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Creating a Framework for Treatment of Obsessive Thoughts

Kathleen M. Rupertus, PsyD Renae M. Reinardy, PsyDThe Anxiety and OCD Treatment Center, LLC Lakeside Center for Behavioral Change Wilmington, Delaware Fargo, North Dakota

Felicity Sapp, PhD Patricia Perrin Hull, PhDOCD and Anxiety Psychological Services OCD and Anxiety Treatment Center ofCalgary, Alberta Houston, Texas

* Describe the rationale and essential components of exposurescripts in the treatment of OCD

* Describe 3 or more exposure techniques for obsessive thoughts

* Describe how to apply exposure techniques to 3 or morethemes of obsessive thoughts

Workshop Goals

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* OCD goes for shock value

* Misconception: “Because I thought it, it must be true”

* Thrives off of uncertainty: “How do I really know …”

* Common themes: Violent, sexual, religious, and/or moral

What are Intrusive Thoughts?

* Written scenario that encompasses the scary feelings andthoughts that OCD brings on when faced with a trigger of aparticular fear

* Allows you to tailor the content of the obsessions andcreate a treatment plan that is individualised to yourclient’s OCD

* The client is mentally put in the trigger situation and itincreases the experience and awareness of your client’sactual feelings and OCD thoughts (i.e., it feels like it ishappening)

Using Scripts with ERP

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* Imagined ERP is necessary for recovery as it helps maintaingains over time when used in conjunction with in-vivo ERP ascompared to use of in-vivo ERP alone (Foa et al., 1980)

* Allows your client to face fears that you are unable to create inreal life or to face fears that have future consequences that areimpossible or highly improbable

* As a first step before an in-vivo ERP task

* Worst case scenarios

Why Use Scripts with ERP?

* Write a scenario that deliberately triggers obsessions and causesanxiety and distress.

* Personalize the scenario based on catastrophic fears and beliefs ofoutcomes.

* Read or record it on a POD and listen to it while allowing in, andfocusing on, thoughts, images and physical sensations that areelicited.

* Do not engage in any behaviors, either physical or mental, toreduce distress elicited.

* Continue listening or reading script until anxiety is reduced by atleast 50% - allowing oneself to become habituated to obsessions.

How to Use Scripts in ERP

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* Deliberately focusing on your fears will not make themworse.

* Thinking about your obsessions will not make themcome true.

* ERP and eliciting anxiety is not dangerous; you will notdie or go crazy.

* ERP does not cause anxiety to be so low that you willignore normal safety practices.

Important Pointsfor Imaginal Exposure

Deliberately focusingon your fears will notmake them worse

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Thinking about yourobsessions will notmake them come true

ERP and eliciting anxiety is not dangerous

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ERP does not cause anxiety to be so low that you ignore normal safety practices

* First person perspective* Questions to elicit triggers* Identify worst fear and feared consequence* Length of script* Level of anxiety elicited* Write in present tone* End with uncertain or tragic outcome* Include no reassuring statements

How to Write a Script

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* Where does it take place and what are the details leadingup to it? (e.g., Setting – When is it occurring? What time ofday? Who is around? Where are you?)

* What are you doing? Your physical movements andactions? (e.g., Stabbing? Walking? Cooking?)

* What thoughts or images come to mind? What is goingthrough your mind in the setting or situation?

* What do you see? Color? Movement? Peoples’ Expressions,Body Language or Actions?

Questions to Elicit Content

* What do you hear? Sounds? Bumps? Sirens?

* What do you feel? Temperature? Pain? Arousal? Itchy?

* What do you smell? Gas? Smoke?

* What body sensations do you feel? Increase heat rate?Panic? Tension? Warm/Cold? Dizziness? Breathing rate?

* What emotions do you feel? Guilt? Doubt? Disgust? Fear?

Questions to Elicit Content(continued)

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* What are you afraid will happen? (e.g., hurt someone?become sick? lose control? steal?)

