User-centred Perspectives in Perinatal OCD(Both pregnancy and motherhood can trigger or worsen OCD)

Objectives:To foster practitioner empathyTo improve efficient CBT provision, distinguishing problematic and useful aspects

Diana WilsonCo-founder of Maternal OCDFully recovered former OCD sufferer Mother of fourFormer OCD UK TrusteeSupport group facilitatorSpokesperson for Maternal OCD

Advisory Panel:Dr Fiona Challacombe, Dr Stephanie Fitzgerald, Dr Anne Perry, Dr Blake Stobie, Dr Adam Radomsky, Dr Liz McDonald

OCD Basic Information• Among top 10 most disabling illnesses (WHO)• Tell-tale sign: 1+ hours per day responding to fears

• Obsessions unwanted intrusive thought, image, urge. Repeats causing distress.

• Compulsions repetitive behaviours or mental acts (driven) – overt and observable, such as checking door locked – covert mental act, not observed, such as repeating phrases

• OCD is third perinatal mental health category after depression and post traumatic stress disorder

• Many popular misconceptions about OCD

CBT for OCD: Language usedUnhelpful or destructive language • Misguided commands:

‘Just ignore the thoughts!’ or ‘Just try to be positive!’• Mistaken absolutes:

‘It’s too ingrained’ or ‘you will just have to learn to live with it’ • Shallow or unsupported assurances:

‘I/you know you won’t actually harm any children’

Helpful language • ‘Once you get into dialogue with OCD you have lost’,

e.g. arguing with oneself over ‘whether you’d actually stab a child’• ‘Try to accept uncertainty’• Acknowledging without actioning intrusive thoughts:

‘Don’t engage’ and ‘let the thoughts wash over you’• ‘OCD plays tricks on the mind’

CBT for OCD: Logic used• Correcting the notion that OCD sufferers typically harm

loved ones: “no one with OCD harms babies.”• Disconnecting past info received from its effect on

current identity or personal narratives: “Did I feed alcohol to babies, as a babysitter, to make them sleep. Is my breast milk contaminating my new-born with the AIDS-virus?”

• Dispelling fear of schizophrenia or that thoughts are externally derived such as in conspiracy thinking. FALSE!

“You shouldn’t have children because of your

OCD.”

AVOID TIME-FRAMES (manage expectations):

“This’ll happen within … months”

“You’ll … by the end of the year”

me

Fear of the enormity:26 years

Fear of disclosure and

the social consequences

Fear of mental health

treatment & professionals

Fear of the inevitability of

having to confront the

fears

Fear of harming my

babies

Fear of being medicated

while breastfeeding

Fear of separation from child

Stages and types of fear

CBT for OCD: Contextualise and Normalise

• Relating patients’ thoughts to the general public’s or your own thoughts. Creating empathy and encouraging opening up:

e.g. The urge to push or be pushed or jump off the platform in front of a train.

• “You cannot shock a therapist”• “I really enjoy working with OCD sufferers because most

respond well to CBT.”

• Useful science-backed (evidence-based) reassurances

CBT for OCD: Contextualise and Normalise

• Encouraging case study reading to – Reduce isolation– Confirm the disorder’s existence– Reassure on nature of OCD and manage doubts

(reading on different harming/checking/contamination themes never actually triggers further obsessional thoughts, making it more ‘objective’)

• Encourage contact with other sufferers, to gain perspective– Live (support groups) or virtual (online)

• OCD sufferers have perfectly accurate memories, just less confident ones (Radomsky) and CBT will help you to restore such confidence.

CBT for OCD:Applying Techniques

• Handling reluctance to confront greatest fears:– Compare anaesthesia in surgery or dentistry!

• Encouraging exaggerated indulgence in the thoughts, to expose as silly, and so to disempower:

“Well okay then I will do exactly as you say and I will go and stab all those pregnant mothers right now!”

CBT for OCD:Applying Techniques

• Relabelling and refocussing (Schwartz) raises concerns: These could become compulsions through avoidance/distraction.

• Ultimatums: ‘take that leap of faith’ unwittingly put enormous pressure on clients. Should CBT fail, this leads to hopelessness from distrust towards therapy, compounding the problem.

• Consider assisted therapy, in the patient’s own environment e.g. 10-minute phone or Skype appointments – to communicate commitment– to reinforce and encourage the importance of exposure,

when patients instantaneously frozen with fear

CBT for OCD:Applying Techniques

• Distinguish between valid fears and irrational fears

• Concept check your advice is taken on, through simple questions

e.g. reality testing working? In the face of fear, it simply may ratchet up the introspection (via too much evidence seeking)

CBT for OCD:Broader practical advice

• Discourage alcohol use:

A quarter of OCD sufferers drink (self-medicate) to excess, ultimately heightening anxiety and increasing the unwanted thoughts

Mixing anti-depressants with alcohol may render them less effective.

• Apply extra empathy and remember diversity: – Exhausted solo parents, or parents of insufferable teenage OCD sufferers – Understanding that OCD is to be robbed of life’s simplest pleasures

in lieu of unrelenting mental torture. – Being flexible: every patient is different, each life situation is unique.

CBT for OCD:Broader practical advice

• Don’t neglect diagnostic screening of post-natal depression when a mother is already diagnosed with perinatal OCD.

• Consider ‘alternative risk’ of how giving in to compulsions can mean role-modelled behaviours are inherited by young children.

• Rejuvenate and motivate: ‘seize the moment’. OCD saps sufferers of the strength to fight, and they then resign ‘letting the thoughts win’.

• Design the patient experience (therapy begins at reception).• Make homework minimal/manageable, do-able

throughout the day, as a bolt-on to normal life.• Signposting to medical care. A ‘plan of hope’!