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Treatment of a Child With Obsessive-Compulsive Disorder With Limited Motivation: Course and Outcome of Cognitive-Behavior Therapy

Bernhard Weidle1, 2 and Gudmundur Skarphedinsson3

1Norwegian University of Science and Technology, Regional Centre for Child and Youth Mental Health and Child Welfare 2Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway 3Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway (RBUP) Oslo, Norway

Motivation is a key ingredient in the successful treatment of pediatric obsessive-compulsive disorder (OCD). As a first-line treatment, cognitive-behavior therapy (CBT) requires extensive client engagement, including participating in exposures and doing homework tasks. A lack of motivation to comply with these tasks may seriously affect treatment outcome. This case study identifies factors interfering with motivation and illustrates motivational strategies to enhance compliance of a child with OCD. The patient was an 11-year-old boy with severe OCD and symptoms of oppositional defiant disorder (ODD). He had extensive OCD-related avoidance behavior but denied the presence of symptoms or did not acknowledge them as a problem. In this article, we discuss the different techniques used to enhance motivation, which subsequently led to a favorable outcome. C© 2016 Wiley Periodicals, Inc. J. Clin. Psychol.: In Session 72:1139–1151, 2016.

Keywords: obsessive-compulsive disorder; children and adolescents; cognitive-behavior therapy; motivation; treatment

Cognitive-behavior therapy (CBT) in the form of exposure and response prevention (ERP) is an effective treatment for pediatric obsessive-compulsive disorder (OCD) (Skarphedinsson et al., 2015). It is recommended as the first-line treatment for mild to moderate OCD and in combination with antidepressants for moderate to severe OCD (Geller & March, 2012). Quality of life is reduced in children with OCD (Weidle, Ivarsson, Thomsen, Lydersen, & Jozefiak, 2015) but improves significantly after treatment, such that responders to CBT achieve the same range of quality of life as the general population.

Motivation to comply with treatment recommendations is a crucial issue in the successful treatment of OCD. In adult OCD, insufficient motivation predicts which patients may expe- rience poorer treatment outcome and which patients do not complete treatment (Simpson, Zuckoff, Page, Franklin, & Foa, 2008). For the majority of patients, psychoeducation about the treatable nature of the disorder and the desire to obtain better quality of life are sufficient motivators. Understanding the treatment rationale and compliance with exposure instructions was significantly related to lower posttreatment OCD symptom severity (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002). Although not studied explicitly in children, this is likely to apply for pediatric OCD as well.

However, in a considerable number of young patients presenting for assessment and treatment for OCD, motivation is very low or even completely lacking. In contrast to adult patients who

Please address correspondence to: Bernhard Weidle, Department of Child and Adolescent Psychi- atry, St.Olavs University Hospital, Post Box 6810 Elgeseter, N-7433 Trondheim, Norway. E-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 72(11), 1139–1151 (2016) C© 2016 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22394

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have to make a decision whether to seek help or not, children are often brought to treatment without actually wishing it. With adults, the decision to enter and remain in therapy may be hampered by ambivalence about therapy, poor insight, and/or low compliance; with children, all of these factors that interfere with treatment motivation may be present. Some therapists use paradoxical interventions to boost motivation, such as telling ambivalent and insufficiently motivated patients that OCD is their problem and not the therapist’s, or inviting them to return when they are bothered enough by their symptoms and ready to work toward positive change.

However, while interventions like this might be appropriate for and work with adults, they are neither appropriate nor beneficial for use with children and many adolescents. Many of these young patients who are not really motivated would be pleased with such an intervention, telling their parents that even the therapist agreed that they did not have to come to treatment. External motivation by parents alone is very challenging for the therapist because he or she is pressured to provide treatment for unmotivated patients. However, parents can be useful allies to overcome motivational obstacles in the treatment of their children.

Poor motivation to engage in therapeutic exposure tasks may be caused by a variety of reasons such as not believing that the treatment will help, lack of self-confidence for being able to comply with exposure, low insight into the nature of OCD, anxiety about potential negative consequences of engaging in treatment (e.g., high workload or high level of anxiety), and the presence of comorbid disorders. Comorbid disorders or subclinical symptoms are frequent in OCD (Ivarsson, Melin, & Wallin, 2008; Storch et al., 2008). If a child is without energy or hopeless due to depression, has no goal directedness due to ADHD, or has poor insight into their OCD due to an autism spectrum disorder, then he or she may be far less motivated to engage in treatment and/or comply with treatment recommendations.

In general, if comorbid disorders cannot be ruled out and if they would likely impede treatment of OCD, then they may need to be treated before addressing OCD to improve the final outcome (Storch et al., 2008). In particular, comorbid disruptive behavior interferes with treatment motivation. Clinical and subclinical disruptive behavior disorders for example oppositional defiant disorder (ODD) and conduct disorder are associated with increased severity of OCD symptoms and poorer treatment outcome (Storch, Lewin, Geffken, Morgan, & Murphy, 2010; Torp et al., 2015).

