DANGER                                                           
IDEATION
REDUCTION
THERAPY (DIRT)
FOR OBSESSIVE-COMPULSIVE WASHERS
A Comprehensive Guide to Treatment

Tamsen St Clare, Ross G. Menzies, Mairwen K. Jones

DIRT is a unique new evidence-based treatment program designed to specifically reduce expectancies of danger or threat in OCD washers. 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 illness or disease and thus reduce the high dropout rate seen in conventional  OCD exposure and response prevention  programs.

DIRT consists of six discrete treatment components aimed at reducing the number of intrusive thoughts experienced and concurrently allowing the client to successfully change the remaining thoughts and beliefs related to illness and contamination. The treatment includes attentional focussing, cognitive restructuring, corrective information, microbiological experiments, filmed interviews, and a probability of catastrophe task. The book includes a resource CD with patient handouts and a DVD of interviews.

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DIRT is a comprehensive treatment package that has been designed to specifically reduce expectancies of danger (threat) in OCD washers. 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 Focussing. Clients are taught a focussing task that is designed to decrease the intrusiveness of obsessional thoughts through increasing the ability to attend to competing stimuli.

Cognitive Restructuring Clients are taught to identify and restructure irrational or unhelpful thoughts related to contamination and disease.

Corrective Information. Clients are presented with: (1) a variety of fact sheets concerning feared contaminants and illnesses; (2) information about the nature and function of the immune system, and; (3) information relating to disease and illness rates in specific populations.

Microbiological Experiment. Clients are presented with the results from a series of microbiological experiments involving contact with anxiety-provoking stimuli such as the inside of a garbage bin and cat fur.

Filmed Interviews. Clients are presented with a number of filmed interviews depicting various workers who have had frequent contact with OCD relevant contaminants. The absence of compulsive behaviour and work related disease in these professionals 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

• The inclusion of Attentional Focussing. Standard cognitive therapy packages for OCD (eg Salkovskis & Warwick, 1985; Salkovskis & Westbrook, 1989) do not include an attentional focussing component. They teach the client to restructure beliefs without attempting to reduce the number of intrusions through meditation-like procedures.

• The exclusive focus on threat expectancies relating to illness/disease. 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, 1997a) the focus of DIRT is exclusively on cognitions relating to illness / disease. The title of our program (Danger Ideation Reduction Therapy) was chosen to continually remind clinicians of the exclusive focus of treatment - the reduction of threat expectancies relating to illness / disease.

• Direct challenging of negative automatic thoughts that relate to illness / disease. Many cognitive packages ignore surface level cognitions relating to illness. We argue that in the majority of cases the client’s belief in their surface level cognitions (e.g., If I touch that door handle I will get cancer of the spleen) 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 client will become ill by engaging in a task would resemble: “you may get sick, you may not. This is about learning to live with the risk”. The rationale behind this 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 becoming ill from engaging in certain behaviours) may well contribute to the high dropout rates seen in ERP programs for OCD. In our experience, many OCD washers have such an inflated expectancy that certain behaviours will lead to illness, 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 illness / disease that is driving the disorder. The emphasis should be firmly on educating the client about the probability and cost of becoming ill. We should note that whilst we do attempt to provide accurate information about likelihood, at no stage do we indicate that the client can know that they will not become ill from engaging in a particular task (unless the task involves no risk whatsoever, e.g., contracting rabies when standing 20 feet from a dog). At no stage do we indicate that the client has complete control over the occurrence of illness. In short, whilst 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.

• The 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 washers 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.  

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