WELCOME. OBSESSIVE COMPULSIVE DISORDER (OCD) WORKSHOP Session 1 OCD Workshop QUESTIONNAIRES AIMS OF SESSION. Keeping Safe GROUP STRUCTURE

Transcription

1 WELCOME OBSESSIVE COMPULSIVE DISORDER (OCD) WORKSHOP Session 1 OCD Workshop Housekeeping -fire exits, toilets, refreshments Introductions, who we are Congratulations on making it this far! CBT approach AIMS OF SESSION Introduction to OCD workshop and its structure Familiarise yourself with group work Definitions of Obsessions and Compulsions QUESTIONNAIRES PHQ-9 scoring on Q9 GAD-7 W&SA OCI Why we use them How often we use them Keeping Safe This course is a psycho education course not group therapy and we are not able to discuss individual problems with you You do not need to discuss anything in the group which may cause you distress If you feel unable to stay in the session please speak to one of the facilitators GROUP STRUCTURE Weekly from pm (with a 10 min break) but not in any school holidays, Psycho-educational group not a therapy group We are not here to get rid of OCD but to learn about it and ways to cope with it Weekly tasks to complete in between sessions Weekly attendance 1

2 ICE BREAKER GROUP CONTRACT Flipchart exercise: What rules would you like the group to agree on over the next eight weeks? INTRODUCTION TO THE WORKSHOP Week 1: Introduction & what is OCD? Week 2: Introduction to CBT and Anxiety Week 3: Motivation to Change & The OCD Model Week 4: Identifying and challenging misinterpretations of intrusive thoughts Week 5: CBT Models for OCD Week 6: Conducting Exposure Week 7: Resistance to Overcoming OCD Week 8: Valued Directions HOPES AND FEARS Flipchart exercise What are some of your hopes for this course What are some of your fears about this course BREAK WHAT CAN HELP? The prospects for suffers of OCD have improved dramatically since the 1970 s. With modern psychological treatment, the majority of people with OCD symptoms will greatly improve within months of treatment and will remain well. Cognitive Behaviour Therapy (CBT) is generally agreed to be the most effective treatment currently available for OCD either alone or in combination with medicine. 2

3 Each person is different but generally Obsessive thoughts and Compulsive behaviour tend to be present Men and women equally suffer with OCD Triggers vary considerably WHAT ARE OBSESSIONS? Recurrent and persistent thoughts (or impulses or images) that cause marked anxiety or distress and are experienced as intrusive and inappropriate. These thoughts are not simply excessive worries about real-life problems. The person attempts to ignore or suppress these thoughts or tries to neutralise them with some other thought or action. The person recognises that the obsessional thoughts are a product of their own mind (not imposed by somebody else). WHAT ARE COMPULSIONS? Repetitive behaviours or mental acts that: the person feels driven to perform in response to an obsession, or according to rules which must be applied rigidly. are aimed at preventing or reducing distress or preventing some dreaded event or situation either are not connected in a realistic way with what they are designed to neutralise or prevent, or are clearly excessive. WHAT EXAMPLES CAN YOU THINK OF FOR Obsessions Compulsions Obsessions Aggression or injurious obsessions Contamination Sexual Religious Need for symmetry Somatic/body Compulsions Checking Washing/cleaning Repetition Counting Ordering Hoarding and collecting Correcting thoughts Irrational /magical rituals Mental compulsions SUMMARY OF SESSION Introduction to OCD workshop and its structure Familiarise yourself with group work Questionnaires Definitions of obsessions and compulsions 3

4 HOMEWORK What is the one thing that you can take away from this session? Use the symptom list to note your obsessions compulsions AIMS OF SESSION INTRODUCTION TO CBT AND ANXIETY Review of Homework Introduction to the general CBT model Learn about Anxiety Session 2 OCD Workshop REVIEW OF LAST WEEK Review of session content any questions? Review of homework tasks OCD symptoms list INTRODUCTION TO CBT Cognitive Behaviour Therapy (CBT) focuses on the thoughtsand images that we have (obsessions) feel (emotions such as anxiety) how these influence our behaviours (including compulsions) physicallyreact (for example shortness of breath). 4