In these instances, both OCD-related and non-OCD-related disruptive behavior is maintained by a coercive cycle of parent–child interaction, in which both negative and positive reinforcement is involved. Parents may (inadvertently) positively reinforce their child’s disruptive behavior (e.g., through increased attention) and the child in turn negatively reinforces the parents’ behavior (e.g., giving into requests).

In addition, punishment and negative reinforcement work together to discourage parents to make demands or reprimand their child, while the child is “encouraged” to respond fully to all requests and reprimands. For example, when a child performs compulsions like washing excessively with an enormous amount of soap and parents try to stop this behavior with rep- rimands, the child may react very angrily, leading to two consequences. First, parents may not interfere with compulsions any more, to avoid the unpleasant anger outbursts; and, second, the child learns that expressing rage causes parents to accept the compulsive behavior, thereby in- advertently reinforcing the child’s behavior. Thus, anger outbursts are quite frequent in children with OCD even without comorbid disruptive behavior, often involving limit-setting situations (Storch, Jones, et al., 2012). In general, the base of aggression in ODD and OCD is different. In ODD, the child refuses to recognize authority mainly with the goal of engaging in pleasurable activities, while in OCD, aggressive behavior usually is provoked by authorities interfering with the need to perform rituals. A careful interview with both the child and parent is needed for assessment and differential diagnosis.

High family accommodation, in which parents perform all rituals or avoidance behaviors the child demands of them, may contribute to poor treatment motivation. Families of young people with OCD and comorbid ODD report this more frequently (Storch et al., 2010). This may occur as a result of high levels of aggressive behavior, forcing families to accommodate the child’s demands. The maintenance of secondary gains, for example, reduced chores and duties or increased attention by caregivers, may also decrease motivation for change. Another

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factor is poor insight into the nature of OCD, as specified in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013) diagnostic criteria: Some children are completely convinced that OCD beliefs are true and that they need to perform their compulsions to prevent catastrophes; they do not recognize the irrationality and exaggerations of their obsessions. In these cases, the OCD symptoms are perceived as egosyntonic.

Other factors preventing the child from engaging in therapeutic exposure tasks are a lack of understanding of the treatment rationale, underestimation of the symptoms, lack of belief that the treatment will help, and/or very high levels of anxiety or disgust. In general, children experience higher anxiety levels and lower ability to tolerate unpleasant feelings than adults. This is especially true in cases of comorbid anxiety disorders. In children with comorbid autistic symptoms, many factors (poor insight, concomitant anxiety disorder, high level of anxiety, and low tolerability of anxiety) may be present (Storch, Arnold, et al., 2012).

Adding motivational interviewing (MI) is considered to be a promising adjunct to CBT for anxiety disorders in adults (Simpson et al., 2008; Westra, Arkowitz, & Dozois, 2009), and in children and adolescents it has been used to promote different health-related behavior. MI is a method for interacting with patients to decrease their ambivalence and support their self- efficacy in their efforts at behavior change (Miller & Rollnick, 2002). The four central principles of MI are as follows: (a) express empathy; (b) develop discrepancy between the undesirable behaviors and values that are inconsistent with those behaviors; (c) roll with resistance rather than confronting it directly; and (d) support self-efficacy. One study examined the effectiveness of adding three sessions of MI to a standard course of CBT for pediatric OCD (Merlo et al., 2010). Albeit limited by a small sample size (n = 16), the results suggested that addressing pediatric patients’ ambivalence about OCD treatment and supporting their self-efficacy to “fight” OCD may accelerate treatment progress and reduce the number of needed sessions to achieve treatment gains.

In the present case, therapy consisted of standard CBT, but integrating elementary principles and techniques for motivation was necessary to induce and maintain the child’s adherence to the treatment course.

Case Illustration

Presenting Problem and Client Description

At the time of the first assessment, “Tommy” was an 11-year-old boy (name and details are changed due to confidentiality) who was referred to the clinic by his family’s general practitioner for assessment and treatment of OCD. He lived together with both parents and a 9-year-old brother. The parents reported a history of normal pregnancy and uncomplicated delivery 2 weeks before term, along with an uncomplicated neonatal period. Psychomotor development including developmental milestones was described to be within the normal range. There was no family history of OCD, but an uncle and grandfather had symptoms of anxiety and depression. The age of onset for OCD symptoms was at about 7 years, starting with exaggerated hand washing and avoidance of touching “contaminated” or “dirty” surfaces. Retrospectively, mild symptoms were observable already at the age of 6 in terms of preoccupation with bacteria and having a clean environment around him.

The parents described a variety of OCD symptoms and avoidance behavior exhibited by Tommy. For example, he washed his hands every time he came in contact with dirty surfaces, to a degree that the dorsal parts of both hands were dry and sore. He avoided touching devices other people had touched such as door handles, keyboards, and remote controls. He opened doors with his feet and touched devices using sweater sleeves as protection for his hands.

