13 In Chapter 12, we learned that CBGT for children with anxiety and depression is an effective form of treatment. This chapter, with its focus on youth obsessive–compulsive disorder (OCD), also emphasizes the benefits to adolescents, families, and society of “catching” early tendencies to develop a serious mental health problem. It can be near heartbreaking to listen to adults successfully treated with CBT for OCD wishing this had been available to them sooner, thus mitigating many painful years of suffering. OCD is a disorder which, similar to other mental health problems, often shows manifestations in childhood above and beyond normal OCD-look-alike behaviors. For example, it is normal for kids to have a high need for certain bedtime rituals being performed in exactly the same way and order every night. First, daddy reads the same story two times, then mommy chases away the monsters under the bed, and then daddy kisses good night tree times and mommy four times. It is also normal for children to engage in mildly superstitious obsessive thinking, such as “If I see three patterns of 3 s before entering my classroom, I will do well on my test.” For those kids who do not spontaneously outgrow these kinds of normal obsessions and compulsions around age 10 and become stuck at what could be termed a prerational stage of cognitive development, a lifelong battle with fears and senseless rituals can start (Söchting & March, 2002). In this chapter, I show how CBGT for OCD in youth is becoming a highly effective intervention for a potentially devastating and not well-understood disorder. I summarize relevant research and present a specific CBGT protocol. I am including this chapter because OCD is more serious and disabling than any other anxiety disorders (Kessler, Chiu, Demler, & Walters, 2005). It is as prevalent as schizophrenia (DSM-5, APA, 2013), yet far fewer treatment resources and public education are available. At most about 25% of youth with OCD receive mental health treatment (Whitaker et al., 1990). When young adults receive effective CBT, they are able to manage their OCD symptoms and prevent the illness from becoming more severe. Although this chapter focuses on CBGT for youth, many adults would benefit from the same treatment approach—with only slight modifications. OCD used to be considered an anxiety disorder, but with the advent of DSM-5 (APA, 2013), it has now become distinct from the anxiety disorders and has its own category: Obsessive–Compulsive and Related Disorders. The related disorders include several body-focused problems such as hair-pulling, skin-picking, nail-biting, and body dysmorphic disorder. OCD and related disorders share features such as the experience of an overwhelming urge to engage in certain behaviors, whether excessive hand washing, picking at one’s skin, or constant checking for facial asymmetries in mirrors. The section on treatment later in this chapter shows how people with body dysmorphic and hair-pulling behaviors can be included in the same group as those with OCD. OCD clinicians and researchers are pleased to see OCD getting a distinct diagnostic category. We view it as progress toward a better understanding of, and treatment for, people with OCD and related disorders. OCD in children and adolescents looks remarkably similar to the disorder in adults. It follows the same diagnostic criteria with the exception of the requirement of insight. Preadolescent children are not expected to recognize that their obsessions and compulsions are unreasonable and due to a psychiatric disorder, but in mid-adolescence, a growing awareness begins. Many treatment manuals for OCD across the age span are based on the older versions of the DSM, but according to both the DSM-IV (APA, 2000) and DSM-5 (APA, 2013), OCD consists of recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that in most individuals cause marked anxiety or distress. Compulsions are defined as repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The obsessions and compulsions are time consuming and take up more than 1 hour per day or cause clinically significant distress or impairment in social, occupational, or other important functioning. DSM-5 allows clinicians to specify whether the person with OCD has good, fair, poor, or absent insight. Absent insight may be coupled with delusional beliefs. The broader range of insight specification in DSM-5 is especially helpful for those OCD sufferers with absent or delusional insight. This improves the chance they can be diagnosed correctly with the kind of OCD involving absent insight/delusional beliefs, as opposed to being diagnosed with a psychotic disorder. For example, a youth may be convinced that the water in his local community is undrinkable and “contaminated.” He will avoid any drinking of tap water at all costs and engage in elaborate compulsive behaviors to ensure no tap water gets into his food or