Cape Cod Institute
 
Behavior OnLine Forums  
The gathering place for Mental Health and
Applied Behavior Science Professionals.
 
Become a charter member of Behavior OnLine.

Go Back   Behavior OnLine Forums > BOL Forums > Cognitive Therapy

Notices

Reply
Thread Tools Display Modes
  #1  
Unread June 28th, 2005, 04:31 PM
joel p joel p is offline
Member
 
Join Date: Sep 2004
Posts: 8
Default EX/RP for impulse control

Hi, I have been seeing a young religious man in his early twenties ( with an apparent OCPD diagnosis) whose main goal in seeking therapy was to deal with a desire to look at woman which he considers to be a sinful act (due to his failing to resist his desires). This takes a few forms, 1. he dreads going to populated areas in the summer (fearing he will see 'scantily clad women') where he would then find himself obsessing, 'don't look, don't look...', if he looks he may than obsess, 'these thoughts will never leave my head unless I masturbate, I must stop thinking of them...' or 2. he fears/attempts to avoid being at locales where he can privately watch TV, for then he is unable to stop a cycle of zipping through channels until finding one suitably provocative, masturbating and then continuing the search - all of which can go on for hours, at the expense of day to day responsibilities (such as academic requirements).
I have been wondering if EX/RP is indicated for such a case (would we have a gambler stand outside a casino if the SUDS was manageable?) if so, would the exposure be to be in public while resisting to watch women (or a more moderate form of this) or to the contrary, to encourage him to partake in the act of gazing yet remain with the thought that these images would not go away on their own.
any thoughts would be appreciated.

Last edited by joel p; June 29th, 2005 at 03:39 AM.
Reply With Quote
  #2  
Unread July 2nd, 2005, 10:00 PM
James Pretzer James Pretzer is offline
Forum Leader
 
Join Date: Jun 2004
Posts: 283
Default Initial thoughts re EX/RP for impulse control

In deciding whether exposure and response prevention (ERP) makes sense for this client my first question is "Are we dealing with OCD, a paraphelia, Obsessive-Compulsive Personality Disorder, or someone with rather extreme religious beliefs?" ERP is likely to be promising if the problem is OCD but I'm not sure it would apply with the other possibilities.

This case is not simple diagnostically. The client's fear of thinking sinful thoughts and avoiding stimuli that might trigger sinful thoughts certainly could be OCD. However, his pattern of channel-surfing until he finds something provocative then masturbating, then surfing more, then masturbating more, etc. sounds like a paraphelia, not like OCD.

I'd want to develop a detailed understanding of the sequence of events and the client's affective response to the thoughts and fantasies he experiences. Then I'd pull out DSM-IV and make sure I'm remembering the diagnostic criteria correctly. If the sexual thoughts/fantasies that he experiences are consistently aversive and are experienced as intrusive, unwanted thoughts that he cannot get rid of, then this might be OCD, especially if he has a history of more typical obsessions or compulsions or a family history of OCD.

However, from what you've written it sounds as though the sexual thoughts and fantasies are pleasurable at first (until he starts feeling guilty over having "sinful" thoughts) and it sounds as though he sometimes seeks out the sexual thoughts and fantasies rather than always avoiding them. If so, this doesn't sound like OCD, it sounds as though either (1) he has ordinary sexual thoughts and fantasies but feel excessive guilt over them or (2) he has a paraphelia (possibly voyeurism). If the problem is excessive guilt over ordinary behavior or is a paraphelia, then ERP is less likely to be appropriate.

When you have time, fill us in on this (changing any potentially identifying information, of course) and I'll have more comments.
Note: I generally wouldn't have a compulsive gambler stand outside a casino (after all, compulsive gambling isn't OCD). However, I can think of scenarios where it might be a good idea. For example, suppose a client with a compulsive gambling problem lives in a town with casinos and it isn't practical for him to simply avoid passing casinos. Late in treatment when working on relapse-prevention it might be quite useful to use ERP as part of the process of equipping him to resist temptation. However, it would need to be done carefully because of the risk of triggering a relapse.
Reply With Quote
  #3  
Unread July 14th, 2005, 07:27 AM
joel p joel p is offline
Member
 
Join Date: Sep 2004
Posts: 8
Default Re: EX/RP for impulse control

Thanks for the insightful response. I think that part of my confusion here is based on the multiple diagnostic elements. I will briefly supply some more background info. (amply distorted for the sake of confidentiality), hopefully this will advance the dialog.