Tommy avoided visiting friends outside home, and when he had friends visiting him, he checked whether they washed their hands after using the toilet by listening outside the bathroom door to the sound of the water from the sink. He also commanded them to perform an additional hand wash before they were allowed to handle gaming controllers or other devices he might have to touch during play. Tommy was not able to use public restrooms, which restricted to a great

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deal the area within which he and his parents could move, meaning that they were not able to visit places far from home. He was also unable to use the bathroom in other private homes, preventing him from staying overnight with friends or extended family. He had time-consuming toilet rituals, such as sitting on the toilet for more than one hour and using 30 or more pieces of toilet paper to assure that he was clean.

Assessment and Case Formulation

The Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Kaufman et al., 1997) and the Schedule for Affective Disorders and Schizophrenia for School Aged Children–Present and Lifetime Version (K-SADS-PL; Scahill et al., 1997) were administered during the initial assessment, indicating that Tommy met the full criteria for OCD. The CY-BOCS total score was 27, which indicated severe OCD (obsessions score 13 and compulsions scores 14). According to K-SADS-PL, he exhibited some symptoms of ODD that were below the clinical range, mainly due to his parents’ report that defiance symptoms were caused by or attributed to OCD. No other comorbid conditions were present.

The most unusual and salient feature during the assessment was his complete reluctance to report symptoms. He did not acknowledge parent-reported symptoms, claiming that his parents had misunderstood his behaviors, or at least denied their actual presence, admitting that he might have had some of these symptoms previously but not anymore. He blamed his parents for exaggerating his normal need for a certain hygienic standard and for bringing him to absolutely unnecessary consultations with a therapist. Needless to say, he was completely unmotivated for any kind of therapeutic approach. Clinical assessment had to rely to a large extent on his parents’ descriptions and Tommy’s acknowledgment that only some of these symptoms might have been previous symptoms. Parents’ descriptions were strengthened by observation of his avoidance behavior during the assessment and the therapeutic sessions.

The case formulation concluded with the hypothesis of poor insight or extreme avoidance behavior or both, by not only concealing the symptoms but also denying them even at the cost of having to visibly lie. For treatment purposes, the therapist had the concept and hope that Tommy’s avoidance and lack of motivation could be changed during the psychoeducational part of the treatment, at least with some additional emphasis on Tommy’s motivation. The parents’ role was considered an important part of the implementation of the CBT: They facilitated homework assignments and obtained reliable information about symptom development and outcome.

Course of Treatment

Standard CBT. The treatment aimed to adhere closely to the treatment protocol of the Nordic Long-term OCD Treatment Study (Thomsen et al., 2013), which comprised 14 weekly sessions of CBT with ERP over a 6-month period. Sessions included one weekly individual CBT session with the client, followed by shorter sessions with one or both of the parents joining in. Each session agenda focused on the hierarchy of targets aimed at (a) reducing the client’s compulsive behaviors, (b) reducing therapy-interfering behaviors such as not collaborating with the therapist or failing to do homework, and (c) focusing on quality-of-life interfering behaviors. Standard CBT, according to protocol, is delivered over a 3–4-month period.

Session 1

The main focus of the first session (joint child and parents) was alliance building with the child and the parents and psychoeducation about the nature of OCD and the therapy. In the session, goals included rapport building, learning about the child’s hobbies and interests, and assessing the family’s knowledge of OCD. An overview of the treatment framework and rationale was provided, including externalizing of OCD. Willingness and motivation for treatment was assessed directly by addressing issues of managing compliance.

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Figure 1. OCD map: Metaphoric visualization of areas controlled by OCD compared to areas controlled by the child.

During the entire session, Tommy showed demonstrative disinterest by not answering ques- tions directed to him, reading a cartoon, and not participating in discussions. He was not motivated to participate actively in the treatment and he continued to deny the presence of symptoms or did not acknowledge them as a problem. In the session, psychoeducation was directed toward the parents with him as a quiet observer. The problem of lacking motivation was addressed, with the therapist expressing the view that motivating factors or rewards might be found during the course of the treatment.

Introducing instruments for symptom registration, the therapist constructed a drawing re- sembling a geographic map (see Figure 1) as a metaphor illustrating which areas in the life of the child were controlled by OCD and which areas Tommy had control. Tommy was able to join in with comments while the therapist made the drawing. However, after about 10 minutes, Tommy abruptly stopped his collaboration and drew a line with the pen over the map, put his hoodie over his head, and refused to talk any more. The therapist ignored this behavior and continued with the program, telling Tommy that even simply listening to the conversation without talking is appreciated.

Two homework tasks were assigned: (a) find a name for the symptoms his parents brought him to the clinic for and (b) register symptoms during the following week (being a detective). Parents were allowed to help Tommy in the event that he failed to comply with the homework. A motivating tool could be to take photos with his cell phone of door handles or other areas he could not touch. To cope with Tommy’s refusal to cooperate, a decision was made that one or both of the parents would join all future sessions. Parental needs were addressed in short parent-only sessions after each session with Tommy.