mouth, ear, and nose when bathing. This person resembles, but is different from, someone with psychosis who believes city engineers are plotting to poison her with contaminated water. OCD affects about 2% of children and adolescents and interferes with school performance and relationships with friends and family (Valleni-Basile et al., 1994). This means that 1 in 50 children in any elementary or high school would meet criteria for OCD and experience significant distress as a result. Boys are more likely to have onset of OCD before they reach puberty, in contrast to girls who tend to develop the disorder during their adolescent and young adult years (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). Similar to adults, the course of OCD in children is usually gradual and influenced by the child’s more general abilities to cope with stress. In the absence of treatment, spontaneous recovery is rare, and a diagnosis of OCD in childhood tends to continue into adulthood and is associated with a higher probability of developing other anxiety, mood, or personality disorders (Thomsen & Mikkelsen, 1993). Given the similarity of expression of OCD in children and adults, recommended treatment protocols are nearly identical for both age groups whether pharmacological or behavioral or a combination. The CBGT protocol outlined in this chapter can thus also be used, with some modification, for adult CBGT for OCD. Several clinical trials have shown that pharmacological treatment is as effective for children with OCD as it is for adults but that symptoms usually recur after discontinuation of medication treatment (March et al., 1998). As we saw in Chapter 3, there is strong empirical support for the efficacy of CBT and CBGT for adults with OCD. The evidence for individual (Reynolds et al., 2013) and group CBT for children and adolescents is also strong and growing (to be reviewed in the following text) as more rigorous studies are carried out. The CBT treatment principle of exposure and response prevention (ERP) has proven just as effective for younger people with OCD as for adults. ERP involves facing the feared or avoided stimulus (exposure) and refraining from performing the compulsive activity (response prevention). For example, a child sitting in a classroom will begin to doubt whether she locked her locker properly (obsession) and will feel a strong need to leave the room and check that she did (compulsion). She may repeat this OCD cycle several times, leaving the classroom up to five times, which renders her unable to focus on what is being taught. When this child engages in ERP, she will learn not to take her obsession at face value, trust herself more, and develop skills helping her refrain from giving into her compulsive need to get up and go check her locker. She will remain in the classroom and become better able to focus. Over time, with repeated exposures, she learns to tolerate anxiety and realize that her worst fear (e.g., someone will break into my locker because I forgot to lock it) is extremely unlikely to come true. In addition to the ERP intervention described earlier, cognitive interventions are also used in CBT for childhood OCD. Cognitive interventions for OCD are designed to target a number of beliefs people hold about the appraisal or meaning of their obsessions. Three broad beliefs have been identified: (1) inflated sense of responsibility, (2) importance of thoughts, and (3) control of thoughts (Obsessive-Compulsive Cognitions Working Group, 1997, 2001). The beliefs interact with the obsessions. That is, when cognitive intrusions (thoughts, images, or impulses) occur, they are likely to be misinterpreted as signaling that this particular thought is very important, that the person is responsible for the thought or its outcome, and that he or she should control the thought. For example, a common child obsession involves uncontrollable images of parents being in a deadly car accident. The child interprets the mere presence of this thought or image to mean that the likelihood of the feared scenario is extremely high. Hence, the child needs to undo the image with various rituals, such as having to count to five or replacing the gruesome image with a happy one of playing monopoly safely at home with the parents. The girl mentioned earlier felt responsible for her locker and wanted to prevent at all costs a break-in. This sense of inflated responsibility is common in children and youth with OCD. They feel personally responsible for a number of things that could go wrong in their lives, far more than what even quite conscientious youngsters feel. There are cognitive techniques designed to discuss the realistic amount of responsibility that can reasonably be attributed to one person. One technique aimed at an inflated sense of responsibility is the pie technique. In the pie technique, the therapist works with the client (or the group) and lists all factors