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APA Psychotherapy Training Videos are intended solely for educational purposes for mental health professionals. Viewers are expected to treat confidential material found herein according to strict professional guidelines. Unauthorized viewing is prohibited.
In Behavior Therapy for Obsessive–Compulsive Disorder, Dr. Samuel M. Turner demonstrates his approach to treating this form of anxiety disorder. Because this approach assumes that obsessive–compulsive disorder (OCD) derives from an underlying core fear, treatment involves exposing the client to fear-producing stimuli and teaching blocking of compulsive behaviors. The therapist takes an active role in encouraging and directing the client in efforts to prevent habitual obsessive responses to fear. In this session, Dr. Turner works with a 32-year-old woman whose obsessive–compulsive disorder takes the form of obsessive washing and avoidance behavior. Dr. Turner helps her to dismantle her fear of contamination with exercises that expose her to her core fear. This video features a client portrayed by an actor on the basis of actual case material. Precipitating Events Helen sought treatment because of fears of contamination and germs, anxiety about contracting a disease, and concerns about excessive washing and cleaning behavior that seriously affect her work performance. She also feels continually nervous and, more recently, depressed. Three months before Helen sought help, her company moved to a new building, and management restructured staff into work teams, with each team sharing office space. Before this, employees had worked in cubicles. Working in the shared space with four other employees, without the barriers she felt that the cubicles had provided, Helen became increasingly concerned about cleanliness and germs, fearing that others might touch her belongings and contaminate them. As a result, Helen began spending more time cleaning and washing at the office and had much less time to devote to her work. Although Helen had experienced these concerns before, they increased markedly after the move. For example, before the move, Helen spent approximately 2 hours per day on washing and cleaning rituals and obsessed about her fears for about the same length of time. After the move, Helen began washing and cleaning approximately 4 hours per day and her obsessive thoughts have increased at the same rate. This has affected her ability to complete assignments, for which she at first compensated by bringing work home. However, she eventually came to believe that the work papers were contaminating her apartment, causing her to clean for hours after bringing the papers home. Consequently, she discontinued bringing work home and failed to meet critical deadlines. Helen's coworkers reported to her supervisor that she was spending hours each day cleaning her desk and work area and that she spent a great deal of time washing in the restroom. As a result of this and because of Helen's declining work performance, her supervisor referred Helen to the company's Employee Assistance Program (EAP). After consulting the EAP, Helen was referred to Dr. Samuel M. Turner because he was was on their list of recognized experts in the field of OCD. Helen is the only child of second-generation Chinese American parents, and her childhood was normal in most respects. However, she was by temperament a high-strung child, easily frightened and generally nervous, and her parents displayed a somewhat excessive concern with cleanliness and germs. For example, whenever Helen came down with a virus or common cold, her mother would interrogate her about whether she had washed her hands immediately after playing outside with other children, often restricting her contact with them. When Helen was 13, her mother was diagnosed with breast cancer and had a mastectomy. While her mother was in the hospital, Helen's father insisted that Helen scrub the house from top to bottom, so that her mother would come home to a sterile environment. After her mother returned home, Helen remembered being hesitant to hug her, for fear she would "catch" her mother's disease. Any time she made contact with her mother after that, she felt compelled to shower extensively. She never told anyone about these fears and they gradually subsided. Helen's fears of contamination resurfaced after she went away to college. Helen was extremely anxious about doing well in school, and she studied more than the typical student. She shared a dormitory room with a young woman named Mary. Mary was very "messy" and frequently littered their room with half-finished bags of potato chips, soda, and other snack foods. Helen spent an inordinate amount of time vacuuming and cleaning to avoid contamination, and she tried to restrict Mary from bringing snacks into their room. Still, Helen had many fears about the germs she believed that her roommate was spreading. After her freshman year, Helen moved into an apartment off-campus to avoid this problem with her roommate. Despite her fastidiousness, soon after moving in, Helen discovered roaches in her kitchen. She spent hours cleaning and fumigating but still had fears that the roaches had brought in germs that would lead to some awful disease, such as cancer. After that, to relieve her anxieties, she had to perform a number of cleaning rituals in her apartment on a daily basis. Helen tried dating in college, but she broke off relationships as soon as she felt that the young man would learn about her rituals or whenever the man would express interest in