TREATING OCD STRATEGICALLY. Strategic Cognitive Behavioral

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1 TREATING OCD STRATEGICALLY Strategic Cognitive Behavioral Therapy One of the distinguishing features oftbis approach is the differential and alternate use of paradox with other types of interventions. The strategic approach is sensitive to and involves the system as a whole, including family members and professionals who have power over the person with the presenting problem. Therapists are also expected to influence teachers and school personnel, who can determine the way a student is identified and labeled. The therapist designs a strategy to achieve the goals of therapy; and if it is not successful, a new strategy is devised. The therapist does not do more of which has not worked, and rather, borrows and utilizes any technique or strategy that could be useful in solving the symptoms. The more precise the assessment, the more clear the problem and goal of therapy, which results in directives that are easier to design and implement. Thus, a family ~ through new experiences as they follow the therapist's directives in order to eliminate problematic symptoms. The first step in giving a directive is to motivate the family or the system to follow the directive: psychoeducation. C Jenny C. Yip, Psy.D. 2005

2 Strategic Psychoeducanon The purpose of psychoeducating a family is to provide a physio-cognitive-behavioral framework of OCD, and to explain the treatment process. Ensuring that each family member understands how OCD functions within the context of the family, and how the family as a whole can defeat OeD is perhaps the most significant motivator and predictor to the success of treatment. Thus, it is first and foremost crucial for the therapist to help the family tmderstand that everyone is allied against OCD, so that each family member side with the child/adolescent. Once. the family understands that they are working coi1abomtively to defeat OCD, the therapist can then illustrate how OCD has evolved and become entangled within the family fimctioning, and methods they will use to defeat it. Learning about OCD and its symptoms is an important first step in tmderstanding how to defeat it. Thus, it is essential to explain the following concepts to the child with <>CDand bislher fiunily. 2 c Jenny C. Yip~ Psy.D. 2005

3 The V-lCious Cycle of OCD Obsessions are repetitive thoughts, images, or impulses that are negative and produce distress and discomfort In order to relief these discomforting feelings of anxiety, fear, shame, and/or disgust, an action or behavior is performed, which reduces or eliminates the distress. However, the reduction of discomfort and distress is only temporary until the obsession is experienced once again. In addition, relieving the anxiety only serves to reinforce and strengthen the original obsession. Thus, the original act or behavior that initially reduced distress is repeated once again to finther reiiefthe discomfort, and becomes ritualized into a compulsion. In turn, each compulsion reinforces the obsession, which leads to further enactment of the compulsion. As a result the vicious cycle of OCD begins. Vicious QeD Cycle. " OBSESSIONS negative thoughts, images, impulses RELIEF distress subsides temporarily ANXIETY. distress, fear, shame, disgust COMPULSIONS repetitive thoughts, images. actions 3 C Jenny C. Yip, Psy.D. 2005

4 The OCD Triangle OCD involves three essential components that influence one another. The cognitive component represents obsessions and involves negative thoughts or images that elicit distress. The affective component represents the response to the thoughts or images, such as feelings of fear and distress. The behavioral component represents compulsions to relieve the discomfort of fear and anxiety. All three components are firmly connected in a triangle, which is necessary for OCD to function effectively. Breaking one of the bonds would weaken the manner in which OCD operates. However, you cannot always control your thoughts, and you cannot always control your feelings, but you can control your behavior. This is where exposure and response prevention (ERP) comes into play to break the triangle. Since response prevention basically means to control your behavior or compulsions rather than giving into it, ERP will isolate the behavioral component and break: the-intense triangle. Breaking the OeD Triangle BEHAVIOR (Compulsions) AFFECTIVE (Anxiety) 4 c) Jenny C. Yip, Psy.D, 2005

5 The Fight or Flight Response Our bodies are made to be equipped for survival From the beginning of time, we have been able to automatically respond to perceived danger, emergency, and/or threat in an instinctual manner. For instance, when faced with a lion, our bodies prepare us to either fight the lion or flee (flight) from it. This "fight or flight" response is primitive and innate, and occurs automatically and out of conscious awareness. In principle, this physiological response transpires through hormones that activate the sympathetic branch of the autonomic nervous system (ANS). In order to protect ourselves, our bodies must take immediate action, in which certain physiological changes occur: heart rate increases, muscles tense, pupils dilate, vision sharpens, awareness intensifies, mouth becomes dry, sweat glands perspire, blood sugar level increases, impulse quickens, perception of pain diminishes, and the gastrointestinal tract slows down as blood is redirected into muscles and limbs, which require extra energy and fuel for nmning or.... fighting. However, when the fight or flight system is activated, we tend to perceive almost everything in our environment as potential threat to our survival. Since we see everything through the filter of possible danger during the fight or flight system, by its very nature, this response bypasses our rational mind, exaggerates our fears, and distorts our thinking. This is the physiological state of the affective component in the OCD triangle. By law, our bodies eventually burnout from remaining in this heightened state of alarm. Hence, through a prolonged period, we go into a state of exhaustion, and our bodies automatically recover to a neutral state. This is the principle behind ERP. Given enough time, the level of discomfort from an obsession will eventually decrease and dissipate. Responding to the -, anxiety through a COmpulsion will reduce the anxiety at a quicker rate, but only at the expense of 5 ejenny C. Yip, Psy.D. 2005

