Session 1: Rapport Building and Clinical Exploration

The 1st session focused on establishing a trusting and supportive relationship between the me and
the client. I welcomed the client into a non-judgmental environment and explained the
therapeutic process, confidentiality policies, and the purpose of therapy. The client was
encouraged to share her symptoms, emotional struggles, and personal history in her own words.

Through empathetic listening, the I began to understand the client’s intrusive thoughts,
compulsions, and their impact on daily functioning. The client shared a long-standing pattern of
contamination fears linked specifically to menstruation, and how these thoughts triggered
compulsive hand-washing. She revealed how this pattern worsened after her father’s death,
which added emotional distress and a feeling of loss of control. This session was crucial for
building comfort and safety, which would support deeper therapeutic work in subsequent
sessions.

Session 2: Psychoeducation and OCD Conceptualization

In 2nd session, the I provided psychoeducation to both the client and her mother about OCD—its
nature, symptoms, and how it is maintained. The client was introduced to the idea that her
obsessions (unwanted thoughts) and compulsions (repetitive behaviors like hand-washing) were
part of a common psychological disorder, not signs of personal failure or impurity.

I used the Wells and Matthews (1994) model and an idiosyncratic example to explain the OCD
cycle: intrusive thought → anxiety → compulsion → temporary relief → reinforcement of the
cycle. This helped the client understand why her rituals, though they provide short-term relief,
maintain her distress in the long term. A visual representation of the cycle was drawn to enhance
understanding, and the client began recognizing how avoidance and rituals perpetuate her
anxiety.

Session 3: Identifying Negative Thoughts and Deep Breathing

In session three, the focus shifted toward identifying the client’s automatic negative thoughts and
emotional reactions. Using a Dysfunctional Thought Record (DTR), the client recorded her
intrusive thoughts, associated emotions, and compulsive responses over the week. Common
thoughts included “My hands are dirty,” “If I don’t wash them, I’ll become impure,” and “I will
be sinful if I stay unclean.” These thoughts were linked to feelings of anxiety, disgust, and fear.

To help manage the physiological symptoms of anxiety, relaxation training was introduced. The
client was taught deep breathing and progressive muscle relaxation techniques. She practiced
them in-session and was instructed to use them at home three times a day. These techniques
helped reduce somatic symptoms of anxiety, such as restlessness and rapid heartbeat, thus
empowering her with non-compulsive ways to calm herself.
Session 4: ABC Model and Introduction to Cognitive Restructuring

This session introduced the client to the ABC model (Activating event – Beliefs –
Consequences) of cognitive behavior therapy. I explained that it is not the situation (e.g.,
touching a door) that causes emotional distress, but rather the beliefs attached to that situation
(e.g., “I will become contaminated”). The client identified and wrote down her irrational beliefs
about dirt and cleanliness.

Through Socratic questioning, I guided the client in examining the evidence for and against these
beliefs. She started to consider alternative explanations, such as “Not every touch causes
infection” or “A little dirt doesn’t make me sinful.” The client’s insight improved as she began to
separate thought from reality. This laid the groundwork for future cognitive restructuring.

Session 5: Exposure and Response Prevention (ERP) – Planning and Initiation

Having prepared the client with cognitive tools, I introduced Exposure and Response Prevention
(ERP), a cornerstone of CBT for OCD. The client created an exposure hierarchy, listing
situations that triggered her anxiety from mild to severe. For example, touching a clean door
handle was rated as low anxiety, while handling garbage with used sanitary pads was rated high.

The first exposure was carried out in-session with mine support. The client was asked to touch a
mildly feared surface and delay washing her hands. Initially, her anxiety rose, but with coaching
and relaxation techniques, it started to subside. This challenged her belief that compulsions were
the only way to reduce distress. She was given homework to repeat this exposure task daily and
track her anxiety levels before and after.

Session 6: Cognitive Restructuring and Advanced ERP

In session six, I revisited the client’s experiences with ERP homework. The client had attempted
exposure to medium-level triggers and reported moderate success. Her anxiety did rise but
lessened over time without resorting to compulsions. Encouraged by these results, I helped her
restructure deeper beliefs, such as "If I am not perfectly clean, I am a bad person."

The session also included more advanced ERP exercises. The client was asked to resist
compulsions after exposure to more difficult triggers, such as contact with dustbins or touching
slightly soiled clothing. Each exposure was followed by reflection, anxiety ratings, and
reinforcement of adaptive thoughts. The client began to internalize the principle that she could
survive discomfort and that avoidance was not necessary.
Session 7: Pink Elephant Technique and Setback Management

To reinforce the cognitive theme that “thoughts are just thoughts,” I used the Pink Elephant
Technique, a thought suppression experiment. The client was told to think about a pink elephant
and then try not to think about it. Predictably, she found it hard to stop the thought, leading to a
realization: trying to suppress thoughts makes them more persistent.

This exercise helped the client understand that controlling or pushing away intrusive thoughts
only makes them stronger. She accepted that thoughts about contamination or impurity could
arise without acting on them. I also addressed occasional setbacks the client experienced—such
as unplanned hand-washing—and normalized them as part of the healing journey. Coping cards
were introduced, containing affirmations like “This is just a thought, not a fact” and “I can let it
pass.”

Session 8: Relapse Prevention and Termination

The final session was dedicated to relapse prevention planning. The client reviewed all the tools
and strategies she had learned during therapy, including ERP, cognitive restructuring, distraction,
relaxation, and problem-solving techniques. She identified early warning signs of relapse, such
as increased irritability, avoidance behaviors, and ritual urges.

I helped the client build a therapy blueprint, summarizing what had worked, what to continue,
and what to do during high-stress periods. The client was empowered with a list of coping
strategies and a schedule for follow-up or booster sessions. With 70% improvement in
symptoms, the client expressed confidence in her ability to manage OCD independently. She was
congratulated on her progress, and the therapy was formally terminated on a hopeful and
affirming note.