CBT Intervention for OCD: A Detailed Case Study at Salford Uni

This case study critically discusses the application of Cognitive Behavioral Therapy (CBT) and Meta-Cognitive Therapy (MCT) in treating a 38-year-old male, Mr. Robert, suffering from severe Obsessive-Compulsive Disorder (OCD). The study details Mr. Robert's history, including the escalation of his OCD symptoms following his mother's illness, leading to compulsive handwashing and praying rituals. The assessment process, emphasizing the importance of establishing a therapeutic relationship and understanding the client's perspective, is outlined. A Salkovskis (1985) model-based formulation illustrates the triggers and maintaining factors of Mr. Robert's OCD. The treatment plan involves Exposure and Response Prevention (ERP) and Cognitive Restructuring, with goals set to reduce anxiety and improve his overall quality of life. The study also includes a critical analysis of MCT, referencing relevant literature and evidence to support its application. Desklib provides similar solved assignments and past papers for students.

PSYCHOTHERAPY FOR OBSESSIVE COMPULSIVE DISORDER

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Table of Contents
Introduction......................................................................................................................................2
Client’s history.................................................................................................................................3
Assessment......................................................................................................................................3
Formulation......................................................................................................................................4
Treatment and rational Chosen........................................................................................................6
Criticism........................................................................................................................................16
Conclusion.....................................................................................................................................17
References......................................................................................................................................19
Appendix........................................................................................................................................24

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Introduction
Cognitive Behaviour Therapy (CBT) is identified as the tried and tested treatment for
almost any mental ailment (Newman et al. 2015). The Third Wave Therapy which is a new CBT
based intervention therapy including Meta-Cognitive Therapy (MCT) (Wells, 1995),
Mindfulness-Based Cognitive Therapy (Segal, Williams and Teasadale 2002), Compassion
Focused Therapy (Gilbert 2005) amongst others. While the third wave intervention methods
have a diversified approach, strengths and weaknesses, they still merge in their distinct
philosophical approaches of CBT as they are collaborative and therapeutic in nature using a
rational approach (Beck 2012).
In this case study, the application of CBT in the treatment of Obsessive Compulsive
Disorder (OCD) patient will be critically discussed. In addition, the application of MCT is
discussed as a third wave approach to the treatment of OCD will be fully examined and
rationalised.
The Case Study will aim to analyse the important information related to the client, which
includes the background history of the client in which the predicament of the client is discussed
along with its maintaining factors and the assessment tools to be used for the mitigation
intervention of the presenting problem while formulating of the underlying philosophy in context
to a chosen model. The different assessment tools deployed will help in the overall improvement
of the condition of the patients with the support of the different CBT tools. It will further
evaluate and rationalise the use of MCT base, CBT according to the requirements of the client.
Finally, the study will do a critical analysis of MCT based on literature and evidence to
recommend the development of the study regarding the present research.
The author currently works as a trainee CBT therapist in Central North West London
Trust (CNWL) supporting individuals with various mental health disorders such as anxiety,
depression, PSTD and OCD. It is important for the practitioner to maintain the confidentiality in
such treatments, so the patient will be referred as Mr Robert. Mr Robert was referred to me from
his GP, for the treatment of severe OCD using the Alternative CBT interventions. His disease
affects him, mentally, emotionally and physically causing issues in his daily social cycle. The

