1. Recurrent and persistent ideas, thoughts, or impulses that are viewed as intrusive, senseless, and time-consuming, or that interfere with the client's daily routine, school performance, or social relationships.
2. Failed attempts to ignore or control these recurrent thoughts or impulses or neutralize them with other thoughts and actions.
3. Recognition that obsessive thoughts are a product of his/her own mind.
4. Excessive concerns about dirt or unfounded fears of contracting a dreadful disease or illness.
5. Obsessions related to troubling aggressive or sexual thoughts, urges, or images.
6. Persistent and troubling thoughts about religious issues; excessive concern about morality and right or wrong.
7. Repetitive and intentional behaviors and/or mental acts that are done in response to obsessive thoughts or increased feelings of anxiety or fearfulness.
8. Repetitive and excessive behaviors and/or mental acts that are done to neutralize or prevent discomfort or some dreaded event; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
9. Recognition of repetitive behaviors and/or mental acts as excessive and unreasonable.
10. Cleaning and washing compulsions (e.g., excessive hand washing, bathing, showering, cleaning of household items).
11. Hoarding or collecting compulsions.
12. Checking compulsions (e.g., repeatedly checking to see if door is locked, rechecking homework to make sure it is done correctly, checking to make sure that no one has been harmed).
13. Compulsions about having to arrange objects or things in proper order (e.g., stacking coins in certain order, laying out clothes each evening at same time, wearing only certain clothes on certain days).
| 1. Describe the nature, history, and severity of obsessive thoughts and/or compulsive behavior. (1, 2) |
1. Establish rapport and a working alliance with the client and parents using appropriate process skills (e.g., active listening, reflective empathy, support, and instillation of hope).
2. Assess the nature, severity, and history of the client's obsessions and compulsions using clinical interview with the client and the parents. |
| 2. Disclose any history of substance use that may contribute to and complicate the treatment of the OCD. (3) |
3. Arrange for a substance abuse evaluation and refer the client for treatment if the evaluation recommends it. |
| 3. Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (4, 5, 6, 7, 8) |
4. Assess the client's level of insight (syntonic versus dystonic) toward the “presenting problems” (e.g., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the “problem described,” is not concerned, and has no motivation to change).
5. Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
6. Assess for any issues of age, gender, or culture that could help explain the client's currently defined “problem behavior” and factors that could offer a better understanding of the client's behavior.
7. Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
8. Assess the client's home, school, and community for pathogenic care (e.g., persistent disregard for the child's emotional needs or physical needs, repeated changes in primary caregivers, limited opportunities for stable attachments, persistent harsh punishment, or other grossly inept parenting). |
| 4. Comply with psychological testing evaluation to assess the nature and severity of the obsessive-compulsive problem. (9) |
9. Arrange for psychological testing or use objective measures to further evaluate the nature and severity of the client's obsessive-compulsive problem (e.g., Children's Yale-Brown Obsessive Compulsive Scale). |
 5. Cooperate with an evaluation by a physician for psychotropic medication. (10, 11) |
10. Arrange for an evaluation for a prescription of psychotropic medications (e.g., serotonergic medications).
11. Monitor the client for prescription compliance, side effects, and overall effectiveness of the medication; consult with the prescribing physician at regular intervals. |
| 6. Verbalize an understanding of OCD and the rationale for its treatment. (12, 13, 14) |
12. Provide the client and parents with initial and ongoing psycho-education about OCD, a cognitive behavioral conceptualization of OCD, biopsychosocial factors influencing its development, how fear and avoidance serve to maintain the disorder, and other information relevant to therapeutic goals.
13. Discuss a rationale in which treatment serves as an arena to desensitize learned fear, reality-test obsessive fears and underlying beliefs (e.g., seeing obsessive fears as “false alarms”), and build confidence in managing fears without compulsions (see Cognitive Behavioral Treatment of Childhood OCD: It's Only a False Alarm—Therapist Guide by Piacentini, Langley, and Roblek).
