf you really are determined not do the exercise, then we should step the treatment and resume it later if you decide you are willing to go on. Of course, I'd rather help you find a way to do the exercise. I'd be relyetant to stop the therapy with you, but 1 am not willing to struggle to try to force you into doing the exposure. If I understand you correctly, you are telling me that you are not willing t© do the exercise that you need to do to get relief with this kind of therapy, 1 don't think that arguing with you into doing what you need to do is helpful. I understand that this is very difficult for you, and 1 don't mean to be condescending or punishing at all because you are unwilling to tolerate the distress of doing this exposure,

Note that the model instruction strikes a balance between firmness about the importance of proceeding with the exposure and respect for the client's experience and prerogative to choose. Try to persuade the client 112

to choose to proceed by articulating the important consequences of the choice, not by arguing with the client. There is a subtle difference between this firmly authoritative approach and an authoritarian condescension, which is probably counterproductive and to be avoided.

Intermediate Exercises If a client has been generally compliant with the treatment plan until a particular high-distress item is scheduled, one option is to develop an exercise that is of intermediate difficulty between the last completed exercise and the one that is stalling progress. Progress with the intermediate item may encourage the client to advance to the more difficult one. The introduction of intermediate steps merits caution, however, because this kind of adjustment to the schedule can appear to sanction further avoidance. Therefore, introduce the intermediate step only as a technique to help the client with confronting the most distressing situation, by the rescheduled date. Several factors may warrant the introduction of intermediate items and the rescheduling of confrontations with the most difficult situations. First, the client might have underestimated the distress for the planned items and did not anticipate the severity of distress actually experienced during exposure. Second, despite the client's compliance with the treatment plan, distress is not decreasing as expected. Third, the client experiences emotional overload from extraneous factors. Misjudging the difficulty of scheduled items can occur despite diligent efforts to develop a good schedule of exposures during the treatment planning period. Clients sometimes have difficulty providing accurate estimates of how difficult a given situation will be, especially if they have avoided such situations for a long time or have never confronted particular target situations. Usually, minor scheduling adjustments to accommodate new information can be made easily, but if a number of scheduled items are much more difficult than had been anticipated, significant changes must be made. Sometimes, for reasons not well understood, fear reduction with exposure occurs more gradually with a particular client, or a particular item, than occurs generally. As we noted earlier, some evidence suggests that severe depression is associated with slower fear reduction during exposure. Some clients who are not obviously depressed also change slowly. For these clients, you may need to reschedule some of the exposure items to allow

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time for fear reduction to occur for items that have already been confronted. Present this rescheduling to the client in a matter-of-fact way.

Crises Unrelated to Exposure Occasionally during treatment, a client suffers intense fear or depression (typically evidenced by crying, shaking, extreme lethargy, etc.) that is not directly related to his or her exposure practices. For example, clients may be upset by a recent event (e.g., a spouse's threat to leave if the client does not improve), by fears of facing future plans (e.g., living on one's own, getting a job), or by other concerns. If a client exhibits such reactions, further exposure is inadvisable because the client likely could not attend adequately to the exposure stimulus and thus distress would not likely decline. Instead of proceeding with the scheduled exposure exercise, encourage the client to talk about the source of the distracting emotional reaction. Proceed with the exposure only when the client is calmer. On the basis of the client's reaction, postpone the exposure until a subsequent session.

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CHAPTER 15

End Exposure: Theme and Variations

The period after the most difficult situations have been confronted and noticeable reductions in distress have been achieved is the third, or end stage of the cognitive-behavioral therapy. During this period, the emphasis shifts from encouraging the client to confront and overcome the most distressing items to strengthening and broadening the achievements that have occurred thus far and preparing the client for independent maintenance of her or his gains. An advantage of having scheduled the most difficult confrontations prior to this third stage is that ample therapy time remains to extend what has already been accomplished.

and Generalizations Repetitions and Perhaps the most obvious course during this stage is continued repetition of prior exposure exercises, that is, a kind of overlearning exercise. However, it may be more important to elaborate on the most difficult situations that have been confronted previously, so that generalization occurs. Thus, a number of variations on the basic theme of the most challenging exposure tasks occupy the end stage of the exposure sequence. For example, a client whose most distressing exposure exercise was contact with a public toilet was repeatedly exposed to the toilet in the clinic and showed reduction in distress from 95 SUDs to 25 SUDs during Sessions 6-9 of a 15-session intensive program. Sessions 10-12 might be devoted to the client's sitting on toilets outside of the clinic, for example, at 115

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restaurants, shopping malls, and theaters. Typically, such exercises evoke less distress than would have been felt before treatment but more distress than is felt about sitting on the now familiar toilet at the clinic. If, as does occur in some cases, the most difficult exposure situations have been especially contrived, or taken place primarily in the therapist's office, the end-stage of the exposure sequence should involve the client's going out into the world to practice what has been learned. For example, suppose that a client who fears HIV infection from contamination with "unknown" substances has become relatively comfortable in the office with touching a spot of dried blood. This client should then go out of the office and confront routine situations that had been and may still be distressing. The pretreatment assessment of patterns of avoidance are particularly relevant in this regard. Perhaps this person would profit from visiting the section of a library that contains a concentration of books about AIDS and paging through some of the books. Perhaps visiting a bar, restaurant, or bookstore frequented by gay men or sitting in the waiting room of a clinic for drug abusers would be challenging. Alternatively, approaching, offering a donation, and shaking hands with an unwashed homeless person who is living on the street may be a useful extension of what has been done in the office. Patterns of the client's behavioral avoidance readily lend themselves to the development of variations on the core exposure exercise.

Teaching Normal Patterns of Behavior Once the client's distress upon encountering the highest specific items on the list has been markedly reduced with exposure, a more general attitude of approach should be discussed and adopted. Explain to the client that OCD involves a style of avoidance and ritualizing in response to distressing ideas and that this style must be replaced by one of deliberate confrontation of distressing situations until spontaneous habituation of distress occurs. Thus, in the end stage of exposure therapy, the client must understand that having done a specific series of exposure tasks during treatment is not enough. Now, the client must actively apply what he or she has learned to a broad variety of situations that arise in daily living. The development of variations of the basic exposure tasks and their confrontation by the client during the end stage of the exposure sequence provides a platform to support this lesson. In other words, the client begins to learn how to generalize by practicing generalizing during the last part of treatment. You can promote this learning not only 116

by helping the client develop the exposure variations but also by explicating the nature and importance of generalization in terms that are readily comprehensible to the client. Another focus of end-stage exposure is the discussion and development of normal practices. For some clients, their rituals have so long compromised certain behaviors that they require guidance about what constitutes a practical daily routine. Once such practices are developed, they can be instituted during the end stage of treatment and practiced for carry over into the post-treatment period. An illustrative example of this problem is that of the client with germ concerns who has washed hands so extensively that he or she has been injured by the washing. During the beginning and middle stages of treatment, strict abstinence from all washing was observed, with supervised 10-minute showers permitted only every third day. This client would find an abrupt lifting of the washing restriction on the last day of treatment difficult, especially without prior preparation for resumption of normal bodily cleansing. Therefore, during the end stage of exposure treatment, you would teach the client how to wash and under what conditions and have the client practice such washing as a part of treatment. This procedure will help the client move successfully from complete abstinence to a satisfactory daily routine.