* If your fear happens, what is so bad about that? What arethe frightening events that follow (e.g., fire? accident?death? go crazy? go to jail?)

* If that happens, what does it mean about you as a person?(e.g., careless? immoral? murderer? pedophile?)

* If your fear happens, what does it mean about what othersthink of you? (e.g., cheater? pervert?)

Questions to ElicitFear and Feared Consequences

* Have your client describe the setting in which the triggersituation occurs

* What are the initial intrusive fearful thoughts or images?* What emotional reactions or physical symptoms do these

initial thoughts provoke?* In response to these feelings, what doubts, fears or

thoughts occur?* Include the desire to ritualize that is not followed through* What is the feared consequence that results by not doing

the ritual?

When writing scripts...

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* When using scripts earlier in treatment or for lower levelanxiety provoking scripts- use vague, general and non-descriptive language

* Since fear and feared consequence is a possibility, notdefinitive, language needs to reflect uncertainty of actionor outcome (e.g., “may happen”)

* End the script with a tragic or uncertain outcome and theneed to take the risk of the possibility of the fearhappening in the future

Additional Points inWriting Scripts

I imagine I am making a chicken casserole dinner for myfamily. I fear that I may not have washed my hands wellenough after touching the raw chicken. I fear that I mayend up spreading germs to my family and that they mayget sick and die. I fear that if this happens that I may notbe able to live with the guilt as it will be all my fault. Thetruth is I have no way of knowing what may happen inthe future. I will have to live with the uncertainty thatmy fears may come true.

Lowest Level Anxiety Script forFear of Contamination/Accidental Harm

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I imagine I am making dinner for my family. I take the knife and cut up the chicken for the casserole.After I am finished, I take the knife and cutting board over to the sink. I start to wash them and myhands at the same time, knowing that I have to get the germs from the raw chicken off so I don’tspread them to my family. I want to wash several times in a certain way using bleach to make surethat all the microscopic germs are removed and I don’t end up spreading them in myhome. Instead, I wash everything once in hot soapy water. Once I am finished, doubt starts toplague me as I start wondering whether I truly washed well enough to get off all the germs thatcould lead to my family catching salmonella. I want to wash everything again and use bleach thistime but I resist. Anxiety starts to mount throughout my body as my heart rate increases and Iworry that I did not remove all the germs. I am afraid that there will be microscopic particles stillpresent on my hands and I am touching other things in the house. What if my children or husbandtouch the same things? I start to try to remember all the things I have touched. Can I clean them? Ican’t remember everything I touched. What if I miss something? My anxiety increases and I start tofeel guilty as the thought that I will be responsible for spreading a deadly disease to my familylodges itself in my mind. What if my children get sick and die and it is all my fault? I could haveprevented this from happening if I washed everything well enough the way OCD wanted me to, butI didn’t so now I will have to live with the consequences if my family dies because of me, as it is toolate and there is nothing I can do. The truth is I have no way of knowing what may happen in thefuture. I know that I will have to take the risk and live with uncertainty that my worst fears maycome true.

Low Level Anxiety Script forFear of Contamination/Accidental Harm

I imagine I am making dinner for my family. I take the knife and cut up the chicken for thecasserole. After I am finished, I take the knife and cutting board over to the sink. I start towash them and my hands at the same time, knowing that I have to get the germs fromthe raw chicken off so I don’t spread them to my family. I want to wash several times in acertain way using bleach to make sure that all the microscopic germs are removed and Idon’t end up spreading them in my home. Instead, I wash everything once in hot soapywater. Once I am finished, doubt starts to plague me as I start wondering whether I trulywashed well enough to get off all the germs that could lead to my family catchingsalmonella. I want to wash everything again and use bleach this time but I resist. As I amtrying to remember all the items I touched and think about how I can decontaminatethem, my children rush in the house after school. They come to the kitchen to grab asnack. Before I can warn them, they have crackers and cheese on the counter, the samecounter where I was cutting up the raw chicken. Anxiety starts to mount throughout mybody as my heart rate increases and I have trouble catching my breath. I worry that I didnot do a good enough job in removing all the germs when I washed. I am afraid thatthere are microscopic particles still present on my hands and that I spread them when Itouched the counter earlier. My anxiety increases and I start to feel guilty and panicky asthe thought that I will be responsible for spreading a deadly disease to my family lodges

