When you meet: assessing obsessive-compulsive disorder

This chapter provides a practical guide to assessing obsessive-compulsive disorder (OCD) that is both informative to the inexperienced clinician and addresses questions raised by the experienced clinician. It will summarize the diagnostic criteria for OCD, including advice on making a differential diagnosis when presented with symptoms that are associated with other disorders; for example, differentiating OCD from psychosis, generalized anxiety disorder, or health anxiety. It will guide the reader through the process of conducting a thorough assessment of the patient’s presenting problems, including OCD and any comorbid problems. The chapter will offer guidance on how to engage the person with OCD and promote trust. There is clear guidance on risk assessment, differentiating between primary risk factors (which clinicians are typically very good at assessing), and secondary risk factors (which may easily be overlooked). Advice on structuring an assessment and on appropriate assessment tools is provided.

Before you meet someone with obsessive-compulsive disorder: understanding the problem

This chapter provides detailed background information on obsessive-compulsive disorder (OCD) that will give the therapist a clear understanding of current knowledge about the context and causes of this problem. Research evidence on the epidemiology of OCD, impact, and causal factors is presented. Here we introduce the cognitive-behavioural model of OCD, offering a discussion of the key elements of this model. The chapter will also include case examples to illustrate different manifestations of OCD (including contamination, checking, rumination, just-right feelings) and common processes that are key in the maintenance of obsessional problems (for example, reassurance-seeking and magical thinking). This chapter reviews the evidence base for the treatment of OCD, including medication, and identifies cognitive-behavioural therapy (CBT) as the recommended treatment.

Beyond the fundamentals

This chapter provides guidance on some of the issues of complexity, using a number of examples, including case illustrations of mental contamination, post-traumatic stress disorder, and perfectionism. There is a detailed consideration of incorporating compassionate mind work on shame. As obsessive-compulsive disorder (OCD) has a great impact on others around the individual, we focus on working with the involvement of family members in symptoms. The chapter also covers adaptations of standard treatment (group and intensive treatment). We consider how to make best use of supervision, including a detailed discussion of OCD-specific competences and metacompetences, as part of continued development as a therapist. There is an outline for how we might prevent OCD in the future, including disseminating understanding of OCD.

Cognitive-behaviour therapy for obsessive-compulsive disorder

This chapter guides the reader through the process of eliciting a shared understanding of obsessive-compulsive disorder (OCD), working collaboratively with the client—a cornerstone of the cognitive-behaviour therapy (CBT) approach. Step-by-step guidance includes examples of therapy dialogue for key aspects of this process. The emphasis in CBT is typically focussed on the here-and-now; this chapter emphasizes how to elicit a maintenance formulation that focusses on how the problem operates in day-to-day life. There is guidance on how much developmental information to include and how much emphasis to place on this. The chapter breaks down different stages of the therapy process, beginning with how to develop a credible alternative explanation to the person’s existing beliefs about their OCD—building up a ‘theory A/B’. This forms the basis for the remainder of the treatment, which essentially involves the client engaging in a process of putting the two theories to the test, often using behavioural experiments. A range of metaphors is described.