potentially and realistically contributing to the feared consequence. For example, a 13-year-old girl may fear that her puppy will get a fatal infection from contaminated food and that the death of the puppy will be her fault and responsibility. The girl may check twice an hour for signs that her puppy is getting ill, which include insisting on getting up during the night. She may refuse to go to school or may text her father at home several times a day to get reassurance that her puppy is fine. This girl has what is considered an inflated sense of responsibility, which is common in OCD. Perhaps a previous pet died, or her parents had told her they did not think she was old enough to take care of a puppy. A number of factors can contribute to inflated responsibility, or there may not be any easily identifiable predisposing reasons. In regard to the obsession about the puppy eating contaminated food, the therapist works with the child to identify other factors that reasonably could contribute to a scenario of the puppy becoming ill from eating contaminated food. The therapist writes them all down: the producer of the pet food, the packaging, the transport of the food, the shopkeeper who sold the food, and the fridge it was stored in. After a circle is drawn on the board, the 13-year-old fills in pieces of the pie that differ in size relative to the importance of each contributing factor. All factors should be pieces of the pie with the girl’s own contribution drawn last. At the end of the exercise, there is often little of the circle left for the person’s personal responsibility or control over the event. This girl may realize that her role in whether the puppy lives or dies because of what it eats may be only 5% in contrast to the previous belief of 90%. Although the pie and various other cognitive techniques can be valuable in any CBT and CBGT for OCD (Salkovskis, 1996; Söchting, Whittal, & McLean, 1997; Wilhelm & Steketee, 2006), research clinicians for childhood OCD agree that the behavioral component in CBT, the ERP, seems to be the key driving force for successfully treating younger people (Barrett, Healey-Farrell, & March, 2004; March, Mulle, & Herbel, 1994). But clinicians acknowledge that faulty beliefs often change indirectly and spontaneously as children have success with their exposures. So, although clinicians may not spend as much time on specific, explicit cognitive interventions for youth as they do with adults, they pay attention and inquire about the kinds of meaning and beliefs the youngsters with OCD hold. A CBGT format has consistently shown great promise from the first uncontrolled, naturalistic evaluations (Chowdhury, Caulfield, & Heyman, 2003; Fisher, Himle, & Hanna, 1998; Thienemann, Martin, Cregger, Thompson, & Dyer-Friedman, 2001) to more rigorous comparisons with individual CBT (Barrett, Farrel, Pina, Peris, & Piacentini, 2008; Barrett et al., 2004) followed by randomized controlled trials (Asbahr et al., 2005; O’Leary, Barrett, & Fjermestad, 2009). The O’Leary study (O’Leary et al., 2009), comparing CBGT to individual CBT, involved 38 participants aged 13–24, who were followed up to 7 years after they completed their CBT for OCD. For those treated with CBGT, 95% no longer met criteria for OCD versus 79% in the individual CBT group. It is rare to get such impressive and long-term follow-up in any CBT treatment outcome study. Clinician researchers evaluating CBGT for OCD in children and adolescents agree that a group format is highly effective and preferable. Given the developmental stage of adolescents, peers are an enormously important source of feedback and support. A group approach thus provides a context conducive to sharing experiences with peers. For these reasons, it has become hard for me to imagine offering CBT to adolescents in anything but a group format. Similar to CBGT for other disorders, CBGT therapists interested in running groups for youth with OCD must take an established individual protocol and adapt it to a group setting. In what follows, I show an example of such a protocol based on three existing CBT manuals for OCD. The rationale for this particular adolescent OCD manual was based on a couple of key considerations informed by both the literature and prior experience with individual CBT for children, as well as with CBGT for adults with OCD. For this adolescent CBGT manual, we first decided to make it primarily a behavioral protocol with emphasis on ERP. An earlier adult OCD CBGT study in which I served as one of the group therapists compared a pure cognitive CBGT condition to a pure ERP CBGT condition (McLean et al., 2001). Results from this study suggested that those treated with ERP improved more on the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS; Goodman et al., 1989) with an average Y-BOCS score of 15.9 after treatment compared to an average score of 18.43 for the cognitive treatment