Unconventional Psychotherapeutic Approach to Pediatric OCD
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“The Ickiness Factor:” Case Study of an
Unconventional Psychotherapeutic
Approach to Pediatric OCD
JUSTINE S. DEMBO, MD, FRCP(C)
Obsessive-compulsive disorder (OCD) is a complex condition with biological,
genetic, and psychosocial causes. Traditional evidence-based treatments in-
clude cognitive-behavioural therapy, either alone or in combination with
serotonin-specific reuptake inhibitors (SSRI’s), other serotonergic agents, or
atypical antipsychotics. These treatments, however, often do not lead to
remission, and therefore, it is crucial to explore other less conventional
therapeutic approaches. This paper describes a case study in which psychody-
namic, narrative, existential, and metaphor therapy in combination with
more conventional treatments led to a dramatic remission of severe OCD in
a 12 year old hospitalized on a psychiatric inpatient unit. The paper, which
is written partly in the form of a story to demonstrate on a meta-level the
power of narrative, is also intended to illustrate the challenges of counter-
transference in the treatment of patients with severe OCD, and the ways in
which a reparative therapeutic alliance can lead to unexpected and vital
change.
KEYWORDS : pediatric obsessive-compulsive disorder; psychodynamic
psychotherapy; cognitive-behavioural therapy; narrative therapy;
countertransference.
INTRODUCTION
Obsessive-compulsive disorder (OCD) is defined for both children and
adults in the DSM-IV-TR as follows: (APA, 2000, p. 462) “Either obses-
sions or compulsions,” with obsessions consisting of recurrent and intru-
sive thoughts, images or impulses experienced as unwanted or distressing,
and compulsions being repetitive behaviours that the person feels driven
to do, usually with the aim of reducing distress. The symptoms must either
Department of Psychiatry, University of Toronto, Ontario, Canada.
Mailing address: Sunnybrook
Health Sciences Centre, Department of Psychiatry FG-47, 2075 Bayview Avenue, Toronto, Ontario,
Canada, M4N 3M5. e-mail: justine.dembo@mail.utoronto.ca
AMERICAN J OURNAL OF PSYCHOTHERAPY, Vol. 68, No. 1, 2014
57
Unconventional Psychotherapeutic
Approach to Pediatric OCD
JUSTINE S. DEMBO, MD, FRCP(C)
Obsessive-compulsive disorder (OCD) is a complex condition with biological,
genetic, and psychosocial causes. Traditional evidence-based treatments in-
clude cognitive-behavioural therapy, either alone or in combination with
serotonin-specific reuptake inhibitors (SSRI’s), other serotonergic agents, or
atypical antipsychotics. These treatments, however, often do not lead to
remission, and therefore, it is crucial to explore other less conventional
therapeutic approaches. This paper describes a case study in which psychody-
namic, narrative, existential, and metaphor therapy in combination with
more conventional treatments led to a dramatic remission of severe OCD in
a 12 year old hospitalized on a psychiatric inpatient unit. The paper, which
is written partly in the form of a story to demonstrate on a meta-level the
power of narrative, is also intended to illustrate the challenges of counter-
transference in the treatment of patients with severe OCD, and the ways in
which a reparative therapeutic alliance can lead to unexpected and vital
change.
KEYWORDS : pediatric obsessive-compulsive disorder; psychodynamic
psychotherapy; cognitive-behavioural therapy; narrative therapy;
countertransference.
INTRODUCTION
Obsessive-compulsive disorder (OCD) is defined for both children and
adults in the DSM-IV-TR as follows: (APA, 2000, p. 462) “Either obses-
sions or compulsions,” with obsessions consisting of recurrent and intru-
sive thoughts, images or impulses experienced as unwanted or distressing,
and compulsions being repetitive behaviours that the person feels driven
to do, usually with the aim of reducing distress. The symptoms must either
Department of Psychiatry, University of Toronto, Ontario, Canada.
