Cognitive Pearl #034 Tevet 28, 5775 January 19, 15

The cognitive approach to OCD involves three overlapping objectives:

1) Containing the obsessions and compulsions

2) Neutralizing and then ultimately eradicating them

3) Relapse prevention.

These need not be sequential objectives; in most cases, at least in my experience, clients go through these phases in different levels of intensity throughout their treatment and beyond.

Let’s consider containing the obsessions and compulsions. The nature of OCD is that it takes over the client’s sense of self. Clients often speak of ‘losing their mind’. What they mean is that the most intimate parts of who they are, their mind and the their thoughts1, have been ‘invaded'; they feel out of control. Needles to say it’s terribly frightening.

So we begin to restore order. Collecting data almost always has a calming effect on clients especially if in doing so we establish an order. Regardless of the reason for the consultation, I use a prepared form that the client helps me complete. The form has three effects: it reminds me to ask items which I might forget: it creates a third party so to speak in the room; and it lets the client see that there is method and structure.

In situations in which it is apparent that OCD is the presenting problem, I use different forms of the Yale-Brown Obsessive Compulsive Scale. At the beginning of treatment I a brief checklist (here). By the third or fourth session I usually use the full length interview (here). This second step further teases out nuances and data that the brief screening tool doesn’t collect. With this information we can design interventions and prioritize which symptoms come first. Most importantly, it helps me determine if other interventions are needed.

Ultimately, the goal of all of this data collection is to help the client feel a sense of order in the disorder. The client will hopefully begin to find some solid ground underneath their feet again. They often find comfort in these beliefs:

There is an illness.

The illness has invaded my life.

Others have been effected by this illness; I am not alone.

The illness will go away with treatment.

Certain dimensions of my life have become infected by this illness. As treatment progresses I will feel more in control over those dimensions. An important part of my treatment will be to boss back this illness so that I can feel in control again.

In the next pearl we’ll touch on some of the supporting characters that play a big role in assessment, treatment, and healing.

Blessings to all!