5 Thoughts Thoughts Obsessions Example Physical Reactions Emotions Physical Reactions Example Mood Example Behaviours Behaviours Compulsions Example O.C.D CAN AFFECT OUR: Thinking Obsessional and intrusive Thought action fusion (TAF) negative thoughts Feelings Anxiety/Fear Guilt/Shame Behaviour Compulsions overt and covert Avoidance Physical sensations Rapid breathing Increased heart rate EXERCISE Do your own hot cross bun Feed back to group if you want to BREAK WE NEED ANXIETY Fight, Flight or Freeze 5

6 WE NEED ANXIETY SMALL GROUP EXERCISE What are the symptoms / physical sensations associated with anxiety SUMMARY OF SESSION Review of Homework Introduction to the general CBT model Learn about anxiety and how it fits into the CBT model Homework setting anxiety diary HOME WORK ANXIETY DIARY Anxiety diary Date & Time Situation Anxie Thoughts ty rating What went through my (0-10) mind before I started to feel this way? Any images? Physical feelings What did I do to cope? Anxiety rating (0-10) 6

7 ANY QUESTIONS? MOTIVATION TO CHANGE AND THE OCD MODEL Week 3 OCD Workshop REVIEW OF LAST WEEK Review of session content any questions/queries? Review of homework task anxiety monitoring diary sheet AIMS OF SESSION Be aware of own motivation to change Appreciating your support network Goals Introducing an OCD Model used in CBT Motivation to Change Whiteboard exercise Pros/benefits Cons/costs EXERCISE In pairs fill in your motivation to change sheet Feed back to whole group Staying the same Changing 7

8 CYCLE OF CHANGE Where do you think you are in the Cycle of Change? Adapted from Prochaska and DiClemente (1986) SUPPORT NETWORKS Importance of support what you need A supportive person is someone who is willing to remind you of your motivation to change and be there to encourage you to keep going even when it gets tough It could be your partner, a friend, a colleague etc. GOALS S specific M measurable A achievable R realistic T Timed Example: I will reduce my hand washing from 10 times a day to 3 times a day by the end of this course. Set yourself one goal to be achieved by the end of the course BREAK OCD MODEL The models used in CBT are evidence based & recommended by the NICE guidelines They are a framework that are used to understand our difficulties This looks at how our experiences in life may have contributed to our current symptoms 8

9 Early Experience Life Events Stella s Story Assumptions Intrusive Thoughts Salkovskis, Forrester & Richards (1998) 5 minutes to read story Start thinking about how her story fits into the model Compulsions Own Interpretation of Intrusions: Attention and Reasoning Bias Safety Strategies (suppressing thoughts, avoidance) Changes in Mood Early Experiences Stella s mother very concerned about cleanliness Assumptions If I don t clean, children will get ill Life Events Injured herself and had to get a tetanus injection Salkovskis, Forrester & Richards (1998) HOMEWORK Use the model we applied to Stella s story on yourself Compulsions Ritual Cleaning Safety Strategies Overprotective Intrusive thoughts Image of child hooked up to monitors in ICU Own interpretations of intrusions If my house is unclean my children will definitely get ill and it will be my fault Attention/reasoning bias Constant worry Mood Anxiety Guilt, Panic ANY QUESTIONS? OBSESSIVE THOUGHTS AND IMAGES Week 4 OCD Workshop 9

10 REVIEW OF LAST WEEK Review of session content any questions or queries? Review of homework tasks: -Models or formulation (we ll add to this throughout the evening) AIMS OF SESSION Explore interpretations of obsessive thoughts and images Identifying unhelpful thinking styles Theory A and Theory B WHAT ARE INTRUSIVE THOUGHTS? Whiteboard exercise: Think of some examples of intrusive thoughts (these do not have to be your own) EXAMPLES OF INTRUSIVE THOUGHTS To hurt or harm someone (impulse) To say something nasty and damning to someone (impulse) Did I commit this crime? (thought) Images of self acting violently or sexually in an inappropriate way (thoughts) Mental picture of family member dead (image) THOUGHTS AND OCD INTRUSIVE THOUGHTS& THEIR MISINTERPRETATIONS People with OCD are very anxious to get rid of their intrusive thoughts because of the anxiety the thought causes Research suggests that individual thoughts are not the problem The problem is the misinterpretation of these thoughts or images as being abnormal, unacceptable or dangerous. I might hurt or harm someone... I m going to say something nasty or damning to someone I might crash when I m driving...this means I am a bad person for having this thought this means I m a nasty uncaring person this means I am dangerous and need to stay away from driving 10