Mailing address: Sunnybrook
Health Sciences Centre, Department of Psychiatry FG-47, 2075 Bayview Avenue, Toronto, Ontario,
Canada, M4N 3M5. e-mail: justine.dembo@mail.utoronto.ca
AMERICAN J OURNAL OF PSYCHOTHERAPY, Vol. 68, No. 1, 2014
57
occupy more than one hour per day or cause significant distress or social
or occupational impairment. The DSM-IV-TR specifies that children do
not need to recognize that the obsessions or compulsions are excessive or
unreasonable, whereas adults do. Population-based studies indicate a
prevalence of OCD in 2% to 4% of children and adolescents, with a mean
age of onset between ages 7.5 years and 12.5 years (AACAP, 2012; Boileau,
2011). Some studies indicate that in OCD affecting children it is more
common in boys (3:2), while in adults it is equally common in men and
women (AACAP, 2012; Boileau, 2011). The etiology of OCD at all ages is
multifactorial, involving a combination of genetic, neurobiological, neuro-
chemical, biological, personality/trait, psychological and social factors. In
some cases, infection with group A beta-hemolytic streptococcus can
create a syndrome that is indistinguishable from OCD; this is part of a
larger group of syndromes known as PANDAS: pediatric autoimmune
neurological disorders associated with streptococci (Shulman, 2009). A full
review of the etiology is beyond the scope of this paper.
In pediatric and adolescent OCD, the most common obsessions involve
religion, sexuality, death or illness, contamination, and over-responsibility
for feared harm to self or others or for catastrophic events (Boileau, 2011;
Butwicka & Gmitrowics, 2010); the most common compulsions, mean-
while, involve cleaning and hoarding (Boileau, 2011). Some research
indicates that young children with OCD have associated features of severe
indecisiveness, extreme slowness, and excessive doubt about trivial matters
(Boileau, 2011). There is some evidence to suggest a higher rate of
comorbid obsessive-compulsive personality disorder (OCPD) traits in
these children (AACAP, 2012), including a tendency toward rigidity,
perfectionism, orderliness, and control. Compared to patients with adult-
onset OCD, those who experience onset in childhood are more likely to
have comorbid disruptive behaviour, tic disorders, mood disorders, other
anxiety disorders, or attention deficit hyperactivity disorder (ADHD)
(Boileau, 2011). Significant to the case featured in this article are several
studies that indicate children who have OCD and comorbid major depres-
sive disorder have greater OCD severity, and tend to have higher levels of
family conflict (Boileau, 2011). Also relevant to the current case, children
with comorbid disruptive behaviour disorders tend to have greater severity
of symptoms, greater levels of family accommodation, more treatment
resistance, and are 3.6 times more likely to be prescribed atypical antip-
sychotics than those without concomitant behavior dysfunction (Storch,
Lewin, Geffken, Morgan, & Murphy, 2010).
Obsessive-compulsive disorder can have a significant impact on func-
AMERICAN JOURNAL OF PSYCHOTHERAPY
58
or occupational impairment. The DSM-IV-TR specifies that children do
not need to recognize that the obsessions or compulsions are excessive or
unreasonable, whereas adults do. Population-based studies indicate a
prevalence of OCD in 2% to 4% of children and adolescents, with a mean
age of onset between ages 7.5 years and 12.5 years (AACAP, 2012; Boileau,
2011). Some studies indicate that in OCD affecting children it is more
common in boys (3:2), while in adults it is equally common in men and
women (AACAP, 2012; Boileau, 2011). The etiology of OCD at all ages is
multifactorial, involving a combination of genetic, neurobiological, neuro-
chemical, biological, personality/trait, psychological and social factors. In
some cases, infection with group A beta-hemolytic streptococcus can
create a syndrome that is indistinguishable from OCD; this is part of a
larger group of syndromes known as PANDAS: pediatric autoimmune
neurological disorders associated with streptococci (Shulman, 2009). A full
review of the etiology is beyond the scope of this paper.