High Anxiety Level Script forFear of Contamination/Accidental Harm

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itself in my mind. What if my children get sick and die? What if later that evening my littleboy starts to cry because of bad cramps in his body and then starts to suddenly vomitviolently and we have to take him to the emergency department in the middle of thenight? I can imagine the doctor telling us that he has been poisoned and has salmonellaand that it is the worst case he has ever seen and that we need to be prepared. Guiltplagues me as I realize that I could have prevented this from happening if I washedeverything well enough the way OCD wanted me to, but I didn’t and now my son may bedying and it is all my fault. What if as I sit by his bedside, I hear his breath become moreand more labored? I cry uncontrollably as I fear that I may lose my son because of mycarelessness and negligence. Why didn’t I do a better job of making sure that all thegerms were gone when I was washing up? This is all my fault, I am a terrible mother and Idon’t think I will be able to go on living with this guilt for the rest of my life if my son dies.There is nothing I can do now but live with the horrible consequences of my carelessness.The truth is I have no way of knowing what may happen in the future. I know that I willhave to take the risk and live with uncertainty that my worst fears may come true and Iwill have to cope with whatever happens.

High Anxiety Level Script(continued)

Other Exposure Techniques for Treatment of Obsessive Thoughts

* Exposure to Uncertainty – to increase tolerance ofuncertainty

* Attentional Retraining – exposure to trigger wordsembedded in list of rhyming words

* Cued Exposures – to reduce unpredictability anduncontrollability of triggers

* Applied to SO-OCD, Postpartum OCD, and OCD withintrusive suicidal thoughtsPatricia Perrin Hull, Ph.D.

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Trigger: 1) Touching door knob2) Intrusive thought: I might stab a loved one.

Ritual considered:1) Wash hands2) Reassure self that you would do no harm

Response Prevention:1) Don’t wash hands2) Don’t reassure self.

Do Exposure to Uncertainty, don’t reassure: 1) Maybe I will get sick, maybe I won’t. There’s no way to be sure. 2) Maybe I would harm loved one, maybe I wouldn’t. There’s no

way to be sure.

Exposure To Uncertainty (My Secret Weapon) –Similarity To Exposure To Contamination Triggers

Exposure To Uncertainty Format –SO-OCD

* Identify the anxiety inducing thought, e.g., “Maybe I am gay/straight.”

* Establish that this is an undesirable thought, (ego-alien vs. ego-identified) that creates anxiety.

* Do Exposure to Uncertainty - Say repeatedly:

* Maybe I am gay (or straight).

* Maybe I’m not.

* There’s no way to be sure.

Watch anxiety (0-10) habituate till drops to half.

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Exposure To Uncertainty Format –Postpartum OCD

* Identify the anxiety inducing thought, e.g., “I could drown mynew baby.”(Common in postpartum OCD)

* Establish that this is an undesirable thought, (ego-alien vs. ego-identified) that creates anxiety.

* Do Exposure to Uncertainty - Say repeatedly:

* Maybe I do want to drown (hurt, molest) my new baby.

* Maybe I don’t.

* There’s no way to be sure.

Watch anxiety (0-10) habituate until drops to half.

Example of Differential Diagnosis : How Do You Know If Thoughts Are Due To

OCD with Intrusive Suicidal Thoughts?

SUICIDAL* You find the idea of killing

yourself desirable, you’relooking forward to itproviding relief fromemotional pain

* You look into ways to killyourself, gather materials(pills, gun), develop a plan

OCD* You are terrified of unwanted

thoughts or images of harmingyourself, and you wonder whyyou are having them

* You avoid things that couldhurt yourself, like pills, guns,knives

Patricia Perrin Hull, Ph.D.