Session 2

The main focus of the second session was to follow up on homework tasks and work with treat- ment motivation. Tommy started the session with a claim that he had stopped performing his compulsions. The homework review revealed that mainly the parents had performed the home- work: They had made a list of symptoms, supplemented by a short video of Tommy’s washing behavior. The father had discussed this list the day before the session and Tommy expressed

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the opinion that the symptoms observed by the parents were wrong or grossly exaggerated. However, he came up with a nickname for the symptoms: the super fool, or SF.

Reviewing the symptom list during the session, asking for his “correct” version, Tommy modified some of the symptoms, denied others, and acknowledged at least a few of them. While working with the symptom list at home as part of the homework task, the father had asked Tommy to decide whether opening the bathroom door with his foot was a symptom that could be added or not. Tommy had become very irritated and touched the door handle in pure rage, just to show that this was not a problem. However, he had to wash his hands afterwards. In the session, the therapist used this example, relating it to the last session’s psychoeducation on how therapy works, giving credit for combating and taking back a bit of the area that was controlled by OCD, even before starting exposure exercises in the sessions.

Following this, Tommy listened to the introduction of the fear thermometer to generate Subjective Units of Discomfort Score (SUDS) ratings on a scale from 1 to 10, using his symptoms as examples. He claimed that his SUDS had already declined substantially. The need to inspect the dry skin of Tommy’s hands, caused by washing, was used to introduce an in-session test exposure to model future exposures. The therapist explored the suggestion that Tommy could put his hands in the therapist’s hands. He was either unable or unwilling to perform this exercise, though he could show his hands and permit inspection of the skin.

In the negotiation of a homework assignment, he agreed to the following: Opening the bathroom door by touching the door handle with his hand (and not his foot) without washing the hands afterwards at least once a day. His parents were tasked with helping to register the development of his SUDS during the exposure. In addition, he was asked to continue the detective work to uncover other OCD-symptoms.

Session 3

In the third session, treatment goals were explored, which included asking Tommy to imagine the things he would be able to do without being hindered by OCD. This discussion was tricky for him, since he was still denying the symptoms or their impact on his life. As such, his goal suggestions were all non-OCD-related, for example, gaining more points in a computer game. After discussion and input by the parents, he agreed to the following goals, because he still claimed that none of the tasks would be challenging for him: (a) use a public restroom whenever and wherever he wanted or needed to, (b) touch all the things he wanted to touch, and (c) allow his friends to touch his Xbox controller without commanding them to wash their hands in advance.

The homework review revealed that he had not complied with the request to register his symptoms as a detective, but he did perform the exercise to open the bathroom door by hand once a day. Although he reported to his parents no subjective discomfort during the exposure, he avoided doing the exercise more often or without being prompted by parents.

Reviewing the symptom list, Tommy claimed that all SUDS were 0 now. To evaluate Tommy’s claims, the therapist again asked him to touch his hands as an in-session exposure. Still claiming that he experienced no distress or discomfort, he allowed the therapist to touch other parts of the body such as the forearms, but he failed to allow the therapist to touch the hands. After negotiating different options for exposure, Tommy chose that the therapist touch his backhands but not his palms, reporting a SUDS of 0 during the whole exposure. The therapist praised his effort. Although Tommy refused any new homework task, he agreed to continue with the task from the last session (touching the door handle). The task of registering other OCD symptoms was modified, and it was decided that his mother would record the time he spent in the restroom. During the session, it was observed that Tommy was primarily uncooperative, hostile, answered arrogantly, lied openly, used inappropriate language toward his parents, and demonstratively stopped all communication when he so chose.

Session 4

The main focus of this session was motivating and socializing Tommy to the therapeutic model. Reviewing the week, Tommy again claimed all SUDS were 0, with the exception of the following

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two symptoms: touching the palms of people outside the family (SUDS 1) and not using an exaggerated amount of toilet paper (SUDS 2), which was the symptom his mother had to monitor as homework. As with the previous week, Tommy performed only his homework when his parents reminded him to do so. His mother’s observations of time use in the bathroom showed that Tommy reduced the time from 45 minutes to about 10–15 minutes each time, except when he needed to defecate, which still demanded a lot of time.

Exposure exercise. Regarding in-session exposure exercises, the therapist made consider- able efforts to find appropriate in-session tasks to give Tommy different choices for exposures, allowing him to choose the “least bad” one. However, no object or surface available in the con- text of the office or the surrounding area was difficult for Tommy to touch. Then the therapist proposed to elaborate on the previous week’s exposure, working with touching hands. Tommy still claimed that he had no discomfort doing this and that it had nothing to do with OCD. However, he again failed to perform the exposure task, arguing that he would be able to touch anyone else’s hands except those of the therapist, offering insulting excuses such as the hands were too dark, too old, too ugly, too hairy, and not recently washed. A compromise was found by again touching the back of the hands, avoiding the palms as he had achieved in the previous session. The exposure experiences were reframed to be at least a good starting point, because he could touch the back of the hands more easily than in the previous session, illustrating that the method was working as predicted.

