MANAGEMENT PLAN OF OBSESSIVE-COMPULSIVE DISORDER (OCD)

BEHAVIORAL DEFINITIONS

1. Intrusive, recurrent, and unwanted thoughts, images, or impulses that distress and/or interfere with the
client’s daily routine, job performance, or social relationships.

2. Failed attempts to ignore or control these thoughts, images, or impulses or neutralize them with other
thoughts and actions.

3. Recognition that obsessive thoughts are a product of his/her own mind.

4. Repetitive and/or excessive mental or behavioral actions are done to neutralize or prevent discomfort or
some dreaded outcome.

5. Recognition of repetitive thoughts and/or behaviors as being excessive and unreasonable, not realistic
worries about life’s problems.

LONG-TERM GOALS

1. Reduce the frequency, intensity, and duration of obsessions and/or compulsions.

2. Reduce time involved with or interference from obsessions and compulsions.

3. Function daily at a consistent level with minimal interference from obsessions and compulsions.

4. Resolve key life conflicts and the emotional stress that fuels obsessive compulsive behavior patterns.

5. Let go of key thoughts, beliefs, and past life events in order to maximize time free from obsessions and
compulsions.

6. Accept the presence of obsessive thoughts without acting on them and commit to a value-driven life.

SHORT-TERM OBJECTIVES & THERAPEUTIC INTERVENTIONS

1. Describe the history and nature of obsessions and compulsions.

 Establish rapport with the client toward building a therapeutic alliance.
 Assess the frequency, intensity, duration, and history of the client’s obsessions and compulsions
(consider using a structured interview such as The Anxiety Disorders Interview Schedule-Adult
Version).

2. Obtain a complete medical evaluation to rule out medical and substance-related causes for
anxiety symptoms.
 Refer the client to a general physician for a complete medical examination to rule out medical or
substance-related etiology for the anxiety.
 Assist the client in following up on the recommendations from a physical evaluation, including
medications, lab work, or specialty assessments.
3. Complete psychological tests designed to assess and track the nature and severity of obsessions
and compulsions.
 Administer an objective measure of OCD to further assess its depth and breadth (e.g., The Yale-
Brown Obsessive-Compulsive Scale; Obsessive-Compulsive Inventory Revised); re-administer as
indicated to assess treatment progress.
4. Disclose any history of substance use that may contribute to and complicate the treatment of
OCD
 Arrange for a substance abuse evaluation and refer the client for treatment if the evaluation
recommends it.
5. 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.
 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).
 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).
 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 under- standing of the client’s
behavior.
 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).
6. Cooperate with an evaluation by a physician for psychotropic medication
 Arrange for an evaluation for a prescription of psychotropic medications (e.g., serotonergic
medications).
 Monitor the client for prescription compliance, side effects, and overall effectiveness of the
medication; consult with the prescribing physician at regular intervals.
7. Keep a daily journal of obsessions, compulsions, and triggers; record thoughts, feelings, and
actions taken.
 Ask the client to self-monitor obsessions, compulsions, and triggers; record thoughts, feelings,
and actions taken; routinely process the data to facilitate the accomplishment of therapeutic
objectives.
8. Verbalize an accurate understanding of OCD, how it develops, and how it is maintained.
 Convey a biopsychosocial model for the development and maintenance of OCD highlighting the
role of unwarranted fear and avoidance in its maintenance.

