barbara.barcaccia@uniroma1.
it
Barbara Barcaccia and Nicola Petrocchi
Associazione di Psicologia Cognitiva, Rome
INTRODUCTION
This case study describes the use of defusion and Acceptance for the treatment of a patient affected by obsessive-
compulsive disorder (OCD).
Despite being today a curable disorder, still some obsessive-compulsive patients are treatment resistant. It is
therefore pivotal that effective psychotherapys techniques are designed and integrated into treatment.
There is generally a long delay (10-15 years) between the onset of OCD and treatment being received. During this
time, patients who suffer from OCD endure disruption within their functioning in all the important areas of life.
Consequently OCD has been rated one of the top ten reasons for disability by the World Health Organization.
CASE FORMULATION
Presented problems
Cassandra is a 39-year-old woman suffering from OCD since childhood. She had a long history of early onset OCD.
When she was 33 she underwent a successful cognitive-behavioural treatment after which she had enjoyed five
years of almost total remission. The news of the pregnancy arrived unexpectedly for her, she was initially dismayed
at it and started to suffer depressive symptoms, the reason why she newly sought help from her psychotherapist.
She initially tended to ruminate on how difficult it would be for her to meet requirements of a good mother, due
to her vulnerability to OCD. Before long, having adjusted herself to the thought of being pregnant, and having
worked on her perfectionism (I still can be a good mother, even though I might make mistakes and even though Im
vulnerable to OCD) she started to recover from the depressive symptoms. She occasionally had obsessive thoughts,
regarding the fear of having done something which might hurt the fetus, but she acknowledged them to be
obsessions, and was capable of managing them. Unfortunately Cassandra miscarried in her second month, and
straight afterwards, during a check-up, a lump was found in her breast. Symptoms of depression and anxiety soon
increased, becoming the breeding ground for a full-blown obsessive-compulsive relapse.
Precipitant factors of the obsessive-compulsive relapse
Having taken the dog out, Cassandra sees a disposable syringe on the pavement, thinks it to be a dangerous
situation and immediately takes fright and flees. Afterwards she wonders: was there blood on the needle of the
syringe? Could it be that a drug addict left it there after having shot-up? Was he/she seropositive? Did the dog put
his paw on it? Could the dog infect me? Did I touch the syringe unawares? Did I deliberately pick it up from the
pavement and then stick the needle in my finger? Is it possible that I did such a thing? Are these obsessions or not?
Should I ask my husband if he thinks this might be true? Is it possible that they made a mistaken diagnosis and
these are not obsessions but true and real memories of events that actually occurred?
Mechanisms of maintenance
Cassandra is overwhelmed by the anxiety attached to the obsession of having either unintentionally or
deliberately pricked her finger with the syringes needle. For that reason she feels compelled to check, mainly
covertly, by reconstructing the facts in her mind. She tries to check whether the scene in which she picks the
syringe up and pricks her finger with a needle is plausible or not, by re-enacting the scene of the crime. The
more she re-enacts it, the more vivid and detailed the scene becomes, due to the fact that Cassandra piles new,
invented details, on the scene, to check if the whole story makes sense; this way the likelihood of it having really
occurred spirals upward and the patient, terrified, asks herself: did I really do such a dumb thing? How is it
possible? Nobody would behave so foolishly! No, its impossible. But how can I be certain? Couldnt it be that Ive
actually done it and afterwards Ive forgotten it because I was shocked? Lets try to recollect everything letter-
perfect. So she starts over the checking procedure, falling into the typical traps of the Obsessive-Compulsive
Disorder, thus maintaining and exacerbating the level of anxiety and the obsessions frequency of occurrence.
INTERVENTION
Sharing the case formulation
The patients main obsession regards the fear of having contracted HIV+, followed by checking rituals, mainly
covert ones. The level of anxiety accompanying the obsessive thought was so high that Cassandra felt she couldnt
stop from checking. Within a few days from the precipitant episode (the sight of the syringe on the pavement) she
had relapsed into OCD, and she would spend most of her waking hours checking: she would recreate the scene of
the crime again and again in her mind to check what had actually occurred. Unfortunately the adopted strategy
of solution becomes the problem, because after these checking efforts her memory would get blurred. So,
tormented by the doubt, incapable of deciding once and for all if she is remembering an actual event or just
imagining it, she starts again from scratch checking the memory, but the doubt goes on and on, ending up in a
catch-22 situation.
Cassandra is helped by the therapist to see the consequences in the medium and in the long term of her checking
behaviours and how counterproductive it can be if she doesnt refrain from ritualising. The psychotherapist tries
as well to normalise the OC relapse, due to the stressful events that recently occurred in the patients life.
Bibliography
Bach, P. & Moran, D. (2008). ACT in Practice: Case Conceptualization in Acceptance & Commitment Therapy. Oakland, CA: New Harbinger.
Barcaccia B. (2010). La formulazione del caso clinico, in Elementi di psicoterapia cognitiva, C. Perdighe and F. Mancini (eds.) Giovanni Fioriti editore, II edition.
Barcaccia, B. (2007). Aderire allevento: attualit della proposta stoica di Seneca, dissertation thesis in Philosophy, University Roma Tre.
Barcaccia, B. (2008, June). Accepting limitations of life: Leading our patients through a painful but healing path. Lecture conducted from Ludwig-Maximilians-Universitt, Munich, Germany.
Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006).). Acceptance and commitment therapy: model, processes and outcomes. Behaviour Research and Therapy, 44(1):1-25.
Mancini F. & Barcaccia B. (2004, June). The Importance of Acceptance in Obsessive-Compulsive Disorder, invited Lecture conducted from Ludwig-Maximilians-Universitt, Munich, Germany.
Mancini F. & Gragnani A. (2005). Lesposizione con prevenzione della risposta come pratica dellaccettazione. Cognitivismo clinico, 2, 1, 38-58.
Michael P. Twohig, Steven C. Hayes, Akihiko Masuda, Increasing Willingness to Experience Obsessions: Acceptance and Commitment Therapy as a Treatment for Obsessive-Compulsive Disorder, Behavior Therapy 37, 313, 2006.
Pence, S. L., Jr., Storch, E. A., & Geffken, G. R. (2010). The effectiveness of intensive cognitive- behavior therapy: A case study in pediatric obsessive-compulsive disorder. Annals of the American Psychotherapy Association
Saliani A., Barcaccia B. & Mancini F. (2011). Interpersonal vicious cycles in Anxiety Disorder, pp.149-183. In Communication in Cognitive Behavioural Therapy, Rimondini M., New York: Springer.
Acceptance and defusion
The patient was invited to try to refrain from checking and accept the presence of the horrible thoughts,
images and emotions in her mind. After all, how effective had her attempts at solution been up to then?
Had they worked? Had the obsessions decreased in frequency? Had her anxiety subsided? No, quite the
reverse!
Acceptance
Cassandra, as any other obsessive-compulsive patient, instinctively believes that her problem will be
solved when evidence will be found that the perceived threat is absent. The final purpose of the
reassurance manoeuvres and of the checking rituals is the finding of such evidence. Therefore, since the
irrefutable evidence of threats absence is impossible to find, there is nothing left to do but fall back on
manoeuvres aimed at reducing the threat, e.g. by re-enacting over and over in ones mind the feared
scene. The stepping stone to breaking this vicious cycle is acknowledging that satisfying the obsessive
patients need for certainty (that nothing dangerous really happened) is an impossibly difficult and
counterproductive task. This kind of therapeutic strategy is a cognitive one, focused on guided discovery;
indeed, Actually: 1) the criteria applied by patients to assess the effectiveness of the reassurances
manoeuvre are far stricter and more rigorous than the ones followed by non-clinical individuals; 2)
generally the patient doesnt strive for partial, but for conclusive reassurance: she would like to achieve
the absolute certainty that the feared event has not occurred and will not occur; 3) the attempts at
finding the mathematical certainty bring about maintenance of the fears and even embitterment, so
that the solution becomes the problem.
Therefore, an effective intervention should be aimed not so much at eliminating conclusively the feared
threat, as to accepting the possibility that the feared event could occur (Barcaccia, 2007; Barcaccia,
2008; Bach & Moran, 2008, Mancini & Gragnani, 2005).
To give further details, the strategy of acceptance (Hayes et al., 2006) will imply two different levels: one
of the external events and one of the internal states. This strategy will facilitate the process of giving
up the avoidant and safety-seeking behaviours.
The psychotherapist helped the patient to replace the search for absolute certainty (pursued through
avoidant behaviours, reassurance requests and other safety seeking behaviours) with an acceptant
attitude (Mancini & Barcaccia, 2004).
Defusion
Once acknowledged the impossibility of reaching the absolute certainty that nothing risky really
happened and the backfire effect that mental checks do have, and having increased Cassandras
willingness to accept both the possibility that the feared event might have occurred and the presence of
distressing thoughts, images and emotions, the patient was ready to address herself to defusion. The
thought which would continuously nag her was: I saw the syringe, I picked it up and I pricked my finger
with the needle. There was as well a mental image: a syringe all covered with blood. Cassandra was
helped to detach herself from the content of the thought and of the mental image by telling herself,
whenever they occurred: Ok, Im now having the thought that I saw the syringe, that I picked it up and
that I pricked my finger with the needle. Ok, Im now having the mental image of a syringe all covered
with blood. She would also try to change the order of the words in the sentence I saw the syringe, I
picked it up and I pricked my finger with the needle (e.g. needle the finger my pricked I and up it picked I
syringe the saw I).
OUTCOME
Standard assessment measures were used to assess the severity of obsessive-compulsive symptoms;
frequency and duration of symptoms were also measured over the course of treatment. At post-
treatment, after six weeks (one session a week), a clinically significant improvement was shown:
PRE-TREATMENT: BDI II 25 Y-BOCS 28 POST-TREATMENT BDI II 16 Y-BOCS 18
REVIEW AND EVALUATION
This case study shows an attempt of integrating ACT techniques, such as defusion, into Cognitive-
Behavioural Therapy: in our perspective CBT and ACT, far from being in opposition to each other, can be
integrated, to the patients advantage.
The patient described in this report is a 39-year-old woman who suffers from OCD symptoms, involving
mainly checking rituals. The case formulation particularly highlighted the reasons of the onset, the
vulnerability, and the mechanisms of maintenance of the disorder, and was constantly shared with the
patient. ACT techniques were integrated into treatment to increase the willingness of the patient to
accept unwanted mental images, thoughts and feelings; moreover, a particular cognitive technique
aimed at making the patient accept the possibility of the threats occurrence has been implemented.
The latter is inspired to the writings of the Stoic philosophers, mainly Seneca: Fate leads the willing and
drags along the unwilling.