The therapist negotiated and detailed mental exposures for the next week’s session. Mental exposure means that the child imagines an anxiety-provoking situation. In this process, Tommy agreed to bring his Xbox controller with him to the next session. The motivation for this agreement seemed to be derived from two sources: (a) He could avoid further questions about other exposure exercises in the session, and (b) he had a tiny experience that exposures were both achievable and might work. However, shortly afterward, he wanted to renegotiate this promise; but the therapist stated that an agreement was an agreement and the task was now written on the list of homework assignments. Tommy also agreed to repeat the homework tasks from the previous week (opening the bathroom door) as well as opening the refrigerator by hand (and not foot), but he refused any other extended task.

Session 5

Session 5 followed the same structure as the previous sessions and elicited the same standard response. When asked how his week had been, Tommy replied in what was his usual manner: “Good, of course.” Reviewing and actualizing the symptom list, Tommy claimed again that all SUDS were 0, but he was willing to discuss the different symptoms in more detail compared with the previous sessions. His parents reported that he used a public restroom during a sporting event, even when the hygienic standards there were suboptimal. This gave the therapist the chance to praise him for having done a very important exposure exercise, which would have been on the plan for future exercises. In addition, the therapist underlined that this was a good example that Tommy’s bravery can triumph over OCD and that he is capable of being the boss himself and not allowing OCD to dictate the decisions.

Homework review. The parents reported that Tommy now mostly opened the bathroom door and refrigerator by hand; but when he did not, they observed that this seemed to be more due to his old habit and not a conscious decision to avoid the door handles. Time spent in the bathroom was still about 10–20 minutes. Most important, the third homework task was honored: Tommy had brought with him the Xbox controller. This had been difficult for him— he had attempted to renegotiate the task with his parents, for example, by offering to bring in another item. When his parents held firm and reminded him to stick to the agreement, he spent a lot of time during morning routines to demonstrate his noncompliance.

In-session exposure. Exposure was prepared and negotiated in detail. The therapist made it clear that he would not force Tommy to complete any action or exposure he had not accepted

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in advance, because this would not be helpful. The important parts of psychoeducation were briefly repeated: (a) the therapist’s role was like a coach who had to push his client but the client was the one who would do the work; and (b) to reset the “false alarm generator,” Tommy had to expose himself to tolerating unpleasant feelings, reminding himself that the situation, though unpleasant, was not dangerous. To cope with the situation, a helpful strategy could be to rely on his reasonable thoughts, and not on the exaggerated obsessions.

Different scenarios for exposure were described and tested: First, he tolerated touching the controller himself without washing his hands first, and then his mother and father touched the controller, which he claimed elicited no discomfort (SUDS rating 0 all together). In the next step, we tested how close the therapist could come to touching the device. After a while, Tommy accepted that a proximity of a few millimeters between the therapist’s hand and his controller was acceptable. He gradually allowed the therapist to touch the controller with the sleeves of the shirt, rather than with the back of his hands, but not with his palms or fingers. The therapist reframed the situation for the next step: touching the controller could reveal or clarify the presence or absence of obsessions and thus allow him to examine them in detail, in case they should be present.

In the following step, Tommy had a hard time concealing his discomfort. Still claiming that he had no OCD, it was impossible for him to provide valid reasons for why the therapist could not touch the controller, despite his previous claims of the therapist’s hands being too dark and too old, etc. Tommy was visibly in a state of high discomfort. The therapist praised him for doing a good job with the exposure exercise, especially in relation to the mental exposure of the last step, which was imagining that the therapist would touch the controller with his palms or fingers. He agreed to continue with further exposures during the next session and he promised to bring back the Xbox controller then.

For homework, Tommy agreed to continue with the previous exercises and add two new tasks: (a) use a public restroom during a planned visit to a distant area and (b) open the main entrance door at home without the sleeves of his pullover as protection.

Session 6

Tommy and his mother reported on their visit to a distant area. They had a pleasant tour and Tommy had used public restrooms on the way. Review of the symptom list: No new symptoms, all SUDS rated 0 by Tommy.

Homework review. Tommy used a public restroom and opened the main entrance door at home without protection. He commented that “of course” this had been possible. His parents reported that Tommy now opened the bathroom and refrigerator doors by hand, a success tempered by his claim to have always done this, also in the absence of parents. Time spent in the bathroom was still about 10–20 minutes. As agreed, he had brought the Xbox controller to the session.

Exposure. In preparation for the exposure, all steps from the last session were briefly repeated including psychoeducation, clarifying and negotiating expectations for the exposure in this session and performing all exposure steps from the last session with the Xbox controller. After this preparation, Tommy was able to tolerate the therapist touching and handling the controller with both palms and fingers with no time limit. Tommy gave SUDS ratings of 0 for the whole exposure procedure, but body language revealed initial tension and stress signs. The therapist praised him for his bravery and huge effort to tolerate the discomfort, as well as highlighting the importance of the task to gradually reset the “false discomfort generator.”