In pediatric and adolescent OCD, the most common obsessions involve
religion, sexuality, death or illness, contamination, and over-responsibility
for feared harm to self or others or for catastrophic events (Boileau, 2011;
Butwicka & Gmitrowics, 2010); the most common compulsions, mean-
while, involve cleaning and hoarding (Boileau, 2011). Some research
indicates that young children with OCD have associated features of severe
indecisiveness, extreme slowness, and excessive doubt about trivial matters
(Boileau, 2011). There is some evidence to suggest a higher rate of
comorbid obsessive-compulsive personality disorder (OCPD) traits in
these children (AACAP, 2012), including a tendency toward rigidity,
perfectionism, orderliness, and control. Compared to patients with adult-
onset OCD, those who experience onset in childhood are more likely to
have comorbid disruptive behaviour, tic disorders, mood disorders, other
anxiety disorders, or attention deficit hyperactivity disorder (ADHD)
(Boileau, 2011). Significant to the case featured in this article are several
studies that indicate children who have OCD and comorbid major depres-
sive disorder have greater OCD severity, and tend to have higher levels of
family conflict (Boileau, 2011). Also relevant to the current case, children
with comorbid disruptive behaviour disorders tend to have greater severity
of symptoms, greater levels of family accommodation, more treatment
resistance, and are 3.6 times more likely to be prescribed atypical antip-
sychotics than those without concomitant behavior dysfunction (Storch,
Lewin, Geffken, Morgan, & Murphy, 2010).
Obsessive-compulsive disorder can have a significant impact on func-
AMERICAN JOURNAL OF PSYCHOTHERAPY
58
tioning, both at home and at school. The 2012 American Academy of
Child and Adolescent Psychiatry (AACAP) OCD treatment guidelines
cites peer problems in 55% to 100% of patients, and isolation and current
or future unemployment at 45% (AACAP, 2012). The World Health
Organization recently stated that OCD (regardless of age group) is the
tenth leading cause of disability worldwide (Gilbert & Maalouf, 2008). In
addition, OCD in childhood tends to be chronic, with 41% to 60% of
children remaining symptomatic into adulthood (Boileau, 2011). Predic-
tors of chronicity include the presence of other psychiatric comorbidities
and poor initial treatment response (AACAP, 2012), and also possibly the
need for hospitalization (Boileau, 2011). The most commonly studied
treatment modalities include cognitive-behavioural therapy (CBT), medi-
cation management (primarily with serotonin-specific reuptake inhibitors
(SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and atyp-
ical antipsychotic augmentation), or combined medication and CBT.
However, CBT, medication, or combinations therein often do not
result in full remission (Boileau, 2011; Leib, 2001). Given this, and the
high side-effect burden of the medications used to treat OCD, it is crucial
that we continue to explore the potential of broader and more integrated
treatments for children as well as adults. The vast majority of contempo-
rary evidence-based research on psychotherapy in children and adoles-
cents with OCD involves cognitive-behavioural therapy exclusively (In-
Albon & Schneider, 2007; McGehee, 2005; Storch, Mariaskin, & Murphy,
2009), and the majority of nonbiological theories about the etiology of
OCD, such as learning theory, are related to the cognitive-behavioural
model (Kempke & Luyton, 2007). Of great concern is that many CBT
experts bluntly dismiss psychodynamic theory with regards to OCD, and
state that psychoanalytic techniques have no place in its treatment (Foa,
2010; British Psychological Society/NICE, 2006). Furthermore, there is
disappointingly little contemporary published research on psychoanalytic
approaches to pediatric and adolescent OCD (Cohen, 2011), although
authors allude to the fact that therapists use these approaches quite
commonly in this population (Fonagy, 1999; Quinn, 2010). Some authors
argue that there is significant overlap between cognitive-behavioural and
psychodynamic theories of OCD, and that the techniques, at least for
adults, can be merged successfully in treatment (Kempke & Luyten, 2007).
