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Section 17
Cognitive-Behavioral Treatment Part Four

Question 17 | Test | Table of Contents

Case Illustration
Presenting Problem/Client Description
Mr. X was a 64-year-old loving grandfather who reported obsessions involving harm to his grandchildren. About 1 year before his assessment Mr. X was preparing a salad for his grandchildren when suddenly he experienced a sudden urge to stab the youngest in the neck with his paring knife. Mr. X was horrified by the thought, and his horror escalated when the thought recurred. He began to replace it with an image of his grandchildren playing safely and happily. Mr. X started to question his personality, wondering whether he had always been a psychopath and never known. He spent hours daily tallying up evidence that he was a psychopath and evidence that he was not a psychopath. This activity afforded him some relief from his anxiety until the obsession recurred and his doubts returned. The impulse soon became thoughts ("Stab my grandchild!", "Kill my grandchild!"). When the thoughts or impulses occurred, Mr. X would try as hard as possible to banish them from his mind. The fact that they returned despite his best efforts was interpreted as evidence that the thought was meaningful. Mr. X declined to be alone with the children and if they visited would not handle any sharp implement. Soon he found it difficult to be in the same room with them even when someone else was present and there were no sharp objects in the area. He began to have difficulty looking at the color red, as it reminded him of blood. He could not watch TV because of concern that he might see a depiction of a violent act that might "give him ideas." When he sought treatment Mr. X had narrowed his range of activities quite severely, being afraid to be out in public lest he act on an aggressive impulse toward a child he saw on the street. His Y-BOCS score was in the moderate to high range.

Case Formulation
Mr. X’s obsessional thought evoked enormous distress because he believed: (1) that he would not be having the thought unless there was a part of him that wanted it to occur; (2) that the more he had the thought the more likely he was to lose control and act on it; (3) that the thought might be prophetic, much as the central character in the movie The Shining had visions of murder months before it happened; and (4) that even having the thought without acting on it was immoral, making him an immoral person. Mr. X was highly invested in not having the thought as its absence would signify that he might not be a monstrous psychopath. Therefore, he avoided thought triggers and tried to banish the thought once it, or anything similar to it in theme or content, entered his mind. His attempts at suppression made him hypersensitive to thought cues and when he experienced thoughts while he was actively suppressing his belief that the thought was meaningful and requiring of action intensified. Mr. X’s attempts to reassure himself were unsuccessful because of his underlying beliefs about the meaning of the thought’s recurrence, but the temporary reduction in anxiety they resulted in was reinforcing enough that he continued to use it as a coping strategy on a regular basis.

Course of Treatment
The 16-session treatment sessions were held for 2 hours weekly for 14 weeks and then biweekly for sessions 15 and 16 and sessions. They were conducted by the author and a cotherapist. Treatment began by obtaining a detailed description of thoughts, emotions, compulsions, neutralizing, and avoidance based on diaries of these events over 1 week.

This information was used to inform Mr. X about the treatment model. Information about OCD, its course, and the effectiveness of cognitive behavior therapy was provided, along with the treatment description. The next session was spent offering Mr. X normative information about violent and repugnant thoughts. We gave Mr. X a list of violent and repugnant thoughts reported by a nonclinical sample of university students (see Clark, 2004) and explained that thoughts of this kind are experienced by many people. We then provided information about attentional processes and thought processes, noting that we all have numerous thoughts throughout the day but that we are geared to attend to thoughts most relevant to our immediate goals, such as the goal of being a loving grandfather.

Mr. X was then asked to identify the extent to which obsessional thoughts other than his target obsessions bothered him now or had bothered him in the past. He reported that he had had a number of other repugnant thoughts in his life but said that these had not bothered him because he was not afraid of acting on them. We explored this idea with him in light of his recent knowledge that attentional processes are drawn to thoughts that have immediate relevance for current goals. He understood the point that the obsessional thoughts may be perceived as significant simply because they reflect current concerns, not because they truly are significant. Mr. X was relieved to learn that his thoughts were not wholly aberrant and was willing to entertain the idea that it was not the thought itself that was the problem, but rather his interpretation of it. We asked him to keep track of the intensity of the thought and his level of belief in the idea that having the thought potentiated action as homework.

Mr. X returned the following week and reported that his belief that the thought was harmful was more intense when his grandchildren were visiting and when he was tired or already anxious. We used this information to illustrate that the thought’s meaning is not static, but varies according to a number of factors. Therefore, it did not represent truth.

