An Interview with Carol Edwards, by Tanya North

Can you describe briefly what cognitive behavioural therapy (CBT) is and how it works to treat a person who has obsessive compulsive disorder (OCD)?

Yes, CBT is a type of talking therapy that considers thoughts, behaviours and emotions and how these work together. For example, by changing a particular behaviour or faulty thinking style, emotions also change; as a result a person starts to experience more favourable outcomes. Basically, the cognitive side of therapy acts as the foundation for exposure response prevention (ERP) which is the behavioural part in CBT.

How does ERP work?

This is where a person faces their fears (obsessions) in small steps and agrees to resist doing their usual responses, which are the compulsions that negatively reinforce the problem. Resisting compulsions starves the obsession and leads to remission, or at least reduced symptoms.

How do you manage clients who put up a block or who are not responding to CBT for OCD?

First, if a client has been prescribed medication I would discuss with them the importance of pharmacological treatment and confirm that they are remembering to take their prescribed dose. If they are not on medication I would refer them back to their doctor for their advice.

What type of medication is usually prescribed and how do they work?

Typically these would be a selective serotonin reuptake inhibitor (SSRI) or the older tricylic anti-depressant known as Clomipramine. These medications are effective for passively altering brain chemistry, and research suggests they can reduce the symptoms of OCD by up to 60% for some people.

Can depression cause a block to a client’s engaging in cognitive behavioural therapy?

Yes, if it appears depression is causing the block and the client isn’t on medication then a referral to their doctor would be advised. An anti-depressant (SSRI) would usually be prescribed. This has two benefits – one to improve mood and two to reduce the OCD symptoms, as noted. If a client is already on medication and this is having little effect, then another SSRI might be prescribed, or augmenting might be discussed as an option.

Is it usually the case that a client takes a break from CBT therapy until their mood improves?

Sometimes this occurs and other times methods can be modified for a few weeks until the medication starts to improve a client’s mood.

Is it true that poor sleep hygiene, unhealthy diet and lack of exercise affects treatment adherence?

Yes, because these three things are important for maintaining healthy functioning and thinking clearly. The monitoring of these is part of the process in therapy.

Also the person’s environment can have benefits and drawbacks. Is that correct?

Yes, in many ways; for example, school, homelife, work etc. Each can make a difference either way.

What would the benefits and drawbacks be within the home environment, and in terms of recovering from OCD?

Educating the client’s family about what OCD is, how it works, and how treatment helps towards recovery can be a great help. So let’s say if a client has support at home where a family member can monitor time for reducing rituals instead of accommodating the rituals, then this would be a clear benefit. However, if there is little or no support then this drawback can be addressed by generating effective ways to carry out homework tasks for reaching desired goals and maintaining gains.

If the client still seems to be putting up a block against treatment, what else would you consider?

I would use motivational interviewing for working with the client to identify clearly their goals and how to reach these; and so basically they would put self-talk to action. A desire, ability, reason and need for making lower level change (commitment) would be the first step and then moving on to higher level change for reaching target goals would follow.

Can you expand on that?

Yes, motivational interviewing uses open questions that can help a person take the steps required for active change. This helps build a healthy self-esteem and raises confidence. Here are two examples on Motivational Interviewing.

Does cognitive therapy work without ERP for people who are hesitant about doing exposures?

To some degree, although cognitive therapy would usually include behavioural experiments. Also visual exposures and listening to exposure scripts on a loop tape can be introduced into cognitive therapy.

How do behavioural experiments work?

These help disprove a person’s hypothesis by gathering information and then discussing the findings in session. For example, if a client has a problem with a specific contamination fear we would discuss what their theory is and then look for “evidence for” and “evidence against” that theory. The person would then test their theory out and report back with the results.

And what about the visual exposures and exposure scripts, how do these work?