My intention in this paper is to add support to the evidence base for the
integration of psychodynamic and other therapeutic modalities in the
contemporary treatment of children, adolescents, and even adults, with
OCD. In a society that increasingly favours short-term and psychophar-
An Unconventional Psychotherapeutic Approach to Pediatric OCD
59
Child and Adolescent Psychiatry (AACAP) OCD treatment guidelines
cites peer problems in 55% to 100% of patients, and isolation and current
or future unemployment at 45% (AACAP, 2012). The World Health
Organization recently stated that OCD (regardless of age group) is the
tenth leading cause of disability worldwide (Gilbert & Maalouf, 2008). In
addition, OCD in childhood tends to be chronic, with 41% to 60% of
children remaining symptomatic into adulthood (Boileau, 2011). Predic-
tors of chronicity include the presence of other psychiatric comorbidities
and poor initial treatment response (AACAP, 2012), and also possibly the
need for hospitalization (Boileau, 2011). The most commonly studied
treatment modalities include cognitive-behavioural therapy (CBT), medi-
cation management (primarily with serotonin-specific reuptake inhibitors
(SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and atyp-
ical antipsychotic augmentation), or combined medication and CBT.
However, CBT, medication, or combinations therein often do not
result in full remission (Boileau, 2011; Leib, 2001). Given this, and the
high side-effect burden of the medications used to treat OCD, it is crucial
that we continue to explore the potential of broader and more integrated
treatments for children as well as adults. The vast majority of contempo-
rary evidence-based research on psychotherapy in children and adoles-
cents with OCD involves cognitive-behavioural therapy exclusively (In-
Albon & Schneider, 2007; McGehee, 2005; Storch, Mariaskin, & Murphy,
2009), and the majority of nonbiological theories about the etiology of
OCD, such as learning theory, are related to the cognitive-behavioural
model (Kempke & Luyton, 2007). Of great concern is that many CBT
experts bluntly dismiss psychodynamic theory with regards to OCD, and
state that psychoanalytic techniques have no place in its treatment (Foa,
2010; British Psychological Society/NICE, 2006). Furthermore, there is
disappointingly little contemporary published research on psychoanalytic
approaches to pediatric and adolescent OCD (Cohen, 2011), although
authors allude to the fact that therapists use these approaches quite
commonly in this population (Fonagy, 1999; Quinn, 2010). Some authors
argue that there is significant overlap between cognitive-behavioural and
psychodynamic theories of OCD, and that the techniques, at least for
adults, can be merged successfully in treatment (Kempke & Luyten, 2007).
My intention in this paper is to add support to the evidence base for the
integration of psychodynamic and other therapeutic modalities in the
contemporary treatment of children, adolescents, and even adults, with
OCD. In a society that increasingly favours short-term and psychophar-
An Unconventional Psychotherapeutic Approach to Pediatric OCD
59
macological treatment strategies, the richness that these other modalities
contribute to treatment may well be lost; furthermore, adolescents like the
one described in this paper may all too often be deemed treatment
refractory and may be heavily medicated or institutionalized when CBT
and first-line medications do not lead to remission. The case study
described in this paper illustrates the ways in which psychodynamic,
narrative, existential, and metaphor therapy enhance the use of CBT and
medication management. It also demonstrates the necessity of complex
interventions in the case of an illness as multifaceted as OCD, and the
indisputable fact that even young children and adolescents can struggle
with sophisticated psychodynamic conflicts. The paper begins with a
summary of the patient’s history, followed by a description of the use of
conventional therapies. Following this is a discussion of key aspects of
different theoretical frameworks, and the ways in which incorporating
these frameworks enriched and enhanced the clinical outcome in this
particular case. I will argue that had we not employed psychodynamic and
other approaches, this patient would likely not have engaged in CBT at all,
nor would she have achieved such a meaningful recovery.
INTRODUCTION TO THE CASE
I will refer to the patient as “Cassandra,” the name of the fictional
character she created during the narrative component of psychotherapy.
Cassandra was a 12-year-old in middle school, living in a suburban house
with her two parents and one younger sister. Her parents, European in
origin, described a generally happy marriage, and were supportive and
loving. They were financially stable, with extended family living nearby.
Her father worked, and her mother was a homemaker. Although there was
no family history of OCD, Cassandra had a paternal grandmother with
severe major depressive disorder who had attempted suicide and survived.
