Adult Psychological Assessment Cases

Case 3

Case Summary

The client was a 40 year old woman, educated up to B.A. and belonged to lower middle socio economic status. The client was referred to the trainee clinical psychologist for the assessment and management of her symptoms. Her primary complaints included repetitive, intrusive thoughts and associated repetitive behaviors, anxiety due to thoughts and disturbance in personal and social life. She was informally assessed by a clinical and diagnostic interview, mental status examination, subjective ratings and baseline for obsessions and compulsions and Y-BOCS. Based on the history and assessment she was diagnosed with Obsessive Compulsive Disorder. Her management plan was devised on the basis of Cognitive Behavior therapy encompassing techniques such as socialization, questioning evidence and mechanism, survey method, cost-benefit analysis, exposure and response prevention and concentration exercises. The techniques and willingness of the client helped in eliminating the client’s symptoms to a considerable degree.

Bio Data

Name: K.S.

Age: 40 years

Gender: Female

Education: B.A.

No. of Siblings: 4 (2 sisters, 1 brother)

Birth order: Third born

Marital Status: Married

No. of Children: 4

Religion: Islam

Informant: Husband, Client Herself

Reason and Source of Referral

The client came to the Centre for Clinical Psychology with the complaints of repetitive and intrusive thoughts of being dirty resulting in excessive hand washing, clothes, cleaning house floor and washrooms. The symptoms also included distress due to her cleanliness behaviors, frustration, low mood, decreased social interaction and disturbance in her personal and social life. She came to the Centre upon the recommendation of her husband’s friend. She was referred to a trainee clinical psychologist for the assessment and management of her symptoms.

Presenting Complaints

Table 1: Complaints of Patient as reported by herself

Duration	Complaints
From 1-3 years	I wash my hands a lot. I am not satisfied even after washing, so I wash again
From 2 years	I wash clothes all day so everyone is clean
From 2 years	It always seems that i am impure
From 2 years	The ground looks dirty so I wash it again and again
From 2 years	I often have a feeling of urination and I change my clothes 3 to 4 times a day
From 2 years	Don’t watch tv. Looks like pajama will be dirty after that
From 2 years	I keep scolding the children to take care of cleanliness
From 1 year	I’m worried about what happened to me. Everyone is upset because of me.
From 1 year	I have reduced meeting with people because I don’t think they care about cleanliness
From 1 year	Looks like I won’t be fine. There is no solution to my problems
From 1 year	Laughter does not make the heart. I live in myself all the time. The mood is extinguished
From 1 year	The house is not functioning properly. There is no courage. There is pain in the muscles of the body all the time

History of Present Illness

The client’s problems started to emerge after a disturbing event occurred in her life in 2014. The client and her family lived in an underdeveloped area where most of the houses were congested and close. Her own house was not built properly so she and her husband agreed to renovate the house. Her husband called upon 3 laborers who were allowed to do plumbing and improve the sanitary lines of the house. The client used to remain home while her husband went to work and all her children would go to school. During the time of renovation, she started noticing the activities of the laborers. The laborers would usually make the house floor dirty with cement, dirt and garbage. The client reported that they would also urinate in the same area as there wasn’t another washroom in the house. They ate with the same hands and in the same place. The dirt did not disturb the client as much as the uncleanliness (Na’paaki) caused by those laborers. She started commanding the laborers to keep the area tidy and do their work with cleanliness. The laborers usually did not comply with the client’s commands so the client herself started to clean the area every day after the laborers left. The client’s husband told her not to clean it as the house would get dirty again the next day, but she felt uneasy so went forward with her own decision. It was then that the client started forming linkages between what was dirty and what became dirty after contact.

From then on, I started noticing what was touching. I used to see that if a child went to a dirty place and then brought his feet on the clean floor, he would tell him to wash his feet. Then if someone came from there and sat on the sofa, she would clean the sofa

The laborers completed their work in approximately 2 weeks after which the client had to clean the house entirely on her own. She found feces in some places which made her extremely angry and upset. She still cleaned the house as properly as she could. It was after then that the client’s symptoms started to emerge. She never got satisfied with the hygiene conditions of the house. She washed the house floor numerously with multiple detergents and also started to make rules for her children to enter the house. She kept an extra pair of shoes outside the house for herself and bought soaps of different companies to keep in the lavatory.

Within a year (2015), the client’s problem exacerbated greatly. She washed her hands innumerably throughout the day and always remained doubtful if she had washed them. She asked children to keep themselves tidy and not to sit on the sofas or chairs if they had not changed their clothes. She made a separate place for her religious activities (Namaz and Quran).

In late 2015, the client’s daughter started menstruating which further increased the client’s symptoms. She would repeatedly tell her daughter to take bath, change clothes, not to sit on something higher rather on the floor and to keep herself away from others. She separated her daughter’s towels, cupboards during her menstruation days. She also washed her daughter’s clothes separately so that the other clothes may not get “Na-paak”. This made her relationship with her daughter distant and the client started to become angry and irritable more often. She noticed every move of her daughter and linked each move with the previous one. This made her think that where ever her daughter sat was then ‘Na-paak’ and she had to wash the place and clothes. Her frequency of washing clothes increased greatly. She started buying large packets of surf and detergents and washed clothes every day for up to 5-6 hours. She would herself change clothes repeatedly which increased up to 6-7 dresses a day in the following year.

