indefinitely. It can keep momentum going and also supports the idea of the young person taking increasing amounts of responsibility in therapy as they work towards ending treatment. The number of sessions will depend on the severity of the problem as well as any comorbid problems or Planning and carrying out treatment 53
other issues that may need to be addressed. Treating the OCD may have a beneficial effect on other problems (especially other anxiety disorders) as the young person learns skills that they can apply elsewhere. However, it may be necessary for treatment also to focus on other problems, such as self-esteem or family factors. While a young person with mild to moderate OCD and little comorbidity may require as few as five treatment sessions, youngsters with more severe problems are likely to benefit from a greater number and clinicians may need to consider somewhere between 12 and 20 sessions. Although there is a relationship between early response in treatment and success at follow-up (e.g. Allsopp and Verduyn, 1988), there is also evidence to suggest that initial non-responders may show significant improvements when therapy is extended (e.g. de Haan et al. , 1998), so clinicians should always ensure that the young person has received an adequate dose of CBT.
Planning treatment
At the end of the initial assessment, the therapist should be clear that the primary problem is OCD and remain aware of any other existing diagnoses and how they interact with the young person’s OCD. The therapist will have gained information about other factors that may be relevant in planning treatment, such as how the OCD is managed within the family and the impact on school functioning. By this stage, they will have collected much of the information necessary to begin making sense of the problem, understand why the problem has persisted for so long and why it has been so difficult to get rid of it. Specifically, it is helpful to have an idea about any triggers and precipitating factors that may be maintaining the OCD before treatment begins.
When planning the first session, the therapist needs to think about who should actually be in the room for the session. This decision will be driven by factors such as the initial formulation about how the problem is working and the wishes of the young person. If family members are present, it can be helpful to share the formulation and any psychoeducation about the nature of intrusive thoughts and anxiety. There are good reasons to include family members if the therapist believes that their behaviour may be maintaining the problem, for example, through giving reassurance or undertaking compulsions for the young person. It can also be helpful to have family members present if the assessment has highlighted that the young person tends to minimise the extent of their OCD. However, this must be balanced with the views of the young person and for adolescents especially having family members present may not always be appropriate. For example, the presence of the parent may be a form of reassurance, or the parent may be highly critical or anxious within the session (e.g. speaking on behalf of the young person too much). In other cases, the young person may find it hard to talk openly in front of their parents or they may feel responsible for not worrying 54
Waite, Gallop and Atkinson
their mum or dad with their concerns. In these cases, it may be possible to negotiate other solutions with the young person, such as taping or videoing the session and allowing family members to watch or listen to some or all of them, having them present for certain parts of the session or having some time with the family members alone to go through important issues at the end of the session.
Carrying out CBT
At the beginning of the first session, it is important that the therapist provides information about the nature and process of CBT: 1
The therapist explains that they will all be working as a team to try and
other issues that may need to be addressed. Treating the OCD may have a beneficial effect on other problems (especially other anxiety disorders) as the young person learns skills that they can apply elsewhere. However, it may be necessary for treatment also to focus on other problems, such as self-esteem or family factors. While a young person with mild to moderate OCD and little comorbidity may require as few as five treatment sessions, youngsters with more severe problems are likely to benefit from a greater number and clinicians may need to consider somewhere between 12 and 20 sessions. Although there is a relationship between early response in treatment and success at follow-up (e.g. Allsopp and Verduyn, 1988), there is also evidence to suggest that initial non-responders may show significant improvements when therapy is extended (e.g. de Haan et al. , 1998), so clinicians should always ensure that the young person has received an adequate dose of CBT.
Planning treatment
At the end of the initial assessment, the therapist should be clear that the primary problem is OCD and remain aware of any other existing diagnoses and how they interact with the young person’s OCD. The therapist will have gained information about other factors that may be relevant in planning treatment, such as how the OCD is managed within the family and the impact on school functioning. By this stage, they will have collected much of the information necessary to begin making sense of the problem, understand why the problem has persisted for so long and why it has been so difficult to get rid of it. Specifically, it is helpful to have an idea about any triggers and precipitating factors that may be maintaining the OCD before treatment begins.
When planning the first session, the therapist needs to think about who should actually be in the room for the session. This decision will be driven by factors such as the initial formulation about how the problem is working and the wishes of the young person. If family members are present, it can be helpful to share the formulation and any psychoeducation about the nature of intrusive thoughts and anxiety. There are good reasons to include family members if the therapist believes that their behaviour may be maintaining the problem, for example, through giving reassurance or undertaking compulsions for the young person. It can also be helpful to have family members present if the assessment has highlighted that the young person tends to minimise the extent of their OCD. However, this must be balanced with the views of the young person and for adolescents especially having family members present may not always be appropriate. For example, the presence of the parent may be a form of reassurance, or the parent may be highly critical or anxious within the session (e.g. speaking on behalf of the young person too much). In other cases, the young person may find it hard to talk openly in front of their parents or they may feel responsible for not worrying 54
Waite, Gallop and Atkinson
their mum or dad with their concerns. In these cases, it may be possible to negotiate other solutions with the young person, such as taping or videoing the session and allowing family members to watch or listen to some or all of them, having them present for certain parts of the session or having some time with the family members alone to go through important issues at the end of the session.
Carrying out CBT
At the beginning of the first session, it is important that the therapist provides information about the nature and process of CBT: 1
The therapist explains that they will all be working as a team to try and
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