condition.1 Although the difference is not huge, the research clinicians running the ERP groups found that the atmosphere was more alive and engaged and that the opportunities for interactions and support among group members were richer compared to the cognitive groups. Although we did not measure the impact of the group climate itself on symptom improvement, our clinical hunch was that the therapists and group members alike found the ERP more interactive—and even fun on occasion. This seemed important when designing a group for youngsters where any overly dry and clinical atmosphere could be a deterrent for full and willing participation. This hunch has been backed up by research showing that—contrary to expectations—adolescents treated for anxiety disorders (not OCD) found the behavioral interventions, such as graded exposure, more useful than the cognitive ones (Barrett, Shortt, Fox, & Wescombe, 2001). Second, we had to figure out how to make ERP more attractive for young people so that they did not drop out of the group. Although our comparative adult study showed ERP CBT to be slightly superior to cognitive CBT, ERP seems to result in more dropouts. The overall dropout rate in our adult CBGT for OCD study was 13%, which is not too bad, but in the ERP condition, it was 19% (McLean et al., 2001). Having close to 20% of people drop out of treatment begins to become a concern. CBT therapists agree that a significant number of people with OCD are not helped by exposure therapy. There is a need for improving our interventions and making them more tolerable for our clients. We decided to develop a protocol based on classic CBT ERP therapy adapted for younger people, but with an important twist that would make it easier for the adolescent to tolerate difficult exposures. It is tough to tell a 14-year-old to “just stand there” after he has touched walls in a public washroom and his anxiety is at a 95% level. So we borrowed an idea from the work of University of California, Los Angeles, neuropsychiatrist Jeffrey Schwartz. In his popularized book Brain Lock, Schwartz permits clients who have exposed themselves to take part in a new activity, something that feels engaging and positive. When we do not specifically allow this refocusing, we find that adolescents with OCD will invariably try to distract themselves anyway by chatting, joking, attempting to leave the room, etc. However, the refocusing option must not actually distract clients from their exposure—as that could interfere with the process of desensitization. Instead, it becomes a means to facilitate enduring the full exposure, to stay emotionally engaged with it, and not to give in to compulsive behaviors. The therapeutic window is the place where clients are able to push and challenge themselves but not become so overwhelmed that they begin to disengage, numb out, flee treatment or give the impression of working hard when they are in fact engaging in task-avoidant behaviors. In a group, therapists must pay attention to the members who may initially seem helpful to others and eager to be a peer model but who are in fact avoiding their own work. Exactly how the refocusing option works in ERP will be illustrated in the section Exposure, response prevention, and refocusing. Thus, the final CBGT adolescent protocol became an integration of (a) an OCD protocol for individual CBT in children (March & Mulle, 1998), (b) the psychobiobehavioral approach for adults popularized in Brain Lock (Schwartz, 1996; Schwartz, Martin, & Baxter, 1992), and (c) traditional exposure therapy designed for adults (Foa & Franklin, 2001; Foa & Wilson, 2001). A more formal test of this integrated adolescent protocol was done in a pilot study consisting of a group of seven adolescents, some of whom were comorbid with ADHD, body dysmorphic disorder, Tourette’s disorder, or depression (Söchting & Third, 2011). The CBGT protocol consists of two main components, psychoeducation and ERP. The group, consisting of between five and eight members, meets for 12 2-hour weekly sessions. The optimal age range for group membership is 14–18, but younger people can be included so long as they understand the treatment rationale for ERP and are able to attend sessions and engage in homework. It is, by the way, a good idea to offer this group during the summer months when children are out of school. Dropout rates are low and some groups have none, suggesting this group treatment is acceptable and tolerable to youth. In the following text, I discuss each of the two key components in the protocol—psychoeducation and ERP. The facilitators begin by engaging the group in a discussion of what defines an obsession and a compulsion and how the two phenomena are connected. A model is sketched on the board starting with a trigger, which is followed by an obsession, which is followed by a range of distressing emotions which in turn leads to a compulsion as a way of