In 2016, the client’s husband noticed changes in her behavior and attitude and saw that the client was becoming asocial. She stopped visiting her sister or her mother and did not leave the house except for something that was very important. She kept an ‘abaya’ which she wore whenever she went outside and changed it as soon as she came back to the house. The client started to remain indoors, did not dress up or get ready besides her husband’s wishes and tried to remain isolated from others. She spent most of her time washing clothes or dishes and keeping the house neat and tidy. The strenuous activity made the client tired after the whole day and she would experience frequent body aches. She started to remain distressed about her health as she realized that she was pushing herself beyond the limit but could not control herself. She considered her husband strict so did not share her problems with him as well. She tried to perform all her duties but her health would occasionally put her down. She also felt helpless about her condition stating,

‘One of my sisters has cancer. When I see him taking medicine, I am jealous that he has the solution to his problems but I don’t have it.

The client’s husband became concerned about her health and sought advice from his colleagues at work. They recommended a psychiatrist and a psychologist but the client was reluctant to visit any doctor as she thought that there was no cure for it. After insistence of her husband, she decided to visit a psychiatrist in a nearby hospital who told her to see a psychologist. She then came to the Centre for Clinical Psychology with the complaints of repetitive and intrusive thoughts of being dirty resulting in excessive hand washing, clothes, cleaning house floor and washrooms. The symptoms also included distress due to her cleanliness behaviors, frustration, low mood, decreased social interaction and disturbance in her personal and social life.

Background History

Family History

Father. The client’s father died at the age of 63 years due to stroke. He was diagnosed with hypertension, diabetes and risk of cardiovascular diseases. He took his medicines regularly but still suffered from a fatal heart attack. He did not have any psychological problems. He was an extremely strict person, remained angry most of the time, was short-tempered, had few social interactions and remained to himself according to the client’s account. The client’s relationship with her father was distant as she never felt comfortable talking to him. Her father did not interact with any of his children from their childhood and used to remain busy in his work. He rarely expressed his love or care for the children. The client reported that she spent most of the childhood remaining scared from her father. Besides the uncongenial relationship, the client still felt sad on her father’s sudden death and occasionally missed and prayed for him.

Mother. The client’s mother was 68 years old suffering from a cataract and heart problems. She took anxiolytics to help her sleep but did not have any significant psychological issues. According to the client, her mother was also strict and had perfectionistic tendencies. The client had some attachment with her mother but still did not feel emotionally linked to her. Her childhood was also filled with her mother’s orders and restriction regarding leaving the house, meeting people, keeping oneself clean and religious obligations. Although the client learned a lot but she did not share her issues with her mother. She used to visit her mother once a week but since the client’s symptoms started appearing she distanced herself from everyone including her mother.

First born sister. The client’s sister was in her forties, was educated up to F.A. and was a housewife. She was married to her cousin and had a contented life. She had no physical or psychological ailment. She remained concerned about her mother’s health but was mostly involved with her family matters. Her relationship with her sister was satisfactory. Both of them used to visit each other occasionally before the client’s symptoms started to emerge. The relationship got distant after the client’s issues but they still talked through phone calls. They took care of each other since childhood and so the client felt more attached to her sister than to her mother.

Second born brother. The client’s brother was 43 years old, educated up to Masters and was a private shop owner in his residential area. He suffered from hypertension. He used to smoke sometimes. The client’s relationship with her brother was distant as he adopted the same attitude exhibited by his father. He was strict in attitude and had conservative opinions about women due to which the client did not feel comfortable while conversing with her brother. She still maintained healthy relationship with his wife by calling her and keeping in touch with their issues. She mentioned that her brother was present for her in the time of need.

Third born was the client herself.

Fourth born sister. The client’s younger sister was in her thirties, was married and a housewife. She had three children and was satisfied at home. She was suffering from breast cancer but was getting her treatment done through surgery and chemotherapy. According to the client, she was a cheerful person who sometimes remained concerned about her health and children but still was social and maintained satisfactory relationships with others. The client also enjoyed being with her but they met less as she resided out of the city. They had pleasant interactions whenever they met and also remained concerned about each other’s health.
General Home Atmosphere (before marriage). The client had an extremely strict atmosphere at home. Her father was the bread winner and dominating figure at that time. She belonged to a lower middle socio economic family. The children weren’t allowed to do what they wanted where girls usually helped their mother while boys sat with their father. The client’s mother also kept a stringent attitude with all her daughters making family bonding weak. The client usually remained quiet whenever she was at home and also restricted herself from talking with the family much. All the members of the family were religious and all religious activities were carried out with discipline and respect.
Personal History
Birth and Childhood History. The client was born through normal delivery by a mid-wife at home. She had average weight at the time of birth and color was pink. There were no problems during pregnancy while the client was conceived. She achieved her developmental milestones at appropriate time. She was a quiet child but played frequently with her sisters. She received love and affection from her parents which gradually reduced when she entered adolescence due to the mindset of her parents. No neurotic traits were reported in the client’s childhood.
Educational History. The client started her education at the age of seven years. She was an above average student who liked going to school. She reported that she was punctual, social and obedient. She had satisfactory relationship with her teachers. She liked Urdu and Mathematics. Throughout her early education she remained a bright student. She passed her matriculation and intermediate with average marks as she had to do the house chores as well. Moreover, her father kept on pressurizing her to quit school and stay at home. Besides the pressure she insisted on going to university and so completed her B.A. in harsh home environment. She claimed that she missed her college and university life as she had made a lot of friends and felt independent when she was out of the house.
Pubertal History. The client achieved puberty at the age of 13 years. She was well-informed about the phenomenon by her mother before it occurred. She coped well with the changes and learned to handle it quickly. She told that her mother was specific in keeping body and house clean. The client and her sisters were extra cautious in handling their sanitary things. They had to be vigilant while going in front of the male members of the house and keeping it strictly confidential. The client handled the situation with ease and perfection besides the extensive pressure. She did not feel difficulty in maintaining cleanliness at that time.
Marital History. The client had been married since 18 years. She had an arrange marriage. Her husband was a 48 years old man who had done B. Ed. and was working as a clerk in a university. The initial years were difficult for the client as she tried to adjust with a person she barely knew. The couple had mutual understanding but the client had complaints from her husband for not giving enough time. Moreover, they also had financial issues as her husband was reluctant in giving money for house expenses. She informed that her husband had a dominant personality and so she remained submissive most of the time. Both of them still maintained a healthy bond having care, love and affection between them. Her husband remained concerned about the client’s health since the last one year. Since the symptoms emerged, the client also observed a change in his husband’s attitude and appreciated his concern. Both of them mutually decided their children’s future but her husband still had the veto power. The client’s husband sometimes showed frustration regarding her symptoms but on other times proved to be supportive as well.
The client had 4 children, 2 sons and 2 daughters. The eldest child was her son who was 17 years old and was studying in first year. The next two were her daughters. Her elder daughter was doing matriculation while the younger daughter was in 8^th class. The youngest child was her son who was still in primary class. The client remained pre-occupied in upbringing her children and fulfilling all her responsibilities. She cooked, cleaned and washed for them and also performed the duty of walking them to school. Since the symptoms emerged, the client’s remained angry most of the time. She scolded them and tried to discipline them to the maximum. Her daughters grew distant from her due to her constant correction and taunts. She still helped them in their studies and remained concerned about them. One of the primary complaints of the client from her children was that they did not maintain cleanliness in the house.
Sexual History. There were no reports of any homosexual or heterosexual experience of the client before marriage. She had a satisfactory sexual life with her husband. There was mutual consent in almost all interactions. The client reported that the interactions had lessened now as she tried to avoid them as she thought that the act will make her dirty. She remained worried constantly that her clothes will get dirty due to arousal. This made her avoid watching the television or sitting close to her husband. The fears made her distant from her husband and she started to remain indulged in religious practices. Even upon the insistence of her husband, she did not get ready or dress up for her husband rather tried to remain physically away from him.
Pre-morbid Personality. Even though the client had calm and quiet personality before her symptoms emerged, she was still a social and content person. She used to meet with her relatives frequently, arranging meet-ups at her mother’s house and sitting in gatherings. She responded to stress calmly and with maturity. She had high religious inclination and maintained her social relationships. Her self-esteem and confidence was low.