11 INTRUSIVE THOUGHTS& THEIR MISINTERPRETATIONS What if I stole something when I was shopping and didn t realise. Mental image of family member dead.. this must mean I m going crazy.this must mean I want something bad to happen to them I must be an awful person What do your thoughts or images mean to you? Complete worksheet to be able to identify the thought and your misinterpretation of the thought. Mental image of self harming or abusing a child.this means I m going to do it I must be a paedophile Early Experiences Stella s mother very concerned about cleanliness Life Events Injured herself and had to get a tetanus injection Early Experiences Very strict religious upbringing Life Events Social worker involved in child protection cases Assumptions If I don t clean, people will get ill Salkovskis, Forrester & Richards (1998) Assumptions People can commit terrible crimes Salkovskis, Forrester & Richards (1998) Compulsions Washing, Cleaning, Checking Intrusive thoughts Image of child hooked up to monitors in ICU Own interpretations of intrusions If my house is unclean my children will definitely get ill and it will be my fault Attention/reasoning bias Constant worry Compulsions Leaving the room If alone with a child, Reassurance seeking Intrusive thoughts Image of self abusing a child Own interpretations of intrusions I m a bad person, I m a paedophile Attention/reasoning bias Constant worry Safety Strategies Drinking Overprotective Mood Anxiety Guilt, Panic Safety Strategies Not having children Mood Anxiety Guilt, Panic BREAK Update your own formulation? 11

12 OVERESTIMATION OF IMPORTANCE OF THOUGHTS Thoughts are just thoughts Thoughts are assumptions and not necessarily factual information They are randomly generated like the lottery balls chosen from the machines Over the years, we tend to get into unhelpful thinking habits. THINKING BIASES Black & White Thinking Magical Thinking (because I ve thought it it s more likely to happen) Absolute Thinking (longing/searching for 100% certainty) Thought-Action Fusion (thinking something is the same as doing it) IN PAIRS... Explore your own unhelpful thinking styles. What do you think are Stella s biases? Challenging our Interpretations In order to challenge the interpretation you can treat it like a research experiment. Step 1 is coming up with an alternative hypothesis Step 2 to find evidence or test the theory out Thought / Obsession: I will harm my daughter Theory A This thought is dangerous because it may cause me to actually hurt her, even though I don t want to This means I must be a bad person for thinking like this and I MUST do something about it Theory B This is just a thought...its not fact This is my OCD talking to me Having this thought does not mean anything about me, its just an example of thinking biases This thought makes me feel anxious but there is no danger here. I don t need to respond to the thought. What are your Theory A and Theory B? 12

13 Thought/image - Obsession: SUMMARY OF SESSION Theory A Theory B Exploring Intrusive Thoughts Developing alternatives to the intrusive thoughts & their misinterpretations ANY QUESTIONS? HOMEWORK Complete the Theory A & Theory B worksheet Complete intrusive thoughts monitoring diary ANXIETY DIARY Date & Time Situation Anxie Intrusive ty Thoughts/Images rating (0-10) What went through my mind before I started to feel this way? Any images? Misinterpretation.THEO RY A What does this mean about me? Are there any thinking biases occurring here? CHALLENGING MISINTERPRETATIONS OF INTRUSIVE THOUGHTS Week 5 OCD Workshop 13

14 REVIEW OF LAST WEEK & HOMEWORK TASKS Review of session content any questions/queries? Review of homework tasks 1) theory A & theory B write your own; completing intrusive thoughts monitoring diary AIMS OF SESSION Challenging interpretations Thought Challenging Record with theory A & theory B Responsibility Pie Charts Hierarchies FROM THOUGHTS TO INTERPRETATIONS In OCD, it is important to focus on the interpretations of thoughts not the thoughts themselves Example: Thought: I need to wash my hands otherwise my family will die. Interpretation: I am responsible for my family s health and well being. THOUGHT CHALLENGING RECORD Situation Unwanted Thought (Intrusion) Interpretation (rate strength in belief) THEORY A Evidence for the inter- pretation Evidence against the interpretation (any thinking biases?) New Interpretation (rate strength in belief) THEORY B CHALLENGING INTERPRETATIONS OF ANXIOUS THOUGHTS What questions can you think of which would help you to challenge you interpretations? CHALLENGING INTERPRETATIONS OF ANXIOUS THOUGHTS The following questions can help us challenge our unhelpful thoughts: Why did I have this thought? Is there an alternative explanation? What is the evidence for and against this interpretation? If a friend had this thought, what would I say to them? Am I getting things out of proportion? What would other people think in this situation? Are my thoughts predicting the future in an unhelpful way? Am I trying to read other people s minds? Is this another example of my typical negative thinking? What s the worst that could happen? Could I cope with that? 14