neutralizing the distressing emotions (Figure 13.1). Figure 13.1 Cognitive behavioral model of OCD. For example, one adolescent’s trigger was attending a religious service with his parents. His obsessions took the form of a repeated and relentless mental image popping into his mind of “God as a jester.” Based on his appraisal of this image as meaning he was a “blasphemous person who secretly had no respect for God” (an example of attaching overimportance to thoughts), he was overwhelmed with guilt and anxiety, which diminished as he engaged in quiet compulsive praying, over and over again. (Incidentally, part of his exposure involved drawing exactly what this jester image looked like, which was at first terrifying for him but later became easier as he came to see the image was “just an obsession” and had nothing to do with his and his family’s actual understanding of what God is about.) Looking at the model on the board, we ask the group where they think treatment ought to intervene in order to interrupt the vicious OCD cycle, with its short-term relief but long-term worsening of OCD. Invariably, some suggest intervening at the level of obsessions. This creates an opportunity for the facilitators to provide education about how common obsessions are. For example, most people will admit to once in a while having a weird thought about how easy it would be to, for example, pull the bow of a performing violinist, or wonder if it was okay to sit down on the toilet seat in a pretty messy public washroom, or even the fleeting thought of how easy it would be to suffocate a screaming baby. The difference between people who do not have OCD and those who do is that the former just smile at their “silly” thoughts, trusting themselves to not act them out. In contrast, people with OCD believe that just because the thought came to them means it must be super important, probably true—and worse—that they may act it out. The youngsters also engage in animated discussions of how the illness of OCD is incredibly sneaky and cruel, trying to get them where it hurts the most. The young fellow with God jester obsessions came to see that it was precisely because his religious practice was important and sacred that OCD would zoom in on that instead of something he cared less about. Youngsters with OCD (and also adults with OCD) are often surprised to hear that there is no recorded incident in history of a person with bona fide OCD causing harm to anybody. Indeed, OCD sufferers are among the gentlest, most conscientious, and careful people—which is one of the reasons therapists enjoy working with them. Charles Darwin likely had OCD, but was nevertheless able to keep it at bay and remain productive in his field. He did, however, struggle. Anecdotes suggest he would wake up in the middle of the night—upset—because he had not written back to somebody in a timely manner or that he had perhaps allowed himself to be misunderstood by not fully explaining an argument or an idea. In other words, Darwin’s conscientiousness hovered just on the border of a more debilitating OCD. After a rich discussion, the group usually agrees that if the OCD cycle is to be broken, treatment will have to be placed after the obsessions but before the compulsions. The facilitators proceed to explain that the treatment principle of ERP is exactly that, namely, to welcome the obsession but to take the power away from it by not neutralizing it with compulsive behaviors. The facilitators further elaborate that over time, group members will begin to see that nothing terrible happens if they just stay with their fear, carry on with more important tasks, and realize it is just an obsession and has nothing to do with the truth about themselves (they are not potentially dangerous people) or how things really are (fatal diseases cannot be contracted from ordinary use of public washrooms). To further help young people diminish the power of obsessions, March and Mulle (1998) introduced the idea of cultivating mindful detachment and of externalizing the OCD. Schwartz also encourages externalizing techniques with his relabeling practice. Relabeling—or mindful detachment—teaches clients that their obsessions are not ordinary thoughts but rather the symptoms of OCD and, therefore, they must be relabeled and referred to as what they are, namely, obsessions. Clients are encouraged to distance themselves from these obsessions and view them as bizarre “messages” that “do not belong to me” and could be experienced as “passing clouds in the sky.” To enhance this idea, and inspired by the March and Mulle protocol, we instruct our clients to make graphic representations of what their OCD looks or feels like and to discuss this with the group (Chapter 2 included an example of such a representation). After about three sessions of psychoeducation, the latter nine are devoted to ERP. The first step involves building a master treatment