Psychological Assessment
The assessment was carried out on an informal basis upon the following lines:
Clinical Interview
Mental Status Examination
Visual Analogue
Baseline for obsessions and compulsions
Clinical Interview
Initially, the client was briefed about confidentiality and therapeutic process. Consent form was signed by the client, which was followed by a detailed clinical interview with the client and her husband. All information was corroborated amongst the informants. The clinical interview comprised of information regarding the client’s familial life, personal history, pre-morbid personality etc. The interview process also included the elicitation of symptoms, their frequency, duration, intensity, maintaining and perpetuating factors. The information was used to device case formulation and management plan for the client.
Mental Status Examination
The client was an average heighted bulky woman wearing a black ‘abaya’. She had neatly done nails and her hygiene was properly maintained. She had her head and face covered but removed the veil in the session room. She sat on the chair while leaning back but her posture was hunched. She gazed towards the floor while talking and kept rubbing her hands. She refrained from touching the table corners or arms of the chair. Her tone and rate of speech was comprehendible. She appeared to have low mood and affect with irritability evident from her frowning. She reported to have frequent obsessions and compulsions. Her long-term memory was intact but she was unable to recall some short term events such as what she ate yesterday or which color clothes did she wear on the day before. She had adequate judgment and abstract thinking. Her insight regarding her problems was present.

Visual Analogue
The client was asked to rate her symptoms on a scale of 0-10 with 0 being the least problematic and 10 being the most. The scale helped in indicating which symptoms were to be prioritized and dealt first. The treatment of most intrusive symptoms also help in subsiding the lower problematic symptoms hence the rating was beneficial with respect to the treatment plan.
Table 2: Symptoms and subjective ratings of the client
Symptoms Rating (0-10)
Thoughts of uncleanliness ‘Na-paaki’ regarding clothes, house floor, sofas etc. 10
Distress due to repeated washing of hands, clothes, household items, floor etc. 10
Inability to control or suppress thoughts 10
Dissatisfaction after using the washroom, washing hands or clothes 9
Anger, frustration, irritability 9
Social withdrawal 8
Hopelessness and worry about the treatment of problems. 8
Inability to handle house chores effectively 7
Baseline for Obsessions and Compulsions
A baseline was given to the client to gain detailed information about her symptoms. The baseline incorporated minute details about the client’s obsessions such as the content of thoughts and the meaning client associated to those thoughts. Moreover the baseline also constituted information about the compulsions of the client which she did to satisfy her thoughts and the time taken in performing those compulsions. The chart also encompassed information about client’s emotional reactions and their intensities.
Table 3: Quantitative Analysis of baseline
Frequency of obsessions 25-30 times per day
Intensity of the drive to perform compulsion 9 on average
Intensity of emotions 8 on average
Duration of obsession Variable (Ranges from 1 minute to an hour)
Frequency of compulsion 5-6 times per day
Duration of compulsion Variable depending upon the compulsion (5-10 minutes in washing body parts, 30-40 minutes in bathing and 2-3 hours in washing clothes)