Homework assignment. Tommy agreed to continue with the previous exercises (main- taining skills) and allow friends to touch his controller at home without making them wash their hands in advance. For the first time, the negotiation process was more collaborative and Tommy admitted the presence of a few symptoms.

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Session 7

Tommy had performed all the homework including not washing his hands before touching the controller. However, he had found a way to get around the issue of his friends touching his controller: He offered them the use of an old controller he had in his possession, which had not been used for some time and so would not be used again by him.

In-session exposure. The therapist was allowed to touch every part of Tommy’s own controller as well as Tommy’s palms and fingers without any visible discomfort. As before, Tommy rated a SUDS score of 0.

Homework assignment. Continuing all previous exercises, maintaining skills, and allow- ing his best friend to use Tommy’s own Xbox controller, preferably whenever he came visiting but at least once.

Session 8

Tommy had performed all homework tasks. He had found it difficult to let his friend touch the controller and performed this task only once, only after being reminded and encouraged by his mother. Although he succeeded with the task, he did not want to repeat the exposure. He was less cooperative in the session and the family had forgotten to bring the controller. Tommy refused to engage in any exposure exercises except mental ones, which involved planning the exposure for the next session, for example, exposing the controller to wet fingers or a little bit of soapy water. As an additional homework task he agreed to let other people touch the controller with wet fingers, for example, friends, parents, or his brother.

In the parents’ session afterward, Tommy’s mother reported considerable symptom reduction, better mood, and increased engagement in social activities such as visiting friends.

Session 9

Tommy was angry when he entered the session; he screamed and cursed because his mother had forced him to bring his controller to the session. The therapist reminded him of the agreement and told him that there was no reason to blame his mother for helping him to stick to it. After reviewing his week in general he calmed down.

Homework review and symptom hierarchy. Although Tommy had carried out the home- work tasks, he did not really accomplish them as his own exercise. Rather, he conveyed a per- ception of being pressed by his parents. No new symptoms were present but letting others touch the controller had become even more difficult. The previous week he had achieved the highest level of skills in an Xbox game, making his controller even more valuable because it now was a “winning premium controller.”

In-session exposure. Tommy was not motivated to do any exposure work. The therapist reviewed the OCD map, updating it by marking all small and big victories. They concluded that the final defeat of OCD was clearly in sight but that OCD tried to entrench and fortify the last stronghold with the controller. Motivation was reworked again using Socratic questioning and stressing the importance of doing exposure work for himself, not his parents. In the end, he permitted the therapist to touch and handle all parts of the controller with no visible discomfort. Previous homework tasks were continued and he agreed to let others touch the controller at least once a day.

Session 10–14

In the following sessions, Tommy became surprisingly cooperative, which extended to exposure with the controller. He tolerated all types of manipulation of the controller, including symbolic

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contamination with different fluids, and complied with all homework tasks. Friends at home were now allowed to manipulate the Xbox controller without restrictions. In the everyday situation at home and in school, OCD symptoms were fewer and did not characterize his days any more. His parents reported that he visited a friend and stayed overnight, an activity he had not been able to do for years. On the other hand, ODD symptoms persisted albeit to a lower degree.

Outcome and Prognosis

Measures

The K-SADS-PL was used to confirm the diagnosis of OCD according to the DSM-IV (APA, 1994) and evaluate comorbidity. Symptom severity was assessed with the CY-BOCS, a semistruc- tured interview comprising checklists of obsessions and compulsions. The Family Accommoda- tion Scale (FAS) (Calvocoressi et al., 1999) was used to measure the extent of the family’s accommodation to the child’s OCD symptoms. Total FAS scores range from 0 to 48, with 48 signifying extreme involvement of caregivers with the child’s OCD symptoms. A nontreating clinician conducted assessments at baseline, posttreatment, and follow-up.

Results

Assessment with CY-BOCS at baseline showed a total score of 27, indicating severe OCD. Family accommodation measured with the FAS showed a total score of 15, indicating moderate accommodation. At the posttreatment assessment, after 14 sessions of CBT, the CY-BOCS total score was 2 (obsessions 0, compulsions 2) and FAS total score was 0, indicating complete remission of OCD and no family accommodation at all.

We followed-up with Tommy once a year for 3 years. He experienced a recurrence of a few symptoms waxing and waning during the follow-up period. At the end of the 3-year follow-up, he had a few new symptoms (e.g., he had to check dishes for impurities). However, none of his previous symptoms were present anymore and he had no avoidance behavior or functional impairment. His parents confirmed his reports. CY-BOCS at the end of the 3-year follow-up was 6 (obsession score 5, compulsion score 1), indicting a low score under the clinical threshold. The prognosis in terms of relapse of OCD is considered good because he had maintained treatment gains and not relapsed over a long period of time.

