Cognitive-Behavior Therapy

Assessments and Interviews before Treatment of Obsessional Disorder

By Pierre Khazen 29/1/06

I.      Assessment includes:

?      A clinical interview

?      Self monitoring

?      Home work assignments

?      Direct observation

II.      Aims of assessment are:

?      To approve of problem list

?      To arrive to a psychological formulation of each problem; factors which led to the problem and recent maintaining factors

?      To assess fitness for the psychological treatment

?      To give tools to assess progress

Reminder:  We are referring to cognitive-behavioural treatment* where assessment and treatment go together. When the connection between triggers, thoughts, neutralizing and avoidance are understood then the treatment can start immediately. Treatment will be based on exposure and response prevention.     


III.      Suitability for treatment and primary and secondary obsessions:  

First question whether a patient is suitable for treatment would be whether Obsessions are primary problem or secondary to another psychiatric or organic disorder. Second question would be whether a patient is interested in such treatment as some are hesitant to take a treatment; treatment is based on mutual relationship and participation; patient who does not carry out needs of treatment can be convinced cognitively; however if a patient does not want to collaborate actively in such treatment despite cognitive efforts by the therapist then this treatment is deemed to fail its object and better is not to take it.

If an obsession developed after a psychiatric disorder or after it worsened then the primary should be treated first (especially in depression); but it is possible that even a primary problem was treated, an obsession remains. Many times, schizophrenic patients develop obsessions but it is not a rule as the number of schizophrenic people who suffer from obsessions is as the number in the general public and people with schizophrenia** usually do not consider their obsessions as senseless while people who do not suffer from schizophrenia find them senseless. This distinguishing is important as some times people with severe obsessions are labelled as psychotic without justification just because they suffered from schizophrenia in the past.

IV.      Interviews:

The first interview starts with open questions like ‘Could you tell me about the problems you have been facing recently’, then the therapist limits his question a bit by asking how the problem affected him during the last week; when a general picture of the problem is provided, the stressing goes to current examples of the problem. The therapist then needs to search for hints as to which factors trigger specific thoughts and behaviours, such events. If the patient gives high account for his obsessions, the therapist needs to direct the interview with statements as to the upsetting thoughts which the patient experiences and if he feels that he needs to do some thing about them (implying to obsessive thoughts and compulsive behaviour).

Reminder: Obsessions involve intrusive thoughts, images (mental pictures in contrast to patients who suffer from schizophrenia where they see images/pictures/things which do not exist in reality) and impulses (feeling the need to do some thing which you do not want to do for real); the patient needs to be asked about them.

V.      Methods to analyse behaviours:

After the general picture of the problem was provided, the next step is to analyse in details behaviours of the patient using examples to specify the problem. This is based on response systems which the therapist asks about; questions about cognitive (what was going on his mind), subjective (what he felt), physiological (his body’s reaction) and behavioural (how he acted) as to his problem. This is illustrated by direct questions the patient is asked as to what he does in regard with his problem. The therapist concentrates on response system to the specific obsession, triggers, avoidance and ritualizing. Afters the therapist collects information, he repeats them to the patient to be accurate of his perception of them then, he asks the question: ‘Did I get it right or perhaps I missed some thing?’

VI.      Assessing cognition:

When evaluating an obsession which a patient experiences, the therapist needs to concentrate on form of thought, image, or impulse and content of intrusions; content of obsession needs to be assessed in details. The therapist may ask the patient whether those thoughts, images or impulses impose themselves into his mind; which sort of thoughts they are; the last time he was upset with them. It is usual that some patients have their obsessional thoughts during sessions so it would be appropriate to ask them whether they had them just then; what was going on their mind; if the answer is positive, then the therapist asks for their details.                                

VII.      Assessing triggers:

Triggers could be obsessional thoughts or images; others are non-obsessional thoughts or images which refer to things which strike obsessional thoughts. An example would be a woman who had an obsessional thought that she may hurt her children; when she read an article the other day about a mother who abused her children, the article set off her obsessional thoughts; the therapist asks her whether there were other things which could strike those thoughts.

VIII.      Assessing rituals:  

As mentioned earlier, covert obsessions are thoughts without compulsive behaviour neutralized mentally which should be assessed by asking patients about recent events where the thought set off concentrating on thoughts and images they tried to create to switch their thoughts to others when their obsessional thoughts occurred and the result afterwards.