Table 4: Qualitative Analysis of baseline
Antecedent/ Triggering Event Children playing around the house
Going outside the house
Children not changing their slippers before entering the house
Going to the washroom
Visiting someone else’s place
Watching the steps and movements of others
Daughter sitting on a sofa during her menstrual cycle
Watching television
Content of obsession He had dirt on his slippers and he did not change it
My Shalwar is dirty
I did not wash my hands properly
The clothes touched the wall, now they are dirty
The floor is dirty
Others don’t keep their house clean
Interpretation of thought The place is Na’paak. I should clean it. If I won’t my prayers will be wasted. God will not accept them.
Emotions/ Affective response Agitation, Anger, Frustration, Irritability
Compulsion/Behavior Repeatedly washing hands, clothes, house floor, washroom
Making daughters wash their clothes in front of her
Keeping a constant check on the cleanliness of the house
Washing hands with two types of detergents
Refraining from leaving the house or visiting anyone else
Repeatedly washing body parts
Seeking reassurance from daughters and husband.
Formal Assessment

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
The scale was a 10 item measure assessing he frequency of obsessions and compulsions, distress felt due to them, resisting them and control over them. Its options consisted of 0 to 4 where 0 indicated absence while 4 indicated extreme severity of the symptom. The client attempted the scale in 20 minutes.
Quantitative Analysis
Table 5: Score and level of severity of patient on items of Y-BOCS
Item Rating Level of severity
Time occupied by obsessive thoughts 3 Severe
Interference due to obsessive thoughts 3 Severe
Distress associated with obsessive thoughts 3 Severe
Resistance against obsessions 1 Mild
Degree of control over obsessive thoughts 3 Severe
Time spent performing compulsive behavior 3 Severe
Interference due to compulsive behavior 3 Severe
Distress associated with compulsive behavior 3 Severe
Resistance against compulsions 2 Moderate
Degree of control over compulsive thoughts 3 Severe

Table 6: Overall score of patient on Y-BOCS
Obsession sub-total Compulsion sub-total Raw score Significance
13 14 27 Severe
Qualitative Analysis
The client’s total score was 27 which fell in the category ‘severe’ indicating that her symptoms were intense and were causing disturbance in her life. She reported extreme severity in feeling distressful about her symptoms and lacking control over her obsessions. Moreover, her scores also show that she felt very little control over her compulsions and also felt extreme distress about them.
Summary of Formal and Informal Assessment
The informal assessment of the client shows the presence of frequent obsessions and the performance of compulsion in response to them. The visual analogue shows that all of the client’s symptoms were highly problematic but obsessions and compulsions were the most intrusive. The frequency, intensity and duration of the compulsions also showed disturbance in her personal and domestic life.
Diagnosis
300.3 (F42): Obsessive-Compulsive Disorder

Points in favor according to DSM-5
The DSM-5 diagnosis of Obsessive Compulsive Disorder requires the presence of at least one of two symptoms; obsessions or compulsions. The client presents with both of them severe enough to warrant clinical attention. Obsessions were identified as being intrusive for the client which made the client feel distressful and so she tried harder to suppress the thought. The compulsions were identified as the repetitive behaviors the client did in order to relieve the anxiety provoked by obsessions. Moreover, the client spent majority of her day satisfying her obsessions thus interfering with her normal daily functioning.
Differential Diagnosis
Major Depressive Disorder: The client did not present with rumination about the past nor were her primary symptoms related to his affect. The low mood and irritability she presented with was due to the irritation and disturbance cause by her primary symptoms i.e. obsessions and compulsions. Moreover, people with MDD do not usually have compulsions so the presence of compulsions in the client points towards the diagnosis of OCD.
Obsessive Compulsive Personality Disorder: The diagnosis of OCPD requires a consistent pattern of orderliness, inflexibility, perfectionism and efficiency since the early adulthood but the client started to experience the symptoms in her late adulthood and after the incident of renovation occurred at her house. The pre-morbid personality of the client does not show any signs or symptoms such as these. Hence, the client was diagnosed with Obsessive Compulsive Disorder.
Idiosyncratic Case Conceptualization
Case Formulation
The client was diagnosed with Obsessive-Compulsive Disorder due to the presentation of her symptoms of repetitive, intrusive thoughts and consequently performing repetitive behaviors to relieve the anxiety cause by those thoughts. Salkoviski et. al (2001) proposed that all human beings have thoughts but when the thought become repetitive and anxiety provoking the become problematic for the person. The individual tends to blame himself for those thoughts or deliberately suppress them. The constant tug-of-war between the thought and its suppression induces negative emotions in the individual causing him to perform behaviors that tend to neutralize that anxiety. These behaviors may be mental acts or overt behavioral responses. The client also presented with the same symptoms that she had repetitive thoughts about uncleanliness. Instead of passing the thought she focused on it and was then compelled to perform the neutralizing behaviors.