Disruptive symptoms, mainly anger outbursts and oppositional attitude, had diminished after the therapy course but were not completely absent, suggesting that these symptoms were not caused only by his need to accommodate OCD.

Clinical Practices

The present case illustrates the integration of motivational strategies into CBT with ERP for a child with OCD and limited motivation combined with subclinical disruptive symptoms. Moti- vation for treatment and willingness to engage in homework assignments are crucial: Without exposure exercises, treatment will fail. At the outset, Tommy violated all principles for a suc- cessful treatment outcome: He was reluctant to learn about treatment rationale and denied his symptoms; he failed to comply with in-session or homework exposure; and he refused self- monitoring of rituals. To overcome the obstacles of poor motivation, both the therapist’s attitude and technical skills were challenged. The case of Tommy demonstrates a variety of factors that might have contributed to the outcome. The most important factors, according to our analysis, are highlighted in the following paragraphs.

Endurance and Timing

Stamina was an important factor. The therapist persevered in the method, demonstrating both staying power and patience with Tommy and his parents, thus gradually socializing him into the treatment model. To catch the child’s attention and foster comprehension, psychoeducation was

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individually adjusted, imparted in small chunks, and repeated again and again in situations in which the message could be demonstrated with concrete examples. It was specifically important to repeatedly stress the rationale for doing the exposure exercises and at points in time when Tommy was receptive to the message. When he was in a mood of noncompliance and resistance, psychoeducation was not directed to him but rather to the parents, with him listening in.

Alliance

Engaging the parents is a standard modification in ERP for children and adolescents. Because it was difficult and took time to build a working alliance with Tommy, it was of particular importance to engage his parents, modeling and encouraging them to modify their behavior. Reframing and directing anger against OCD and not parents was one of the techniques used. Gradually Tommy saw them as allies against OCD rather than being “bad” parents who forced him to do undesirable or unpleasant things. Carefully selected rewards can be a powerful tool to both build an alliance and enhance motivation. However, Tommy’s parents decided not to use external rewards, to avoid extensive negotiations. They had learned in the past that rewards did not work well for Tommy, and only led to him demanding another and bigger reward before completing the task or as soon as he had accomplished it. An indirect reward was to shorten the session when he collaborated well.

Addressing Motivation

During the course of therapy, Tommy’s lack of motivation was directly addressed by stressing to him that there were some impairing symptoms that were restricting his social life. He was informed that his parents and his therapist believed that this was caused by OCD, despite the fact that he did not. It was carefully explained that to get rid of OCD, collaboration is the best strategy. His lack of motivation was reframed: If motivation to collaborate is more based on getting rid of the therapy than getting rid of the symptoms of OCD, this is okay. Motivation is useful wherever it is derived from.

Consistency and Predictability

A basic attitude of being empathic but consistent was critical. For example, the therapist insisted that an agreement was an agreement, allowing no renegotiations, but accepted other misbehavior, thus carefully picking the battles. Instead of engaging in a power struggle regarding whether Tommy’s version of the symptom report or that of his parents was right, the different perspectives were acknowledged, allowing Tommy to save face. A decisive point for the course of the therapy was predictability. The therapist both expressed verbally and demonstrated in practice the attitude that he will keep to the rules and agreements. Exposure exercises were carefully selected, well prepared, and achievable. Nothing impossible was demanded, which allowed Tommy to participate gradually, take control, and eventually take the lead in the therapeutic process.

Exposure Modification

In-session exposures were the most crucial part to test and model homework assignment. If a child does not perform the assigned homework, then treatment will not succeed. Therefore, significant emphasis was placed on overcoming Tommy’s resistance. As a tool in this process, the therapist negotiated and detailed exposures for the next week’s session, which also included mental exposures that evoked images of anxiety-provoking situations. Although these mental exposures allowed Tommy to resist physical exposure in the actual session, they prepared him for actual and agreed-upon exposures in the next session.

During this process, the therapist described and discussed the function of mental exposures, acknowledged that Tommy engaged in a mental exposure, and praised him for his ability to tolerate the unpleasant images or thoughts, thus modeling the real exposures for the next week. Tommy was not interested in discussing in detail how, when, and where the homework exercises

1150 Journal of Clinical Psychology: In Session, November 2016

should be performed. However, he listened to the discussion of the role of his parents, who were also assigned homework. They were asked to assist him with his homework, for example, to help him remember to do the exercises, coach him through the exercises, and take care of the records as a secretary.

During exposure exercises, the child is commonly thought to experience a reduction of anxiety (habituation) or a tolerance of the anxiety without performing rituals. To promote this experi- ence, the child has to be encouraged to remain long enough in the frightening situation. Previous research on CBT mainly focused on the habituation process, which is based on the emotional processing theory (Foa & Kozak, 1986) that anxiety level will be reduced every time an exposure is performed.

