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(p. 44) (p. 45) Session 4: Cognitive Restructuring/Blame Reduction 

(p. 44) (p. 45) Session 4: Cognitive Restructuring/Blame Reduction
(p. 44) (p. 45) Session 4: Cognitive Restructuring/Blame Reduction

John Piacentini

, Audra Langley

, and Tami Roblek

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Subscriber: null; date: 23 October 2019

Child Only

Session Outline

  • Review homework and events of the past week

  • Obtain global improvement ratings for the past week

  • Review cognitive coping strategies

  • Continue ERP according to the symptom hierarchy

  • Prepare for the family session

  • Develop and assign the homework exercises for the coming week

(p. 46) Review

At the beginning of this session, review the events of the past week, including:

  • Any significant environmental events

  • OCD symptoms and impact on functioning at home, and during academic and social activities

Have the child describe one positive occurrence since the last session.

Homework Review

Reward any compliance with homework.

Reframe noncompliance to reduce negative feelings in the patient, solve problems with compliance difficulties, and encourage the patient to comply with homework during the coming week.

Complete Patient, Parent, and Clinician Global Improvement Ratings

The patient, parents, and therapist will complete the Child/Adolescent Global Improvement Rating, the Parent Global Improvement Rating, and the Clinician Global Improvement Rating scales respectively. These scales allow the therapist to monitor systematically the course of treatment from multiple perspectives and can be found in the appendix.

Cognitive Coping Strategies (Including Cognitive Restructuring)

Cognitive restructuring is used throughout treatment to help patients “distance” themselves from their OCD symptoms to enhance motivation and manage extreme anxiety during exposures and response prevention. Along these lines, children are taught to recognize and relabel their obsessive thoughts, urges, and feelings in a more realistic fashion. (p. 47)

The following are examples of techniques to help the child relabel his or her obsessive thoughts:

  • Encourage the child to estimate the probability that his or her feared outcome will occur. For example, a child who is afraid of touching door handles for fear of catching an illness can be encouraged to restructure his or her thoughts more reasonably in the following way:

    • “What are the chances/probability that if you touch the door handle, you will get sick?”

    • “How many other people have touched the door handle and have not gotten sick?”

    • “Has everyone who has touched the door handle become sick?”

    • “I touch the door handle every day and I’m not sick.”

  • Encourage the child to reframe the symptom in terms of OCD. For example:

    • “Nothing bad will happen if I don’t check that lock. It’s just my OCD talking.”

  • Encourage the child to “beat” or “fight” the OCD by reframing the obsessive thought. For example:

    • “That’s just my OCD talking and, if I check the lock, my OCD will become more powerful and will win.”

It is very important to help the child feel more in control of and stronger than his or her OCD, because this will give the child motivation and reinforcement to engage in exposures and cognitive restructuring. Depending on the age of the child, it is often helpful to encourage the child to make up funny names to call his or her OCD. For younger children it can also be useful to have the child draw a picture of what his or her OCD looks like when it is in control of the child, and also what it looks like when the child is in control of it. The child can then stomp on the picture of OCD in control, crumple it up, scribble on it, throw it in the trash can, or engage in any other behaviors that may serve to enhance a sense of mastery over the OCD symptoms. Another way to encourage feelings of control in the child is to ask him or her to visualize negative images of the OCD and then to picture the OCD as being shrunken or destroyed by himself or herself, or by some other means. This exercise (p. 48) can also be enhanced by having the child envision himself or herself as having superpowers that can be used in the fight against OCD.

Exposure Plus Response Prevention

Choose the next hierarchy item from the patient’s completed My Symptom List and have the patient perform ERP as described in the previous session. As noted, the more realistic the exposure, the more effective in producing the desired result. Encourage contact with the feared stimuli during the entire exposure period, incorporating the cognitive coping and encouragement strategies reviewed earlier during the session.

Although the therapist should refrain from providing reassurance to the child (e.g., “There aren’t any germs on the doorknob, so don’t worry; you won’t get sick”), the child should be encouraged to use his or her coping thoughts to challenge the targeted obsession.

Case Vignette

In the following dialogue, T represents the therapist and P represents the patient.

T: You’re doing great. Do you remember what we just talked about in terms of people getting sick from touching doorknobs?

P: Yes, we talked about how kids probably touch the doorknob at school a thousand times every day and I’ve never heard of anyone getting sick from it.

T: So what does that tell you about the fear you are feeling?

P: That it’s just my OCD talking and if I want to get better, I need to resist giving in.

T: That’s exactly right and you’re doing an excellent job. I’m really proud of you.

The therapist should continue to assess anxiety ratings every 30 seconds at the start, then less frequently as the exposure proceeds, and should (p. 49) graph the child’s anxiety ratings on the EPR Practice Form. Note when the anxiety ratings begin to decrease and use this decrease to tell the child that treatment is working just like you discussed at the beginning of therapy (and as illustrated in Figure 1.3 and discussed during session 1). Continue each exposure trial until the patient’s OCD thermometer rating returns to the baseline level or decreases to at least 50% of baseline, shaping the exposure and using therapist modeling and cognitive restructuring as needed. Depending on the speed with which the child’s anxiety habituates to the initial exposure target, additional exposure trials to symptoms farther up the hierarchy may be conducted. However, it is important to allow enough time at the end of the session for the child’s anxiety to return to the baseline level and to plan the weekly homework assignment. As the exposure target becomes easier to tolerate, the therapist can increase the difficulty level by gradually adding new elements.