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How Do You Know If Thoughts Are Due To OCD with Intrusive Suicidal Thoughts?

SUICIDAL* You avoid talking about

your plan or giving hint, sothat no one will stop you

* You think about suicidewhen you want to, but notall the time

OCD* You talk to trusted people –

family, doctor, therapist, friend- about thoughts, and say youdon’t want to kill yourself

* You are not able to stopthinking about thoughts orimages involving killingyourself, but wish you couldstop, and you fear you couldact on them

Patricia Perrin Hull, Ph.D.

Exposure To Uncertainty Format –Intrusive Suicidal Thoughts

* Identify the anxiety inducing thought, e.g., “Maybe I do want tokill myself / commit suicide.”

* Establish that this is an undesirable thought, (ego-alien vs. ego-identified) that creates anxiety.

* Do Exposure to Uncertainty - Say repeatedly:* Maybe I do want to kill myself.* Maybe I don’t.* There’s no way to be sure.Watch anxiety (0-10) habituate until drops to half.

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GAY DROWN SUICIDE

Day Frown PesticideSay Crown FiresideGay Drown SuicidePay Brown CountrysideBay Ground Mountainside

Attention Retraining Using Trigger Words “Gay,” “Drown,” And “Suicide” Embedded With Neutral Words

For trigger word “gay”, create list of rhyming or similar words,repeating list saying each word 1x, then 2x, then 3x. Rate anxietyafter 2-3 rounds of reading each list, until anxiety to trigger worddrops to half.

Day Day Day Day Day DaySay Say Say Say Say SayGay Gay Gay Gay Gay GayPay Pay Pay Pay Pay PayBay Bay Bay Bay Bay Bay

Exposure To Trigger Word “Gay” Embedded With Neutral Words

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ERP: Imaginal Exposure to Address Unpredictability/

Uncontrollability of Intrusive Thoughts

To address unpredictability/uncontrollability of intrusive thought

or image, which contributes to shock effect and anxiety /distress:

* Choose common cue word and think of thought when you hear it

(e.g., weekend, today, car, store)

* Choose cue time (e.g., every hour on the hour), or set alarm on

phone to cue doing an exposure

* Choose cue activity (entering a room, hanging up the phone,

stopping at red light)

* Create visible trigger – (word on post-it in drawer, passing a red

(black, silver) car

When cued by word, time, alarm, activity, openingdrawer, do one or more of the following exposures:* Exposure to Uncertainty* Bring intrusive image to mind* Attention Retraining- Do exposure to embedded

words* Listen to recorded Imaginal Exposure Script

ERP: Imaginal Exposure to Address Unpredictability/ Uncontrollability of Intrusive Thoughts

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(Final Thoughts) - Common Unhelpful Behaviors/

Misdiagnoses Of Therapists

* Saying “Just don’t think about that” (Thought Suppression)

* With SO-OCD, exploring latent homosexual fears

* If postpartum mother/father has thoughts of harming child,

having child taken away (CPS)

* Thinking fears of harming are psychotic delusions

* Telling patient that he /she has unconscious aggressive feelings

* Reassuring patient repeatedly

* Advising patient with relationship OCD to get divorced

Patricia Perrin Hull, Ph.D.

* “Danielle”, age 43* Married with 3 children (son 20; daughter 17; son 14)* History of childhood anxiety (6 years old)- fears included “the

devil will get me”, being abducted by aliens* older brothers would intentionally play on/invoke her fears

* Intermittent episodes of debilitating depression related tothyroid issues* multiple hospitalizations for depression during course of OCD

treatment

* Intrusive obsessions of harm began within 3 months of the birthof her oldest child

Case Example

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* What if I kill my kids? Family?

* What if I suddenly become crazy and do it?

* What if the devil possesses me and I do it?