14. Prescribe reading or other sources of information (e.g., CDs, DVDs) on OCD and exposure and ritual prevention therapy to facilitate psycho-education done in session (e.g., Treating Your OCD with Exposure and Response (Ritual) Prevention: Workbook by Yadin, Foa, and Lichner; Brain Lock: Free Yourself from Obsessive-Compulsive Behavior by Schwartz; Obsessive-Compulsive Disorder: Help for Children and Adolescents by Waltz). |
| 7. Express a commitment to participate in Cognitive Behavioral Therapy for OCD. (15) |
15. Confirm the client's motivation to participate in treatment; use motivational interviewing techniques, a pros-cons analysis, and/or other motivational interventions to help move the client toward committed engagement in therapy. |
| 8. Complete a daily journal of obsessions and compulsions as guided by the therapist. (16) |
16. Instruct and ask the client to self-monitor and record obsessions and compulsions including triggers, specific fears, and mental and/or behavioral compulsions; involve parents if needed; review to facilitate psychoeducation and/or assess response to treatment. |
| 9. Identify and replace biased, fearful self-talk and beliefs. (17) |
17. Explore the client's biased cognitive self-talk, beliefs, and underlying assumptions that mediate his/her obsessive fears and compulsive behavior (e.g., distorted risk appraisals, inflated sense of responsibility for harm, excessive self-doubt, thought-action fusion-thinking of a harmful act is the same as actually doing it); assist him/her in generating thoughts/beliefs that correct for the biases (or assign “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner by Jongsma). |
| 10. Learn cognitive coping strategies to manage obsessions therapeutically. (18) |
18. Teach cognitive skills such as constructive self-talk, “bossing back” obsessions, distancing and nonattachment (letting obsessive thoughts images and/or impulses come and go) to improve the client's personal efficacy in managing obsessions (supplement with “Thought-Stopping” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 11. Participate in exposure and ritual prevention therapy for obsessions and compulsions in individual or small group format, with or without family. (19) |
19. Enroll the client in exposure and (response) ritual prevention therapy for obsessions and compulsions in an intensive (e.g., daily) or non-intensive (e.g., weekly) level of care; individual (preferred) or small (closed enrollment) group; with or without family involvement (e.g., see Treatment of OCD in Children and Adolescents by Wagner; OCD in Children and Adolescents by March and Mulle; Cognitive Behavioral Treatment of Childhood OCD: It's Only a False Alarm—Therapist Guide by Piacentini, Langley, and Roblek; FOCUS by Barrett). |
| 12. Participate in imaginal exposure to feared external and/or internal triggers of obsessions without use of compulsive rituals. (20, 21, 22) |
20. Assess the nature of any external cues (e.g., persons, objects, situations) and internal cues (thoughts, images, and impulses) that precipitate the client's obsessions and compulsions.
21. Direct and assist the client in construction of a hierarchy of feared internal and external fear cues (or assign “Gradual Exposure to Fear” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
22. Select initial imaginal exposures to the internal and/or external OCD cues that have a high likelihood of being a successful experience for the client; do cognitive restructuring during and after the exposure. |
| 13. Participate in live (in vivo) exposure to feared external and/or internal triggers of obsessions without use of compulsive rituals. (23, 24, 25) |
23. Teach the client to use coping strategies (e.g., constructive self-talk, distraction, distancing) to resist engaging in compulsive behaviors invoked to reduce the obsession-triggered distress; ask the client to record attempts to resist compulsions (or assign Treating Your OCD with Exposure and Response (Ritual) Prevention: Workbook by Yadin, Foa, and Lichner; or “Refocus Attention Away From Obsessions and Compulsions” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review during next session, reinforcing success and providing corrective feedback toward improvement.
24. Design a reward system for the parents to reinforce the client for attempts to complete exposures while resisting the urge to engage in compulsive behavior.
25. Assign an exposure homework exercise in which the client gradually reduces time given per day to obsessions and/or compulsions, encouraging him/her to use coping strategies and the parents to use reinforcement of the child's success (or assign “Ritual Exposure and Response Prevention” in the Child Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 14. Parents participate in therapy to provide appropriate support, facilitate the client's advancement in therapy, and help manage stresses encountered in the process. (26, 27, 28, 29) |
26. Include family in sessions to identify specific, positive ways that the parents can help the client manage his/her obsessions or compulsions (see FOCUS by Barrett).