Rules for "Normal" Behavior Because many clients have long histories of failure in making useful practical judgments about situations pertaining to their obsessional concerns, you may help them develop some rules for "normal" behavior. Two sets of example guidelines, one for washers and one for checkers, are provided in Appendix A. Such rules can bear much of the burden of decision making about formerly problematic situations. For example, for a client who before treatment washed hands 50 times per day to remove dirt and germs before treatment, the following rule might be appropriate: Wash only when real soil is present, that is, soil that can be seen, felt, or smelled without close examination. You must discuss the implications of the rule with the client: There is to be no routine washing before meals or after using the toilet, unless there is obvious soil on the hands. The particular stipulations of a rule will depend on your judgment about what will be useful and practical and on the client's willingness to adopt the rule. 117

It is tempting to conceptualize posttreatment behavioral guidelines as rules for normal behavior, but such rules need not necessarily reflect cultural norms. For example, a client who had been overly concerned with contamination from bathrooms might do well to refrain from routine washing after using the bathroom, despite certain contrary social mores. Similarly, it might be an ordinary practice of a certain religion to say a prayer upon having a proscribed thought. However, a client with a history of concern with unacceptable thoughts coupled with compulsive praying would profit by abandoning that particular religious practice, at least for several months. Just as an individual who has had difficulty with alcohol might do well to violate social convention and generally abstain from alcohol, even at a New Year's Eve party, so an individual with a particular OCD history will profit from following seemingly unconventional rules. The client's active contribution to both the development of variations on the basic exposure themes and to the development of rules for posttreatment behavior are a partial preparation for maintenance of gains made during treatment. The next chapter elaborates on ways to prepare the client to maintain treatment gains.

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CHAPTER 16

Relapse Prevention: Self-Exposure

As noted in Chapter 4, the effects of exposure treatment for OCD are generally quite durable for many clients. Some clients, however, loose some of the gains made in treatment, and a few relapse to their pretreatment level. Therefore, procedures to enhance maintenance of gains should be incorporated into treatment. This chapter describes some proven relapseprevention procedures: education about the process of relapse, training in self-exposure, and planning for changes in lifestyle. Begin the discussion of relapse by explaining that some people are vulnerable to OCD and that because of this predisposition, certain stressors can intensity OCD symptoms. Explain to the client that occasional symptom recurrences are actually reactions to stressors, not symptoms of relapse. Also instruct the client to view occasional symptom recurrences as opportunities for applying what she or he has learned during treatment, not as failure.

The Process of Relapse You can help the client understand the process of relapse with the following explanation: Treatment by exposure and ritual prevention modifies your obsessive-compulsive habits and reduces your symptoms. However, as we discussed when you

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first entered treatment, OCD rarely disappears completely, even after a successful treatment. Indeed, after a period when you have been doing quite well, a stressful situation may arise that provokes anxiety and urges to ritualm. It is important for you to be aware that this could happen so that you can be prepared to cope with it in a way that maintains the gains you achieved here with the therapy. The most important factor in maintaining your gains is that you continue to apply actively what you learned during this treatment. If you don't practice what you've learned here, you'll forget how to cope with occasional obsessive intrusions and urges to ritualize. Consequently, when they come up some time in the future, you can fail back into the old habits of avoidance and ritualizing. In order to strengthen your newly learned habits, you must continue t& practice them. If you don't practice, you'll lose what you've learned and won't cope well with an obsessive intrusion when it arises.

Rules for Self-Exposure Review with the client the principles of self-exposure, continuously assess how much the client understands, and promote the client's mastery of the concepts. Relapse prevention through self exposure involves: SI

recognizing when an obsessive intrusion occurs, using felt distress as a telltale signal;

S refocusing on the task at hand, rather than doing a ritual, as a first step in coping with the intrusion; S

if the distressing intrusion persists, entertaining it in an exaggerated way until the associated distress decreases; and

H

if a pattern of distressing intrusions arises, purposely and repeatedly confronting situations that evoke the intrusions until the distress, frequency, and duration of the intrusions decrease markedly.

Stress-Management Techniques Implicit in the diathesis-stressor hypothesis of OCD exacerbation is the potential for using stress-management techniques to augment self-exposure for relapse prevention. Generally, you can teach the client to identify emotional stressors in day-to-day life and to recognize her or his own 120

habitual methods of coping with those stressors. Help the client develop a list of potentially problematic situations (e.g., extra household responsibilities, school or job performance demands, specific interpersonal conflicts). During the session, introduce appropriate coping techniques and practice them with the client, with reference to the most common stressors for that particular individual. A variety of stress-management techniques are available, including assertiveness training, cognitive restructuring, relaxation training, and so on.

Meeting With Significant Others It is often useful to meet with some of the client's significant others during the end stage of treatment to apprise them of the client's progress and to offer suggestions about how they can help the client maintain gains. Of course, the content of such instructions will depend on the nature of the relationship between the significant others and the client and on the client's wishes regarding such communication. Significant others can often profit from a discussion with you and the client about the nature of OCD and its treatment. Misconceptions about the disorder and unrealistic expectations about outcome can be addressed. The diathesis-stressor hypothesis that had been described to the client, as well as the concepts of lapse and relapse, can be shared with the family. Discuss the potential effects of criticism and other interpersonal stressors in exacerbating OCD symptoms. If the client and the significant others do not exhibit strong patterns of conflict surrounding the OCD, explore ways that the significant others can help the client to practice self-exposure and to recognize occasional symptom recurrences.

New Activities and Interests For some clients, obsessions, avoidance, and rituals have occupied so much time and energy for such an extended period that they seriously impeded the development of satisfying and productive activities. These clients will need to develop new interests to occupy time formerly spent on obsessions and rituals. Also, some individuals are unskilled or disorganized in developing new interests and activities, and without help in this area, their posttreatment transition to a satisfying routine can be particularly difficult. Assess the client's capacity for planning new social or occupational goals and offer skills training or help in problem solving. 121

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Training in the application of self-exposure, stress management, and daily living changes can involve more than simply instructing the client in his or her principles and practice. Encourage the client to pursue these activities between sessions, and review progress and consult on problems during subsequent sessions. You can promote the client's independence by becoming decreasingly instructive. During the later scheduled treatment sessions, encourage the client to describe progress and problems and to develop his or her own homework tasks. Offer corrective suggestions to shape the client's increasingly independent application of the learned techniques.

Scheduling Follow-Up Contacts At the end of therapy, it is important to schedule a number of brief telephone contacts that can be spaced further and further apart. These contacts help the clients to make the transition from intensive treatment to independence. During each telephone contact, review the client's use of the maintenance procedures and address any difficulties in their application to problem situations that have arisen since the last contact. Encourage clients to contact you after all scheduled sessions have been completed, especially if the OCD symptoms worsen or if a setback does not respond readily to self-exposure or stress-management tactics.

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CHAPTER 17

Resistance and Other Difficulties

Ideally, exposure-based treatment for OCD proceeds smoothly. The client's diagnosis is clear and uncomplicated. The assessment reveals all the important OCD symptoms, and they lend themselves readily to practically achievable exposure exercises. The client understands the procedures and their rationale and pursues treatment energetically and with consistent self-discipline. The therapist mimics the grand master's proficiency with beginning, middle, and end segments of treatment, demonstrating thorough knowledge of technique and artistry in his or her suave application. The client adheres to the rules and performs the exercises. Client distress occurs but decreases on schedule, like clockwork. Of course, departures from the ideal commonly occur and must be addressed as they arise, lest they become serious impediments to progress. One or more of the following difficulties sometimes emerge during exposure-based treatment for OCD. Suggestions for handling them are also described.

Concealment of Symptoms Few clients purposely conceal ritualizing that was specifically proscribed by the therapist. Discussing any such discovery promptly, calmly, and without animosity can often correct the problem. A useful way to address it is by considering matter-of-factly its implications for 123

treatment outcome. Coaching both the support person and the client in handling such violations can often be helpful. There are three tactics available for dealing with the concealment of rituals. One tactic is to teach the support person to report directly to the therapist any observed difficulties. This approach entails the risk of provoking conflicts if the client perceives himself or herself as subordinate to you and the support person. An alternative tactic is to have the support person speak to the client. This approach can also provoke conflicts, however, if the support person lacks interpersonal skills. A third alternative is for the therapist to meet together with the client and the support person to discuss progress and problems. Teach both the client and the support person how to discuss perceived violations. The following sections provide example discussions.