6 reinforcing the original obsession and the resulting vicious cycle. Preventing the compulsive response will lengthen the time the discomfort is experienced, but will break the OCD triangle and the vicious cycle. Thus, you can either choose the flight mode and give in to OCD by performing a compulsion, or take charge and fight OCD by enduring the discomfort until it declines on its own. "Fight or Flight" Response -0- "FUGHT" (vicious compulsive cycle) -s'- "FIGHT" (ERP) nme(mln) -, 6 Jenny C. Yip, Psy.D. 2005

7 Reestablishing Healthy Biochemical Functioning through CBT As you change your behavior through response prevention, your thoughts and feelings will consequently change bylearning that time rather than compulsion is the healthy way to reduce anxiety. Research has shown that a biochemical disparity occurs in the brains ofocd individuals. The good news is that psychotherapy can alter patterns that stem, in part, from a biological base. PET scans, which are a form of radiograph that measures energy usage in different brain regions, have shown that the management of OCD through CBT alone actually causes chemical changes in the brains that reflect normal functioning and resemble PET scans of brains under psychotropic drug treatments. In other words, over time, our thoughts, emotions, and behaviors actually influence our brain fimctionidg. Thus, given enough time, CBT naturally retrains the biochemicals in the brain to operate normally without the use of psychotropic medications. Understanding the role the brain plays in OCD will help to avoid demoralization... and frustration in senseless atteinpts to terminate intrusive thoughts and compulsive urges. Figure 1. Photograph of PET seadsof frontal cortex eomparibg DOrmai to OCD iddiriduab pre aud post CBT treatmeut. 7 C Jenny C. Yip, Psy.D. 2005

8 Cognitive Model DIOCD People with OCD tend to have thoughts that distort their perception resulting in errors in beliefs, ideas, or attitudes. For instance, individuals with OCD are likely to overestimate the threat in certain situations, and accept more responsibility for situations than is reasonable, which leads to guilty feelings that elicit compulsions for relief of the discomfort. Some people with OCD hold perfectionistic or inflexible attitudes, and spend a great deal of time completing a task, ~ because it is important for them to "do it right" without any minuscule mistake, even at the expense of getting the job done. Other individuals with OCD believe that simply having certain kinds of thoughts is bad, and waste much energy and effort avoiding such thoughts. However, no person can actually control hisiher thoughts in this manner. In reality, trying to control such thoughts only keeps you attuned to them., which strengthens the obsessions rather than reducing them. These errors in thinking and/or beliefs are "' ~' the fundamental cognitive basis underlying OeD. The diagram below shows how certain factors -~, contribute to our perception and interpretation of our environment. Interpretations that involve neutral emotions generally do not lead to any behavioral consequence. However, individuals with OCD tend to interpret intrusive thoughts to have meanings of threat, harm, and/or danger, which result in negative emotions and, in turn, engage in avoidance or rituals to reduce the discomfort. 8 e Jenny C. Yip, Psy.D. 2005

9 Cognitive Model of OCD Intrusion (obsession) Beliefs (general or specific) / Other Factors (history, family, biology, stress, Information) Moodstate (anxiety, distress, depression) I \ Negative Emotions (fear, shame) 1.Compulsions & Avoidance Neutral Emotions 1 No Further Action 9 Jenny C. Yip, Psy.D. 2005

10 Family Involvement in DCD Family members and/or friends have a tendency to become a central part of their child's obsessions and compulsions. For instance, a child with OCD probably has tried to control hislher own behavior (e.g., handwashing) as well as those of other family members and/or friends. Many pathological doubters seek reassurance from their parents, request their friends to keep a distance from them, or ask their siblings to check door locks more often than necessary. This repetitive behavior often irritates those who are pulled involuntarily into the vicious cycle of OCD. In order to reduce their own frustration, family members may surrender to the OCD by complying to the child's request, which, in turn, only reinforces the obsessions and rituals. Thus, treatment cannot succeed without the agreement offamily members' involvement in order to change the unhealthy ways they respond to the child's symptoms. As part of treatment, the following guidelines should be adopted: "' 1. Family members must stop performing rituals because of the child's obsessions. 2. Family members must stop helping the child perform hislher compulsions. 3. Family members and the child must agree that bisjher requests for reassurances will not be granted. 10 <0Jenny C. Yip, Psy.D. 2005