Danger Ideation Reduction Therapy (DIRT) for Obsessive Compulsive Washers: A Comprehensive Guide to Treatment

DIRT for washers is a unique evidence-based program to treat people suffering from obsessive–compulsive disorder (OCD) specifically, OCD washers whose behaviour is characterised by expectancies of danger.

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. The program 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 components may be used selectively or concurrently, as and how a therapist decides is appropriate for individual clients.

The treatment components are attentional focusing, cognitive restructuring, corrective information, microbiological experiments, filmed interviews and the probability of catastrophe task. Included in the program is a DVD of 8 filmed interviews about risk assessment. Additionally, a resource CD contains all 45 handouts and worksheets so that therapists don’t have to photocopy these resources from the book.

What makes DIRT different to other OCD treatments?

Unlike most other OCD treatment programs DIRT features:

• inclusion of attentional focusing.
• exclusive focus on threat expectancies relating to illness or disease.
• direct challenging of negative automatic thoughts that relate to illness or disease.
• use of factual information to provide assurance of the real likelihoods of various outcomes.
• rote learning of restructured cognitions.

DIRT has been shown to be a highly successful treatment, able to shift even the most intractable of cases. Randomised control studies have established that DIRT represents a viable alternative to the standard behavioural approach. In addition, DIRT appears to have several potential advantages over behavioural and pharmacological treatments:

• Unlike in an Exposure and Response Prevention (ERP) program, clients who undergo the DIRT regime are not asked to confront anxiety-provoking (feared) stimuli. This is particularly important since many sufferers either refuse exposure treatment or drop out before completion because of its anxiety-provoking effects.
• Unlike medication used in the treatment of OCD, DIRT achieves its success without the complication of physical side effects.
• DIRT is a highly structured treatment package involving films, information sheets and worksheets which are relatively inexpensive to package and administer.
• DIRT appears to require relatively few sessions for its therapeutic effect. Substantial reductions in OCD symptomatology have been achieved in as few as six clinical hours.
• DIRT may prove beneficial for intractable patients who have failed with standard treatments, and for those who exhibit poor insight.

Table of Contents

Acknowledgments

DVD contents

CD resource contents

About the authors

How to use this manual

Chapter 1 - Introduction to DIRT

Chapter 2 - Treatment Rationale

Chapter 3 - Attentional Focusing

Chapter 4 - Cognitive Restructuring

Chapter 5 - Corrective Information

Chapter 6 - Microbiological Experiment

Chapter 7 - Filmed Interviews

Chapter 8 - Probability of Catastrophe Task

References

DVD contents

• Interview with Mark (Canecutter)
• Interview with Mark (Special Education Teacher)
• Interview with Kim (Registered Nurse)
• Interview with Ann (Lab Worker)
• Interview with Claudia (House Cleaner)
• Interview with Eddy (Fitter and Turner, Printer)
• Interview with Julie (Gardener)
• Interview with Ann-Marie (Bank Teller)

CD resource contents

Chapter 2 Handout

1. Why Do I Have OCD? And How Can DIRT Help?

Chapter 3 Handouts

1. Attentional Focusing Card
2. Attentional Focusing Monitoring Form

Chapter 4 Handouts

1. Cognitive Restructuring
2. Thinking Exercises
3. Cognitive Monitoring
4. Cognitive Monitoring Form
5. Cognitive Challenging
6. Thought Challenging Worksheet

Chapter 5 Handouts

1. Normal Behaviours Information Sheet
2. Normal Behaviours Worksheet
3. The Immune System Fact Sheet
4. Immune System Worksheet
5. Faeces Fact Sheet
6. Faeces Worksheet
7. Urine Fact Sheet
8. Urine Worksheet
9. Hepatitis Fact Sheet
10. Hepatitis Worksheet
11. Vomiting Fact Sheet
12. Vomiting Worksheet
13. HIV and AIDS Fact Sheet
14. HIV and AIDS Worksheet

Chapter 6 Handouts

1. Microbiological Report
2. Microbiological Experiment Worksheet

Chapter 7 Handouts

1. Occupational Interview Worksheet 1: Mark (Canecutter)
2. Occupational Interview Worksheet 2: Mark (Special Education Teacher)
3. Occupational Interview Worksheet 3: Kim (Registered Nurse)
4. Occupational Interview Worksheet 4: Ann (Laboratory Worker)
5. Occupational Interview Worksheet 5: Claudia (House Cleaner)
6. Occupational Interview Worksheet 6: Eddy (Fitter and Turner/Printer)
7. Occupational Interview Worksheet 7: Julie (Gardener)
8. Occupational Interview Worksheet 8: Ann-Marie (Bank Teller)
9. Occupational Interview Transcript: Dr Ralph (Infectious Disease Physician)
10. Occupational Interview Worksheet 9: Dr Ralph

Chapter 8 Handouts

1. Probability of Catastrophe Worksheet 1
2. Probability of Catastrophe Worksheet 2
3. Probability of Catastrophe Worksheet 3
4. Probability of Catastrophe Worksheet 4
5. Probability of Catastrophe Worksheet 5
6. Probability of Catastrophe Worksheet 6
7. Probability of Catastrophe Worksheet 7
8. Probability of Catastrophe Worksheet 8
9. Probability of Catastrophe Worksheet 9
10. Probability of Catastrophe Worksheet 10

"Danger ideation reduction therapy (DIRT) for obsessive compulsive disorder (OCD) is a new intervention focusing on providing corrective information, and is the subject of a new comprehensive guide to treatment for compulsive washing. The components of DIRT are well presented in this manual-based treatment and the documentation includes dialogues, filmed interviews with workers in dangerous occupations, and fact sheets to persuade the client to exchange beliefs about danger for beliefs about safety. The book is well organized and user friendly. Clinical trials have shown DIRT to be an effective treatment. Although DIRT as a stand alone therapy seems to offer some advantages over conventional CBT, it may function currently more as an adjunct to help cognitive restructuring. DIRT certainly encourages us to rethink some assumptions about the use of corrective information in treating OCD."
- Kieron O'Connor, Department of Psychiatry, University of Montreal, Canada, Department of Psychology and Psychoeducation, University of Quebec in Outaouais, Canada  read the full review