plan in the form of an exposure hierarchy to guide a systematic approach to the ERP exercises to be practiced both in the group sessions and between them. In Chapter 9, I reviewed how to build an exposure hierarchy, and it is the same process for younger people. Based on the completed hierarchies, the group facilitators meet before the group session and plan individual, paired, or trio exposures for all group members. This enhances treatment compliance due to the support, humor, and sense of shared experience. To further improve treatment compliance, the facilitators strive to develop creative exposures. As a psychologist with an admitted tendency to be more comfortable with sitting in my chair, hands in lap, I have greatly benefited from cofacilitating CBGT for OCD with an occupational therapist. Occupational therapists get up from their chairs, move around, and magically create all sorts of wonderful and highly therapeutic props for OCD exposures, such as look-like-blood pieces of gauze, flowers that need to be potted in “dirty” soil, and clay for sculpting a particular sexual or aggressive obsession, to name just a few. Some examples of effective exposures in our groups have included a 14-year-old girl with contamination fears who collected various junk and garbage items from the street before using art supplies to create her contamination collage. A veritable piece of modern art! A 13-year-old girl with obsessions about getting cancer contacted the local cancer agency to inquire about volunteering there. She also drew a story board depicting herself receiving treatment for cancer in a hospital. A 15-year-old boy with obsessions about everything being “just so” and neatly ordered was eventually able to tolerate group members writing personal and encouraging messages on his group folder. He had been especially distressed by spelling mistakes and messy erasing. A 17-year-old young man who obsessed that he was gay directed a skit with various roles assigned to all the group members, where he played the role of a gay man attempting to pick up another. During the debriefing, he expressed relief from having acted out his worst fears, which then lessened their grip on him. For any youngster who obsesses about being lesbian, gay, bisexual, or transgender (LGBT), it is obviously important to have at least one thorough assessment (a second opinion is helpful too) to ensure that the obsessions are indeed consistent with OCD and not related to the emergence of an LGBT identity, which must not be pathologized. The refocusing option in ERP allows people to do something engaging and wholesome for at least 15 minutes after their exposure. Instead of performing compulsions, group members refocus on an alternative behavior, a behavior that is constructive and enjoyable, such as walking, exercise, crafts, or listening to music. Alternatively, they can refocus by trying to continue the activity that their compulsive urge had interrupted. This is especially relevant for doing ERP at home outside of the group sessions. Reviewing one’s success with battling OCD in the form of repeating positive self-talk is another highly portable refocusing option. Optimal activities require concentration and the involvement of other people and are thus incompatible with the compulsive behavior. After 15 minutes, group members notice that the urge to perform the compulsion has diminished. The aim of refocusing on an alternative behavior is to facilitate response prevention, not to interfere with the process of desensitization. This approach has also been successfully used in a wait-list-control telephone-administered CBT for OCD (Taylor et al., 2003). Here are two examples of refocusing activities following an exposure. A 15-year-old has repacked several garbage bags as part of his exposure and is struggling with a strong need to go and wash his hands. He eases this urge by engaging in a card game with two other group members. There is usually lots of laughter during such a game and the added therapeutic benefit of a kind of “double exposure” as the “contaminated” cards are passed around. After 15 minutes, his anxiety has decreased from an initial rating of 95/100 to 50/100, and he feels more confident he can manage the rest of the group and return home without washing his hands. A 17-year-old girl who has written a poem on the board with several deliberate mistakes for “the world to see” (her OCD included perfectionism) may attempt to cope with her urge to go and correct the mistakes by making some candles (the occupational therapists need to have all supplies available prior to the group starting). As she returns and sees the board, her anxiety increases, but it does not seem as important as she simultaneously admires the candles she made and receives compliments about them. The facilitators strive to work with group members’ particular interests as this increases compliance and motivation. The