Discussing Problems With Client; and Support Person: I have asked to meet with both of you so that we could discuss your progress in the program so far, including any problems. I'd like to speak with both of you from time to time because the support person sometimes notices important things that the client might not have paid much attention to, and so might not have reported to me. For example, sometimes a client might have become so accustomed to a certain ritual that it is taken for granted and not even noticed, even though another person would notice. So, I'd like to ask you [support person] what you've noticed about how [client] is doing with obsessive-compulsive habits since the program began. Well, she's definitely doing a lot of things she didn't do before. She sits places she wouldn't sit before, and we've gone to some restaurants, and museums, and stuff. We went to the movies, too, and she wouldn't do that before. Also, we were able to get out of the room in time to make the movie, and there was no way we would have been able to do that before.

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You know that her job is to stop doing all rituals. Have you noticed her doing any rituals since we began the program? Well, I'm not sure if they're rituals, but something was going on when we went to the movie. We had to sit in the back and she made us wait until everyone else left the movie until we could leave. That seemed a little weird. What did you do when you noticed this? Well, I didn't really know what to do. I know she's not supposed to be washing, but this wasn't washing so I wasn't sure whether I should have said anything about it. You know she gets mad sometimes if I say anything. [to client] I'd like to ask you about this thing you did at the movie. Do you remember that situation? Yes, but I didn't think it was a ritual. I guess I just always do that, you know. Could you talk about what you were doing in that situation? Well, first I wanted to make sure that the place we sat wasn't filthy. You know how people dump their filth all over the seats and floors in movies, and the seats in the back were okay. The other thing was that I don't like people rubbing against me because they could be dirty, so if you wait till they all leave, you can get out without getting squished into that crowd. Now, I didn't think this all through when I was there. I just always did it that way when I used to go to a movie. Before this week, it's been a long time since I've been in one, but I always looked for a clean seat in the back and waited till people went out before leaving. 125

So did you know this was obsessive-compulsive? I can see it, but I didn't think of it then. I just did it. I'd call what you did avoidance, rather than ritualizing, because you tried to stay away from contaminants. I think it's interesting that [support person] noticed what you were doing, but you just did it automatically, out of habit, without noticing that it was an avoidance. Can you think of a way [support person] could have helped you with it at that time? I guess tell me to stop ritualizing, right? Actually, I'd suggest something a little bit different. For, one thing, [support person] figured you were doing something obsessive-compulsive but wasn't sure whether it was ritualizing, and in fact, it was more like avoidance than ritualizing. Second, you weren't even very aware that you were avoiding, so I'm not confident that telling you to stop ritualizing would have been so helpful. Usually, a helpful thing to do if you [support person] notice [client] doing something that you think she shouldn't be doing is, first, to tell [client], gently, that you notice her doing it and to ask whether [client] thinks that it is an obsessive-compulsive habit. If [client] recognizes that it is, you can ask if it is one of the things she has discussed with me and whether she's supposed to be working on it. If she says it is part of her homework, you can remind her that it is important for her to follow the program to get better and ask if you can do anything to help her through it. It is also good to suggest that she discuss the event with me, so that we can work on it together. Is that clear? I think so.

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It is generally best not to try to order [client] around or to try to make her do what she's supposed to do. People usually don't respond to being told strongly what to do, so if you ask questions and make suggestions and offer to help, that approach will probably work better than just telling her to stop.

When a client acknowledges a violation and agrees to continue efforts at compliance, little further discussion is required. However, if ritualizing occurs repeatedly, especially if the ritualizing is prolonged and intentional rather than brief and automatic, you should reiterate the rationale for these rules and alert the client to the implication of a pattern of violations—unsatisfactory outcome. As noted in Chapter 14, consideration of treatment discontinuation because of the likelihood of poor outcome can communicate the seriousness of ritualizing during treatment and sometimes can be a powerful motivator for the client. However, raising the issue of treatment discontinuation must be done carefully, in a supportive manner, otherwise the client will react with anger or depression to a perceived rejection by you.

First Instance of Concealment I understand from (support person) that you were handwashing five or six times this weekend before you ate dinner, (support person) mentioned it to me because, as you remember, in one of our introductory sessions we agreed that (he or she) would let me know about anything that might seem to be a problem during the treatment. When we started treatment, we agreed that you would not wash before eating and that, if you did not follow this rule, you would tell me about it immediately so that I could help you work out a way to overcome it. What happened? If the client acknowledges the difficulty and renews the contract, you need not pursue the issue further. However, if a significant second infraction of the treatment contract occurs, you should proceed by again reminding the client of the rules, the rationale for these rules, and the need to discontinue treatment at the present time.

Second Instance of Concealment This is the second time that you have washed and not reported to me that you did not keep the no-washing ry!e. I'm very concerned about what this 127

means about your progress with this treatment. As we agreed at the outset, it is essential that you follow the no-washing rule during treatment if you are to get relief from the OCD with this program. Every time you ritualize by (washing, checking, repeating, etc.), you are practicing and strengthening your OCD pattern. You keep yourself from learning that anxiety goes down eventually without rituals, and you don't allow your obsessions to be disconnected from distress. Unless you stop your ritualiling, confronting feared situations won't be of much help to you. Furthermore, if you don't tell me when you do a ritual I cannot help you find a way around the problem. You can see that if you are not following the "no rituals" rule quite strictly and also not giving me a chance to help you do better with this, then you should probably stop doing the program now, because it probably won't help you much if you keep doing it this way. Perhaps it would be better to wait until you feel you are really prepared to follow through with all the requirements. It can be quite difficult for people to resist the urge to ritualize, and it may be that you are just not ready yet and will feel more able to do so at a future point. I think that it is better for you to stop treatment now than to continue going through the distress of the exposure practices when they are not so likely to help you much in the long run. If that happened, you might mistakenly come to believe that you had a good cognitive-behavioral therapy program, and that it did not work, when really, you did not do the exercises in the way that has been found to work well.

Symptom (Ritual) Substitution Although concealment of symptoms does not seem to arise very often in voluntary adult clients, the replacement of proscribed rituals with subtle avoidance patterns is quite common. Self-awareness of such substitutions varies from client to client. An example of a replacement is the client's use of hand lotion to "decontaminate" as successfully as handwashing does. Such substitutions, as well as the core rituals, must be proscribed. Simply describing potential replacement patterns to clients and cautioning them against adopting them can be preventative. Also, encourage clients to report any subtle patterns that they notice as they become more aware of their functioning so that you can discuss and address the patterns as part of the treatment plan, as in the following example: Now that you've stopped your rituals, do you notice yourself doing any other special things to relieve your anxiety? Sometimes people find themselves doing new things to avoid distress, or slightly different things t© reduce distress. Have you noticed yourself doing anything like this? 128

Unforbidden Avoidance Some individuals do the prescribed exposures without ritualizing but continue to engage in unreported and sometimes unnoticed avoidance. They do not go beyond the very specific exposure tasks that have been detailed in treatment. This pattern is equivalent to fulfilling the "letter of the law, but not the spirit." For example, a client might faithfully do the prescribed exposure exercise of placing contaminated clothing back in the closet for a second wearing but make certain that it does not touch the other garments in the closet. Also, a client might enter a public bathroom, as assigned, but delay the entry or departure until another person is entering or leaving, so as to avoid touching the contaminated handle. Although unproscribed avoidance may simply constitute a strong habit that has become automated, it often betrays either a misunderstanding of the principles of exposure or even an ambivalent attitude toward treatment. Furthermore, it prevents habituation of anxiety to feared situations and thus portends poor outcome. Continuation of avoidance patterns, after thorough explanation and strong encouragement from you to do otherwise, is a problem that merits serious discussion and consideration with the client of treatment discontinuation.