Visual exposures work similarly to live exposures. For the latter people face their obsession directly and resist the corresponding compulsions in-vivo. With visual exposures, a client envisions resisting compulsions whilst mentally facing their obsession. In doing this they bear with the anxiety as they would do if this were done in-vivo. Adding exposure scripts increases effectiveness. This is because the words for this are chosen carefully to drive the idea that accepting uncertainty is better than struggling with doubts. All these three things (behavioural experiments, visual exposures and exposure scripts) can work effectively with cognitive therapy when maintained.

How do you work with hoarders who are treatment resistant?

Well just to note, hoarding symptoms have been associated with poor adherence and a greater chance of refusing treatment, and so modified strategies would be implemented here. If adherence to therapy is still refused a referral for more advanced treatment would be looked into.

How does insight and pathological doubt play a part in non-adherence to treatment?

These would be taken into account during assessment; or at other times either (or both) would generally be revealed during the course of treatment. Gauging the level of insight and pathological doubt provide clues as to how CBT could work for each individual and to show whether this is likely to be effective or not.

See more here: Addressing Insight and OCD

Can overlapping conditions cause treatment resistance?

The possibility of co-morbid disorders such as generalised anxiety disorder, social phobia, somatization disorder and agoraphobia can increase the chance of a person opting out of therapy, and so extra resources may be needed here.

How effective is CBT treatment for people on the autism spectrum?

It is showing potential for people on the lower end of the spectrum (Asperger’s) by adapting strategies to target obsessive-compulsive symptoms. What needs teasing apart initially however are atypical obsessions, or better put, keen interests, often seen in people with Asperger’s. These are wanted and do not cause distress, unless prevented. In comparison, obsessions seen in OCD are unwanted and cause distress which is made worse if/when compulsions to prevent perceived harm (or to feel right/clean) cannot be carried out. Further, many people who have Asperger’s appear to have a more developed theory of mind than those on the higher end of the spectrum; thus, insight into the symptoms of OCD is more established; yet for people on the higher end of the spectrum emotion management would be more advisable than traditional CBT.

Why else is this?

Well since CBT looks at thoughts, feelings and behaviours and how these interact with each other; and autism considers the triad of impairments which are social communication, social interaction and social imagination, the view is that many autistic individuals do not understand that other people have their own plans, thoughts, and points of view. This refers to a theory of mind. If people on the autism spectrum have difficulty understanding other people’s beliefs, attitudes and emotions then cognitive therapy wouldn’t be helpful. A lack of insight into obsessive rituals means different levels of support are usually required; for example, emotion-management to prepare for change etc.

How do you work with pathological demand avoidance for children who have OCD?

I work with the child (and their family) to find what triggers their behaviours. This way, underlying difficulties come to the surface and can be addressed and monitored. It also helps to understand the outcome of certain situations and helps find strategies for healthier consequences. Non-negotiable boundaries that are non-personal can be helpful. For example, “Hygienically people are required to wash their hands once only after using the toilet; if people wash their hands more than once they can lose valuable time, get sore hands, and prolonged anxiety.” A reward that outweighs the urge/need to repeatedly handwash (or other compulsion) might follow. For instance, “Because you washed your hands once only for the past week, a lot of time has been saved, I can spend that time with you, what would you like to do, play a game, watch a movie, eat out?” Alternatively, “I have two hours free time, we can’t spend time together until you have finished washing your hands.” The child learns without noticeable intervention that some behaviours get pleasant rewards and some don’t.

What are your final words on treatment resistance?

In a nutshell, the points raised above would be factors to address and to rule out what isn’t causing non-adherence and to then see what is left to work with. If non-compliance or resistance to treatment remains then a referral back to the client’s doctor or other professional would be advised. For people on the autism spectrum adapted CBT methods are showing promise for people with Asperger’s; or emotion-management for people on the higher end of the spectrum. If any person has a lack of insight into their OCD then CBT with mindfulness and other modified strategies such as Acceptance Commitment Therapy (ACT) can be implemented. A reward system can help with PDA co-morbid with OCD.

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