Leisure Skills Inventory, an occupational therapy tool, is a helpful aid in planning exposures with refocusing. Clients can fill it in at the same time they complete other pregroup measures. It asks people about a wide range of leisure activities, from golfing, dancing, and knitting to political involvement (see Appendix H). New research on brain plasticity may offer further support for the benefit of pairing an adverse experience (the exposure) with a pleasant one (the refocusing). Similar to scores of other neuroscientists interested in brain plasticity, Rick Hanson (2009) describes how mental activity can change neural structure. Hanson argues that because of the brain’s well-known negativity bias—like Velcro for the bad but Teflon for the good—this cultivation needs to be skillful and sustained. Otherwise, positive experiences wash through the brain like water through a sieve, while negative ones are caught every time. People can learn to turn positive mental states into positive neural traits by (a) having a good experience in the first place, (b) helping it last 10 or more seconds while feeling it in your body, and (c) sensing that it’s sinking into you. It is not about denying or being unaware of what is unpleasant and anxiety provoking but about also—simultaneously—accessing what feels good and pleasant. By taking in the good, you can weave some of these gems into the fabric of your brain and your life. As you build up inner strength and fulfillment through this gradual cultivation, there is less need for the ancient survival reaction of fear and anxiety. The refocusing option has the added benefits of supporting adolescent clients in increasing their self-esteem as they begin to engage with new interests or leisure activities—making less space, in a sense, for their OCD. Any clinician who has worked with OCD clients knows how their lives are usually impoverished. It is difficult for many to answer the question: what will you do when OCD takes up less time in your life? In fact, my experience with OCD has included many examples of adolescents (and adults) who are reluctant and feel ambivalent about what getting better will entail, perhaps fearing they will become just ordinary people. A more comprehensive treatment approach, which supports the client in developing new interests and talents, is therefore highly therapeutic. It has been invigorating for my practice to follow the research in brain plasticity, which was not available when I was a student. More research directly comparing the refocusing option to traditional ERP, ideally in a randomized controlled design, would be helpful. CBGT for youth OCD can enhance adherence to treatment by providing opportunities for turning developmental issues into helpful process factors. When adolescents share coping skills during difficult exposure challenges their anxiety is mitigated due to a sense of “being in it together.” The earlier example of a young man with gay obsessions showed how important it was to not be judged by his peers when he shared these obsessions. Developmentally, adolescence involves the central psychosocial task of moving emotionally from the family of origin “group” to a peer group. Adolescents who can make this transition and reattach to a positive peer group are better equipped to achieve mature adult functioning, including creating connections to healthy communities (Rachman, 1975). Although a CBGT group for youth OCD does not focus on these developmental issues per se, they are reinforced as important process variables. Shared humor is another factor that may contribute to the effectiveness of CBGT for youth OCD, and it behooves the facilitators to work with humor. It goes without saying that the facilitators pay attention to when humor may become sarcastic and experienced as diminishing for a group member. Fortunately, the vast amount of humor in these groups is healthy and appropriate. The use of humor may be particularly relevant for people with OCD in that exaggerating fears and worst-case scenarios can promote insight into the “silliness” of obsessions, thereby reducing their power. Humor usually comes easy to adolescents—and it is a helpful reminder to not forget to also work with humor in adult OCD groups. The facilitators can include warm-up exercises at the beginning of each youth group to stimulate creative thinking and humor. For example, one game is called The Big Fat Lie, where each group member in turn tells a plausible but outrageous story about an object that is passed around the group. Another warm-up game includes working with the alphabet where the first person starts with the letter A saying, “My name is Alison, my partner’s name is Adam, we live in Ankara, and sell Anchovies.” The next person gives a name, a partner’s name, a place, and something to sell starting with B. It is not difficult to picture how these brief warm-ups get the groups off to a