Incomplete Abstinence From Rituals Although clients are asked to cease all ritualizing from the first day of intensive treatment and although they are substantially compliant for the most part, they rarely achieve consistent and immediate total abstinence. Even when a client is highly motivated to stop ritualizing, the habit can be so strong that lapses still occur. The client should monitor carefully and report these lapses to you. In turn, you should inspect selfmonitoring forms daily and address lapses immediately. Remind clients of the crucial role of refraining from rituals, but also caution them against self-criticism founded on unrealistic perfectionism. Encourage the client to continue to work toward complete elimination of rituals, but not to become discouraged by occasional lapses. Teach the client to counter occasional ritualizing with intentional self-exposure, which provides the client a useful way of coping with lapses and an alternative to discouragement. If the client perceives you as a supportive ally in addressing lapses, rather than as a punitive authority, he or she will likely be more forthcoming in reporting difficulties and in seeking help with them. Above all, avoid interpersonal animosity about the client's failure to comply with instructions. 129

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Handling Arguments Sometimes, when the scheduled time to confront a particular feared object or situation arises, a client will offer various rational arguments about danger in an attempt to justify refusal to proceed with the planned exposure. Arguing with clients about doing the exposure tasks is generally unproductive. Often, a client has a considerable history of argument with others about the irrationality of obsessive concerns about harm. However, these arguments have afforded little if any relief from the symptoms. Time spent on such arguments takes time away from a procedure of documented efficacy: exposure practice. Reminding clients of the prearranged treatment plan may help circumvent arguments. Thus, it is important to have agreed previously on an exposure schedule. Client should agree in advance to follow the arranged schedule of exposure without argument about danger. Explain that arguments about danger are actually part of the OCD pattern. If you discover a new feared situation, revise the plan by agreement. If a client declines to do a scheduled exposure, acknowledge the client's difficulty and encourage her or him to proceed. The following example may help convince reluctant clients to proceed: I'm sorry that you are having so much difficulty with today's exposure task, I know it's difficult and that you're frightened, but it is important that you move ahead with this if you are to get the relief that you want. To overcome your fear, you have to confront this situation without having a guarantee that it is safe. I did tell you that we wouldn't tie any exposures that are high-risk, but there can be no absolute certainty of safety. Delaying while you try to get a guarantee may be easier than doing the exposure now, but it would not reduce your fear in the long run. Remember, a powerful way to get relief from your obsessive fear is to complete our schedule of exposures. Today we are scheduled to (exposure task), and the best thing you can do for yourself is to confront the situation, even though it is distressing. The longer you wait, the longer you worry about having to do it. Once you do it, it will bother you for a while, but you can expect to feel better in the long run.

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Emphasizing the Clint's Control Over the Treatment If the client becomes irritated or saddened, believing that you are trying to coerce him or her to confront the situation, emphasize that the client must choose but also that this choice has important consequences. Sometimes a client will ask if you are going to "make" her or him do the exposure. The following is a model for dealing with such an attitude. I'm not going to make you do this. You must make a choice about whether or not to do it. Your choice has important consequences for you. You must do it if you are to get relief from your obsessive fears with this program. What you put into this program largely determines what you get out of it, and if you don't confront this, it will continue to bother you. So, you have a choice to make: Confront this thing even though you don't want to, or choose to preserve your OCD by choosing not to do the exposure. It is clear that it is a very distressing choice to have to make, but I do not see a way around the choice. 1 want to help you choose to confront this and get relief from the OCD. Is there anything you'd like me to do to help you with this? This presentation bypasses a struggle with the client about the exposure by describing the task as an opportunity for a courageous choice. With it, you also remind the client of the relationship between exposure practice and outcome. Thus, it makes clear that it is not you who needs the client to do the exposure but, rather, the client who needs to do the exposure. If you communicate in some way that you need the client to do the task and become frustrated or angry when the client has difficulty, the client will probably perceive this attitude and lose motivation.

Intermediate Tasks If progress is stalled because of a particularly difficult exposure task, propose moving to a less difficult version of that task as an intermediate step. Encourage the client to develop the intermediate task, offering suggestions about the particulars. Having the client develop the task makes the client feel in control rather than coerced. Explain the intermediate exposure as preparatory for the more difficult task that has become an obstacle to progress. An intermediate task can decrease fear through generalization of the exposure effect and increase the client's confidence. Both of these processes can encourage the client to confront the more 131

difficult item. Therapist modeling of the exposure task sometimes apparently helps clients advance, but attempts to document this technique experimentally have been unsuccessful.

Emotional Obstacles Some clients react with anger or sadness to exposure exercises that are expected to evoke obsessive fear. Alert the client that these emotional reactions can interfere with the exposure exercises. Accordingly, help the client focus on those aspects of the exposure that provoke the obsessional fear, rather than on other emotions. If this approach fails, you need to reevaluate the treatment plan.

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CHAPTER 18

Adjustments for Clients With Mental Retardation

Diagnosis of OCD 68?

Mental retardation is defined as significantly subaverage general intellectual functioning with onset before the age of 18. An IQ score more than two standard deviations below the mean is considered significantly subaverage. On the basis of the diagnostic criteria used, the prevalence of mental retardation ranges from l%-9% of the psychiatric population (e.g., Kolb, 1973), with the majority (90%-96%) falling within the mild range (IQ scores from 50 to 70). Although data about joint occurrence of OCD and mental retardation are scarce, findings from a study of 283 clients of a residential facility for individuals with mental retardation indicated the incidence of OCD (3.5%) similar to that for the population as a whole (Vitiello, Spreat, & Behar, 1989). Reid's (1985) observation of a low incidence of anxiety disorders among individuals with mental retardation might have been vulnerable to the effects of "diagnostic overshadowing," in which mental retardation masks other pathology. He argued that "it requires a degree of intellectual sophistication to experience and describe the various components of the obsessional symptomatology, including the feeling of subjective compulsion, the struggle against compulsion and the retention of insight. This sophistication is beyond all but very marginally mentally handicapped people" (p. 314). As noted in Chapter 7, however, it is questionable whether insight into the senselessness of obsessive-compulsive fears 133

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and rituals characterizes all OCD. Several studies have indicated that individuals with OCD exhibit a broad range of insight about the senselessness of ideas, thoughts, impulses, and images. Therefore, the diagnosis of OCD in individuals with mental retardation should not depend on the degree of insight they reveal.

Behavioral Stereotypes versus Rituals Behavioral stereotypes frequently occur in individuals with mental retardation and should be distinguished from the distress-motivated rituals of OCD. Behavioral stereotypes are typically overlearned habits that involve neither distress nor awareness that the behavior is excessive. Atypical stereotyped movement disorder has been observed in approximately 65% of the institutionalized individuals with mental retardation (Kaufman & Levitt, 1965). Accurate topography and phenomenology of OCD symptoms in such an individual requires both a clinical interview and behavioral observations. The discourse of persons with mental retardation has been found to be repetitive and especially subject to demand characteristics (Guidollet, Bolognini, Plancherel, & Bettschart, 1988). Restricted verbal abilities, fear of strangers, and general performance anxiety limit the usefulness of the clinical interview (Ballinger, Armstrong, Presly, & Reid, 1975; Pilkington, 1972).

Interviewing the Client Offer an explicit rationale for the clinical interview itself and ensure that the client understands its purpose. Otherwise, the client may simply not comprehend the importance of the interview and remain unmotivated to cooperate. Because limited cognitive abilities inhibit communication and understanding, interview questions should be concrete and specific. Because such persons often exhibit shorter attention spans than those without mental retardation, scheduling several brief information-gathering periods rather than one extended period is recommended.