During this session we also addressed Mr. X’s beliefs about the meaning of failures in thought control. At assessment, Mr. X believed that if his thought returned despite his efforts to control it, it must have an important meaning and should not be ignored or discounted. We asked Mr. X to try to suppress thoughts about a white bear for several minutes; he was unable to do so perfectly. We discussed current research on thought suppression in light of this experience, noting that even if suppression does not lead to a paradoxical increase in frequency, it is almost never fully successful. Negative interpretations of failures of thought control (e.g., "I’m going crazy," "The more I have this thought when I’m trying to get rid of it the more likely it is that it is meaningful") make the thought seem more important than it may actually be. Furthermore, failures in thought control lead to a decline in mood state, which makes negative thoughts even more accessible and credible. Homework for the week was to monitor all thoughts, including strange, silly, nonsensical thoughts, as well as thought appraisal and moods.

The next week, Mr. X reported that he had experienced numerous strange, silly, and unexpected thoughts and recognized that this past week was not an exception, but that in the past he simply ignored such thoughts because he deemed them unimportant. We discussed the differences in his obsessional thoughts and again explored the idea that the obsessional thoughts in and of themselves are not a problem; but rather, his appraisal of their meaning makes them so. We also addressed Mr. X’s conviction that having thoughts of violence made him immoral by asking whether having the strange, silly thoughts he reported made him strange and silly. Finally, we discussed Mr. X’s ability to monitor and control every unacceptable, immoral thought that might enter his mind. Mr. X agreed that such a task would be exceedingly difficult, if not impossible, and that he would likely be able to concentrate on little else should he attempt it. We then discussed whether, in light of this realization, his conclusion that he was immoral for "allowing" such thoughts to enter his mind was a fair one.

We then discussed Mr. X’s readiness to begin exposure. We sketched out a hierarchy of feared thoughts and situations. The hierarchy was based on level of anxiety experienced if the usual ritual (e.g., rationalizing, thought replacement) was prohibited along with avoidance strategies (e.g., keeping his hands in his pockets at all times, avoiding looking at his grandchildren’s necks, avoiding touching them).We identified situations in which experiencing the impulse would be moderately upsetting, quite upsetting, and overwhelmingly upsetting (e.g., having the impulse while in his home near knives with the children absent versus present). Mr. X was asked to flesh out the hierarchy during the next week and to be prepared to begin exposure in the next session.

The following week, Mr. X was ready to engage in exposure. He wrote out all of his thoughts related to the impulse to stab his grandchild on a sheet of paper, the least anxiety evoking thought ("Pick up a knife") followed by the most ("Kill Y[grandchild’s name]"). Mr. X read the first sentence aloud over and over again. He was encouraged to attend to the meaning of every word rather than simply recite the words automatically. Mr. X had significant difficulty doing so at first, shaking visibly, his voice trembling and his brow sweating. However, after about 15 repetitions he began to feel bored and his mind began to wander. He then read the next sentence in the list aloud over and over again, and, so on until he reached the most difficult sentence. Throughout the therapist acted as coach and facilitator, keeping Mr. X focused on the source of his anxiety, taking anxiety ratings, and making encouraging statements such as "You’re doing really well. If you can keep going this exercise is really going to pay off for you."

At the end of the session we processed his progress, specifically discussing what about these stimuli had changed that he could tolerate them with considerably less anxiety. Mr. X reported that he was beginning to believe that the thoughts might just be thoughts rather than prophetic warning signs or indications of character flaws. As such, he was not as afraid of them or the consequences of speaking them aloud. For homework Mr. X was asked to begin exposure to the next items in his hierarchy (while continuing to practice the items handled that day). These included staying in the same room as his grandchildren, handling knives when his grandchildren were absent, and wearing something red without attempting to preempt or suppress thoughts the color triggered.

In the next session, Mr. X reported that he had had initial success with the exposure but found it more difficult if he had recently seen or was soon to see his grandchildren. Mr. X reported that he had become increasingly concerned that speaking his thoughts aloud would lead him to lose control and act on the thoughts. He also became concerned that speaking the thoughts aloud might make the act seem more palatable or attractive, given that he might actually have psychopathic tendencies. He found himself retreating to the more cautious strategy of avoiding the thoughts rather than risking harm to his grandchildren by expressing the thoughts aloud. Mr. X said that if he knew certainly he was not a psychopath he would be able to practice exposure without fear.

We did some cognitive restructuring about Mr. X’s perceived need for 100% certainty that he was not a homicidal maniac before he would feel fully safe in having the thoughts. We acknowledged that we did not know for certain that the probability of him being a homicidal maniac was 0%, just as we did not know absolutely that his wife or his neighbor was not a homicidal maniac. We pointed out that the difference between people who have OCD and those who do not have OCD is that the latter are able to live in accordance with the obvious balance of probabilities and dismiss as unimportant the potential for events of very low probability. As a result, people who do not have OCD are able to accept educated risks and not organize their life around fending off negative events of minute probability. We drew up an agreement that from this point forward Mr. X would act according to the balance of probabilities. For example, he would behave as if he were not a homicidal maniac and therefore did not need to take precautious to protect others from his potential actions.