Cassandra’s medical history was unremarkable, except for pneumonia at
age 10 years. She had recently begun menstruating, with regular cycles. She
had no known history of streptococcal infection. She also had no history
of tics, ADHD, or other diagnosed psychiatric or medical comorbidities.
Although she did not meet criteria for a disruptive behaviour disorder, she
was described by her parents at baseline as quite “oppositional,” control-
ling, and perfectionistic.
Cassandra developed OCD six months prior to her hospital admission,
when the family had moved to her maternal grandmother’s house while
their own home was renovated. Her first symptoms included prolonged
and repetitive ordering and re-ordering of shoes by the front door, refusal
AMERICAN JOURNAL OF PSYCHOTHERAPY
60
contribute to treatment may well be lost; furthermore, adolescents like the
one described in this paper may all too often be deemed treatment
refractory and may be heavily medicated or institutionalized when CBT
and first-line medications do not lead to remission. The case study
described in this paper illustrates the ways in which psychodynamic,
narrative, existential, and metaphor therapy enhance the use of CBT and
medication management. It also demonstrates the necessity of complex
interventions in the case of an illness as multifaceted as OCD, and the
indisputable fact that even young children and adolescents can struggle
with sophisticated psychodynamic conflicts. The paper begins with a
summary of the patient’s history, followed by a description of the use of
conventional therapies. Following this is a discussion of key aspects of
different theoretical frameworks, and the ways in which incorporating
these frameworks enriched and enhanced the clinical outcome in this
particular case. I will argue that had we not employed psychodynamic and
other approaches, this patient would likely not have engaged in CBT at all,
nor would she have achieved such a meaningful recovery.
INTRODUCTION TO THE CASE
I will refer to the patient as “Cassandra,” the name of the fictional
character she created during the narrative component of psychotherapy.
Cassandra was a 12-year-old in middle school, living in a suburban house
with her two parents and one younger sister. Her parents, European in
origin, described a generally happy marriage, and were supportive and
loving. They were financially stable, with extended family living nearby.
Her father worked, and her mother was a homemaker. Although there was
no family history of OCD, Cassandra had a paternal grandmother with
severe major depressive disorder who had attempted suicide and survived.
Cassandra’s medical history was unremarkable, except for pneumonia at
age 10 years. She had recently begun menstruating, with regular cycles. She
had no known history of streptococcal infection. She also had no history
of tics, ADHD, or other diagnosed psychiatric or medical comorbidities.
Although she did not meet criteria for a disruptive behaviour disorder, she
was described by her parents at baseline as quite “oppositional,” control-
ling, and perfectionistic.
Cassandra developed OCD six months prior to her hospital admission,
when the family had moved to her maternal grandmother’s house while
their own home was renovated. Her first symptoms included prolonged
and repetitive ordering and re-ordering of shoes by the front door, refusal
AMERICAN JOURNAL OF PSYCHOTHERAPY
60
to empty her backpack or to discard numerous useless items, such as store
tags and shopping bags, and a gradual decreasing attention to her own
hygiene. Furthermore, she had become increasingly angry with her grand-
mother, with whom she eventually refused to associate altogether. She
developed contamination obsessions and compulsions about her grand-
mother, and began also to avoid food, clothing, toys, furniture, and other
items that her grandmother may have touched. She began to refuse any
food that was even remotely associated with her grandmother, and then
with her other family members, and her parents had to take her out to
restaurants or buy prepackaged food in her presence, in order to get her
to eat. She began losing weight. She developed elaborate rituals around the
staircase at home, taking up to two hours to get up the stairs, and
completing a number of rituals on each step. If her parents so much as
moved or breathed audibly during her ascent, she would have to start
again at the beginning. Her parents and sister, uncertain of how to cope
with this, accommodated and tried to be as quiet as possible during the
staircase rituals; each time they accommodated further, however, Cassan-
dra’s symptoms worsened. She developed compulsions in the car as well,
requiring that the radio be on at all times and that the windows remain
open even in mid-winter. She was afraid to inhale the car air, which she
believed was tainted by her parents’ association with her grandmother. She
became increasingly (and constantly) distressed and her hygiene deterio-
rated further, as she refused to shower or change her clothes. She became
unable to hide her rituals from her friends, and she was eventually unable
to attend school.