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different habits he has acquired due to his anxiety and the panic in various situations causes him
to lose focus on his daily tasks, thereby affecting his life.
Client’s history
Mr Robert is now a 38 year old bachelor living with his 72-year-old mother. After being
diagnosed with OCD officially, he requested to be treated for it via through psychotherapy, as it
will eliminate any other mental disorders documented by the psychiatrist. He has been suffering
from OCD for a while and was taking medicines for it but asked for help as the medicines were
affecting his health.
The severity of the OCD of the client escalated after his mother was hospitalised and was
on life support due to an illness. In due time she recovered, but since the incident, he has
continuous intrusive, and aberrant thoughts fearing his mother would die, believing her sickness
resulted from contamination in his house, however his mother refused to accept the statement.
Mr Robert washes his hands as many as six times hourly to atone for his complex thoughts and
has spurts of severe anxiety if he does not do so. Even though, the number of times he washes his
hands has increased recently, the extreme handwashing resulted to breaking down of his skin,
leading to open wounds. He has also developed a habit of constant praying thinking this would
help the condition of the mother.
The constant visits to the washroom to wash his hands has also affected his job as a
computer engineer putting his relationship in significantly bad terms with the line manager, and
currently, he took sick leave for his treatment. The general physician is looking after his
reference for CBT considering the chronic nature of his affliction which was further worsened by
his mother’s illness.
Assessment
The rationale for the study assessment includes gaining the important information related
to Mr Robert for a better evaluation of his case, to ascertain the suitability of the CBT and form a
therapeutic relationship in collaboration with him. The important rationales of the CBT include:
inspecting suitability, collecting an authentic case history, evaluation of the extent or the
advancement of the disorder, establishment of a case conception for the overall treatment of the

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individual (Westbrook 2014). According to Abramowitz (2013), assessment focusses on the
understanding of the strengths and weakness of the individuals along with an in-depth analysis of
the problems faced by the person, triggered by the environment, behaviour, physical sensation
and thoughts. In addition, Will and Sanders (2013), postulate that having a complete idea of the
presenting factors in the analysis, improves the remedial relationship and mutual interaction with
the clients, which is extremely necessary for the treatment through CBT. Likewise, Leahy,
Holland and McGinn (2012) recognised that the evaluation improves the expression of empathy,
knowledge and acumen which are important elements in framing a therapeutic relationship.
The condition suitability of Robert was ascertained through several of questioning
sessions including the ability to rationalise that Robert could agree to therapy, to make sure if his
condition was perceptible, predictable, and he was able to agree with the therapists (Dryden and
Branch 2012). Robert is also informed of the whole components of CBT including setting
agendas, working in collaboration to develop a therapeutic relationship, assessment, formulation,
intervention, goal setting homework and prevention from relapse. Therefore, to work
collaboratively, the client will have a better understanding of the CBT model and the
intervention to be used for the treatment (Grant, 2010).
OCD is one of the most unnerving of the members of the anxiety family of disorders,
which is categorised can be understood by deep-seated and unwanted thoughts which are
unnecessary for the individuals and to compensate for these thoughts they have obsessional
habits. The in-depth evaluation in the case of Mr Robert was to make sure about the symptoms of
OCD along with its triggers and implications. In the UK almost one in every fifty individuals
suffers from OCD and the related issues in the society (Ocduk.org, 2018).
Formulation
Conceptualisation or Formulation in this type of psychotherapy process is the
comprehension of the situation according to Kuyken, Padesky and Dudley (2008). Similarly,
Steffen (2013) defines views formulation as a psychological map defining the patient’s current
problem, although the concept framing is disparate from the normally known problems of the
psychological analysis (Beck 2012). Salkovskis 1985 model of OCD was used to have a better
understanding of the type of issues faced by Robert in his OCD. Rees and Anderson (2013),

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further emphasise on the fact that Cognitive behaviour models see clients with OCD having
different notions exaggerating the sense of anxiety. The Salkovsis 1985 model is one which has
been tried and tested in conceptualisation and intervention processes by many researchers as it
gives a more detailed scenario in the condition of OCD (Westbrook 2014; Berman et al. 2015).
Mr Robert was diagnosed with OCD at a young age which helped in managing it with the
help of the medicine prescribed by his GP. Mooney (2014) informs that OCD treatment with
medicine has been effective over the years. In the current scenario, although, Robert’s situation
deteriorated because his mother’s illness which triggers his anxiety. Since he blames himself for
the illness, it led to extreme anxiety, and therefore the constant handwashing ritual and praying
that he practised was a way to neutralise the anxiety. The formulation is represented in the form
of a diagram to show the causes and the course of his actions. Salkovski’s (1985) model alludes
that the situation of the OCD is in the understanding of perception by the patient and not the
thought itself, but its interpretation is the major reason of the anxiety in the patients. On the
contrary, McGinn and Sanderson (1999) suggest that the intrusive thoughts do not naturally
result to greater anxietycause anility. An in-depth study of OCD by Ladouceur, Gosselin and
Dugas (2000) proved that the increased sense of self-responsibility and blame increases the level
of anxiety in a person. Leahy et al. (2012), argued that the neutralino behaviour is no explanation
of the abnormally of the obsessions.

