It is not uncommon for OCD patients to exhibit treatment-interfering behavior that substantially hinders treatment progress. OCD patients are often ambivalent about treatment. They may wish to decrease the distress and interference of the disor-der, but they may be quite reluctant or fearful to challenge long-standing beliefs and refrain from compulsions. For example, patients who report that they are moti-vated to seek treatment might still frequently cancel sessions. Therapists should address cancellations immediately. Setting clear goals for treatment or creating a treatment contract that includes length and frequency of sessions may help prevent these problems (Wilhelm & Steketee 2006). However, if cancellations are frequent, therapists should address non-compliance by explaining the relationship between treatment compliance and improvement. Therapists should consider using cognitive strategies to help patients to explore dysfunctional beliefs that might be associated with treatment-interfering behaviors. Cognitive strategies such as downward arrows (Greenberger & Padesky, 1995) can help the patient to explore these beliefs, which might lead to better treatment compliance.
If treatment compliance becomes an issue later in therapy, then the patient might have irrational beliefs about getting better. As illustrated in Table 1, some patients have a fear of positive expectations or believe that they do not deserve to get better.
They might therefore begin avoiding sessions when they start to improve. A ther-apist might want to consider using the downward arrow and Socratic questioning together to help the patient explore his/her thoughts about treatment non-compliance (for a description of these techniques, see Beck, 1995). For example, in the
aforementioned case, Maria initially suggested that she was afraid that she would never get better, which in turn would mean that she was doomed to be a bad mother.
After several sessions marked by improvement, Maria still had a difficult time acknowledging that she was getting better. In fact, Maria began to fear that, even if she were to continue improving, she would inevitably relapse.
Cognitive restructuring was initially used to help Maria identify cognitive distor-tions related to her thought that improvement in treatment had a direct reladistor-tionship to her role as a mother (e.g., overgeneralization, fortune-telling) and to collect evi-dence for and against these distortions. As therapy progressed, the downward arrow strategy was used to help Maria identify her core belief related to fear of failure in her role as a mother. Below is an example of this interchange.
T: Maria, I have been so impressed by your progress. You were able to hold your baby near the microwave several times in the past week. Yet, you mentioned that you are afraid that you will relapse.
P: Yes, I have been thinking that the progress has been too good to be true. In fact, I am sure I will relapse in the next few weeks.
T: Okay, I can see how that thought would make you anxious. How about we spend a few minutes exploring the meaning of this thought for you? What would that mean to you if you relapsed?
P: It would mean that I failed treatment.
T: And if you have a thought such as “I failed treatment,” what would that mean?
P: That I might never be able to get better.
T: And what would that mean for you if you would never get better?
P: It would mean that I will continue to be sick and not be able to take care of the baby.
T: What would it mean for you if were not able to take care of your baby?
P: It would mean that I am a horrible mother that cannot even take care of her baby.
T: What would it mean about you, if you were a bad mother?
P: It would mean that I am a failure.
T: Okay, Maria this is an important point. It looks like you are afraid to improve in treatment because you are afraid that if you were to relapse, it would mean that you failed, which in turn would mean that you are a bad mother. Is that right?
P: Yes!
T: I can understand why this thought makes you so anxious. Why don’t we spend a few minutes examining how this core belief of being a failure is getting in the way of our work together?
The therapist continued this dialogue by using Socratic questioning to help Maria examine the evidence for and against her core belief and to find alternative ways to think about her progress in therapy. Furthermore, Maria and the therapist
collaboratively designed a behavioral experiment that challenged Maria’s core belief by helping her collect actual evidence against this belief.
Another treatment-interfering behavior is session tardiness. Patients often get stuck ritualizing at home or in the bathroom at the therapist’s office and thus are late for session. Patients might also cancel at the last minute because they feel overwhelmed about coming to session or are stuck in a ritual. Therapists should address this behavior right away. For example, therapists might discuss alternative hypotheses for reasons why they are not coming to session on time. If the patient suggests that they have a difficult time managing their time, then time manage-ment skills (such as breaking down the steps needed prior to coming to session) can help the patient improve attendance. Alternatively, if the patient is stuck ritualiz-ing before session, then the therapist might want to create contritualiz-ingencies that might help the patient come in on time such as telling patients that the appointment is scheduled for an hour earlier to increase the likelihood that they will be on time for session.
Homework compliance is a key predictor of treatment outcome for patients with OCD. However, given that exposure-based homework can be unpleasant, it is not uncommon for patients to avoid it. One way to address homework non-compliance is to engage the patient in problem solving by conducting a pros–cons analysis of completing homework. It is also helpful to engage patients in a discussion about their short-term versus long-term goals. If the patient has set specific goals for treat-ment, the therapist can also use these goals to encourage the patient to complete homework. Metaphors can also be helpful. For example, the therapist could sug-gest to the patient that completing homework is like riding a bike, or learning to swim or drive. At first, such new activities can be somewhat anxiety-provoking.