Prepare for the Family Session

The patient and therapist need to negotiate the exact degree of disclosure regarding OCD symptoms and ERP activities that the child will make during the family meeting immediately after the individual session.


  • Instruct the child/adolescent to practice at home the exposure (or exposures) conducted during session. Note: Be sure to specify the frequency of exposures during the week and remind the child to continue the exposures until the OCD thermometer ratings decrease by at least 50%

  • Have the child/adolescent self-monitor home-based ERP using the OCD thermometer

  • Have the child/adolescent graph his or her anxiety ratings for each exposure and bring the graphs to the next session for review and discussion

(p. 50) Family Session: Continued Psychoeducation/Blame Reduction

Session Outline

  • Continue psychoeducation about OCD to further minimize the family’s feelings of blame, guilt, and anger

  • Review the child’s session and reward the child’s efforts and progress

  • Review the child’s ERP homework and agree on the reward for compliance

  • Negotiate continuing disengagement from the child’s OCD symptoms


At the beginning of this session, review the events of the past week, including any significant events, OCD severity, and impact on individual and family functioning.

Have family members describe one positive occurrence since the last session.

Continue Psychoeducation

Note: Depending on the age and maturity level of the child, as well as the quality of the family relationships, the patient may not be included at all or only for certain portions of this discussion.

Use psychoeducation and cognitive restructuring to continue challenging parental and sibling feelings of blame, guilt, or anger about the child’s illness. Review the OCD analogies (e.g., caveman, fire alarm) presented during earlier sessions and provide additional information regarding the etiology of OCD, including explanations of learning and genetics theories, which are discussed in the following sections.

(p. 51) Avoidance and Reinforcement

When OCD makes someone feel anxious, he or she may begin to avoid certain situations or objects (e.g., schoolwork, bathrooms, cracks in the sidewalk). Thus, the child is not able to experience the situation or object as innocuous and his or her anxiety increases, along with his or her tendency for future avoidance.

Negative Reinforcement

When a child is seeking excessive reassurance, for example, and the parent appropriately refuses to provide it, the child’s behavior may escalate (e.g., tantrum, yelling, increased and repeated demand for reassurance). If the parent then gives in and provides reassurance, then both the parent and the child are reinforced for their behavior. That is, the parents are rewarded by their child’s decreased negative behavior and the child gets what he or she wants. Behaviors that are reinforced in this way will occur more often in the future. That is, the child will continue to engage in escalating outbursts to get the reassurance he or she wants, or that the OCD says he or she needs, and the parents will comply to appease the child. In this sense, the lack of disengagement is actually promoting continuance of the child’s symptomatology. This is why disengagement is such an important part of the family component of OCD treatment.


Explore the presence of OCD or OCD symptoms in other family members and relate it to genetic and learning theories. Explain that OCD often runs in families and appears to be an interaction of genes and environment, and is not just a “behavior problem.” Describe the role of environmental factors, especially stress, in triggering and exacerbating symptoms. Reiterate that, although family factors can exacerbate OCD, parents do not cause OCD, and that OCD is not simply a learned behavior and is not the child’s fault.

(p. 52) Review the Child’s ERP Session (Including Cognitive Intervention) and Reward Efforts

As during the previous session, the child is to describe and, if possible, demonstrate his or her successes during the individual session. The family should acknowledge these efforts. The child should also describe (with assistance from the therapist, if necessary) the cognitive restructuring and coping strategies learned during the individual session. These techniques are to be adopted and used by all family members to assist the child in fighting his or her symptoms.

Negotiate Family Disengagement From the Child’s OCD Behaviors

Review the disengagement efforts made during the previous week and solve any difficulties. Ongoing family disengagement efforts, in most cases, are closely integrated with the child’s individual ERP. When a symptom is addressed during individual treatment or assigned as homework, it is presented during the family session and family disengagement is negotiated. Only symptoms that affect other family members (e.g., reassurance seeking or requests for assistance with grooming, dressing, schoolwork) are addressed in this fashion. When a request is made, family members are to continue encouraging the child to relabel and reattribute the behavior. Some examples include the following:

  • “That sounds like your OCD talking.”

  • “Do you really believe that something bad is going to happen if you don’t do that right now?”

  • “What are the chances that your OCD is making you feel this way right now?”

  • “Remember, [child’s name for OCD] might get bigger (or more powerful or will win) if you do that right now.”

If the child persists, the family member is to avoid engaging in a power struggle with the child and calmly refuse the request, referring back to the arrangements agreed upon during the treatment session. It is extremely important that all family prompts and disengagement efforts be done in a calm and emotionally neutral, yet supportive, fashion.

(p. 53) Review Homework and Reward System for the Coming Week

The child is to describe the homework assignment for the coming week. The child, therapist, and family should negotiate family involvement in homework and the rewards for compliance.

Family Homework

  • Each family member should use cognitive strategies such as relabeling and reframing with the child at least once during the coming week and should encourage the child to do the same. Examples include:

    • Relabeling: “That sounds like your OCD talking.”

    • Reframing: “Do you really believe that something bad might happen if you don’t do that?” “If we do that right now it might help [child’s name for OCD] get more powerful.”