Other Sources of Information Because of the special limitations of the clinical interview, alternative sources of information become particularly important with individuals who are mentally retarded. Self-monitoring is not useful with this population because of inaccurate counting (Peck, 1977), which may be due to deficits in capacity to recognize problem behavior or to memory impairments. In light of these limitations of self-monitoring, direct 134

observations by you and acquaintances are essential. The client's observations must be compared to those of third-party observers. A rating scale for evaluating compulsive behavior and its severity in individuals who are mentally retarded has been developed by Vitiello et al. (1989). On the basis of interviews of observers of the client, raters were found able to rate the overall severity of compulsions independently of clients' reports. Interrater reliability of severity was satisfactory (r = .82), as was interrater agreement in classifying behavior as compulsions versus stereotypes versus repetitions (kappa = .82). This scale is a means of obtaining observational data on the frequency and severity of obsessive-compulsive symptoms from the third-party observers who are knowledgeable about the client's daily activity.

Treatment of OCD Although no controlled outcome evaluations of OCD treatment of persons with mental retardation are available, a variety of case reports are. Hurley and Sovner (1984) described the application of behavioral procedures such as exposure and response prevention, visual screening, positive reinforcement, and overcorrection. Visual screening is a punishment procedure in which the client receives a painless aversive stimulus immediately following a ritual. Overcorrection involves restoring the disrupted environment and the client's practicing an appropriate behavior in the restored environment. Matson (1982) reported successful treatment of OCD in three adults with mild retardation, via reinforcement procedures and overcorrection. Hiss and Kozak (1991) described the successful application of exposure and response prevention procedures to OCD in a man with mental retardation.

Adjustments of Exposure Treatment The same basic procedures of exposure and ritual prevention that have been found helpful in adults without intellectual impairments are applicable with individuals with intellectual impairments. As described previously, these procedures involve confronting situations that evoke obsessional distress and refraining from rituals. A typical treatment regimen includes assessment, prolonged confrontation with situations that trigger obsessional distress, daily self-exposure homework, and supervised ritual prevention during the treatment program.

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Because therapy by exposure and response prevention is a learning-based procedure, learning disabilities that would be expected to influence the course of therapy must be taken into account in adapting the program to a client who is mentally retarded. Learning difficulties that often occur with mental retardation are pessimism, impaired discrimination learning, distractibility, limited verbal repertoire, and slow information processing speed.

Pessimism Learning can be adversely influenced by low self-expectations, and such pessimism may be especially prevalent in individuals who are mentally retarded because of a history of failure and frustration (Balla & Zigler, 1979; Beier, 1964). A schedule of exposure tasks may be developed and adjusted to accommodate a low threshold for frustration. In addition, very frequent praise for successes help in countering a pessimistic attitude. Of course, you must closely match exposure tasks to the client's capacities so that successes occur regularly. impaired Discrimination and Psstractibiiity Because discrimination learning can be especially difficult for a client who is mentally retarded, distinctions among exposure-relevant cues must not be taken for granted. You must compensate for the client's impairments in discrimination learning by devoting particular attention to important distinctions and offering explicit instruction and coached rehearsal as needed. You can accommodate the client's shorter-than-average attention span by scheduling shorter sessions or by varying activity within the session. Prolonged imaginal exposure will probably be difficult with these clients because of their trouble concentrating for long periods on the imagery. Various knowledge deficits typical of individuals with mental retardation can be expected to influence exposure therapy. For example, limited linguistic functioning can reduce ability to learn abstract concepts. This deficit, in turn, can limit the client's generalization of specific learning to different but related situations (Borkowski & Cavanaugh, 1979). Successful exposure therapy likely depends on the client's capacity to generalize from concrete exposure situations to similar situations in vivo. One compensatory tactic is exposure to many items in a fear category: The more exhaustive the list is, the less generalization is required of the client.

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Another approach to the problem of generalization is training designed specifically to promote generalization. A procedure called verbal selfinstruction training (VSIT) has been used to teach persons with intellectual disability the use of general strategies. It employs covert selfinstruction to promote adaptation to new situations and includes problem identification, attention control, evaluation, and correction of errors. In reviewing studies of VSIT, Gow and Ward (1985) concluded that there is ample evidence of its efficacy for people with mild to moderate intellectual functioning. Slower Learning Learning tends to be slower than average for those who are mentally retarded. This slower learning may be due, in part, to a limited repertoire of behavioral responses, both in number and complexity (N. Ellis, Barnett, & Pryer, 1960). With the Stroop paradigm, N. Ellis, Woodley-Zanthos, Dulaney, and Palmer (1989) found evidence for cognitive inertia or rigidity in individuals with mental retardation. Saccuzzo and Michael (1984) found deficits in the performance of persons with mental retardation on signal detection, discrimination, and visual screening tasks. Cromwell, Palk, and Foshee (1961) and Franks and Franks (1950) found that individuals who are organically impaired are much slower than average in extinguishing conditioned responses. Thus, anxious reactions can be expected to be especially persistent in this population (Ollendick & Ollendick, 1982). Merill (1985) reported slower semantic processing speed in those who are mentally retarded. Thus, when verbal mediators are important, these individuals have a learning disadvantage compared to persons with mental retardation (Berkson & Cantor; 1960, Blue, 1963). Hiss and Kozak (1991) suggested that compensation for slower learning in exposure therapy can take several forms: (a) making sessions long enough to allow habituation, providing that the client can remain attentive; (b) frequent sessions; and (c) minimizing what is to be learned during each session. In sum, you must adjust the pace of the therapy to match the learning capacity of the client. Maintenance of Gains Because maintenance of gains from cognitive-behavioral therapy for OCD depends on continued application of the principles of exposure by the client, difficulties with abstraction may limit the durability of treatment effects in individuals who are mentally retarded. A client must have a certain intellectual capacity to understand whether a particular experience constitutes an OCD urge and to know what sort of exposure practice 137

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is appropriate to counter the difficulty. If a client's intellectual deficits preclude, this kind of decision making, the individual either will not recognize when self-exposure is called for, or will be at a loss regarding just what to do. Failure to implement self-exposure when obsessive intrusions arise invites relapse. One special measure that might help to inhibit relapse with these individuals is to continue follow-up sessions indefinitely, so that you can assess problems as they arise and describe the needed exposure practices concretely. Alternatively, if the individual is living in a group home or other environment in which staff support is available, staff can be trained to help the client to continue with regular exposure practices and to pursue ad hoc consultation with you about any new problems that arise. Contingency management might also be considered: A schedule of rewards for regular exposure practice may motivate the client to practice self-exposure in the absence of more intellectually motivated efforts.

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CHAPTER 19

Adjustments for for Children

Among adults with OCD, one third to one half develop the disorder during childhood or adolescence (Rasmussen & Eisen, 1990). Thus, there is a clear need for effective treatments for OCD in children, and alleviating OCD during childhood may reduce adult morbidity. SRIs and exposurebased treatment that have been found helpful with adults are promising treatments for children as well Qenike, 1992; Leonard, Lenane, & Swedo, 1993; March, Mulle, & Herbel, 1994; Rapoport, Swedo, & Leonard, 1992). Published reports of controlled trials of medication versus exposure treatment for OCD in children and adolescents are not available. Interim analyses of an unpublished trial in the Netherlands (van Engeland, de Hann, & Buitelaar, 1994) indicate benefits for both cognitive-behavioral therapy and medication relative to pretreatment. However, the study did not include a placebo-control condition, and between-group differences were not found.