good engaged and cohesive start. These warm-ups are another helpful contribution from occupational therapists cofacilitating OCD groups. OCD groups often feel transdiagnostic because of the incredible variation in symptom expression. Each member’s unique obsessions and fears whether of not having turned off the stove or of brushing up against a young girl in a crowded area, require a highly individually tailored exposure treatment plan. These differences do, however, not influence treatment outcomes. Part of the education about OCD involves clients’ learning that it is the same psychological mechanism that drives the different expressions of obsessions and that the treatment principles are also similar. Efforts to create more pure groups by lumping “washers” or “checkers” or “obsessions only” into distinct groups probably have more to do with lessening the anxiety of the group therapists than the clients. The challenges of working with different subtypes of OCD were reviewed in Chapter 9. Not only are clinicians encouraged to include all subtypes of OCD in their groups but to further include the OCD-related disorders. For example, a youngster may have both OCD and hair-pulling (trichotillomania) and someone in the group may have body dysmorphic disorder, tics, and only mild OCD (Farrell, Waters, Milliner, & Ollendick, 2012; Himle, Fischer, Van Etten, Janeck, & Hanna, 2003). Our OCD groups for adolescents (and adults) include people with hair-pulling (trichotillomania), skin-picking, and body dysmorphic disorder. All these disorders are now reclassified in DSM-5 as part of Obsessive–Compulsive and Related Disorders. Hoarding has also commonly been included in most CBT groups for OCD, but it presents a particular challenge and is best treated in separate compulsive hoarding groups. Hence, consistent with the new DSM-5 diagnosis of hoarding disorder, I have added a separate chapter devoted to hoarding, Chapter 15. The OCD-Related Disorders involve repetitive behaviors—such as pulling one’s hair out, picking at one’s skin, or biting nails—that are similar to features of OCD in that they involve a strong urge to engage in a behavior that will bring about a sense of release and relief from pent-up tension. For example, hair pulling (trichotillomania) involves repetitive pulling out of one’s hair from scalp, eyebrows, eyelashes, or anywhere on the body, including pubic area. Onset is usually during the teen years and before age 17. Body dysmorphic disorder involves an intense preoccupation with a defect in appearance. The defect is either imagined, or if a slight defect is present, the individual’s concern is markedly excessive (e.g., believing one’s hair hangs asymmetrically and one’s eyes are too far apart or too close together). Like hair-pulling disorder, onset is usually during adolescence, but help is often not sought until early or middle adulthood. CBT for both disorders involves a number of components, including self-monitoring, relaxation training, cognitive restructuring with primary focus on perfectionism, ERP, and habit reversal training. Habit reversal training involves encouraging the client to engage in a behavior that is incompatible with the habit (an agonist action). For example, a woman who in addition to OCD has a vocal tic in the form of uncontrollable loud grunts may be trained to engage in deep breathing as soon as she notices the slightest urge to “grunt.” For a full description of the CBT approach for tics, see O’Connor’s treatment manual Cognitive-Behavioral Management of Tic Disorders (2005). For body dysmorphic clients, cognitive restructuring in the form of positive self-affirmations and acceptance is included as well as exposure. In a CBT group for OCD, people with these two disorders benefit from the same psychoeducation about how a thought, image, or urge leads to behavior that neutralizes intense anxiety or other negative feelings. So, in addition to working with examples from the OCD people, the facilitators may say to a group member, 16-year-old Ken, with hair-pulling disorder: Therapist:
Youth Obsessive–CompulsiveDisorder (OCD)
OCD in Children and Adolescents
CBT for Youth OCD
Behavioral interventions
Cognitive interventions
CBGT for youth OCD
CBGT Protocol for Youth OCD
Psychoeducation in CBGT for adolescent OCD
Exposure, response prevention, and refocusing
Capitalizing on the Group for Youth OCD
Disorders Related to OCD
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Youth Obsessive–CompulsiveDisorder (OCD)
And for you, Ken, the issue is not so much a thought about contamination or inappropriate behavior, but rather an overwhelming urge to reach for your scalp and pull. In fact, you’re not even fully aware of this strong urge until after the fact, in a sense. Just like Winnie said she felt better after washing her hands, you feel better after having pulled and find it near impossible to not pull. Did we get that right?