* What if I act on a sudden impulse and I do it?

* What if I conclude it’s better for everyone and I do it?

* What if I really have a psychotic disorder and not OCD and I do it?

Intrusive Obsessions of Harm

* Sharp objects (knives, scissors, sewing needles)

* Being close (proximity) to the children

* Being home alone with the children

* Watching/listening to the news

* TV shows involving violence

* Topics such as schizophrenia or psychosis

* Serial killers (Ted Bundy, Jeffrey Dahmer, Charles Manson)

* Women who killed their children- Andrea Yates (drowned 5 children in bathtub), Christy Sheets (shot daughter and son), Julie Schennecker (shot daughter and son)

Triggers

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To all triggers* sharp objects (knives, scissors, sewing needles)* being close (proximity) to the children* being home alone with the children* watching/listening to the news* tv shows/movies that might involving violence* schizophrenia, psychosis* serial killers and women who killed their* making herself do something she didn’t want to do (such as a chore

or exercising or eating “healthy”)

Avoidance Compulsions

* Trying to figure out “why” people kill

* Comparing characteristics or life experiences of knownkillers to her own characteristics and life experiences (todetermine whether she is likely to kill or not)

* Trying to figure out how she “felt” when she had anintrusive thought

Mental Compulsions

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* Scroll through news headlines, watch local news

* Sleep with butter knife next to bed

* Research books on women who have killed their children

SUDs: 20s-30s

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* Cued ERP to trigger words- index cards/post it notes… “serialkiller”

* Place a plastic bag on the back of each kid’s chair at the dinnertable

* Scissors- upside down in tin, tip up* Force self to do 1 thing/day you don’t want to do (go for a walk,

eat healthy, chore)* Remain seated next to kids while having a harm thought (not

alone)* Look at pictures of women who have killed their child/ren

SUDs: 40s

* Cued ERP to uncertainty, commercials- “I can’t be sure thatsomeday I won’t harm my kids.”

* Cued ERP to trigger words- Write “M” or “K” on hand (murder,kill)

* Sit in kitchen and look at knife block (alone)* Hug kids while having thoughts of stabbing them* Use scissors on a project with a child in the room* Go for a walk with Emily, with butter knife in pocket* Hold fake knife to picture of kid/s

SUDs: 50s

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* Cued ERP to uncertainty, when initiating a conversation with husband-“Maybe I am a serial killer.”

* Image board- Psychotic (next slide)* Read about psychotic disorders* Cued ERP to trigger words- Write “P” on hand (psychotic)* Eat dinner with steak knife at place setting* Watch a Nike commercial (Just Do It)* Cued ERP to trigger phrase- hang up Nike magazine ads* Chop food/fruit in kitchen (husband at home)* Watch Snapped, Dexter, American Psycho with husband* In session- make a list of all the ways to kill the kids, play game* Force self to do 2 things/day you don’t want to do

SUDs: 60s

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* In session- ERP to uncertainty, while holding knife- “I can’t be surethat someday I won’t harm my kids.”

* Cued ERP to trigger phrase, commercials- say or write “Today’s theday.”

* Cued ERP to trigger words- index cards/post its with murder, kill,stab

* Sleep with scissors next to bed* Remain seated next to kids while having a harm thought (alone)* Knit sitting next to one of the kids* Watch Snapped, Dexter, American Psycho while alone* Books/podcasts- women who have killed their children (alone)* In session- close eyes, stab pillow w/fake knife, imagine it’s one of

the kids

SUDs: 70s

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* Cued ERP to trigger phrase, when initiating a conversation withhusband- “I am going to kill __________.”

* Go for a walk with Emily, with steak knife in bag* Script- A Matter of Time* Listen to podcast “Sword and Scale”* The Sword and Scale true-crime podcast is an immersive audio

experience covering the dark side of humanity and human nature.Our stories delve into the worst of the worst and include murder,rape, dismemberment and cannibalism. No crime is too brutal and novictim is too pure. The worst monsters are real.