Reminder: The process in covert obsessions is having a thought (re: obsession), try to neutralize it (switch to another thought when it strikes***), and ritualize as a result (the ritualizing would be mental**** and not behavioural).

IX.      The element of avoidance

Cognitively, this refers to thinking of other things and preventing or avoiding from thinking about specific things; this act of preventing exposure to thoughts will only make the problem bigger and the urge to think about the avoided thoughts will increase. Important characteristics of obsessions are mostly subjective and it is necessary to know whether patients reckon that these obsessions are connected to their personality. It is also considered to know how much patients resisted their obsessions and rituals because by this, we could figure out how much they thought their response prevention was rationale. The fact that a person does not resist would not mean that a person is not obsessional but a person who believes that his thoughts are sensible, usually he is considered as not obsessional. Patients believe that their behaviour has a rationale basis but became exaggerated; treatment would want to convince that ‘risks’ which a patient anticipates if he halts his obsessional behaviour do not happen.

X.      The element of emotions:

Emotions should be considered and mood changes when an obsession happens. It is supposed that anxiety is the most dominant feeling when as obsession happens but discomfort and depression are assessed as well; significant number of patients report about tension, anger and repugnance as well and questions by therapists should refer to whether mood changes happen prior or after the obsession and behaviour. Illustrated questions for an assessment would include ‘does it feel as if you were before a work interview?’ (Refers to anxiety), or ‘do you feel you had enough?’ (Refers to depression); it is worth noting that obsessions are associated with depression as many patients diagnosed with depression develop obsessions.       

XI.      The element of behaviour:

Behaviour needs to be assessed; on the other hand, behaviour which could trigger obsessional thoughts needs to be assessed; behaviour which prevents exposure***** needs to be assessed; behaviour which eliminates obsessional thoughts need to be assessed; behaviour which prevents reappraisal needs to be assessed; all these need to be considered carefully. Many times, behaviours form triggers such cases when a driver thought he hit someone when he turned right so he turns around to check no one is hurt; this behaviour triggered an obsession to check when ever he turned right. Avoidance could be passive or active and they should be examined; therapist should ask his patient whether there were things he does not do to prevent obsessions set off (Passive avoidance) and on the other hand, should ask him whether there were things he does do to prevent such obsessions set off (Active behaviour); both cases should be encouraged negatively. Common question which relates to overt rituals is whether the patient tries to ‘puts things right’ or ‘make sure that nothing goes wrong’ when his obsessional thought occurs. If a patient was prevented to make his ritual, he may ritualize covertly; this should be asked about quite often.

XII.      The element of reassurance:

Reassurance request is common among obsessional patients; it is another neutralizing behaviour. Reassurance is used by patients to check act and second to burden responsibility on the asked person when answers. Reassurance eliminates exposure to the troubling thought and influences reappraisal. Neutralizing, ritualizing, reassurance and compulsive behaviour could be postponed some times after obsession occurs. The behaviour should be investigated detailing form of the act; how much time it takes; how often; and does it take same shape each time. Elements which increase or decrease such behaviours should be assessed as well; these elements could be of events, influences, cognitive******. 

I believe in the school of Behaviourism and much less in the Psychoanalytic school as I find it unscientific and more similar to philosophy and literature as you can not prove it. I suppose CBT is more sensible and efficient than treatment based on the Freudian approach (did it help Marlyn Monro?) as it is empiric. I am sure that as time goes on, psychology will lose trust in the psychoanalytic approach (more than it does today) and turn to cognitive-behaviour therapy as a major way of treatment. Elements such dreams, unconsciousness, anal and phalic stages will be seen as ancient history. While nowadays the tendency is towards cognitive approaches, future of psychology will be more dependant on brain researches and discoveries as this will neutralise psychological theories and relate disorders to neurobiology but still, there could not be a case where psychological factors are eliminated completely as the continuous interaction between the two demands dual considerations as atmosphere affects cognition and by that, chemical reactions in the brain change as well.       

* Cognitive-behavioural treatment is all that is discussed in this article; cognitive refers to areas of thinking, language, memory and perception; in this context, thinking is most related to.    

** Schizophrenia is a psychiatric disorder which shows features such hallucinations, delusions, racing  thoughts, poor social functioning, disorganised thoughts, concentration difficulties, difficulties in completing tasks, seeing things and hearing voices which do not exist in reality; it demands medical treatment.         

*** Or put things right.

**** Or cognitive in this context.

***** Or avoidance.

****** Stages are summarized to three: 1. Interview 2. Assessment 3. Treatment.