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OCD Formulation of Robert based on OCD Model (Salkovskis 1985)
Short circuit
habit
Appraisal/ meaning
Responsibility for outcomes (harm, contamination, died)
Situation
Trigger
Intrusion (the mother’s illness)
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(
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Response
Behavioural
Frequent hand washing, praying
Emotional
Severe Anxiety/ Distress/ Guilt

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Treatment and rational Chosen
The functional analysis in the case of the psychotherapy assessment makes sure of the
individual’s perspective relating to the different aspects of the OCD. The questions in the
functional analysis of Robert focus on understanding the different trigger mechanism of the
OCD. In this case, the illness of his mother acted as the trigger of his OCD causing the patient to
have the constant habit of washing his hands and constant praying. The patient needs to be made
sure of the wellness of his mother so that it does not trigger his OCD. This can be an explanation,
given that there are numerous researches linking Emotional trauma to OCD development
(Williams, 2018).
Goal setting was contemplated toward the start of the mediation for an arranged remedial
cooperative relationship in fulfilling the specific needs of Robert. Simmons and Griffiths (2014),
examined the significance of objective setting and its impact on CBT which ought to be specific,
measurable, achievable, realistic and timely (SMART) as created by Drucker (1954). In any
case, (Whittington and Grey 2014) proposed that there ought to be space for adaptability and
change anytime in SMART with the full help of the client. Robert's long-term objectives were to
be better through having sensible contemplation, an impulse that is not influencing his day to day
life and recapturing his life back socially, physically and economically. In an exchange with
Robert, it concurred that transient objectives were to provoke his negative considerations and
practices, along these lines lessening nervousness by his manifestations of OCD. It was closed
together with Robert that 12 sessions of CBT approach would be used, and there will be a survey
at the sixth session.
National Institute for Clinical Excellence (NICE 2014), suggested that CBT is the best
treatment of OCD, as apparent by Dèttore et al. (2015); Kapoor, Mehta and Sagar (2015), where
they built up the viability of CBT on OCD through research papers. In treating OCD indications,
the most fitting mediations are Exposure and Responses Prevention (ERP), Cognitive rebuilding
among arranged others (Leahy et al. 2012). Lottie Morris and Jim Nightingale, (2014), advanced
ERP as the mental treatment of decision for OCD. Likewise, Amir et al. (2015); Sassano-
Higgins, Sapp and Van Noppen, (2015) showed ERP's viability in late research examines. In
spite of the fact that it is a very much grounded treatment, there is a low number of individuals
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e
s
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)