Comorbidity in Pediatric OCD More than one disorder may be diagnosed in a single child, and OCD frequently co-occurs with other disorders. In a study conducted for the National Institute of Mental Health (Swedo et al., 1989), 70 children and adolescents comprised the sample, which excluded children with mental retardation, eating disorders, and Tourette's disorder, only 26% of the participants had OCD as the sole disorder at baseline. Tic disorders 139

(30%), major depression (26%), specific developmental disability (24%), oppositional disorder (11%), attention deficit disorder (10%), conduct disorder (7%), separation anxiety disorder (7%), enuresis (4%), alcohol abuse (4%), and encopresis (3%) were the most common comorbid diagnoses.

Adjustments of Exposure Treatment Cognitive-behavioral therapy for children with OCD follows the same principles of exposure and ritual prevention that guide treatment for adults. However, the procedures typically require adjustments to accommodate the developmental level of the child. The developmental levels of children from 6 to 16 years of age span a broad developmental range. Notably, however, there are also large developmental differences among children within a narrow age range. Intellect and motivation are principle issues that must be taken into account in adjusting exposure treatment for children, and they are interrelated. If we assume that the mechanism of exposure operates in children as it does in adults, your fundamental tasks are the same with children as with adults: figuring out what situations must be confronted and persuading the client to confront them despite distress. These two fundamental tasks entail two attendant difficulties. First, psychological assessment routinely relies on the client's self-observations as reported to the clinician. Because of children's limited intellectual development and limited skills in self-observation, their OCD symptoms can be considerably more difficult to assess than those of adults. Thus, assessment is customarily more difficult with children than with adults. Second, because children have less sophisticated methods of coping with distress than do adults and because they can have greater difficulty anticipating long-term consequences than do adults, persuading them to confront distressing situations for prolonged periods without ritualizing can be especially challenging. Some of the special adjustments to exposure therapy for clients who are mentally retarded can be also be useful with children. Doing whatever it takes to teach the child about OCD and its treatment is probably fundamental to success with exposure based therapy. The first phase of treatment is assessment, but education about the nature and treatment of OCD is inextricably linked with accurate assessment. If the child does not understand what the OCD symptoms are, he or she will be unlikely 140 selva

to describe them to you with sufficient thoroughness to allow the development of a useful exposure plan. Understanding is also linked to the child's motivation to describe the difficult experiences he or she is having. The more clearly the child views OCD as a difficulty to be overcome with you as a helping coach, rather than as a form of wickedness, the more likely will the child participate actively in the development and implementation of a treatment plan.

Teaching Children and Families About OCD Many children and their families have held limited or erroneous knowledge of OCD and its treatment by cognitive-behavioral therapy. They might have developed misunderstandings on their own, or in the context of interpersonally oriented individual or family therapy or in the context of pharmacotherapy. Unhelpful interpersonally-oriented concepts of the problem range from "the child could just stop if he or she wanted to" to "the-real fault lies with the parents, not with the child." Another commonly held mistaken idea is that "because OCD is caused by a chemical imbalance, it can be treated successfully only with medicine." The nature of exposure therapy is often little understood, and some parents and children harbor concerns about coerciveness or the use of pun-

ishing behavior-modification procedures.

Explanation of OCD as a Psychobiological Disease One approach to educating clients and families about OCD (March & Mulle, 1993) is to explain OCD as a psychobiological disease, rather like other medical illnesses such as astigmatism or diabetes. A strength of this approach is its contradiction of unhelpful ideas that the OCD is the child's or parents' fault, and inclinations toward destructive criticism and blame. This explanation can be particularly important if the family has suffered a history of frustrating interactions regarding OCDrelated problems. The psychobiological explanation of OCD has a downside with regard to the cognitive-behavioral treatment rationale. It can go too far in denying that the child and family members are agents who can make choices about how to behave and that these choices indeed have predictable consequences for the quality of the child's and family's experience. Furthermore, the choice to confront situations that provoke obsessional distress and to abstain from rituals is fundamental to successful cognitive-behavioral therapy for OCD. What the child and probably also the family 141

members choose to do matters very much when it comes to whether the OCD symptoms diminish with exposure treatment.

Explanation of OCD as a set of Strong Habits An alternative to the biologically oriented explanation is that OCD symptoms are a set of strong habits of thinking, feeling, and acting. Although some evidence for a genetic influence does exist, how people develop OCD habits is not really clear. So, blaming the child or the parents is not warranted or helpful. It is quite clear, however, that OCD symptoms can be weakened through practice, in particular, through the practice prolonged exposure exercises and abstinence from rituals. This understanding of OCD lends itself readily to the analogy of the therapist as an expert coach who, like a batting coach or music teacher, helps people to develop exercise programs that will enable them to achieve what they want to be able to do. In the case of batting, the program may involve diet, weight lifting, and many careful practice swings with a pitching machine. In music, it may involve hours of performing scales or arpeggios that help a person play a particular composition. In the case of OCD, it involves various exposure exercises along with not doing various things that the child has become accustomed to doing.

EvaluationgParents' Parents' Obsercations Especially for young children, but also for adolescents, the parents' observations of problem areas can be useful in the assessment of symptoms. Parents' observations can be compared to the child's self-report, and discrepancies can be discussed and resolved. Sometimes a problem behavior that the parents identify as an OCD symptom has nothing to do with OCD. Sometimes, the child does not recognize a particular difficulty to be OCD related or understand how it fits together with other OCD symptoms. Often with children, problems rooted in OCD are identified by parent and child only as lateness, disobedience, slowness, social withdrawal, stubbornness, or academic difficulties. Informing the child and parents of the relationship of all these difficulties to OCD is a means of teaching them about the disorder.

Paceof of Exposurefor for Children In addition to special efforts at education and assessment, another customary adaptation of exposure treatment for children involves adjusting the intensity of the program to the child's capacities. Typically, the 142

adjustment entails decreasing the pace of therapy: The younger the child is, the less demanding is the pace of treatment. The typical 7-year-old will be less amenable to sitting attentively for a 2hour session than will the typical adult. Thus, the double-length sessions that are customary for an intensive exposure program are abandoned in favor of briefer sessions. Similarly, a young child may not profit so much as an adult from the daily frequency of sessions that typifies an intensive program for severe OCD. For children, then, weekly or twice-weekly sessions are recommended. For older adolescents, an intensive program of daily, 2-hour sessions may be entirely appropriate. Another way to slow the pace of treatment for children is by reducing the maximum emotional distress that the child endures during exposure. Adults are more experienced than children in tolerating distress and routinely cope with the distress of prolonged exposure until the distress decreases spontaneously. Children readily become overwhelmed by distress, to the point that they do not pay sufficient attention to the exposure situation. Therefore, a more gradual schedule of progress through increasingly difficult exposure tasks for children than for adults is recommended. Besides special efforts at education aimed at motivating the child to participate actively in treatment, other procedures can also help. For example, a program of rewards for completing a schedule of exposure tasks and for refraining from rituals, can be helpful for some children who have difficulty engaging themselves fully with the treatment program.

A Model Treatment Program An exposure program for a child with OCD might involve 12 weekly sessions of 60-90 minutes each. Treatment planning occupies from 2 to 4 sessions. Once treatment planning is completed, each session begins with a review of the preceding week's experiences with OCD, and with the homework tasks. The goals of treatment are reviewed, and the specific goals of the day's session are explicated. Each week, the child receives some new instruction and completes some exposure exercises. At the end of each session, homework for the coming week, including exposure, refraining from rituals, and self-monitoring, is assigned.

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Assessment and Treatment Planning You must adjust assessment and treatment planning on the basis of the child's developmental level. For young children, substituting a "fear thermometer" for the more abstract subjective units of distress is a conventional way of helping them offer useful ratings of distress. A fear thermometer is a picture of a thermometer that depicts levels of distress from 0 to 100, instead of temperature values. The child can indicate the level of distress by selecting a position for the "mercury column" on the thermometer. Using the thermometer, the child can rank OCD symptoms according to distress.