15 GROUP EXERCISE: THOUGHT CHALLENGING RECORD BREAK Situation Unwanted Thought (Intrusion) Interpretation (rate strength in belief) THEORY A Evidence for the inter- pretation Evidence against the interpretation (any thinking biases?) New Interpretation (rate strength in belief) THEORY B RESPONSIBILITY PIE CHART Group exercise RESPONSIBILITY PIE CHART Step 1 Chose an event that has happened or which you dread might happen. Step 2 Give an estimate of how responsible you are for it. Use a percentage; 0% = not responsible, 100% =totally responsible. Step 3 Make a list of all of the other contributory factors which might have influenced the outcome. Step 4 Draw the pie and allocate a segment to each contributory factor, except your own. The size of each segment should roughly represent the proportion of responsibility allocated to the factor. Step 5 Give each segment a percentage value, being careful not to exceed 100% for the total pie. Step 6 Using the pie add up the segments and take the result away from 100. This is your contribution! GRADED HIERARCHIES Have a look at the handouts & see if you can start to write your own graded hierarchies SUMMARY OF SESSION Feedback on your homework Challenging interpretations Thought Challenging Record Responsibility Pie Charts Hierarchies 15

16 HOMEWORK Complete your own responsibility pie chart Complete your hierarchies -identify the least anxiety provoking trigger/situation Use your thought challenging record with your least anxiety provoking trigger or situation either: straight after you have completed your compulsion, or just before your do your compulsion. OCD WORKSHOP MANAGING EXPOSURE TO FEARED SITUATIONS IN OCD Week 6 OCD Workshop REVIEW OF LAST WEEK & HOMEWORK TASKS Review of session content any questions/queries? Review of homework tasks a) complete your own responsibility pie chart; b) complete your hierarchies -identify the least anxiety provoking trigger/situation; c) use your thought challenging record with your least anxiety provoking trigger or situation either: straight after you have completed, or just before your do your compulsion AIMS OF THE SESSION Introduction to the rationale of exposure Start planning first exposure task BEHAVIOURAL APPROACH: OCD AS A LEARNED REACTION Whiteboard exercise Long term effect is that link is strengthened Link between Obsessions and Compulsions established Trigger Anxiety Increase Learning that compulsions/rituals brings short term Relief of anxiety Physical Reactions (heart beating, breathing faster etc.) Trigger Intrusive Thought (Obsession) Interpretation Compulsion or Avoidance Temporary Relief Emotion (Anxiety etc) 16

17 WHAT IS EXPOSURE AND RESPONSE PREVENTION (ERP)? Exposure: Exposing ourselves safely to situations which triggers our obsessions and compulsions. This will mean exposing ourselves to our feelings of anxiety - sitting with the anxiety/ride the wave of anxiety Response Prevention: resisting performing the compulsions that we would usually carry out to relieve the anxiety caused by this exposure. Aim of ERP We learn that if we ignore the compulsive urges, the intensity of the compulsions and the anxiety related to them lessens over time. This is called HABITUATION. This also reinforces our beliefs in Theory B.. Thoughts are just thoughts and cause anxiety, Any fears of negative consequences or even catastrophes occurring as a result of not carrying out compulsions are not reinforced. BEHAVIOURAL EXPOSURE AND RESPONSE PREVENTION (ERP) HOW DO WE DO EXPOSURE AND RESPONSE PREVENTION (ERP)? There are 3 key factors to effective ERP: 1. Gradual gradual confrontation to the fear using your graded hierarchies which grade the predicted anxiety triggered by the feared object/activity 2. Prolonged exposure must for sufficient time for your anxiety levels to reduce by at least 50% in the presence of the feared object/activity 3. Repeated more than once! Additional exposure cements improvement PLANNING ERP TASKS EXPOSURE & RESPONSE PREVENTION GRADUAL Find the situation with a compulsion which you rated with the lowest amount of imagined anxiety on your graded hierarchy Plan a time when you can expose yourself to this trigger/obsession when you will not use your compulsion to alleviate your anxiety Ensure that you are able to do this WITHOUT DISTRACTION exposure yourself to the anxiety without distractions (family members, TV, radio anything which can take your mind off the anxiety) PROLONGED stay with the trigger until your anxiety reduces by itself by at least 50% Record your exposure task REPEATED repeat this regularly practice every day if possible. Move up the hierarchy to the next step when you feel you are used to the anxiety and feel comfortable coping with it without using your compulsions SAMPLE HIERARCHY FOR CONTAMINATION FEAR AND WASHING COMPULSION Situation/steps Level of anxiety Sleep with shoe in bed 100 Go to bed without showering 90 Take out rubbish end then eat dinner 85 Use public toilet and wash hands for 30 seconds 75 Touch pavement hands flat 60 Touch office floor hands flat 45 Touch Living room floor hands flat 40 Drink from drinks can without wiping it 30 17

