Step-by-Step Treatment Manual

The embarrassing nature of unwanted sexual thoughts in individuals with obsessive-compulsive disorder (OCD) increases shame and generates feelings of disgust. This requires a specialized approach by clinicians to address the challenges associated with the sexual subtype of OCD (S-OCD). This chapter first addresses psychoeducation as it relates to unwanted sexual thoughts, facing fears, and building mental fitness. The authors then provide a session-by-session guide designed to assist clinicians in the provision of exposure and response prevention therapy (Ex/RP) to S-OCD sufferers. The protocol provides strategies aimed at increasing a client’s behavioral flexibility and control in the specialized treatment of S-OCD using Ex/RP and also includes cognitive therapy, acceptance and commitment therapy (ACT), and mindfulness techniques.

Introduction

Sexual obsessions are perhaps the least understood manifestation of obsessive-compulsive disorder (OCD) and include worries about sexual orientation, infidelity, sexual deviations, incest, pregnancy, and blasphemous thoughts. Although about 25% of those with OCD are believed to have symptoms with sexual themes (S-OCD), mental health professionals have difficulty making a proper diagnosis. Few clinicians know how to treat this form of OCD, and there are very few materials available to guide clinicians. Treatment using cognitive-behavioral principles is sometimes unconventional, and few therapists receive training in how to address S-OCD their academic programs. Even well-educated psychology students and practicing therapists have stigmatizing attitudes toward sexual obsessions compared to other types of OCD content. This manual takes the best cognitive-behavior therapy strategies for the treatment of OCD, and illustrates how to apply them to clients with S-OCD. It contains direct written step-by-step instructions for therapists as well as educational handouts and diagrams for clients to promote learning.

Troubleshooting Common Problems, Issues, and Resources

Practitioners working with OCD sufferers are sometimes presented with complicated issues that make it difficult to see significant progress within a client’s treatment. Being skilled at recognizing when treatment is at a standstill is important in and of itself. It is impossible to predict all of the problems that can arise, but being mindful of common glitches can support therapists in recognizing the barriers that sometimes make clients and therapists feel stuck. Discord within a client’s sense of self, fear, lack of trust, time management, family dynamics, and comorbidities are some of the common themes therapists see come up for their clients. There are also matters related to logistics and ethics that therapists may face. This chapter includes illustrations of real-life situations that therapists can take note of, as well as suggestions on how to address the obstacles to better support clients in reaching their goals for OCD wellness. Also included is a list of books, articles, and other resources.

Treating Sexual Orientation Obsessions

This chapter presents a case study of the treatment of sexual orientation obsessions in obsessive-compulsive disorder (also called SO-OCD or H-OCD for homosexual OCD). The case study includes information about the client background and case conceptualization of a male with upsetting sexual thoughts who was effectively treated using exposure and response prevention by the authors. Included are measures administered, Real-life examples of his exposure hierarchy, and sample imaginal exposures from the case that serve as realistic examples of what treatment may include. Additionally, this chapter includes additional detailed sample ideas of in vivo and imaginal exposures that can be used as part of treatment for SO-OCD for other clients.

Association Splitting

Beginning with a description of a semantic network conceptualization of intrusions in obsessive-compulsive disorder (OCD), the authors lay the groundwork for the development of the cognitive therapeutic technique of association splitting. The basic principles of association splitting are then elaborated. The existing research evidence for the efficacy of association splitting for treating various forms of obsessions is also described in detail. This is followed by an extensive discussion of the pragmatic utility of association splitting for complementing established cognitive-behavior therapy programs for OCD (e.g., exposure and response/ritual prevention) in overcoming certain treatment barriers. The chapter concludes with an easy-to-understand walk-through of the steps that therapists can take to guide their clients in their practice of association splitting for sexual obsessions, within and outside of therapy sessions.

Assessing Clients with Sexual Obsessions

This chapter reviews the most important considerations when assessing a client with sexual obsessions within OCD (S-OCD). Clients typically experience increased shame surrounding symptoms and obsess about the cause and meaning of obsessions, and this chapter provides guidance for therapists during the initial consultation. Also reviewed are recommended assessment strategies and helpful clinical tools, with a table of measures. Differential diagnosis for S-OCD versus pedophilic disorder and sexual identity confusion are contrasted. Also provided are examples of OCD surrounding transgender fears, bestiality fears, and S-OCD with psychosis. Clients with OCD are often undermedicated by their physicians, and so included is a review of medication options for OCD and common side effects, written to be accessible to therapist nonprescribers. The chapter ends with a discussion of how to communicate with other mental healthcare providers, including physicians and other prescribers, therapists, social workers, clergy, and traditional healers.

Treating Pedophile Obsessions

This chapter contains a case study of the treatment of pedophilic obsessions in OCD (also called P-OCD). The case study includes the background and case conceptualization of an adult client who was effectively treated using exposure and response prevention with values-based exposures using acceptance and commitment therapy. Examples of values-based exposure hierarchies are provided from the case and serve as realistic examples of what treatment may include. The authors discuss treatment and outcome session by session and include complicating factors and treatment implications. In addition, this chapter includes detailed example ideas of in vivo and imaginal exposures that can be used as part of treatment for P-OCD for clients.

Understanding Sexual Obsessions

Obsessive-compulsive disorder (OCD) has a heterogeneous presentation, and many of those afflicted experience symptoms that include sexual content. Sexual obsessions occur across ethnicity, race, and culture, although they may present as culturally bound syndromes. Common types of sexual obsessions include pedophile obsessions, sexual orientation obsessions, fears surrounding sexual/gender identity changes, religious sexual obsessions (scrupulosity), fears about committing a sexual assault, and irrational impregnating fears. This chapter reviews common concerns about the dangers posed by individuals with these forms of OCD and discusses the prognosis for those receiving proper treatment. The authors also review the four manifestations of OCD—contamination fears and cleaning rituals, doubting and compulsive checking rituals, symmetry obsessions and ordering rituals, and unacceptable/taboo thoughts and mental rituals. They describe how sexual symptoms fit into these four major dimensions.

Relationship Issues

This chapter discusses the impact of sexually themed obsessive-compulsive disorder (OCD) on relationships, with a focus on intimate partners. Discussed is the role of family accommodations on relationships and how OCD can interfere with relationship and marital satisfaction. Included are strategies for therapists surrounding family counseling and interventions that may include partners in the OCD treatment process. A review of common sexual problems associated with OCD is provided, which includes difficulties surrounding impregnating obsessions, sexual orientation obsessions, obsessions surrounding sexual deviance, and contamination fears. Also discussed is the mechanism by which anxiety and depression contribute to sexual difficulties by reducing sex drive. Several medications for OCD can result in sexual side effects, and clients should be warned of these difficulties in advance. Also discussed is how to talk to partners and others about sexual obsessions in OCD. The relationship itself can become an obsessional concern for clients, sometimes called relationship OCD, which may require an approach to treatment that combines OCD-specific cognitive-behavioral approaches and couples therapy.