J. comes from a very strict household, his extremely dominant father has instilled in him an overdeveloped sense of responsibility and fear of authority. J. suffers from many ‘classic’ OCD symptoms – DSM verified - (counting, checking, washing) many of which he has succeeded in controlling in various degrees over the years. He describes what sounds like a hoarding problem (which, ironically, spares him the temptation to search for pornography on the net, since he fears he will not be able to delete these files!) When in therapy, if he has a thought which he has planned to share, he feels compelled to share it otherwise he will be troubled by obsessive thoughts the following week). In addition, we have completed some sessions focusing on his thought-action-fusion tendencies (i.e. if I think of my friend’s wife miscarrying this hastens the probability). ERP was quite successful.

Regarding the specific problem, I tend to agree that the primary component isn’t OCD related (especially since engaging in the act is initially pleasurable for him) but rather impulse-control related, exacerbated by religious – and overall - rigidity. On the other hand, J.’s tendencies to employ OCD mechanisms are quite existent here as well (the attempt to suppress the repetitive and undesirable thoughts to engage in the voyeuristic act). My impression is that J. doesn’t meet the voyeuristic criteria, since when he is able to distance himself from the stimuli (such as by attending an all-male college far from home), he is able to avoid such activities.

The sequence of thoughts/fantasies could be something like this: ‘I am on my way home, there is a TV there, I’m going to end up watching/masturbating, I know that I will not be able to stop myself, It’s wrong I shouldn’t do this, I wish my parents had allowed me to block access to some channels’. Once in front of the TV.: (repeatedly), ‘I shouldn’t be doing this, this is sinful….. as long as I am already sinning it doesn’t matter if I carry on…I hate myself, why don’t I have any self control…’
Part of my difficulty in laying out a therapy plan, is that – as opposed to compulsive gambling for instance – the possibility of having him avoid the stimulus is limited (unless he locks himself up at college… ). Some brief attempts at working on the rigid beliefs were unsuccessful.

My current thoughts are to seek out a religious authority acceptable to J who would sanction frequent masturbation, thus possibly reducing the sexual buildup to a more manageable level hopefully reducing the need to get to this vicious cycle. The obsessive tendencies may kick in doubting the validity of such an authority etc.

As a postscript, any thoughts as to why in the case of addictions, ERP wouldn't reduce anxiety buildup?

Last edited by joel p; July 21st, 2005 at 10:46 PM.
Reply With Quote
  #4  
Unread July 28th, 2005, 09:33 PM
James Pretzer James Pretzer is offline
Forum Leader
 
Join Date: Jun 2004
Posts: 283
Default Re: EX/RP with addictions

You asked "As a postscript, any thoughts as to why in the case of addictions, ERP wouldn't reduce anxiety buildup?"

Actually, exposure and response prevention makes a lot of sense with addictions when the individual has been using substance abuse for short-term relief of anxiety or when cravings are a problem. If it is possible to get the individual to face situations that trigger anxiety and/or cravings and tolerate the anxiety/cravings until they pass rather than using their substance to relieve the anxiety/craving, this can be quite useful. Repeated exposure and response prevention should diminish the anxiety and/or cravings and decrease the likelihood of relapse.

However, this can be tricky. It is not easy for individuals with a substance abuse problem to tolerate intense anxiety or intense cravings without giving in and turning to their substance for relief. Obviously, we don't want to trigger a relapse by putting a recently abstinent client into a situation that they can't handle. Personally, I'd be fairly cautious.