18 BREAK What may stop you from starting ERP? RESISTANCE TO ERP Concealment Shame Guilt Anger Pride Depression Putting too much importance/value on our thoughts- it s a sin to have the thought-i will be punished. I am bad. Exaggerated sense of responsibility Fears of failure of others reactions of treatment wanting certainty Pessimism I ve tried it before and. My OCD is different Delaying starting (procrastination) What could help to overcome your resistance? WAYS TO HELP OVERCOME RESISTANCE Be patient Keep records of your progress Take small steps Reward yourself! Don t give up if you have setbacks Stay focussed on the long-term view-keep weeding your OCD Involve others Find someone to talk to about it. Get started and start exposure Make exposures long enough for your anxiety to reduce of its own accord Resist rituals to reassure you if you can t resist, start by delaying the rituals and then build up to resisting completely. Keep healthy Fill the gap Make life worth living.. SUMMARY OF THE SESSION Feedback on your homework The rational of Exposure & response prevention (ERP) How to start ERP planning and actioning Resistance to ERP & how to overcome it 18

19 HOMEWORK ANY QUESTIONS? Start exposure & response prevention at the lowest level of your graded hierarchy Keep a diary to record this exposure and the outcome of it AIMS OF THE SESSION OCD WORKSHOP MANAGING EXPOSURE TO FEARED SITUATIONS IN OCD CONTINUED Week 7 OCD Workshop Review your homework ERP graded hierarchy Continue with exposure response prevention planning the next weeks tasks REVIEW OF LAST WEEK Review of session content any questions/queries? Review of homework tasks graded hierarchies What are your.. Successes Problems Hitches GRADED HIERARCHY 19

20 LEARNING POINTS FROM YOUR HOMEWORK TASKS BEHAVIOURAL EXPOSURE AND RESPONSE PREVENTION (ERP) What did you learn about Your anxiety symptoms? Your thoughts & thought patterns? WHAT IS EXPOSURE AND RESPONSE PREVENTION (ERP)? Exposure: Means exposing yourself to your feelings of anxiety sitting with the anxiety/ride the wave of anxiety Response Prevention: in connection with Exposure, means not acting on the impulse to carry out your normal compulsion or to avoid the anxiety HOW DO WE DO EXPOSURE AND RESPONSE PREVENTION (ERP)? There are 4 key factors to effective ERP: 1. Gradual gradual confrontation to the fear using your graded hierarchies which grade the predicted anxiety triggered by the feared object/activity 2. Prolonged exposure must for sufficient time for your anxiety levels to reduce by at least 50% in the presence of the feared object/activity 3. Repeated more than once! Additional exposure cements improvement 4. Without distraction to experience a reduction in anxiety you must feel some fear at first in order to experience and learn the anxiety reduces naturally in the presence of the feared object or situation EXPOSURE & RESPONSE PREVENTION PLANNING ERP TASKS BREAK GRADUAL Find the compulsion which you rated with the lowest amount of imagined anxiety (if you didn t do this compulsion) on your graded hierarchy Plan a time when you can expose yourself to this trigger/obsession when you will not use your compulsion to alleviate your anxiety (response prevention) Ensure that you are able to do this WITHOUT DISTRACTION exposure yourself to the anxiety without distractions (family members, TV, radio anything which can take your mind off the anxiety) PROLONGED stay with the trigger until your anxiety reduces by itself by at least 50% Record your exposure task in the diary sheets REPEATED repeat this regularly practice every day if possible and only move up the hierarchy to the next step when you feel you are used to the anxiety and feel comfortable coping with it without using your compulsions 20