Timpano et. al, (2010) studied the relationship between Obsessive-Compulsive (OC) symptoms and types of parenting. They found that OC symptoms were significantly correlated with an authoritarian parenting style. Strict parenting leads to the formation of OC beliefs that have a high ratio of personal responsibility in it and emphasizes greatly on the importance of thought. When these beliefs are triggered they cause OC symptoms. The OC beliefs thus act as mediators between parenting style and OC symptoms. The present client also had strict parents, stringent childhood and conservative upbringing. This formed OC beliefs in her that everything that comes in her mind is because of her and every bad thought is a sin. As her family was religious as well, the concept of sin and punishment was embedded in her belief system making her more prone towards developing OC symptoms.
Rachman (1997) proposed that OCD symptoms usually develop due to the meaning associated with their thought rather than the thoughts alone. This means that the individual has the power to interpret his/her thoughts constructively or in a negative manner. The people who attach negative connotations with the thought content get stuck in a cycle of thinking, interpreting, suppressing and neutralizing. This cycle then forms an OCD cycle which has both obsessions and compulsions driving it. The client was also stuck in the same process where the thought of dirtiness meant that the place was ‘Na-paak’ and it was a sin not to keep cleanliness in the house. The extreme meaning attached to the thoughts then resulted in distress and further, compulsions.
It has been studied that patients with Obsessive-Compulsive Disorder usually have an attentional bias and they are hyper vigilant towards the cues. The cues that were commonly found were repeated checking for contamination and washing. Scholars found that OCD patients responded more quickly and specifically to OCD relevant cues e.g. a dirty toilet, broken door etc. (Moritz, Muhlenen, Randjbar & Fricke, 2009; Tata, Liebowitz, Prunty, Cameron &Pickering, 1996). The present client also presented with an attentional bias where she mostly focused on the cleanliness of the house and would notice everyone’s behavior precisely. She would form linkages in every individual’s behavior by focusing on what the person touched first and later. The hyper vigilance and faulty interpretation caused her to react with distress towards her intrusive thoughts.
Management Plan
Short-Term Goals
Short-Term Objectives Therapeutically Applied Techniques
To develop a sound therapeutic alliance with the client Active listening, Unconditional positive regard, Reflecting on client’s words, empathy
To provide the client with information regarding her diagnosis and treatment Psycho-education
Normalization
To make the client aware with her symptoms and their formation Socialization with the CBT model, Suppression Experiments, Worry postponement experiments
To deal with intrusive thoughts i.e. obsessions Detached mindfulness
Questioning the evidence and counter evidence
Questioning the mechanism
Cost-benefit analysis
To deal with behavioral responses i.e. compulsions Exposure and response prevention
Mini-survey about normal/distressing thoughts
Disconfirmatory maneuvers
Improving the quality of life and restoring pre-morbid level of functioning Activity scheduling
To relieve fatigue and body aches Progressive muscle relaxation
Increasing client’s concentration and decreasing doubts regarding the execution of her actions Concentration exercise combined with detached mindfulness, doubt reduction techniques
Relapse prevention Therapy Blueprint
Long Term Goals
Follow up sessions to increase therapeutic compliance and to assess the presence of symptom substitution.
Continuation of short-term goals
Increase in social activities and improvement in quality of relationships
Session Reports/ Management Plan
Session No.1 Time of session: 45 minutes
Session Agenda
Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings
Techniques
Therapeutic Alliance
Rationale: To develop a trustworthy and sound relationship between the client and the therapist. Procedure: Therapeutic alliance was developed active listening by giving the client ample time to express herself and her problems. Unconditional positive regard was practiced by being non-judgmental about the client’s views, underlying issues and intents. Empathy was provided by projecting an understanding view of the therapist and that the client’s problems were being recognized. Outcome: This encouraged the client to open up. . It helped to effectively engage the client in therapy.
History taking
Rationale: To obtain a comprehensive account of the development of client’s problems, its predisposing, maintaining and precipitating factors. Procedure: Informed consent was obtained from the client. Information about the client’s symptoms, their intensity and presenting situations were elicited. Moreover, client’s support system, social functioning, familial life and personal views were also obtained in the history Outcome: The client elaborately discussed all her life domains and cooperated with the client in giving every piece of information.
Mental Status Examination
Rationale: To assess the client’s current level of functioning and physical appearance. Procedure: The therapist observed several of the areas herself such as grooming, eye contact, posture, gait, speech etc. While some questions were directly asked from the client i.e. questions about cognitive functioning, mood, insight etc. Outcome: Obsessions and compulsions were the most significant information obtained from the examination.
Symptoms Elicitation and Subjective Rating
Rationale: To understand the client’s problems, elicit disorder specific symptoms and obtain a subjective rating of each symptom. Procedure: The client was asked to tell about the symptoms she experienced while the therapist tracked down the relevant and specific details. Moreover, the client rated her symptoms on a scale of 0-10. Outcome: The procedure helped in identifying the specific severity of each symptoms and helped in prioritizing them for treatment.
Homework given: Dysfunctional thought record and chart for obsessions and compulsions
Session No.2 Time of session: 45 minutes
Session Agenda
History taking (continued), Validation of history from husband, differential diagnoses, formal assessment (Y-BOCS)
Review of previous session: The client herself came up with information which she forgot to tell in the previous session.
Homework review: She did not fill the DTR or compulsions chart
Techniques
History taking (continued)
Rationale: To fill in the gaps in the history and obtain more information about past life. Procedure: Elaboration was requested from the client on few matters regarding her symptoms, symptom substitution and relationships. Outcome: More information was gained that helped in understanding the client’s disorder and the maintaining and precipitating factors.
Validation of history from husband
Rationale: To cross-check the client’s account with her husband’s verbatim. Procedure: The therapist separately interviewed the client’s husband with the consent of the client and inquired about the problems. a joint interview was also held afterwards which helped in synchronizing the complaints. Outcome: There were slight differences in the client’s verdict and husband’s verdict which were resolved in the joint session.
Differential Diagnoses (American Psychological Association, 2013)
Rationale: To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure. She was asked to clarify some of the symptoms, while symptoms from other disorders were ruled out. Specific symptoms of OCD were elicited more. Outcome: The differentials helped in confirming the diagnosis of OCD and ruling out GAD or Depression.
Formal assessment
Rationale: To corroborate informal assessment with standardized and developed questionnaires. Procedure: Y-BOCS was administered collaboratively by the client and therapist. The statements not understood by the client were clarified. It took the client 30 minutes to complete the test. Outcome: The instrument helped in obtaining a qualitative analysis of the client’s symptoms.
Homework given: Dysfunctional thought record and chart for obsessions and compulsions were given again and client was briefed about cooperative and treatment adherence.
Session No.3 Time of session: 45 minutes
Session Agenda
Psycho-education, Activity Scheduling
Review of previous session: The client trusted the therapist and felt comforted and understood after the previous session
Homework review: The client filled the DTR and obsessions chart. Gaps in the chart were filled during the session.