having a sexual relationship. Her contamination fears precluded the possibility of her becoming sexually involved; even mild affection raised her anxiety level. Helen's fears of contamination and germs grew quite pervasive as she became older, although the degree of severity waxed and waned. They now involve her person, home, car, and work environment. For example, she must inspect clothes that she has worn before hanging them up, but if she misses a spot and discovers it later, she must wash or dry clean not only that piece of clothing but also all of the clothes that have surrounded that article in the closet. Similarly, if she discovers bird droppings or leaf sap on her car, she must immediately wash the entire car, inside and out, even if this means being late for work. If the car has been in the garage before she notices the sap or droppings, she feels the entire garage is contaminated and must be scrubbed as well. Once, after having her piano tuned, she became convinced that the piano technician had contaminated it. She could not play the piano for several months and only then after cleaning it several times. In addition to these compulsive behaviors, Helen exhibits extensive avoidance behaviors. She avoids all areas where there are hospitals, stores, and restaurants in which she has observed any lack of attention to cleanliness and avoids certain parts of the city in which she has observed "dirty" people or trash. Although Helen is aware intellectually that there is no link between cleanliness and cancer, whenever she or her belongings are touched by someone or something she considers dirty or messy, she obsesses about becoming diseased and is impelled to compulsively clean herself and her surroundings. These obsessions and compulsions have come to negatively affect virtually every aspect of Helen's functioning. Questions
Notes on Previous Sessions Sessions 1 and 2: The first two sessions were devoted to diagnosis and assessment of the patient. In the first session, conducted in a general interview format, Helen's mental condition, presenting problem and its course, and other historical material were explored. In the second session, a more structured diagnostic assessment format was used. Helen completed the Structured Clinical Interview for DSM Diagnosis (SCID) and the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS). Each of these sessions lasted about 2 hours. Sessions 3 and 4: In the third session, Dr. Turner confirmed with Helen her diagnosis of OCD and spent at least half of the session educating her as to the nature of the disorder, what could be expected if it was left untreated, and how treatment could help. After this, he introduced Helen to the self-monitoring diary, which he designed specifically for the behaviors involved in her disorder (e.g., washing and cleaning rituals). The diaries would enable Helen to record the frequency and duration of her obsessive thoughts and compulsive behaviors. Possible triggers for the thoughts or behaviors were to be recorded, and Helen was taught how to assess the overall distress that she experienced with regard to these triggers. Dr. Turner also told Helen that the diaries would be used throughout her treatment. In the fourth session, Dr. Turner went over the diary entries Helen had recorded and then explained to her in more specific detail how the treatment would proceed. He explained what the treatment would be like, what would be expected of Helen, and what kinds of problems she might have. Before this session, Dr. Turner had devised the flooding scene, and he also developed a concurrent response prevention plan. He went over the broad outlines of the flooding scene with Helen to be sure that it had strong relevance and briefly described how he would ask her to "not respond" with her usual avoidance behaviors (i.e., compulsive behaviors). Session 5: To be viewed. Questions
Stimulus Questions About the Session Dr. Turner begins the session with a 3-minute straightforward explanation of the exposure procedure.
About 10 minutes into the session and 4 minutes into the exposure scene, the verbal description of the cancer is vivid, and Helen expresses intense anxiety.
Soon thereafter, Helen questions whether the treatment should continue and suggests a less intense pace.
About 16 minutes into the session, Helen asks Dr. Turner whether her anxious feeling is normal.
For the next 20 minutes, the imaginal exposure continues, and Helen experiences high levels of anxiety. In one instance she describes her anxiety as an 11 or 12 on a 10-point scale. She asks Dr. Turner several times to stop the procedure.
About 42 minutes into the session, Helen's anxiety lessens to a more moderate level.
About 45 minutes into the session, Dr. Turner ends the imaginal exposure and proceeds to in vivo exposure.
About 53 minutes into the session, Helen inquires about the possibility of contagion from the scarf. She asks, "Isn't the cancer going to spread?"
About 5 minutes later, Dr. Turner briefly shifts Helen's attention from her contamination fears to more neutral topics, such as her musical interests.
About an hour into the session, Helen asks whether the cancer patient who owns the scarf is still alive. As she did earlier, Helen also seeks reassurance for her feelings of anxiety.
About 67 minutes into the session, Dr. Turner gives Helen her homework assignment, including specific instructions about her washing routines.
Exposure therapy requires an enormous commitment from both the patient and the psychologist.
General Questions
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