21 HOMEWORK Continue with your ERP tasks OCD WORKSHOP Putting it all together Week 8 OCD Workshop AIMS OF THE SESSION Feedback from last session & h/wk feedback Course overview Review goals set at start of course Therapy Blueprint Questionnaires Next Steps. Questionnaires IAPT questionnaire OCI 2 Course Evaluations REVIEW OF LAST WEEK Review of session content any questions/queries? Review of homework tasks ERP and Valued Directions WHAT ARE OBSESSIONS? Recurrent and persistent thoughts (or impulses or images) that cause marked anxiety or distress and are experienced as intrusive and inappropriate. These thoughts are not simply excessive worries about real-life problems. The person attempts to ignore or suppress these thoughts or tries to neutralise them with some other thought or action. The person recognises that the obsessional thoughts are a product of their own mind (not imposed by somebody else). 21

22 WHAT ARE COMPULSIONS? Repetitive behaviours or mental acts that: the person feels driven to perform in response to an obsession, or according to rules which must be applied rigidly. are aimed at preventing or reducing distress or preventing some dreaded event or situation either are not connected in a realistic way with what they are designed to neutralise or prevent, or are clearly excessive. Obsessions Fearful thoughts or pictures Frightening thoughts/images Internal images Things out of place Doubting images Compulsions Checking Washing Avoidance Correcting thoughts Irrational tasks O.C.D CAN AFFECT OUR: Thinking obsessions negative thoughts Feelings anxiety guilt Behaviour Compulsions Avoidance Physical sensations Rapid breathing Increased heart rate WE NEED ANXIETY Fight, Flight or Freeze ANXIETY DIARY Motivation to Change Date & Time Situation Anxie Thoughts ty rating What went through my (0-10) mind before I started to feel this way? Any images? Physical feelings What did I do to cope? Anxiety rating (0-10) Whiteboard exercise Pros/benefits Cons/costs Staying the same Changin g 22

23 CYCLE OF CHANGE S specific M measurable A achievable R realistic T Timed GOALS Adapted from Prochaska and DiClemente (1986) Example: I will not eat any cakes for the next month Set yourself one goal to be achieved by the end of the course Early Experiences Stella s mother very concerned about cleanliness Life Events Injured herself and had to get a tetanus injection INTRUSIVE THOUGHTS& THEIR MISINTERPRETATIONS Compulsions Washing, Cleaning, Checking Safety Strategies Drinking Overprotective Assumptions If I don t clean, children will get ill Intrusive thoughts Image of child hooked up to monitors in ICU Own interpretations of intrusions If my house is unclean my children will definitely get ill and it will be my fault Salkovskis, Forrester & Richards (1998) Attention/reasoning bias Constant worry Mood Anxiety Guilt, Panic I might hurt or harm someone... I m going to say something nasty or damning to someone I might crash when I m driving...this means I am a bad person for having this thought this means I m a nasty uncaring person this means I am dangerous and need to stay away from driving INTRUSIVE THOUGHTS& THEIR MISINTERPRETATIONS OVERESTIMATION OF IMPORTANCE OF THOUGHTS What if I stole something when I was shopping and didn t realise. Mental image of family member dead.. this must mean I m going crazy.this must mean I want something bad to happen to them I must be an awful person Thoughts are just thoughts They are randomly generated link the lottery balls chosen from the machines 23

24 THINKING BIASES Black & White Thinking Magical Thinking (because I ve thought it it s more likely to happen) Absolute Thinking (longing/searching for 100% certainty) Thought-Action Fusion (thinking something is the same as doing it) Physical Reactions (heart beating, breathing faster etc.) Trigger Intrusive Thought (Obsession) Interpretation Compulsion or Avoidance Emotion (Anxiety etc) Temporary Relief DEVELOPING ALTERNATIVES The alternative explanation is that the danger is not as great as you think, but rather you are just a person who is extremely worried about harm and danger, i.e. that the interpretation of the thought is not true. BEHAVIOURAL APPROACH: OCD AS A LEARNED REACTION Whiteboard exercise Long term effect is that link is strengthened Trigger Anxiety Increase We label our interpretations as Theory A and the alternative Theory B Link between Obsessions and Compulsions established Learning that compulsions/rituals brings short term Relief of anxiety Thought / Obsession: I will harm my daughter ANXIETY DIARY Theory A This thought is dangerous because it may cause me to actually hurt her, even though I don t want to This means I must be a bad person for thinking like this and I MUST do something about it Theory B This is just a thought...its not fact This is my OCD talking to me Having this thought does not mean anything about me, its just an example of thinking biases.thought-action action fusion This thought makes me feel anxious but there is no danger here Date & Time Situation Anxie Intrusive ty Thoughts/Images rating (0-10) What went through my mind before I started to feel this way? Any images? Misinterpretation.THEO RY A What does this mean about me? Are there any thinking biases occurring here? 24