9. Verbalize an understanding of the treatment rationale for OCD.

 Provide a rationale for treatment to the client, discussing how treatment serves as an arena to
desensitize learned fear, reality-test obsessional fears and underlying beliefs, and build
confidence in managing fears without compulsions.
 Assign the client to read psychoeducational chapters of books or treatment manuals or consult
other recommended sources for information on the rationale for exposure and ritual prevention
therapy and/or cognitive restructuring for OCD.
10. Identify and replace biased, fearful self-talk and beliefs.
 Explore the client’s biased schema and self-talk that mediate his/her obsessional fears and
compulsions; assist him/her in generating thoughts that correct for the biases; use rational
disputation and behavioral experiments to test fearful versus alternative predictions.
 Assign the client a homework exercise in which he/she identifies fearful self-talk, identifies
biases in the self-talk, generates alternatives, and tests though behavioral experiments, review and
reinforce success, providing corrective feedback toward improvement.
11. Participate in imaginal or in vivo exposure to feared internal and/or external cues.
 Assess the nature of any internal cues (thoughts, images, and impulses) and external cues (e.g.,
persons, objects, and situations) that precipitate the client’s obsessions and compulsions.
 Assist the client in the construction of hierarchies of feared internal and external fear cues.
 Conduct exposure (imaginal and/or in vivo) to the internal and/or external OCD cues; begin with
exposures that have a high likelihood of being a successful experience for the client; include
response prevention and do cognitive restructuring within and after the exposure.
 Assign the client homework exercises in which he/she repeats the exposure to the internal and/or
external OCD cues, using response prevention and restructured cognitions, and records responses
review during subsequent sessions, reinforcing success, problem solving obstacles, and providing
corrective feedback toward improvement.
12. Verbalize an understanding of relapse prevention
 Provide a rationale for relapse prevention that discusses the risk and introduces strategies for
preventing it.
 Discuss with the client the distinction between a lapse and relapse, associating a lapse with a
temporary setback and relapse with a return to a sustained pattern of thinking, feeling and
behaving that is characteristic of OCD.
13. Identify situations at risk for a lapse and strategies for managing these risk situations.
 Identify high-risk situations and rehearse the management of future situations or circumstances in
which lapses could occur.
 Instruct the client to routinely use strategies learned in therapy (e.g., continued everyday
exposure, cognitive restructuring, problemsolving), building them into his/her life as much as
possible.
 Develop a “coping card” or other reminder on which coping strategies and other helpful
information can be kept and consulted by the client as needed (e.g., steps in problem-solving,
positive coping statements, other strategies that were helpful to the client during therapy).
 Schedule periodic maintenance or “booster” sessions to help the client maintain therapeutic gains
and problem-solve challenges.
14. Participate in Acceptance and Commitment Therapy (ACT) for OCD.
 Use an ACT approach to OCD to help the client accept and openly experience obsessive
thoughts, images, and impulses without being overly impacted by them, and committing his/her
time and efforts to activities that are consistent with identified, personally meaningful values
 Teach mindfulness meditation to help the client recognize the negative thought processes
associated with OCD and change his/her relationship with these thoughts by accepting thoughts,
images, and impulses that are reality-based while noticing, but not reacting to, non-reality-based
mental phenomena.
 Assign the client homework in which he/she practices lessons from mindfulness meditation and
ACT in order to consolidate the approach into in everyday life.
 Assign the client reading consistent with the mindfulness and ACT approach to supplement work
done in session.
15. Identify and discuss unresolved life conflicts
 Explore the client’s life circumstances to help identify key unresolved conflicts that may
underlie OCD.
16. Verbalize and clarify feelings connected to key life conflicts
 Encourage, support, and assist the client in identifying and expressing feelings related to key
unresolved life issues.
 Assess for secondary gains the client may be receiving by remaining disordered with OCD
(e.g., attention, care-receiving, avoidance of activity); directly address gains, if evident.
17. Accept or work to resolve identified life conflicts.
 Explore the resolution of identified interpersonal or other identified life conflicts; assist the client
with acceptance of those that cannot be changed or use a conflict resolution approach to address
those that can.
18. Gain insight into how childhood experiences might influence current struggles with OCD and
take appropriate actions.
 Use an insight-oriented approach to explore how current obsessive themes (e.g., cleanliness,
symmetry, aggressive impulses) may be related to unresolved developmental conflicts (e.g.,
psychosexual, interpersonal); process toward the goal of insight and change.
19. Implement the Ericksonian task designed to interfere with OCD
 Develop and assign an Ericksonian task that is consistent with the theme of the client’s obsession
or compulsion (i.e., “symptom as task”); process the results with the client. (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.
20. Engage in a strategic ordeal to overcome OCD impulses
 Create strategic ordeal that offers a cure to the client for the obsession or compulsion.
21. Develop and implement a daily ritual that interrupts the current pattern of compulsions.
 Help the client create and implement a ritual (e.g., find a job that the client finds necessary but
very unpleasant, and have him/her do this job each time he/she finds thoughts becoming
obsessive); follow up with the client on the outcome of its implementation and make necessary
adjustments.