Adult Treatment Planner

Objectives and Interventions

• Describe the history and nature of obsessions and compulsions.
  • Establish rapport with the client toward building a therapeutic alliance.
  • Assess the client's frequency, intensity, duration, and history of obsessions and compulsions (e.g., The Anxiety Disorders Interview Schedule for the DSM-IV by DiNardo, Brown, and Barlow).
• Complete psychological tests designed to assess and track the nature and severity of obsessions and compulsions.
  • Administer a measure of OCD to further assess its depth and breadth (e.g., The Yale-Brown Obsessive-Compulsive Scale by Goodman and colleagues, 1989a, 1989b).
• Cooperate with an evaluation by a physician for psychotropic medication.
  • Arrange for an evaluation for a prescription of psychotropic medications (e.g., serotonergic medications).
  • Monitor the client for prescription compliance, side effects, and overall effectiveness of the medication; consult with the prescribing physician at regular intervals.
• Participate in small group exposure and ritual prevention therapy for obsessions and compulsions.
  • Enroll the client in intensive (e.g., daily) or nonintensive (e.g., weekly) small (closed enrollment) group exposure and ritual prevention therapy for OCD (see Obsessive-Compulsive Disorder by Foa and Franklin).
• Verbalize an understanding of the rationale for treatment of OCD.
  • Assign the client to read psychoeducational chapters of books or treatment manuals on the rationale for exposure and ritual prevention therapy and/or cognitive restructuring for OCD (e.g., Mastery of Obsessive-Compulsive Disorder by Kozak and Foa; Stop Obsessing by Foa and Wilson).
  • Discuss how treatment serves as an arena to desensitize learned fear, reality test obsessional fears and underlying beliefs, and build confidence in managing fears without compulsions (see Mastery of Obsessive-Compulsive Disorder by Kozak and Foa).
• Identify and replace biased, fearful self-talk and beliefs.
  • Explore the client's schema and self-talk that mediate his/her obsessional fears and compulsive behavior, and assist him/her in generating thoughts that correct for the biases (see Mastery of Obsessive-Compulsive Disorder by Kozak and Foa; Obsessive-Compulsive Disorder by Salkovskis and Kirk).
• Undergo repeated imaginal exposure to feared external and/or internal cues.
  • Assess the nature of any external cues (e.g., persons, objects, situations) and internal cues (thoughts, images, impulses) that precipitate the client's obsessions and compulsions.
  • Direct and assist the client in construction of a hierarchy of feared internal and external fear cues.
  • Select initial imaginal exposures to the internal and/or external OCD cues that have a high likelihood of being a successful experience for the client: do cognitive restructuring within and after the exposure (see Mastery of Obsessive-Compulsive Disorder by Kozak and Foa; Treatment of Obsessive-Compulsive Disorder by McGinn and Sanderson).
• Complete homework assignments involving in vivo exposure to feared external and/or internal cues.
  • Assign the client a homework exercise in which he/she repeats the exposure to the internal and/or external OCD cues using restructured cognitions between sessions and records responses (or assign "Reducing the Strength of Compulsive Behaviors" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); review during next session, reinforcing success and providing corrective feedback toward improvement (see Mastery of Obsessive-Compulsive Disorder by Kozak and Foa).
• Implement relapse prevention strategies for managing possible future anxiety symptoms.
  • Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of symptoms, fear, or urges to avoid and relapse with the decision to return to fearful and avoidant patterns.
  • Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.
  • Instruct the client to routinely use strategies learned in therapy (e.g., continued exposure to previously feared external or internal cues that arise) to prevent relapse into obsessive-compulsive patterns.
  • Schedule periodic "maintenance" sessions to help the client maintain therapeutic gains and adjust to life without OCD (see Hiss, Foa, and Kozak, 1994, for a description of relapse prevention strategies for OCD).
• Implement the use of the thought-stopping technique to reduce the frequency of obsessive thoughts.
  • Teach the client to interrupt obsessive thoughts using the thought-stopping technique of shouting STOP to himself/herself silently while picturing a red traffic signal and then thinking about a calming scene.
  • Assign the client to implement the thought-stopping technique on a daily basis between sessions (or assign "Making Use of the Thought-Stopping Technique" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); review implementation, reinforcing success and redirecting for failure.
• Identify key life conflicts that raise anxiety.
  • Explore the client's life circumstances to help identify key unresolved conflicts.
  • Read with the client the fable "The Friendly Forest" or "Round in Circles" from Friedman's Fables (Friedman), and then process using discussion questions.
  • Assign the client to read or read to him/her the story "The Little Clock That Couldn't Tell Time" or "The Little Centipede Who Didn't Know How to Walk" from Stories for the Third Ear (Wallas); process the stories as they are applied to the client's current life.
• Verbalize and clarify feelings connected to key life conflicts.
  • Encourage, support, and assist the client in identifying and expressing feelings related to key unresolved life issues.
• Implement the Ericksonian task designed to interfere with OCD.
  • Develop and assign an Ericksonian task (e.g., if obsessed with a loss, give the client the task to visit, send a card, or bring flowers to someone who has lost someone) to the client that is centered around the obsession or compulsion and assess the results with the client.
• Engage in a strategic ordeal to overcome OCD impulses.
  • Create and sell a strategic ordeal that offers a guaranteed cure to the client for the obsession or compulsion. (Note that Haley emphasizes that the "cure" offers an intervention to achieve a goal and is not a promise to cure the client at the beginning of the therapy. See Ordeal Therapy by Haley.)
• Develop and implement a daily ritual that interrupts the current pattern of compulsions.
  • Help the client create and implement a ritual (e.g., find a job that the client finds necessary but very unpleasant, and have him/her do this job each time he/she finds thoughts becoming obsessive); follow up with the client on the outcome of its implementation and make necessary adjustments.