25 Situation THOUGHT CHALLENGING RECORD Unwanted Thought (Intrusion) Interpretation (rate strength in belief) THEORY A Evidence for the inter- pretation Evidence against the interpretation (any thinking biases?) New Interpretation (rate strength in belief) THEORY B CHALLENGING INTERPRETATIONS OF ANXIOUS THOUGHTS The following questions can help us challenge our unhelpful thoughts: Why did I have this thought? Is there an alternative explanation? What is the evidence for and against this interpretation? If a friend had this thought, what would I say to them? Am I getting things out of proportion? What would other people think in this situation? Are my thoughts predicting the future in an unhelpful way? Am I trying to read other people s minds? Is this another example of my typical negative thinking? What s the worst that could happen? Could I cope with that? RESPONSIBILITY PIE CHART SAMPLE HIERARCHY FOR CONTAMINATION FEAR AND WASHING COMPULSION Situation/steps Level of anxiety Sleep with shoe in bed 100 Go to bed without showering 90 Take out rubbish end then eat dinner 85 Use public toilet and wash hands for 30 seconds 75 Touch pavement hands flat 60 Touch office floor hands flat 45 Touch Living room floor hands flat 40 Drink from drinks can without wiping it 30 WHAT IS EXPOSURE AND RESPONSE PREVENTION (ERP)? Exposure: Means exposing yourself to your feelings of anxiety sitting with the anxiety/ride the wave of anxiety Response Prevention: in connection with Exposure, means not acting on the impulse to carry out your normal compulsion or to avoid the anxiety Aim of ERP We learn that if we ignore the compulsive urges, the intensity of the compulsions and the anxiety related to them lessens over time. This is called HABITUATION. This also reinforces our beliefs in Theory B.. Thoughts are just thoughts and cause anxiety, Any fears of negative consequences or even catastrophes occurring as a result of not carrying out compulsions are not reinforced. 25

26 BEHAVIOURAL EXPOSURE AND RESPONSE PREVENTION (ERP) HOW DO WE DO EXPOSURE AND RESPONSE PREVENTION (ERP)? There are 3 key factors to effective ERP: 1. Gradual gradual confrontation to the fear using your graded hierarchies which grade the predicted anxiety triggered by the feared object/activity 2. Prolonged exposure must for sufficient time for your anxiety levels to reduce by at least 50% in the presence of the feared object/activity 3. Repeated more than once! Additional exposure cements improvement Concealment Shame Guilt Anger Pride Depression RESISTANCE TO ERP Putting too much importance/value on our thoughts- it s a sin to have the thought-i will be punished. I am bad. Exaggerated sense of responsibility Fears of failure of others reactions of treatment wanting certainty Pessimism I ve tried it before and. My OCD is different Delaying starting (procrastination) WAYS TO HELP OVERCOME RESISTANCE Be patient Keep records of your progress Take small steps Reward yourself! Don t give up if you have setbacks Stay focussed on the long-term view-keep weeding your OCD Involve others Find someone to talk to about it. Get started and start exposure Make exposures long enough for your anxiety to reduce of its own accord Resist rituals to reassure you if you can t resist, start by delaying the rituals and then build up to resisting completely. Keep healthy Fill the gap Make life worth living.. BREAK Reviewing goals What goals did you set at the start of this course? Have you managed to achieve these goals? What new goals would you like to set for the next few months? 26

27 BLUEPRINT FOR THE FUTURE What have I learned? How can I build on this? What s my plan of action? What will make it difficult for me to put this Plan of Action into practice? How can I deal with these difficulties? What might lead to a setback? For example, stresses, life problems, relationships and so on. If I do have a setback, what will I do about it? Keep Jumping! 27