Ritual Prevention You may graduate the difficult task of ritual prevention for the child. Ask the child to divide ritual prevention tasks into low, medium, and high difficulty, according to the situation. Plan to tackle the low- and medium-difficulty tasks first. As the medium-difficulty tasks become easier with practice and as the child gains more confidence about selfcontrol in the face of exposure, tackle the tasks that were originally highdifficulty. This gradual approach to refraining from rituals is designed to increase the likelihood of successful completion of any given task, so the child will become increasingly self-confident in exercising self-control and in resisting the urges to ritualize.

Reframing OCD as the Child's Enemy One approach to helping children comply with a regimen of exposure exercises and ritual prevention is to offer some specific training in how to cope with obsessive intrusions. March and Mulle (1993) suggested that cognitive restructuring aimed at increasing the child's sense of personal efficacy can be helpful in this regard. For example, children can be taught to think of OCD as something to be systematically resisted and to congratulate themselves for successful resistance. In other words, children learn to view OCD as a kind of enemy to be fought, with you, family, and friends as allies in this struggle. In addition, you can rehearse with the child specific self-talk about how to struggle against the OCD, and the child can use this self-talk when a distressing obsessive intrusion occurs.

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Family Involment With Treatment As with adults, whether and how to involve family and friends in the treatment is an important issue with children. In general, the younger the child is, the more the treatment will entail parent training. As discussed previously, parents' observations of problem behaviors are important for assessment of the OCD topography in young children, so parents must participate in some of their child's treatment-planning sessions. With adolescents, however, incorporating parents into the treatment program can often be counterproductive, because of the adolescent's desire for privacy and independence and because of preexisting attendant patterns of interpersonal conflict. Many parents will usually want to know about the content and progress of treatment and may meet briefly with you and the child at each session. Unless the parents participate in a contingency management program, however, persuade the child to take the initiative to work hard to complete the program. To this end, instruct parents to stop giving the child specific instructions designed to reduce OCD symptoms. Also instruct parents to be generally supportive but not to try to force the child to do the exercises. Although some parents are often tempted to try to make the child accept the treatment, their highly motivated efforts to do so often backfire. Being supportive means praising the child for participating in the program, for doing the exposure exercises, and for resisting urges to ritualize. In some cases, extensive family involvement in rituals requires that family members play a more central role in treatment. As in the treatment of adults with OCD, you must help family members and friends identify ways they collaborate with the ritualizing of the client and coach them in ways to resist their own collaborative habits.

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CHAPTER 20

Conclusion

Cognitive-behavioral therapy leads to marked improvement in the large majority of clients with OCD who complete the treatment. Moreover, the majority of clients maintain this improvement. The principles of this treatment have been established through the methods of clinical science, but many of the details of their successful implementation depend on the creative ingenuity of the skilled therapist. In this guide, we have described a basic intensive program that we have found to be highly effective with adults: intensive treatment for a short period of time followed by 8-10 weekly sessions. The extent to which various departures from this protocol might diminish outcome are unclear. For some clients, fewer sessions seem adequate; for others, not. The concentrated efforts required during the intensive treatment phase may not be feasible for every therapist and client in clinical practice, but our clinical experience suggests that single weekly sessions are generally inadequate for all but those with mild symptoms. Perhaps three sessions weekly would suffice for many clients. Definitive studies to evaluate the various interesting permutations of the protocol would be expensive affairs and have not been done. Special populations, like children and individuals with mental retardation require adjustments of the procedures and expectations. Therapy tasks must be adjusted to the learning capacity of the individual, and the durability of gains may depend on continuing support in the social environment. 147

Although most adults show immediate posttreatment improvement, about 20% relapse. At greatest risk for relapse are clients whose improvements at the end of treatment were only moderate (Foa et al., 1983). This finding supports the approach that clients should receive the full course of treatment and that exposure exercises and ritual prevention should be systematic, following a well-designed program. A haphazard approach on the part of the therapist, the client, or both will compromise both short-term and long-term gains. Despite the documented efficacy of exposure-based treatment, 25% of individuals with OCD whom we evaluate decline to accept this form of cognitive-behavioral therapy. Efforts to understand the factors influencing the acceptability of exposure treatment are indicated so that more clients may profit from this powerful remedy.

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Pitman, R. K., Green, R. C., Jenike, M. A., & Mesulam, M. M. (1987). Clinical comparison of Tourette's disorder and obsessive-compulsive disorder. American Journal of Psychiatry, 144(9), 1166-1171. Price, L. H., Goodman, W. K., Charney, D. S., Rasmussen, S. A., & Heninger, G. R. (1987). Treatment of severe obsessive-compulsive disorder with fluvoxamine. American Journal of Psychiatry, 144(8), 1059-1061. Rabavilas, A. D., & Boulougouris, J. C. (1974). Physiological accompaniments of ruminations, flooding and thought-stopping in obsessive patients. Behaviour Research and Therapy, 12(3), 239-243. Rabavilas, A. D., Boulougouris, J. C., & Stefanis, C, (1976). Duration of flooding sessions in the treatment of obsessive-compulsive patients. Behaviour Research and Therapy, 14(5), 349-355. Rachman, S. (1976). The modification of obsessions: A new formulation. Behaviour Research and Therapy, 14(6), 437-443. Rachman, S., & DeSilva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16(4), 233-248. Rachman, S., DeSilva, P., & Roper, G. (1976). The spontaneous decay of compulsive urges. Behaviour Research and Therapy, 14(6), 445-453. Rachman, S., Marks, I. M., & Hodgson, R. (1973). The treatment of obsessive-compulsive neurotics by modelling and flooding in vivo. Behaviour Research and Therapy, 11(4), 463-471. Rachman, S. J., & Wilson, G. T. (1980). The effects of psychological therapy (2nd ed.). Oxford, England: Pergamon Press. Rapoport, J. L., Swedo, S.E., & Leonard, H. L. (1992). Childhood obsessive compulsive disorder. Journal of Clinical Psychiatry, S3, 11-16. Rapoport, J., & Wise, S. P. (1988). Obsessive-compulsive disorder: Evidence for basal ganglia dysfunction. Psychopharmacology Bulletin, 24(3), 380-384. Rasmussen, S. A., & Eisen, J. L. (1989). Clinical features and phenomenology of obsessive compulsive disorder. Psychiatric Annals, 19(2), 67-73. 160

Rasmussen, S. A., & Eisen, J. L. (1990). Epidemiology of obsessive compulsive disorder. Journal of Clinical Psychiatry, 51, 10-13. Rasmussen, S. A., & Tsuang, M. T. (1986). Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. American Journal of Psychiatry, 143(3), 317-322. Rauch, S. L., Jenike, M. A., Alpert, N. M., Baer, L., Breiter, H. C., Savage, C. R., & Fischman, A. J. (1994). Regional cerebral blood flow measured during symptom provocation in obsessive-compulsive disorder using oxygen 15-labeled carbon dioxide and positron emission tomography. Archives of General Psychiatry, 51(1), 62-70. Reed, G. F. (1985). Obsessional experience and compulsive behaviour: A cognitive structural approach. Orlando, FL: Academic Press. Reid, A. H. (1985). Psychiatric disorders. In A. M. Clarke, A. D. Clarke, & J. M. Berg (Eds.), Mental deficiency: The changing outlook, (4th ed., pp. 278-325). New York: Te Free Press. Riggs, D. S., Hiss, H., & Foa, E. B. (1992). Marital distress and the treatment of obsessive-compulsive disorder. Behavior Therapy, 23, 585-597. Roper, G., & Rachman, S. (1976). Obsessional-compulsive checking: Experimental replication and development. Behaviour Research and Therapy, 14(1), 25-32. Roper, G,, Rachman, S., & Hodgson, R. (1973). An experiment on obsessional checking. Behaviour Research and Therapy, 11(3), 271-277. Saccuzzo, D. P., & Michael, B. (1984). Speed of information processing and structural limitations by mentally retarded and dual-diagnosed retarded-schizophrenic persons. American Journal of Mental Deficiency, 89(2), 187-194. Salkovskis, P. M. (1985). Obsessional compulsive problems: A cognitive behavioral analysis. Behaviour Research and Therapy, 23(5), 571-583. Salkovskis, P. M., & Warwick, H. M. (1985). Cognitive therapy of obsessive-compulsive disorder: Treating treatment failures. Behavioural Psychotherapy, 13, 243-255. 161

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APPENDIOX A Therapist and Client Forms

165

Information Gathering: First Session Name of Therapist

Date_

Name of Client Address

Telephone Number Age of Client

Marital Status.