However, with practice, it is likely that they will become “second nature” and less anxiety-provoking. Regardless of the approach, it is very important that therapists validate patients’ attempts to complete any homework. It is fine to be empathetic about the challenges involved with homework, but it is essential for homework non-compliance to be addressed before moving on. Below is an example of ways a therapist might address homework non-compliance with OCD patients
T: Maria, what do you think got in the way of you doing the homework this week?
P: I had a hectic week, so I just didn’t have any time.
T: Do you think that this will happen regularly, that your life is so busy that it will be difficult to fit in the homework necessary for this therapy?
P: It is difficult for me to find extra time. I am always tied up either at work or with the kids, who always need my attention. By the evening, I just feel exhausted.
T: I can understand how difficult it can be to find time. But I think it is important for us to figure this out before moving on. Perhaps, Maria, this is not the time for you to be working on the OCD problems.
P: Oh no, I have to work on the OCD! I am concerned about the time I spend on my rituals and that my kids will learn some of them from me. It broke my
heart when my daughter told me that she didn’t want to play with her toys because it took me so long to put them away “the right way.”
T: Okay, so it sounds important to you and your family as well. So, let’s try to brainstorm ways that you might find some time. If you think back to this past week, can you think of any way you might have found time to do this assignment?
P: I guess I could have asked my husband to watch the kids for a while in the evening.
T: Do you think he would be willing to do that?
P: Well, I guess he might not like it but he also hates the OCD. So, I think if I tell him I need time to complete my assignment to get better, he might be willing to help me out.
T: Great idea, Maria. How confident are you that you will be able to complete the assignment for the next week?
P: 90%.
T: Okay. I think these are great odds. I am also very confident that you will be able to complete the assignment. Let’s write that down as the first item in your homework this week: discuss child care with husband tonight, and identify when he would be willing to watch the children so you can do your OCD homework.
This kind of dialogue conveys several messages to patients. It teaches them that homework is important and that it is their responsibility to complete it. In addition, it suggests to patients that you understand their difficulties, while at the same time conveying the notion that you take homework seriously. Finally, it models problem-solving skills.
At times, patients will change the topic to less anxiety-provoking subjects as a way to avoid discussing the OCD. One way to make sure to stay on topic is to set a collaborative agenda in the beginning of the session. The therapist can also ask the patient for permission to interrupt and redirect to the agenda, especially for patients who get distracted easily. If despite these efforts patients continue to derail, then the therapist and patient must assess if the OCD is the primary concern for the patient.
If not, the patient might need other treatments prior to addressing the OCD.
A very common challenge in working with patients with OCD is perfectionis-tic standards held by the patient, which can interfere with their interpretations of progress in treatment. Patients might say or believe, “I still have a long way to go;
a little progress means nothing; I will never be able to get better.” Such statements might be representative of core beliefs about being a failure, or reflect past unsuc-cessful therapy experiences. One way to address such concerns in the beginning of therapy is to demystify progress in treatment by directly discussing patients’ expec-tations for progress versus what progress might realistically be like. It is important to highlight to patients that there will be ups and downs in treatment but that they would end up overall doing much better than if they were not in treatment. The therapist can suggest that a monitoring form will be used weekly to monitor change over time. This can be very important for perfectionistic patients, as data might help
them acknowledge progress. In addition, the therapist should include a discussion of lapses in treatment as normal and expected, and perhaps suggest that these are times in therapy when fine-tuning can be productive. If the therapist believes that the patient’s core belief of being a failure is getting in the way of treatment, then cognitive strategies such as downward arrow or behavioral experiments might help the patient identify dysfunctional thoughts and challenge the core beliefs.
T: Last session we discussed your difficulties at work. You mentioned that you are getting behind at work because you keep checking and rechecking your memos, letters, and e-mails because you want to make sure that they are perfect. During our session, you came to the conclusion that this behavior was excessive and that the consequences of keeping this up was worse than perhaps making the mistake. So, I was thinking it might be helpful for you to conduct an experiment to test this belief. Are you willing to try this?
P: Does that mean I will have to do something different? I am always so scared to do something different.
T: It makes sense that you would fear doing something different. So, perhaps we should start small and see what happens. For example, how would it feel to send a memo to your close co-workers where you purposefully misspell something?
P: I guess I could do that. I am always fixing prepositions, and making sure I get them correct. I guess I could use an ‘in’ when I know I should use ‘on’.
T: Great idea! Let’s begin there. This would mean that you write the e-mail and leave a wrong preposition. I want to remind you that this also means that you would not reread it more than once, and you would leave the mistake there, right?
P: That will be hard to do, but I am willing to try it.
In summary, regardless of patient’s initial motivation for treatment, CBT for OCD will challenge the patient’s dysfunctional beliefs and ask him/her to behav-iorally confront anxiety-provoking situations. Thus, treatment itself is likely to be difficult for patients, which might generate several of the therapy-interfering behav-iors described above. It is important for clinicians to be mindful of what they are asking patients to do and to find ways to collaboratively engage OCD patients in the challenge of designing and implementing the strategies that can help them improve, at a level that is appropriate to the patients’ abilities at the time.