Techniques
Psycho-education (Wells, 1997)
Rationale: To orient the client towards her symptoms, their development, precipitating factors, treatment plan and prognosis. Procedure: The client and her husband were educated about the client’s disorder in detail. The psycho-education comprised of Obsessive-Compulsive Disorder, the causes of development of symptoms, its modes of treatment (medical and psychological) and prognostic factors. Normalization involved the provision of information about the incidence and prevalence of the disorder in indigenous population and their recovery rates. Moreover, the client was also briefed about the therapeutic process, length and duration of sessions, role of the psychologist and client herself and the duration in which the effectiveness of treatment will reveal itself. Outcome: This information gave hope to the client about the effectiveness of treatment as she previously thought that there was no cure for her symptoms and she will have to live in the same way throughout her life. The purpose of the therapy was also provided in order to instill internal locus of control.
Psycho-education (Development of symptoms)
Rationale: To make the client understand the process and functioning of her symptoms. To help to educate the client about the intervention point in the cycle. Procedure: The client was socialized with the CBT model by first explaining her each step in Rachman’s OCD cycle. The simple version of the cycle was helpful in educating the client about obsessions and compulsions and where the cycle had to be broken. After the client had occupied an understanding of how both processes operated, the Wells and Mathews model was explained. The client was then encouraged to put her own examples in the model making it idiosyncratically specific. She identified her thought and behaviors readily, but the therapist had to explain the in between process of meta-beliefs and appraisals regarding intrusions. She was explained about the importance of the meaning she attached to her thoughts and how those meanings led to the development of the symptoms. Outcome: Initially, it was difficult for the client to accept the model but various examples from her own life helped to make it simpler and understandable for her.
Activity Scheduling
Rationale: To make the client indulge in productive activities rather than ruminating over her thoughts and to restore the client’s pre-morbid level of functioning. To make her concentrate on other people and other tasks rather than just washing or cleaning. Procedure. In order to introduce distractions and a healthier social life, she was asked to bring groceries for her house and visit her mother or sister twice a week. Outcome: The client agreed to follow the schedule assigned which helped her greatly as she liked visiting her sister. She also felt that she was performing her religious obligation of visiting her mother through this process. The techniques increased her outgoing behaviors and also got her to keep herself maintained and fresh.
Homework given: To complete the tasks given in activity schedule. She was also given the CBT model to read it again daily until the next session.
Session No.4 Time of session: 45 minutes
Session Agenda
Revisiting psycho-education, thought-suppression experiments, worry postponement
Review of previous session: The previous session was thoroughly reviewed to summarize the information given to the client which she received in the last session. The therapist briefly provided with the psycho-education again and also emphasized to follow the activity schedule completely.
Homework review: She follow the activity schedule up to 50% as she could not visit her sister’s or mother’s house during the week. But she took time out to do the groceries and also managed to read the CBT model of OCD almost daily.
Techniques
Worry-postponement experiment (Wells, 1997)
Rationale: To make the client realize that worrying is in her own control and that she can shut it off whenever she desires. Procedure: She was asked about the times she was really busy and what thoughts occupied her time when she was busy in a particular task. Then she was asked to identify her thoughts when she lied down and was alone. The client’s distressing thoughts mostly occupied her time when she was alone. The thoughts did not occur to her in busy times such as when talking to someone, sitting in a group of people, indulged in cooking etc. Outcome: The procedure was helpful by making the client understand that she was in control all the time. She understood that she could switch the button off whenever she wanted so the thoughts would go away.
Thought-suppression experiments (Wells, 1997)
Rationale: to explain to her that the more she tried to get rid of the thoughts, the more they would re-occur in her mind. Procedure: She was initially asked to think about a blue rabbit for 1 minute. After that, she was asked to stop thinking about the blue rabbit for 1 minute and not let the thought of the rabbit come in her mind again. She was unable to do so which fulfilled the purpose of the experiment. She was then briefed about the rationale of the technique and how it applied to her intrusive thoughts as well. Outcome: The client understood the technique and its rationale. She also realized that only distraction is not the solution to the problems.
Homework given: To complete the tasks given in activity scheduling and try both thought suppression experiment and worry postponement experiment at home. She was also asked to identify half an hour as the worry time when she can sit and think about the distressing thoughts.
Session No.5 Time of session: 45 minutes
Session Agenda
Verbal Reattribution by normalizing thoughts/worries (concept of mindfulness) and mini survey
Homework review: The client was able to follow the activity schedule completely. She felt happy after visiting her family. She reported that it was unable for her to deliberately bring the distressful thoughts in her mind during the worry-time specified. After practicing the experiments at home, she was also convinced that her worry was in her own control
Techniques
Normalizing thoughts/worries (concept of mindfulness) (Wells, 1997)
Rationale: To make the client realize the importance of remaining in the present was told along with the effectiveness of viewing situation objectively. Procedure: The client was explained through various exemplifications that thoughts are a person’s own creation and every individual has a different thought about the same situation. So the client was encouraged to see every trigger as a particular situation which she would view without letting her own beliefs and biases come in between. Additionally, she was also explained that an individual comes across hundreds of thoughts during the day but the thoughts on which he focuses will be the ones that would create distress. So the concept and a thought coming and letting it pass by without letting it intrude in the client’s daily functioning was proposed. Outcome: Through repetitive explanations and examples during the session, the client was able to grasp the concept and take control over her thoughts. The information that everyone comes by these thoughts but does not stress over them, significantly clicked the client and helped to convince over the normality of thoughts.
Mini-survey (Wells, 1997)
Rationale: To provide the client with evidence about normal thoughts and distressing thoughts. Procedure: A column was made in which 5 people were listed down and each person was asked about the specific thoughts that the client experienced (thoughts of Na-paaki, uncleanliness). They were then inquired if they felt distressed after those thoughts or did any behaviors or actions to reverse the thought. The frequency of thoughts and related behaviors were listed down. Some people were also asked about the interpretation they gave to their thoughts. Outcome: The client felt somewhat relieved that the thoughts are a normal process but the meaning one attaches to them and the neutralizing behaviors are the point that is problematic.
Homework given: To conduct a mini-survey at home as well and to practice mindfulness by focusing on the present and try to let go of thoughts.
Session No.6 Time of session: 1 hour
Session Agenda
Introduction to Exposure and Response Prevention (ERP), formation of hierarchy, conduction of the first step.
Homework review: The client continued to follow the activity schedule. She also tried to practice mindfulness by focusing on the task she was doing. Moreover, she also completed a mini-survey of 5 people at home by asking about their thoughts and relevant behaviors.
Techniques
Construction of hierarchy for ERP (Wells, 1997)
Rationale: To reduce the client’s compulsions and train her in dealing constructively with her anxiety by staying in the situation. Procedure: At first, she was briefed about the procedure and what was required by her. All steps were clarified and queries were answered. After the introduction, a hierarchy was developed by the client with the least anxiety provoking situation to the most. Each situation was also given a rating regarding the level of anxiety felt in those circumstances. Outcome: The client was able to construct the hierarchy with the collaboration of the therapist.
Conduction of first step of the ERP (Wells, 1997)
Rationale: To make the client experience distressing thoughts but unable to perform neutralizing actions. Procedure: After listing down the situation, the client was exposed to the least anxiety provoking stimuli and then stopped from performing the anxiety reducing behavior. During the time anxiety ratings were taken across 1-minute intervals. The client was asked to wash her hands and then close the tap after it. At first the client was hesitant and did not close the tap. But after insistence, she closed the tap after which she was asked not to wipe or wash her hands rather let them remain as they were. It was seen that the client’s anxiety reached its peak within 2-3 minutes and remained high for approximately 10 minutes. The anxiety then reduced automatically until it was completely gone. Initially it was difficult for the client to carry on with the technique as she thought she won’t be able to handle the anxiety. Outcome: With repetitive insistence and exposure during the session, the client productively dealt with all her hierarchical situations.
Homework given: The next step of the hierarchy was given as homework and the client was asked to make her daughter sit near her while she was doing it. The co-therapist was designated to refrain the client from performing any neutralizing behavior and also monitor her anxiety.
Session No.7 Time of session: 45 minutes
Session Agenda
Verbal Reattribution (Questioning the evidence and questioning the mechanism)
Homework review: The client asked about the second step of the hierarchy. She reported that she was able to deal with the second situation in 2-3 days. She repeatedly did it throughout the day and by continuous practice she did not felt the need to perform her previous behaviors. Moreover, she also told that she tried to restructure her thought during ERP as well which helped her continuing with the procedure
Techniques
Questioning the evidence (Verbal Reattribution) (Wells, 1997)
Rationale: To make the client identify evidence and counter evidence of thought in order to disconfirm her beliefs. Procedure: The most frequent and distressing thought of Na-paaki was addressed by this technique. She was first asked to define what Na-paaki was and how she got to know that the objects were Na-paak. As the client did not have problems with dirt she did not focus on it. Hence, she had no strong or visible evidence of proving that something was Napaak. She reported that she just felt like the objects were Napaak when someone touched it after coming from outside or visiting the washroom. Outcome: This led to the disconfirmation of her beliefs that when there is no solid evidence of a phenomenon, then how is it possible to have happened. The technique was helpful in thought-event diffusion of the client.
Questioning the mechanism (Wells, 1997)
Rationale: To question the client’s understanding of how things got unclean and what ‘Ahkamaat’ have been given regarding Na-paaki in the religion. Procedure: The disconfirmation of beliefs was furthered by discussing empirical quotes (Ayahs and Ahadees) about Napaaki. She herself told how an object or place would become Napaak based on the religious beliefs. The instances were limited (2-3) and she realized that there was a different between dirt and Napaaki. Her belief around the strictness of achieving purity in the religion decreased and she found that it give space and freedom for minor mistakes. Outcome: The whole process of questioning the thoughts affected the client greatly and major improvement was seen after the client was convinced.
Homework given: The client was asked to continue her activity schedule and add a visit to the neighbors’ house in it. She was also asked to question her own thoughts each time they came by finding evidences and convincing her upon the illogical cognitions.
Session No.8 Time of session: 45 minutes
Session Agenda
ERP continued, Relaxation exercise
Homework review: The client was inquired about her emotions and thought processes across the past week and how she helped herself in coping with the distressing thoughts. The client told that she evaluated evidence regarding each thought that came and tried to reduce the consequent compulsion she previously did by restricting herself and using the techniques learned during session.
Review of previous session: In order to make the concepts more clear and revise them for the client, verbal reattribution strategies were discussed again and all of the client’s ambiguities were answered.
Techniques
Continuation of hierarchy
Rationale: To make the client exposed towards more anxiety provoking situations and make her deal with them as well. Procedure: The third and fourth step of the hierarchy was carried out in the session. The third step was carried out by asking the client to touch his feet and shoes thoroughly and then refrain from washing hands. She was asked to talk to the therapist randomly and concentrate on handling the situation without carrying out any compulsion. The client was given ample time for her anxiety to reduce from 100% to 10-20%. She was then asked to carry out the third step of touching the floor and then stay in the same situation. The procedure for preventing from washing was followed. Each situation was repeated 2-3 times. Outcome: The client felt extremely distressful in the start. She disagreed on carrying out the task but the therapist tried to reassure the client. After being convinced, the client carried out the task and handled them fairly well.

