On the last track, we discussed the three main categories of obsessions and effective strategy number one: Rational Argument. The three main categories of obsession include: harm; lust; and filth.
On this track, we will discuss four steps in effective behavioral strategy number two: Creating a Ritual Journal. The journal will include the following four steps: defining compulsions and obsessions; a compulsions chart; an obsessive thought chart; and an exposure story.
Cognitive Behavior Therapy Four Steps in Creating a Ritual Journal
Step 1 - Defining Compulsions and Obsessions
The first step in helping a client create a ritual journal is defining the client’s compulsions and obsessions. I have found that many of my OCD clients have more than one compulsion, but some are more intense than others. Because of this, the client will focus his or her attention on correcting the more severe obsessione instead of also being mindful of the other compulsions.
Elizabeth, age 38, was a compulsive washer. This compulsion began while Elizabeth was studying to be a surgeon. When she assisted in the operating room, Elizabeth was required to wash her hands repeatedly to avoid transferring infection. The risk of infecting a patient became so embellished in her mind that Elizabeth would spend twenty minutes to half an hour scrubbing.
Afterwards, if she had gotten blood on her hands, Elizabeth would spend another half hour to an hour trying to get the blood off. Elizabeth stated, "Even after my hands and arms were raw, I still thought I could smell blood on them." The compulsion most directly came from an obsession about infection. Because the constant washing affected her life most directly, Elizabeth wanted to focus treatment on that compulsion.
However, I believed that she had another compulsion that she was not admitting to herself. I asked Elizabeth to write in her journal a detailed account of her routine before beginning an operation. Elizabeth wrote, "First I put on my scrub bottoms, then the top, then my shoes and cap. Then I wash my hands for an extended period of time. Finally, I put on my smock and then I count the instruments three times. If I get a different number than any other time, I start over."
I asked Elizabeth why she does this. She stated, "I don’t know, it just makes me feel better." Obviously, Elizabeth also had a mild checking compulsion in addition to her washing compulsion. Because I saw that Elizabeth had a tendency to develop extreme compulsions, I also wanted her to be mindful of this ritual as well.
Think of your Elizabeth. Could he or she have more than one compulsion? Would writing out a detailed account help to bring these other rituals or fears to the surface?
Step 2 - Compulsions Chart
The second step in creating a ritual journal is a compulsions chart. Although most OCD clients are aware of the toll their compulsions take on their daily life, few ever sit and analyze the circumstances around them. I asked Elizabeth to keep track of her rituals throughout the day. I asked her to record the time of the ritual, the type, the minutes spent on the ritual, the ritual trigger, and the specific fear or feared consequence.
I explained to Elizabeth, "Such triggers as time of day can cause you to resort to a compulsion. If you understand such small triggers, you might be more prepared to stop yourself, or at least be conscious of what you are doing." For several days, Elizabeth faithfully recorded each extended washing or counting. After a week had passed, I asked Elizabeth to go back and note any trends that might have occurred.
Elizabeth stated, "I seem to be more anxious in the late afternoon. Procedures that occur between eight and eleven p.m. tend to make me wash and count more often. My triggers were almost always the operation itself, and the number of minutes I spent preparing was proportional to the difficulty of the procedure and the amount of blood I got on me. Also, I think I spent more time washing in the evening because I felt my infection risk accumulated over the day. In other words, the bacteria and viruses congregated on my hands the longer the day went on."
Now that Elizabeth could give a time frame of susceptibility, she could begin to prepare herself for obsessive thoughts.
Step 3 - Obsessive Thought Chart
In addition to defining compulsions and a compulsions chart, the third step in creating a ritual journal is an obsessive thought chart. Although a co mpulsion chart is effective in mapping out for the client the social triggers of their condition, I feel that an obsessive thought chart can help the client be more aware of the severity of their compulsions. I feel that this step is essential when making an exposure routine, which we will discuss later on in the course. Do you agree?
I asked Elizabeth to write down all of her obsessive thoughts and behaviors in one column and to the right of each thought, rate their discomfort level, ranging from zero to one hundred. When Elizabeth finished, her discomfort chart included "washing for an operation", which she rated as an 80 and "counting the instruments" which she rated as a 60. This rating system will prove useful when it comes time for Elizabeth to begin exposing herself to her fears and obsessions.
Think of your Elizabeth. Would he or she benefit from an Obsessive Thought Chart? How about a ritual journal in general? Would playing this track for your client be beneficial?
Technique: Writing an Exposure Story
Strategy number two is an "Exposure Story." Now that Elizabeth had started her Ritual Journal, I asked her to make her first entry an "Exposure Story." As with many OCD clients who wish to cure themselves of their obsessions, one of the best treatments is exposure. But at this early stage in treatment, I did not feel that Elizabeth was quite ready to go to that extreme.
Instead, I stated to Elizabeth, "I want you to write a story in which you place yourself in a situation that would cause you anxiety and make you want to perform a ritual. Remember to include your triggers: time of day, situations, etc. I want you to write the story without the rituals. Try to include any anxious feelings you know you would most likely experience in this situation."
After a few days, Elizabeth returned and read her story aloud to me. She stated, "It’s about 9 o’clock at night, and I’m nearing the end of my shift. It was a long day, and I’m really tired and feel grimy. I want to go home and take a four hour bath, which I probably would do. I get to the sink outside of the operating room and start scrubbing. I time myself. One minute goes by, and I’m done. I turn off the sink with my elbow, so I don’t contaminate it. But then I start thinking, ‘What if I missed some bacteria? What if the small strand of bacteria I didn’t wash off gets into the patient and they get infected?
"What if they die? I would be a killer!’ But I don’t go back to the sink, I continue into the operating room and focus my attention on the patient and the operation. I want to count the instruments, but my nurse assures me that they are all there, and I trust her. I feel a little anxious, again. I perform the operation without a hitch and a few days later the patient is still doing fine. My feelings of anxiety don’t let up until a few weeks after the surgery when I know that nothing bad has happened."
Notice that she anticipated the anxiety she will feel when exposed to her fears. This sort of rehearsal will help Elizabeth prepare herself for her actual feelings of anxiety. Would your OCD client benefit from writing an exposure story?
On this track, we discussed four steps in effective behavioral strategy number two: Creating a Ritual Journal. The journal included the following four steps: defining compulsions and obsessions; a compulsions chart; an obsessive thought chart; and an exposure story.
On the next track, we will discuss three types of obsessive thoughts and effective behavioral strategy number three: Cutting Down Thoughts. These three types of obsessive thoughts include: mental disaster image; violent mental image; and solution thought.
Peer-Reviewed Journal Article References:
Olatunji, B. O., Ebesutani, C., & Tolin, D. F. (2019). A bifactor model of obsessive beliefs: Specificity in the prediction of obsessive-compulsive disorder symptoms. Psychological Assessment, 31(2), 210–225.
Reynolds, S. A., Clark, S., Smith, H., Langdon, P. E., Payne, R., Bowers, G., Norton, E., & McIlwham, H. (2013). Randomized controlled trial of parent-enhanced CBT compared with individual CBT for obsessive-compulsive disorder in young people. Journal of Consulting and Clinical Psychology, 81(6), 1021–1026.
Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 79(2), 247–252.
Online Continuing Education QUESTION 2
What are four parts to an effective ritual journal? To select and enter your answer go to .