* Chop food/fruit in kitchen, kids in another room, home alone

SUDs: 80s

Any day could be “the day” that I finally kill the kids or Ed. All of myharm thoughts reflect who I really am inside and some day the “realme” is going to come out. Maybe I’ll have a schizophrenic episode and Iwill kill my kids, enjoying every moment of it. Maybe I’ll becomepossessed and kill them, realize after the fact what I’ve done, and behorrified and remorseful and full of guilt. Maybe God will tell me to killthe kids and I’ll find reassurance that I was only doing what God wantedme to do… or maybe after I kill them I will realize it wasn’t God after all,and I’ll be left with the horror of what I’ve done. Or maybe I’ll just killthem in order to make the thoughts stop. I won’t want to kill them but Iwill do it anyway, because it is the only way to permanently get rid ofthese thoughts. I may not know how I’ll do it, but I DO know it’s only amatter of time.

A Matter of Time

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* Cued ERP to trigger phrase, when initiating a conversation withhusband- “Today I am going to kill __________.”

* Script- Finding Peace* Watch movies/documentaries (Silence of the Lambs, serial killers,

mothers* Sleep with steak knife next to bed* In session ERP- Stab photo of child* Write newspaper account of stabbing/murdering children* Home alone with kids, no rituals/avoidance

SUDs: 90s

There’s nothing stopping me from killing my family at any timebecause nothing is permanent- not how I feel at any given moment, ormy values, or my anxiety level, or my reasons for or against killingthem.

I can imagine at any moment I may get to the point where it makesmore sense to kill them and myself than to not. I’ve habituated to theidea of killing them, so I think it through more than ever before and itjust makes sense to end everyone’s problems by ending their lives andmy own. Why, if I love and care about them, would I want them tocontinue to suffer in this life? There’s no fear… there’s no trying tomake myself do something I don’t want to do. I’m ALL in with nothingto stop me.

Finding Peace

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I plan it all out very carefully and am at peace with my intentions. I feelgreater and greater relief and I stab each of my children, and then mymom, my dad, and my husband, because I know what I am doing isthe right thing for everyone. It’s just me know, and I take a full bottleof klonopin. I close my eyes one last time, knowing that everyone isfinally at peace.

Finding Peace (cont’d)

Wilmington Mother Brutally Murders Her 3 Children

Monday August 12, 2018Written by David Ernest

Saturday afternoon, police were called to the neighborhood of CountryGates in Wilmington, Delaware and were horrified at what theydiscovered. Forty-three year old Danielle Cleaver was taken into custodyfor the brutal and fatal stabbings of her three children, ages 19, 16, and 13years old.

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Their father, Eric Cleaver, had left the house only 20 minutesearlier, running out to pick up milk for the children’s breakfast. Hecame home to find his wife holding a bloodied butcher knife, herclothes soaked in blood. She was crying hysterically and repeatingthe phrase, “I can’t believe I did it! It wasn’t OCD! My best guesswas wrong… and I’ve killed my babies!”

Fifty-eight year old Chip Albertini lives across the street from theCleaver’s and has watched the children grow up. He told our reporters,“Danielle seemed like a loving and attentive mother. I can’t imaginewhat snapped inside for her to have done this to those children.”Funeral arrangements have not yet been announced.

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* Make list of similarities between self and serial killers* Sleep with butcher block next to bed* Chop food/fruit in kitchen, kids present, while home alone with

kids

SUDs: 100

* “Ben” Age 12* Lives with mother, father and older sister* History of other childhood anxiety- shyness, academic worries,

perfectionism, moral scrupulosity* Family accommodation behaviors, home schooling

* Autism Spectrum* Intrusive obsessions have been present for at least 3 years* Could not discuss themes at start of therapy