27. Teach parents how to remain calm, patient, and supportive when faced with the client's obsessions or compulsions, discouraging parents from reacting strongly with anger or frustration.
28. Teach family members their appropriate role in helping the client adhere to treatment; assist them in identifying and changing tendencies to reinforce the client's OCD (recommend Freeing Your Child from Obsessive-Compulsive Disorder: Powerful, Practical Solutions to Overcome Your Child's Fears, Worries, and Phobias by Chansky; Helping Your Child with OCD by Fitzgibbons and Pedrick).
29. Teach family members stress management techniques (e.g., calming, problem-solving, and communication skills) to manage stress and resolve problems encountered through therapy (or assign “Progressive Muscle Relaxation” or “Problem-Solving Exercise” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 15. Implement relapse prevention strategies to help maintain gain achieved through therapy. (30, 31, 32, 33) |
30. Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of symptoms, fear, or urges to avoid and relapse with the decision to return to fearfuland avoidant patterns.
31. Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.
32. Instruct the client to routinely use strategies learned in therapy (e.g., continued exposure to previously feared external or internal cues that arise) to prevent relapse into obsessive-compulsive patterns.
33. Schedule periodic “maintenance” sessions to help the client maintain therapeutic gains and adjust to life without OCD (see A Relapse Prevention Program for Treatment of Obsessive Compulsive Disorder by Hiss, Foa, and Kozak for a description of relapse prevention strategies for OCD). |
| 16. Identify support persons or resources that can help the client manage obsessions/ compulsions. (34, 35) |
34. Encourage and instruct the client to involve support person(s) or a “coach” who can help him/her adhere to therapeutic recommendations in managing OCD.
35. Refer the client and parents to support group(s) to help maintain and support the gains made in therapy. |
| 17. Participate in an Acceptance and Commitment Therapy for OCD. (36) |
36. Use an acceptance and commitment-based approach (see Acceptance and Mindfulness Treatments for Children and Adolescents by Greco and Hayes) to help the client change from experiential avoidance of obsessions and compulsions to a more psychologically flexible approach of acceptance of thoughts, images, and/or impulses and commitment to valued action (recommend The Mindful Way Through Anxiety: Break Free from Chronic Worry and Reclaim Your Life by Orsillo and Roemer; or The Stress Reduction Workbook for Teens: Mindfulness Skills to Help You Deal with Stress by Biegel). |
| 18. Verbalize and clarify feelings connected to key life concepts. (37) |
37. Encourage, support, and assist the client in identifying and expressing feelings related to key unresolved life issues (or assign “Surface Behavior/Inner Feelings” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 19. Participate in an Ericksonian task that involves facing the OCD. (38) |
38. Develop and design an Ericksonian task (e.g., if obsessed with a loss, give the client the task to visit, send a card, or bring flowers to someone who has lost someone) for the client that is centered on facing the obsession or compulsion and process the results with the client (see Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. by Haley). |
| 20. Engage in a strategic ordeal to overcome OCD impulses. (39) |
39. Create and promote a strategic ordeal that offers a guaranteed cure to help the client with the obsession or compulsion (e.g., instruct client to perform an aversive chore each time an obsessive thought or compulsive behavior occurs). Note that Haley emphasizes that the “cure” offers an intervention to achieve a goal and is not a promise to cure the client in beginning of therapy (see Ordeal Therapy by Haley). |
| 21. Participate in family therapy addressing family dynamics that contribute to the emergence, maintenance, or exacerbation of OCD symptoms. (40, 41) |
40. Obtain detailed family history of important past and present interpersonal relationships and experiences; identify dynamics that may contribute to the emergence, maintenance, or exacerbation of OCD symptoms.
41. Conduct family therapy sessions to address past and/or present conflicts, as well as the dynamics contributing to the emergence, maintenance, or exacerbation of OCD symptoms. |
| 22. Remove unneeded, hoarded items from area of possessions. (42) |
42. Encourage the client to use cognitive and behavioral coping strategies (e.g., calming skills, cognitive restructuring, distraction, ritual prevention, etc.) while reducing hoarded items from possession (or assign “Decreasing What You Save and Collect” in the Adolescent Psychotherapy HomeworkPlanner by Jongsma, Peterson,and McInnis). |