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getting access to it (Goetter et al. 2014). Likewise, Schirmbeck and Tundo (2015) showed that
patient with OCD could resist the interventions. In handling the behavioural viewpoint, ERP was
acquainted with Robert to deal with his obsessive and compulsive conduct.
In order to tend to Robert's physical indications, there was psycho-instruction on how the
body responds to anxiety and its symptoms; as per Seif and Winston (2014), psycho-training is a
basic part of CBT. Robert was shown unwinding procedures (Westbrook 2014); these unwinding
strategies will aid in unwinding his body when he is in a tensed mode. In addition, Socratic
Questioning (SQ) was used as a method for testing the obsessional contemplation in accordance
with Padesky (1993). SQ is a cornerstone component for CBT (Wills and Sanders 2013) and
(Padesky 1993) affirmed that SQ is completely for guided revelation not for modifying a
person's sentiment on their concern.
ERP comprises of constantly uncovering customer's contemplations while keeping them
from playing out their habits with the basis for disintegrating the maintaining factor (Amir et al.
2015). The impact of the intercession lies in rehashing the introduction to lessen the tension and
forestalling customs, so they can understand that the contemplation is innocuous (Seif and
Winston 2014). Notwithstanding, there is an underlying serious tension toward the start of
overseeing ERP (Sassano-Higgins et al. 2015). ERP was used for Robert as expressed above; he
was presented to his obsessional thought process yet also kept from washing his hands, as he
regularly did if under extreme tension. He occupied with the conduct of deferring his habit
ceaselessly as the impulse comes in the avoidance of customs (Seif and Winston 2014). A minor
decrease was seen in Robert both from praying, hand washing and score of the evaluation
apparatuses.
Tragically, in the following session as arranged in the motivation setting, Robert declined
to take an interest in ERP, vocalising his feelings of fear. This issue brought about backpedalling
to his standard habits, which were incited by extreme tension and other related obsessional
musings. Strangely, Monaghan et al. (2015) foreordained that occasionally on account of OCD,
the possibility of presentation can be so terrifying for customers that they may decline to
endeavour it or cling to the escalated regimen. Leahy et al. (2012), investigated that the most
issue looked in OCD was untimely dropouts and customers confronting their fixations
(Schirmbeck and Tundo, 2015). Mentally, ERP can treat OCD. However, Torp (2015) contended

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that there are some featured impediments, for example, delayed holding up records and a
deficient number of therapists.
There were questions asked on the effectiveness of ERP to treat Robert's concern, in spite
of the fact that Fisher (2009) expressed that it was clear that a few customers with OCD won't
show signs of improvement with just a standard CBT approach, which can once in a while rely
upon an individual as well as the seriousness of the case. As indicated by Morris and Nightingale
(2014), 25% of the customer with OCD reject ERP, and numerous analysts suggest formulation-
driven cognitive therapy in the mix with ERP, instead of exclusively ERP. Through more SQ, the
present issue supposedly related to his comprehension, which implies ERP was insufficient as a
behavioural intercession for treating Robert's case.
The case was under observation to know the following stage and ways to manage
Robert's problems. Clinical Supervision (CS) in CBT is an imperative segment used by all CB
advisors for extra information, quality, seeing issues from different points of view and putting a
check in CBT rehearse (Reiser, 2014). Also, CS is required by the British Association for
Behavioural and Cognitive Psychotherapies (BABCP) (2015) for constant practice as a CB
specialist (Babcp.com, 2015).
In supervision, different intercessions were taken into consideration at given Robert's
showing issues incomprehension. Due to the current introducing factor, a descriptive
clarification of MCT was given. We commonly concurred on experimenting with MCT as a
mediation. Also, new SMART objectives were set, in light of intellectually diminishing his
obsessional habits, and the length of treatment will be expanded relying upon the result of MCT.
The model and treatment of MCT have exhibited to be a skilled hypothesis and the
remedy of psychological issue in grown-ups and kids (Esbjørn, Normann, and Reinholdt-Dunne
2015). Metacognition is characterised by the control, screen and evaluation of considerations by
the interior intellectual components (Wells 2011); these are comprehensive of reasoning,
memory and portion of consideration (Flavell 1979). Thus, MCT discusses the part of
metacognition and metacognition convictions, and its effect on mental issues. As it were, MCT
manages the style of reasoning, which remains a steady factor, not the substance of thought, not
at all like CBT, which can be variable (Fisher 2009). The MCT focusses on building a