Number of Children and Ages

Living Arrangement.

Current Work Situation

Obsessuibs (Anxiety/Discomfort Evoking Material External Cues: Sources of Anxiety/Discomfort (e.g., feces, urine, parents, hometown)

Internal Cues: Thoughts, Images, Impulses, Doubts (e.g., "God is bad")

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Bodily Sensations (e.g., heart palpitations, sweat)

Consequences: Harm From External Sources (e.g., VD from using public toilets)

Harm From Internal Cues (e.g., "I will go crazy")

Harm From Experiencing Long-term High Anxiety

Avoidance Patterns: Passive Avoidance

Rituals

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167

Relationship Between Avoidance and Fear Cues,

Events Surrounding Onset of Problem,

Historical Course of Problem

History of Psychiatric Treatment for Obsessive-Compulsive Problems and Other Problems

General History: Medical History

Educational History

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Employment History

Previous and Current Relationship With Parents

Previous and Current Relationship With Siblings

Previous and Current Relationships With Friends

Dating/Sexual History

Previous and Current Relationship With Spouse

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169

Information: Second Session Name of Therapist

Date_

Name of Client Comments About Client's Self-Monitoring,

Obsessions (Anxiety/Discomfort Evoking Material) External Cues (Specific Situations, Circumstances and/or Objects) Cue

SUDs Treatment Session*

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. *Next to each cue, specify the day of treatment it is scheduled for exposure. All items must be included during the first five treatment sessions. 17Q

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Internal Cues (Thoughts, Images or Impulses [e.g., "God is bad"] or Bodily Sensations) Cue

SUDs Treatment Session*

1. 2. 3. 4. 5.

6. 7. 8.

9. 10.

Consequences (Harm From External Source [e.g., "I will get VD if I use public toilets"], Internal Cues, or Long-term Anxiety) Type of Harm

SUDs

1. 2. 3. 4. 5.

6. *Next to each cue, specify the day of treatment it is scheduled for exposure. All items must be included during the first five treatment sessions. Copyright © 1997 Graywind Publications, Incorporated. All rights reserved. 171 H

Avoidance Behavior Passive Avoidance (Specific Situations) Situation

SUDs

1. 2. 3. 4. 5.

6. 7. 8.

9. 10. 11. 12. 13. 14. 15.

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Rituals (Describe the Daily Routine in Detail) 1.

2.__

3.__

4._

5.__

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173

Therapist Form: Exposure Sessions Name of Therapist

Session,

Name of Client

Date

Initial Depression

Initial Anxiety

Initial Urge To Ritualize

Response Prevention: Were there any violations? D Yes D No If yes, describe

Inspection of Homework Assignment: How much time was spent on homework?

Describe Patterns of SUDs and Urges To Ritualize

Description of Imaginal Exposure

Description of In Vivo Exposure

174

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In Vivo Exposure

Imaginal Exposure SUDs

SUDs

Beginning

Beginning

5 minutes

5 minutes

10 minutes

10 minutes

15 minutes

15 minutes

Vividness

20 minutes

20 minutes

25 minutes

25 minutes

30 minutes

30 minutes

35 minutes

35 minutes

Vividness

40 minutes

40 minutes

45 minutes

45 minutes

Remarks:

Homework Instructions:

Final Depression

Final Anxiety

Final Urge To Ritualize^ Copyright © 1997 Graywind Publications, Incorporated. All rights reserved.

175

Exposure Homework Session Number

Date

1. Situation To Practice

Time To Practice _ SUDs

SUDs

Beginning

40 minutes

10 minutes

50 minutes

20 minutes

60 minutes

30 minutes 2. Situation To Practice

Time To Practice. SUDs

SUDs

Beginning

40 minutes

10 minutes

50 minutes

20 minutes

60 minutes

30 minutes

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Tape Homework Tape Number

SUDs

Pre

Peak

End

1. 45 minutes 2. 45 minutes

Comments or Difficulties

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177

Client Instructions for Ritual Prevention: Washing 9

During the treatment period, you are not permitted to use water on your body: No handwashing, no rinsing, no wet towels or wash cloths are permitted.

• The use of creams and other toiletry articles (bath powder, deodorant, etc.) is permitted unless you find that the use of these items reduces your feeling of contamination. • Shave with an electric shaver. 9

Use water for drinking or brushing your teeth, but take care not to get it on your face or hands.

• Supervised showers are permitted every 3 days for 10 minutes each, including hair washing. Ritualistic or repetitive washing of specific areas of the body (e.g., genitals, hair) during showers is prohibited. Showers should be timed by your support person but he or she does not need to observe you directly. • Exceptions to these rules may be made for unusual circumstances, for example, medical conditions necessitating cleaning. Check with your therapist. • At home, if you have an urge to wash or clean that you are afraid you cannot resist, talk to your support person and ask him or her to remain with you until the urge decreases to a manageable level. • Your support person should report observed violations of response prevention to your therapist. He or she should attempt to stop such violations through firm verbal insistence, but without using physical force or arguing. Faucets can be turned off by the support person if you give prior consent to such a plan. Special Instructions

178

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Client Instructions for Ritual

Prevention: Checking 6a^

• Beginning with the first session of exposure and response prevention, you are not permitted to engage in any ritualistic behavior. • Only "normal" checking is permitted for most items (such as one check of door locks), • For items ordinarily not checked (e.g., empty envelopes to be discarded), all checking is prohibited. • Exceptions may be made in unusual circumstances, but you must check with your therapist first. ® At home, if you have an urge to check that you are afraid you cannot resist, talk to your support person and ask him to her to remain with you until the urge decreases to a manageable level. 8

Your support person should report violations of response prevention to your therapist. He or she should attempt to stop such violations through firm verbal insistence, but without using physical force or arguing.

Special Instructions

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179

Guidelines for "Normal" Behavior: Washing 3

Do not exceed one 10-minute shower daily.

« Do not exceed five 30-second handwashings per day. • Restrict handwashing to the following occasions: before meals after using the bathroom after handling greasy or visibly dirty things • Continue to expose yourself deliberately on a weekly basis to objects or situations that used to disturb you. • If objects or situations are still somewhat disturbing, expose yourself twice weekly to them. • Do not avoid situations that cause some discomfort. If you detect a tendency to avoid a situation, make it a point to confront it deliberately at least twice a week. Other Rules

130

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Guidelines for "Normal" Behavior: Checking 6^

9

Do not repeat more than once any checking of objects or situations that used to trigger an urge to check.

• Do not check even once in situations that your therapist has advised you do not require checking. • Do not avoid situations that trigger an urge to check. If you detect a tendency to avoid, confront these situations deliberately twice a week and exercise control by refraining from checking. • Do not assign responsibility for checking to friends or family members in order to avoid checking. Other Rules

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