By the mid-winter, her illness was so severe her parents brought her to
a community hospital, and though she had a three-week admission, she did
not receive any specific treatment for OCD. The inpatient psychiatrist
suggested aripiprazole, but Cassandra and her parents refused because
they were concerned about side effects. Following the admission, Cassan-
dra saw a psychologist for three CBT sessions, but the therapeutic alliance
was quite poor. Within the next month, Cassandra further deteriorated,
and began refusing to enter the front door of her house. On a particularly
cold night, she was unable to enter the house at all, and resisted her
parents’ desperate attempts to carry her in, until she urinated in her clothes
on the doorstep. Once in the house she begged her mother to kill her with
a kitchen knife; her parents managed to force her into the car, and drove
her to a downtown hospital. On the way there, Cassandra attempted to
exit the moving car on a busy street, and her parents restrained her. She
was assessed in the emergency room and then rerouted to our community
An Unconventional Psychotherapeutic Approach to Pediatric OCD
61
tags and shopping bags, and a gradual decreasing attention to her own
hygiene. Furthermore, she had become increasingly angry with her grand-
mother, with whom she eventually refused to associate altogether. She
developed contamination obsessions and compulsions about her grand-
mother, and began also to avoid food, clothing, toys, furniture, and other
items that her grandmother may have touched. She began to refuse any
food that was even remotely associated with her grandmother, and then
with her other family members, and her parents had to take her out to
restaurants or buy prepackaged food in her presence, in order to get her
to eat. She began losing weight. She developed elaborate rituals around the
staircase at home, taking up to two hours to get up the stairs, and
completing a number of rituals on each step. If her parents so much as
moved or breathed audibly during her ascent, she would have to start
again at the beginning. Her parents and sister, uncertain of how to cope
with this, accommodated and tried to be as quiet as possible during the
staircase rituals; each time they accommodated further, however, Cassan-
dra’s symptoms worsened. She developed compulsions in the car as well,
requiring that the radio be on at all times and that the windows remain
open even in mid-winter. She was afraid to inhale the car air, which she
believed was tainted by her parents’ association with her grandmother. She
became increasingly (and constantly) distressed and her hygiene deterio-
rated further, as she refused to shower or change her clothes. She became
unable to hide her rituals from her friends, and she was eventually unable
to attend school.
By the mid-winter, her illness was so severe her parents brought her to
a community hospital, and though she had a three-week admission, she did
not receive any specific treatment for OCD. The inpatient psychiatrist
suggested aripiprazole, but Cassandra and her parents refused because
they were concerned about side effects. Following the admission, Cassan-
dra saw a psychologist for three CBT sessions, but the therapeutic alliance
was quite poor. Within the next month, Cassandra further deteriorated,
and began refusing to enter the front door of her house. On a particularly
cold night, she was unable to enter the house at all, and resisted her
parents’ desperate attempts to carry her in, until she urinated in her clothes
on the doorstep. Once in the house she begged her mother to kill her with
a kitchen knife; her parents managed to force her into the car, and drove
her to a downtown hospital. On the way there, Cassandra attempted to
exit the moving car on a busy street, and her parents restrained her. She
was assessed in the emergency room and then rerouted to our community
An Unconventional Psychotherapeutic Approach to Pediatric OCD
61
hospital, where we admitted her to our child and adolescent inpatient unit.
Of note is that during the initial interview, Cassandra and her parents
denied any significant history of other anxiety disorders, depression, or
other psychiatric comorbidities; however, given that she presented with
suicidal ideation and a history of social withdrawal, irritability, mood
lability, anhedonia, weight loss and insomnia, we suspected that she was
suffering from a major depressive episode of several months’ duration. On
initial presentation, she was very thin, pale, and significantly malodourous,
and she appeared older than her stated age. She was furious with her
parents and highly guarded, hostile, and reluctant to engage on interview,
often refusing to speak. When she did speak, everyone was struck by her
adult vocabulary, her tenacious and complex arguments, and her lack of
warmth.