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communication channel between the different individuals helping in the overall understanding of
the different aspects of the anxiety disorder helping the individual mitigate their issues. Fisher
and Wells (2008) proceeded to guarantee that the particular component of MCT from different
methodologies focuses exclusively on the metacognition forms while others harp on the different
insight spaces like overstated peril, conviction affirmation, and swelled duty. In this way, Fisher
(2012) confirms, an all the more metacognitively predominant treatment is required for different
types of OCD, is MCT.
The MCT includes the Self-Regulatory Executive Function (S-REF) built up in 1996 by
Wells and Matthews, which is the supporting guideline of MCT. Moreover, Wells, (2011)
recommended that the S-ref depends on three levels of cognisance: the level of intelligent and
programmed forms, the online sort of procedures that is aware of constrained limit responsible
for evaluation and activity execution, at last, the long haul put away memory.
Inside this status, there are two areas recognised as the metacognition and comprehension
spaces (Fisher, 2012). On the other hand, in CBT there are no levels of insight rather there are
segments of refinement illustration (e.g.) Negative Autonomic Thoughts (NATs) and pattern that
produces negative considerations adding to the mental misery (Wells 2011). Then again, MCT
convictions are related to the style of reasoning and metacognition, which reliably produces the
ideas as showed by Wells (2011).
Using the observations by Fisher and Wells (2009), the model comprises of a discrete
style of reasoning and managing pressure, which bounce back and prompts amplification and
upkeep of passionate enduring, connected to a style of reasoning called Cognitive Attentional
Syndrome (CAS). CAS was seen to cause broad negative reasoning with mental issues (Wells,
2011) and Fisher (2012), expounded on how CAS assumes a basic part in keeping up the
consistent rumination and stress related with OCD.
According to Wells and Mattews (1996), metacognition information is characterised as
the acknowledgement people have about their cognisance and is partitioned into constructive and
contrary convictions. The positive perspectives see the advantage in connecting with on each
piece of CAS, on account of Robert concentrating on over the top considerations that prompted
his customs, supposing it is sure because it expels his obsessional contemplations. While the

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negative learning focuses on the direness of the discernment, which is understood in OCD as
metacognition combination convictions about interruptions, displayed in type of thought
occasion combination, thought activity combination and thought question combination (Fisher
2012). The understanding of the different of aspects of the Behavioural disorder by the patient
and understanding of the root cause will help in the mitigation of the problem.
Thus, in utilising MCT on account of Robert, the style of reasoning was basic which
comprises of consistent stressing and his preparing mode. In this way, CBT was insufficient for
his since he harped on the substance of his NATs and convictions. Fisher and Wells (2008) states
that a mix of CBT and MCT has turned out to be viable through research did with four members.
They discovered that the blend of presentation with MCT decreased the OCD manifestations. In
any case, there were confinements in the investigation, for example, the quantity of the members,
self-report measures, single case research and association of just a single advisor. Moreover,
Fisher and Wells (2009) determined that paying little mind to the mental issue, a specific request
must be followed in MCT. In MCT the treatment begins with an evaluation, case-detailing that
the CAS and Metacognitive convictions are inserted in, and after that customers are acquainted
with the model to have a superior knowledge called socialisation (Fisher 2012). This is likewise
a comparable procedure in CBT the points of interest of MCT had just been talked about with
Robert beforehand (Westbrook, Kennerley and Kirk 2016).
The Wells and Cartwright (2004) Metacognition Questionnaire - 30 (MCQ-30) helped in
the evaluation. MCQ-30 was used in surveying the positive convictions about stress, negative
convictions about wildness and risks related to musings for Robert's situation. Robert scored 108
which was named extreme. Moreover, CAS-1 was used to quantify the metacognitive
convictions of Robert, with high scores of 19 on 3 inquiries and on the fourth inquiry “can’t
control my thought”: 97%, “worrying helps me cope”: 96% and “focusing on threat keeps me
safe”:100% (Wells, 2011). In the assessment, an engaged survey in evaluation assembles a
strong establishment for case plan in MCT (Fisher and Wells 2008).
In participation, another detailing was framed in light of MCT for OCD by Wells and
Papageorgiou (2000). Fundamentally, the different parts of MCT case detailing incorporate; the
triggers, the mulling nature, positive convictions that find out if the reaction is because of the
trigger and the negative convictions. Fisher (2012) states that the best routine with regards to