My leaning would be to consider this type of intervention only if the client was fairly stable, had a fairly high level of motivation, and had adequate skills for coping with anxiety and cravings without recourse to substance abuse. I'd want to do initial exposure and response sessions in a controlled environment where substance abuse isn't an option (i.e. therapist's office, treatment program, etc.) and I'd want to make sure that we've set aside enough time so that there's time for the anxiety or craving to peak and come back down to near-baseline levels before the client leaves. (It might not be necessary to be so cautious but I don't have a lot of first-hand experience with this so I'm going to be cautious)
Reply With Quote
  #5  
Unread July 29th, 2005, 08:52 AM
JustBen JustBen is offline
Member
 
Join Date: Jul 2004
Posts: 58
Default Re: EX/RP for impulse control

Quote:
Originally Posted by joel p
My current thoughts are to seek out a religious authority acceptable to J who would sanction frequent masturbation, thus possibly reducing the sexual buildup to a more manageable level hopefully reducing the need to get to this vicious cycle. The obsessive tendencies may kick in doubting the validity of such an authority etc.

If J belongs to a religion which condemns masturbation, and you present a religious authority that condones it, I don't think you could then characterize his doubt concerning this person's validity as an "obsessive tendency". (To put it another way, if I were to refer you for consultation to an "expert" in cognitive therapy, and when you met her she immediately rejected some very basic aspect of cognitive therapy and started talking in Gestalt terms, would it be an "obsessive tendency" for you to doubt the validity of her authority as an expert in CT?)

I only mention it because it seems like this move could lead to a deterioration in the therapuetic alliance due to trust issues. Even if it worked, it could backfire in a big way: Giving a person with obsessive-compulsive tendencies the moral green light to masturbate could be the creation of a new and even more destructive pattern of behavior.
Reply With Quote
  #6  
Unread August 7th, 2005, 12:12 AM
joel p joel p is offline
Member
 
Join Date: Sep 2004
Posts: 8
Default Re: EX/RP for impulse control

Thanks for the comments. You seem to be making two separate points.
Regarding the use of a religious authority, I believe your remark requires a clarification on my part. J harbors religious convictions - perhaps I should say schemas or core believes - which leave room for clergy to render decisions enabling certain behaviors which may generally be prohibited if there is a justification for such. Thus, my thought was that if he was told by such an authority that his attempt to uphold the prohibition of masturbation was greatly undermining his ability to lead a productive life in other areas etc. this could be helpful.

your second comment, if I have properly understood it, touches on a significant and basic point, (which has received some attention on this forum), i.e. will the removal of one outlet not create a defensive void for an even more destructive one to assume it's place, as I believe the psychodynamic approach would question much of the work of symptom (or solution) oriented approaches.
Reply With Quote
  #7  
Unread August 9th, 2005, 09:23 AM
JustBen JustBen is offline
Member
 
Join Date: Jul 2004
Posts: 58
Default Re: EX/RP for impulse control

Thanks for the clarification, Joel. It seems your client has a surprisingly unusual religious belief system. With so much "power" granted to the clergy, I can't help but wonder why he didn't seek pastoral counseling to begin with. (Shame associated with his behavior and thoughts perhaps.)

Concerning your second point, I don't believe in "symptom replacement" -- the idea that helping a client defeat a symptom is useless because another will spring up to take its place as part of the client's psychodynamic defense. In this case, however, the symptom appears to be an "obsessive tendency"; the thoughts concerning women are the object of the tendency. You can help the client deal with the object of the tendency, but it does seem likely that another object will replace it.

The idea that masturbation will provide a "release" is very common, but considering this statement - "he is unable to stop a cycle of zipping through channels until finding one suitably provocative, masturbating and then continuing the search - all of which can go on for hours, at the expense of day to day responsibilities (such as academic requirements)" - it seems to me very likely that masturbation could be the new object of the tendency, and that it could cause even more profound problems than the ones he currently faces.

Please keep us informed on how things progress, if it seems appropriate.
Reply With Quote
Reply

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Forum Jump


All times are GMT -4. The time now is 07:40 AM.


Powered by vBulletin® Version 3.7.3
Copyright ©2000 - 2019, Jelsoft Enterprises Ltd.
Copyright © 1995-2004 Behavior OnLine, Inc. All rights reserved.