The research of Craske and colleagues (2008), however, which is based on inhibitory learning theory, has demonstrated that even when exposure in general leads to habituation, anxiety reduction is not an absolutely necessary condition for improvement over time. This means that exposure to the discomforting situation may lead to improvement of OCD, even without the experience of diminishing anxiety level during the exposure. Because of Tommy’s lack of cooperation in anxiety or discomfort assessment (SUDS-rating), we don’t know whether his anxiety really diminished or not. However, Tommy’s improvement seems to be in line with the view that tolerating exposure to unpleasant feelings was the important task, irrespective of the anxiety level experienced.

Conclusion

CBT is an effective but challenging treatment. As in general psychotherapy, clinicians need to adjust treatment to the patient’s personality and developmental stage, potential comorbidity, and the family’s style. Comorbid ODD is associated with high levels of aggression, negativity, oppositional behavior, and challenge to the therapeutic alliance. In case of clear-cut comorbid ODD, it is recommended to start treatment for this first, for example, using parent manage- ment training. The present case reflects the complexities of successfully integrating CBT with motivational techniques for a child diagnosed with OCD and subclinical ODD symptoms with a combination of noncompliance, resistance, and lack of motivation. The results suggest that CBT combined with different techniques to enhance treatment motivation and compliance can be applied successfully to difficult cases such as children with severe OCD and poor treatment motivation.

Selected References and Recommended Readings

Abramowitz, J. S., Franklin, M. E., Zoellner, L. A., & DiBernardo, C. L. (2002). Treatment compliance and outcome in obsessive-compulsive disorder. Behavior Modification, 26(4), 447–463.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick, J., Fisk, D., Vegso, S. J., . . . Price, L. H. (1999). Family accommodation of obsessive-compulsive symptoms: Instrument development and assessment of family behavior. Journal of Nervous and Mental Disease, 187(10), 636–642.

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Opti- mizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35.

Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and ado- lescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51(1), 98–113.

Ivarsson, T., Melin, K., & Wallin, L. (2008). Categorical and dimensional aspects of co-morbidity in obsessive-compulsive disorder (OCD). European Child & Adolescent Psychiatry, 17(1), 20–31.

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Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., . . . Ryan, N. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS- PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980–988.

Merlo, L. J., Storch, E. A., Lehmkuhl, H. D., Jacob, M. L., Murphy, T. K., Goodman, W. K., Geffken, G. R. (2010). Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: A preliminary study. Cognitive Behaviour Therapy, 39(1), 24–27.

Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.

Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., . . . Leckman, J. F. (1997). Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(6), 844–852.

Simpson, H. B., Zuckoff, A., Page, J. R., Franklin, M. E., & Foa, E. B. (2008). Adding motivational interviewing to exposure and ritual prevention for obsessive-compulsive disorder: An open pilot trial. Cognitive Behaviour Therapy, 37(1), 38–49.

Skarphedinsson, G., Hanssen-Bauer, K., Kornor, H., Heiervang, E. R., Landro, N. I., Axelsdottir, B., . . . Ivarsson, T. (2015). Standard individual cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A systematic review of effect estimates across comparisons. Nordic Journal of Psychiatry, 69(2), 81–92.

Storch, E. A., Arnold, E. B., Jones, A. M., Ale, C. M., Wood, J. J., Ehrenreich-May, J., et al. (2012). The role of co-occurring disruptive behavior in the clinical presentation of children and adolescents with anxiety in the context of autism spectrum disorders. Child Psychiatry and Human Development, 43(5), 734–746.

Storch, E. A., Jones, A. M., Lack, C. W., Ale, C. M., Sulkowski, M. L., Lewin, A. B., . . . Murphy, T. K. (2012). Rage attacks in pediatric obsessive-compulsive disorder: Phenomenology and clinical correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 51(6), 582–592.

Storch, E. A., Lewin, A. B., Geffken, G. R., Morgan, J. R., & Murphy, T. K. (2010). The role of comorbid disruptive behavior in the clinical expression of pediatric obsessive-compulsive disorder. Behaviour Research and Therapy, 48(12), 1204–1210.

Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., . . . Goodman, W. K. (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive- compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47(5), 583–592.

Thomsen, P. H., Torp, N. C., Dahl, K., Christensen, K., Englyst, I., Melin, K. H., et al. (2013). The Nordic long-term OCD treatment study (NordLOTS): Rationale, design, and methods. Child and Adolescent Psychiatry and Mental Health, 7(1), 41.

Torp, N. C., Dahl, K., Skarphedinsson, G., Compton, S., Thomsen, P. H., Weidle, B., . . . Ivarsson, T. (2015). Predictors associated with improved cognitive-behavioral therapy outcome in pediatric obsessive- compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 54(3), 200–207.e201.

Weidle, B., Ivarsson, T., Thomsen, P. H., Lydersen, S., & Jozefiak, T. (2015). Quality of life in children with OCD before and after treatment. European Child & Adolescent Psychiatry, 24(9), 1061–1074.

Westra, H. A., Arkowitz, H., & Dozois, D. J. (2009). Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23(8), 1106–1117.

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