STABILIZATION , TREATMENT STRUCTURE , AND MEDICATION MANAGEMENT
Our primary goal was to ensure that Cassandra was medically stable. A
physical exam, a full blood-work panel, titres for streptococcal antigens,
and a CT head scan were all normal. Fortunately, Cassandra ate well
because the food we provided had not come into contact with her family.
As per the AACAP OCD treatment guidelines, we proposed a combina-
tion of medication management and CBT. Cassandra adamantly refused
medication and became hostile toward my supervisor for insisting upon it.
She was willing to begin CBT, however, and so we began CBT prior to the
initiation of an SSRI. She was well-versed on the side effects and risks of
the different medications, and argued her case with the manner and
understanding of a much older adolescent. There were many painfully
lengthy negotiations with her, regarding the type of medication (SSRI
versus atypical antipsychotic), dosing, and dosage form (liquid versus
capsule versus pill), all of which she refused. My supervisor believed
Cassandra was incapable of making decisions with respect to treatment,
and as per provincial law for adolescents age 12 and older, Cassandra was
allowed to contest this finding with the help of a lawyer. At this point my
supervisor and I discussed which of us would be involved in the legal
review board hearing, as thus far Cassandra had clearly employed the
defense mechanism of splitting, such that my supervisor was “all bad” and
I was “all good.” My supervisor proposed that we use the splitting to our
advantage, and she advocated for a finding of incapacity during the review
board, whereas I was completely uninvolved in the hearing and continued
treating Cassandra with daily CBT. Cassandra was found incapable with
respect to antidepressant but not antipsychotic treatment, and therefore
AMERICAN JOURNAL OF PSYCHOTHERAPY
62
Of note is that during the initial interview, Cassandra and her parents
denied any significant history of other anxiety disorders, depression, or
other psychiatric comorbidities; however, given that she presented with
suicidal ideation and a history of social withdrawal, irritability, mood
lability, anhedonia, weight loss and insomnia, we suspected that she was
suffering from a major depressive episode of several months’ duration. On
initial presentation, she was very thin, pale, and significantly malodourous,
and she appeared older than her stated age. She was furious with her
parents and highly guarded, hostile, and reluctant to engage on interview,
often refusing to speak. When she did speak, everyone was struck by her
adult vocabulary, her tenacious and complex arguments, and her lack of
warmth.
STABILIZATION , TREATMENT STRUCTURE , AND MEDICATION MANAGEMENT
Our primary goal was to ensure that Cassandra was medically stable. A
physical exam, a full blood-work panel, titres for streptococcal antigens,
and a CT head scan were all normal. Fortunately, Cassandra ate well
because the food we provided had not come into contact with her family.
As per the AACAP OCD treatment guidelines, we proposed a combina-
tion of medication management and CBT. Cassandra adamantly refused
medication and became hostile toward my supervisor for insisting upon it.
She was willing to begin CBT, however, and so we began CBT prior to the
initiation of an SSRI. She was well-versed on the side effects and risks of
the different medications, and argued her case with the manner and
understanding of a much older adolescent. There were many painfully
lengthy negotiations with her, regarding the type of medication (SSRI
versus atypical antipsychotic), dosing, and dosage form (liquid versus
capsule versus pill), all of which she refused. My supervisor believed
Cassandra was incapable of making decisions with respect to treatment,
and as per provincial law for adolescents age 12 and older, Cassandra was
allowed to contest this finding with the help of a lawyer. At this point my
supervisor and I discussed which of us would be involved in the legal
review board hearing, as thus far Cassandra had clearly employed the
defense mechanism of splitting, such that my supervisor was “all bad” and
I was “all good.” My supervisor proposed that we use the splitting to our
advantage, and she advocated for a finding of incapacity during the review
board, whereas I was completely uninvolved in the hearing and continued
treating Cassandra with daily CBT. Cassandra was found incapable with
respect to antidepressant but not antipsychotic treatment, and therefore
AMERICAN JOURNAL OF PSYCHOTHERAPY
62
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