Progressive muscle relaxation (Bernstein & Borkovec, 1973)
Rationale: To reduce the client’s muscle tension and bodily pain. Procedure: The client was first told the rationale of the technique and how it will help her in the treatment of bodily pains. After that she was told about the 16 muscles that would be focused upon in the exercise. The therapist then demonstrated how each muscle will be tensed and then relaxed. After the elaborate explanation, the client was asked to relax on her chair and then each muscle of the client was focused. She was asked to first tense each muscle then relaxing it. Double time was given for the client to relax each muscle as compared to the duration of tension. The neck, shoulder and thigh muscles were focused more as the client felt more pain in them. Outcome: She understood the procedure and felt relaxed after the exercise.
Homework given: The third and fourth step of the hierarchy was given to practice at home as well. She was also asked to practice PMR daily before sleeping. A handout was given to the client in which a diagram of each muscle was provided in case the client forgot.
Session No.9 Time of session: 45 minutes
Session Agenda
Doubt reduction techniques, Review and therapy blueprint, Post-assessment
Homework review: She was asked if she did the exercise she was told. The client complied with all the instructions. She did the relaxation exercise 5 days per week before sleeping. She dedicated 20 minutes to the exercise daily. Moreover she continued to do the tasks given in ERP and reported that she felt less anxious now.
Techniques
Doubt Reduction techniques (Wells, 1997)
Rationale: To that make client’s behavior ‘stand out’ in memory and will consequently reduce the doubt that motivates checking. Procedure: The client was asked to divide each contamination tasks into smaller steps and focus on those steps while they were being done. For example if she went to the restroom, steps such as opening the door, using the toilet, using the water, washing hands, closing tap and coming out of the washroom were defined. She was asked to revise each step while doing it and then consider the task completed. She was also asked to tick mark each activity after they were done by her. Outcome: This made her less doubtful for each task and she revisited each task relatively less.
Relapse Prevention and Therapy Blueprint (Wells, 1997)
Rationale: To revise all techniques and answer all queries of the client. Procedure: The client’s symptoms were first revised with which she initially sought treatment. After the review of problems, solutions that were implemented were focused. Each technique was revised and the rationale of each procedure was explained again. Most effective strategies were also identified. She was also briefed about the steps she would take if future problems occurred and how she should continue the short term goals. Outcome: The review helped in summarizing the therapeutic sessions and to identify most valid techniques.