We agreed to address Mr. X’s other concerns during exposure and in his homework for the upcoming week. Mr. X had taken in some articles that were red and read aloud the thoughts about harming his grandchildren while looking at or holding the items. Mr. X was asked to keep track of how much he wanted to stab his grandchildren as he read aloud the thoughts. Over the course of the exposure exercise Mr. X reported no change in his desire to commit the murderous act: that is, his desire to stab his grandchild was absolutely and confidently zero, although he had spoken aloud the thoughts many times. To address Mr. X’s concern that having the thoughts increased the likelihood of harm to his grandchild we asked him to spend the next week trying to make himself win the lottery by thinking about winning it. Finally, to address his concern that having thoughts about an inappropriate act led to loss of control over behavior, we asked Mr. X to go to a grocery store and try to make himself lose control by thinking about yelling something inappropriate. Mr. X was also to continue exposing himself to the color red, to read the newspaper without avoiding articles describing violence, and to continue reading aloud his thoughts.

At the next session Mr. X reported that he had been unsuccessful in winning the lottery and unsuccessful in embarrassing himself in the grocery store. He also found that he was able to tolerate news stories about violence and that he was now quite bored reading his thoughts aloud. In this and the next several sessions, Mr. X continued his exposure to thoughts, gradually decreasing his avoidance and increasing the level of risk he was willing to take. He took sharp implements to the session, starting with a paring knife and eventually an axe, and read aloud his thoughts about violence while handling the implements. Between sessions he allowed himself to experience the thoughts in the presence of his grandchildren and eventually he was able to have the thought of stabbing his grandchild while chopping food in the kitchen while his grandchild was present. Mr. X also began to interact with his grandchildren much more and agreed to stay with them even when no other adult was present. Mr. X began to watch action shows on television and was able to rent violent movies.

Outcome and Progress
By session 16, Mr. X worried far less about having the thoughts and impulses involving stabbing and found that he no longer had the need to try to preempt their occurrence. His ability to concentrate improved, and he was able to reengage in many of the activities that were previously too difficult. As Mr. X’s range of activities increased, he noticed that the thoughts occurred far less frequently and when they did occur they required little or no response from him. Mr. X was finally able to enjoy his grandchildren again without concerns that he was a danger to them. His score on the Y-BOCS was now in the nonclinical range.

Clinical Issues and Summary
Mr. X reported obsessions of stabbing his grandchildren. At the time of treatment he was unable to spend time with them and was preoccupied with attempts to suppress and control his obsessions. Cognitive restructuring targeted beliefs that having the thought meant he was a psychopath, that the more he had the thought the more in danger he was of losing control and acting on it, and that having the thought meant he was immoral. This work was complemented by exposure to the obsessions themselves (note, not exposure to the idea of his grandchildren’s being murdered) and to situations, people, colors, and objects he currently avoided in order to prevent the obsessions. Mr. X was highly responsive to treatment; his symptoms were nonclinical by the end of treatment.
-Purdon, Christine. Wiley Periodicals, Inc. J Clin Psychol/In Session 60, 2004.

Personal Reflection Exercise #10
The preceding section contained information about cognitive-behavioral treatment of repugnant obsessions. Write three case study examples regarding how you might use the content of this section in your practice.

Update
Neurobiological Outcomes of Cognitive
Behavioral Therapy for Obsessive-Compulsive
Disorder: A Systematic Review

Poli, A., Pozza, A., Orrù, G., Conversano, C., Ciacchini, R., Pugi, D., Angelo, N. L., Angeletti, L. L., Miccoli, M., & Gemignani, A. (2022). Neurobiological outcomes of cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review. Frontiers in psychiatry, 13, 1063116. https://doi.org/10.3389/fpsyt.2022.1063116

Peer-Reviewed Journal Article References:
Curling, L., Kellett, S., & Totterdell, P. (2018). Cognitive analytic therapy for obsessive morbid jealousy: A case series. Journal of Psychotherapy Integration, 28(4), 537–555.

Liggett, J., & Sellbom, M. (2018). Examining the DSM-5 alternative model of personality disorders operationalization of obsessive–compulsive personality disorder in a mental health sample. Personality Disorders: Theory, Research, and Treatment, 9(5), 397–407.

Olatunji, B. O., Ebesutani, C., & Tolin, D. F. (2019). A bifactor model of obsessive beliefs: Specificity in the prediction of obsessive-compulsive disorder symptoms. Psychological Assessment, 31(2), 210–225.

QUESTION 17
What four beliefs caused Mr. X’s obsessional thought to evoke enormous distress? To select and enter your answer go to Test.

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