DANGER
IDEATION
REDUCTION
THERAPY (DIRT)
FOR OBSESSIVE–COMPULSIVE CHECKERS
A Comprehensive Guide to Treatment

Lisa D. Vaccaro, Mairwen K. Jones, Ross G. Menzies, Tamsen St. Clare

DIRT for Obsessive–Compulsive Checkers is a unique new evidence-based treatment program designed to specifically reduce expectancies of danger or threat in OCD checkers. Unlike many traditional OCD treatments, DIRT is based on the rationale that the therapist should provide as much factual information as possible to decrease the expectancy of harmful events and thus reduce the high dropout rate seen in conventional  OCD exposure and response prevention programs.

DIRT is a comprehensive treatment package that has been specifically designed to reduce expectancies of danger (threat) in those with Obsessive Compulsive Disorder (OCD) with predominant checking concerns. The dominant concerns in this population include fear of fire, damage, theft, harm to others and other physical losses. The original DIRT package, Danger Ideation Reduction Therapy (DIRT) for Obsessive–Compulsive Washers: A Comprehensive Guide to Treatment (St Clare, Menzies & Jones, 2008), was developed for OCD sufferers with contamination concerns. It has been modified in the present program to cover material that is relevant to individuals with checking concerns. All information presented is designed to reduce the expectation that harmful events will follow any failure to check. There is no discussion of alternative cognitive constructs, such as perceived responsibility or perfectionism, nor is there an exposure and response prevention component. The treatment package consists of six discrete treatment components. The attentional focusing component is aimed at reducing the number of intrusive thoughts experienced, and the remaining components work concurrently to allow the client to successfully change the remaining thoughts and beliefs that people with obsessive–compulsive checking experience.

OVERVIEW

DIRT is a comprehensive treatment package that has been designed to specifically reduce expectancies of danger (threat) in those with Obsessive Compulsive Disorder with predominant checking concerns. It consists of six discrete treatment components.The attentional focussing component is aimed at reducing the number of intrusive thoughts experienced, and the remaining components work concurrently to allow the client to successfully change the remaining thoughts and beliefs related to illness and contamination. The six treatment components are listed below.

Attentional Focusing

Clients are taught a focusing task that is designed to decrease the intrusiveness of obsessional thoughts through increasing their ability to attend to competing stimuli.

Cognitive Restructuring
Clients are taught to identify and restructure irrational or unhelpful thoughts related to their checking concerns.

Double-Checking Experiments
Clients are educated about how the habit of repeated checking is implicated in maintaining dysfunctional beliefs and thus checking behaviour.

Corrective Information
Clients are presented with (a) a variety of fact sheets concerning topics pertinent to checking, (b) information about the statistics of disaster, injury, crime, and (c) information relating to normal behaviour and fears in the community.

Filmed Interviews
Clients are presented with a number of filmed interviews depicting various workers who have had regular contact with OCD relevant checking stimuli. The absence of compulsive behaviour and/or neutralising activities and the absence of feared outcomes (e.g. fire/theft/error) occurring is emphasised.

Probability of Catastrophe Task
Clients are asked to compare their global estimates of the probability of specific negative outcomes with the probability that all the steps necessary for that outcome will occur concurrently.  

Differences between DIRT and standard
Cognitive Therapy packages for OCD

Inclusion of Attentional Focusing
Standard cognitive therapy packages for OCD (e.g., Salkovskis & Warwick, 1985; Salkovskis & Westbrook, 1989) do not include an attentional-focusing component. They teach the client to restructure beliefs without attempting to reduce the number of intrusions through meditation like procedures.

Exclusive Focus on Danger Expectancies Relating to Feared Outcomes
Other cognitive packages for OCD tend to target variables such as inflated personal responsibility and perfectionism. In accordance with findings from our cognitive mediation studies (Jones & Menzies, 1997b) the focus of DIRT is exclusively on danger cognitions relating to feared outcomes. The title of our program (Danger Ideation Reduction Therapy) was chosen to continually remind clinicians of the exclusive focus of treatment — the reduction of danger expectancies.

Direct Challenging of Negative Automatic Thoughts That Relate to Probability and Severity of Harm
Many cognitive packages ignore surface level cognitions relating to feared outcomes. We argue that in the majority of cases the client’s belief in their surface level cognitions (e.g., If I don’t check the door is locked an intruder will come in and murder my family) is the problem, and should therefore be the target of therapy.

The (Repeated) Provision of Factual Information to Provide Assurance of the Real Likelihoods of Various Outcomes
The issue of assurance provision is a contentious one within the OCD treatment literature. The majority of OCD treatment packages will not comment on the likelihood of danger occurring to the client if he/she engages in anxiety-inducing tasks. A standard response to questions about whether a feared outcome could occur if the client does not check or repeat a task would resemble: Your house may get robbed, it may not get robbed. This is about learning to live with the risk. The rationale behind this approach is that a key feature of OCD is intolerance to uncertainty, and that provision of reassuring information is feeding into that intolerance. In our opinion, refusal to provide relevant factual information (such as the likelihood of fire or theft occurring in specific situations) may well contribute to the high dropout rates seen in ERP programs for OCD (Emmelkamp & Foa, 1983; Kozak, Liebowitz, & Foa, 2000). In our experience, many OCD checkers have such an inflated expectancy that certain feared outcomes will occur that they are unable to tolerate the risk, and therefore drop out of traditional treatments. The DIRT approach provides an alternative to the traditional perspective on this issue. We believe that the therapist should provide as much factual information as possible, as this will decrease the expectancy of danger that is driving the disorder. The emphasis should be firmly on educating the client about the probability and severity of the feared outcome. We should note that while we do attempt to provide accurate information about likelihood, at no stage do we indicate that the client can know that the feared outcome will not occur (unless the compulsive behaviour is logically disconnected from the feared outcome). Further, at no stage do we indicate that the client has complete control over the occurrence or prevention of a feared outcome. In short, while we attempt to provide our clients with accuracy, we do not attempt to provide them with certainty. For this reason, we do not believe that DIRT feeds into pathological intolerance for uncertainty.

Rote Learning of Restructured Cognitions

One other technique that we have found to be unique to the DIRT package is that we request our clients to rote learn their restructured cognitions. In our experience, the high danger expectancies held by OCD checkers can be difficult to shift, by virtue of the fact that they have been present for an extended period of time and are habitual. We have also noticed that for most clients, particular thoughts recur frequently. We have found rote learning to be helpful in gradually decreasing the client’s belief in their maladaptive thoughts, and in preparing them to be able to challenge their thoughts at times of high anxiety. In the early stages of cognitive restructuring, clients often complain that they are unable to restructure their thoughts when they are in anxiogenic situations. We have found that overlearning of restructured thoughts generated during times of comparatively low anxiety can greatly assist in enabling clients to restructure cognitions when they are anxious. We encourage clients to overlearn their restructured cognitions by both writing them and saying them repeatedly.

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    RRP $169.95
    ISBN: 9781921513282
    AAP Item Number: 4-921513282
    144 pages A4 softcover with CD & DVD
    First published 2010

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