Post Assessment
Rationale: To assess the difference between the severity of pre-treatment ratings and post treatment ratings of symptoms. Procedure: The client was asked to rate all her symptoms again on a scale of 0-10. Outcome:
Symptoms Pre-treatment Ratings (0-10) Post-treatment Ratings (0-10)
Thoughts of uncleanliness ‘Na-paaki’ regarding clothes, house floor, sofas etc. 10 4
Distress because of washing hands, clothes, household items, floor etc. 10 2
Inability to control or suppress thoughts 10 2
Dissatisfaction after using the washroom, washing hands or clothes 9 3
Anger, frustration, irritability 9 3
Unable to remember or recall immediate actions 9 1
Social withdrawal, remaining inside the house 8 3
Hopelessness and worry about the treatment of problems. 8 1
Inability to handle house chores effectively 7 3
Homework given: Therapy blueprint was given. A chart for the frequency and intensity of obsessions and compulsions was given again to determine post-treatment ratings.
Session No.10 (Follow-up session) Time of session: 45 minutes
Session Agenda
Follow-up on the progress of goals.
Homework review: The chart for obsessions and compulsions was revied to determine post-treatment rating of frequency and intensity of obsessions.
Area of Baseline Pre-treatment Rating Post-treatment rating
Frequency of obsessions 25-30 times per day 5-6 times per day
Intensity of the drive to perform compulsion 9 on average 4 on average
Intensity of emotions 8 on average 4 on average
Duration of obsession Variable (Ranges from 1 minute to an hour) 1-10 minutes
Duration of compulsion (5-10 minutes in washing body parts, 30-40 minutes in bathing and 2-3 hours in washing clothes) 1-2 times per day
Techniques
Follow-up
Rationale: To check the compliance of client with treatment techniques and to asses the betterment in all symptoms. Procedure: An interview was conducted with the client and her husband to assess the improvement in the symptoms. Outcome: Both the client and her husband informed that she was considerably better and she was trying hard to completely eliminate all her problems.
Therapeutic outcome
The therapy was effective in dealing and subsiding the client’s obsessions and compulsions. It improved the client’s quality of life and made her more cheerful, hopeful and functional. The client’s compliance and strategies increased the outcome of the therapy.
Limitations and Suggestions
The client was initially reluctant and non-compliant with the therapist’s suggestions but with repeated insistence she started to follow the therapeutic protocol.
The client was irregular in her sessions hence, long gaps occurred between some sessions. The client was requested to follow the schedule so she became regular after 4^th session.
References;
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
Moritz, S., Von Muehlenen, A., Randjbar, S., Fricke, S., & Jelinek, L. (2009). Evidence for an attentional bias for washing-and checking-relevant stimuli in obsessive–compulsive disorder. Journal of the International Neuropsychological Society, 15(03), 365-371.
Tata, P. R., Leibowitz, J. A., Prunty, M. J., Cameron, M., & Pickering, A. D. (1996). Attentional bias in obsessional compulsive disorder. Behaviour Research and Therapy, 34(1), 53-60.
Timpano, K. R., Keough, M. E., Mahaffey, B., Schmidt, N. B., & Abramowitz, J. (2010). Parenting and obsessive compulsive symptoms: Implications of authoritarian parenting. Journal of Cognitive Psychotherapy, 24(3), 151-164.
Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A practice manual and conceptual guide (1^st ed.). New York: John Wiley & Sons.