Case Example

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* I may have accidentally prayed to the wrong person* I will accidentally make a deal with the devil* The devil with get my soul* I may have sinned * I may be a bad person (smoke, drink, sensation in mouth)* I may go to hell* I may have done that for the devil* Objects become cursed when I look at them with bad thoughts* I may become possessed* I do not always know if my intention was good or evil

Intrusive Obsessions:Religious Scrupulosity

* Words- Hell, Devil, Evil, Possessed* Similar words- Hello, Sign* Prayer- incomplete feeling* Decision making* Going to church* Seeing “cursed” objects* Any “bad” behavior* Seeing people smoke or drink (sensation)* Being near a bar, or seeing cigarettes at gas station* “Certain part” of his body

Triggers

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* Constant repetitive prayer* Reassurance from parents and sister* Avoidance of Church* Will not use certain words* Washes hands after OCD thought* Will not breathe on himself during OCD thought* Avoids looking at and touching “cursed objects”* Will not allow parents to drive by bars/bad places* Avoids any environments where people drink/smoke

Compulsions

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Fear Thermometer

Build a hierarchy10 Freak out anxiety9 Extreme anxiety8 Strong anxiety7 Pretty strong anxiety6 Kind of strong anxiety5 Moderate anxiety4 Somewhat anxious3 A little bit of anxiety2 Tiny bit of anxiety1 Calm

Subjective Units of

Distress

SUDS

* Slight, insignificant change to prayer* Delay asking parents for reassurance* Look at a picture of their church on computer* In session, ERP to words: Hello, Sing, Sign* Image of a restaurant that serves alcohol (with thought)

SUDs: 20s-30s (2-3)

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People are drinking alcohol in there

* Cued ERP to trigger words: Hell….o, Sin….g* Leave out more details of prayer “sloppy prayer”* Parents respond 1x only for reassurance* Glance at cursed object at home* Image of bar or cigarette pack

* Read “boy book” on “certain part” of his body

SUDs: 40s (4)

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* Cued ERP to uncertainty: I do not know if God is a little upset with meright now

* ERP to trigger words: Sinful, Sin, Bad Person* Shorten prayer to just a few words* Drive by church* Exposure to phrase: I may have done some bad things in my life* Exposure thought and just rinse hands* In session: Look at closed bottle of wine or cigarette pack from

distance* Sensation exposure

SUDs: 50s (5)

* Delay prayer* ERP to trigger words: Devil, Satan, Evil* Images with exposure phrases* ERP to phrases: I may not always remember all of my thoughtsduring the day. I may not always understand my intentions

* Get close to cursed objects* In session: Hold “sealed” cigarette

SUDs: 60s (6)

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That is a little devil

* In session- ERP to uncertainty: I might have just prayed to thewrong person. I might be bad.

* Cued ERP to trigger phrase: More realistic cartoon of Devil on

wall with thought, Maybe he is not so bad* Parents respond- I am not going to answer that to reassurance

seeking

* Hold/use a cursed object

* Walk by bar or someone smoking with exposure thought

SUDs: 70s (7)

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* Cued ERP to trigger phrase: I may have accidentally made a deal* Do not ask for reassurance at all* Go to church with family* ERP to phrase: I may become possessed one day* Harder exposure thought and breathe on hands/self* Touch a cigarette or bottle of alcohol* Look at Satanic book from across the room

SUDs: 80s (8)

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* ERP to trigger phrase: I hope the Devil will win my soul, I hope Ibecome possessed right now

* Completely resist doing prayer ritual* Eat candy with thought, I am doing this for the Devil* Write ERP prayer to Devil

SUDs: 90s (9)

* Exposure response from parents- You probably did and will go tohell

* ERP to phrase: I intentionally made a deal with the Devil todayand he now has my soul

* ERP to Phrase: I will go to hell, I deserve it* Draw a pentagram* Read from Satanic Bible

SUDs: 100 (10)

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* Psychoeducation* What is OCD, what is religious practice?* Family accommodation behaviors* Work with religious leaders* Resisting reassurance* Discuss typical religious practice

Other Considerations