Integrating the 4T psychoeducational model into cognitive-behavioral therapy: A case study of harm-related obsessive-compulsive disorder

Abstract

Background: Obsessive-Compulsive Disorder (OCD) is a chronic psychiatric condition characterized by intrusive obsessions and repetitive compulsions that result in significant functional impairment. Harm-related obsessions and checking compulsions represent some of the most distressing and treatment-resistant symptom clusters. Cognitive-Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) remain the gold-standard interventions; however, their effectiveness may be limited in cases involving intrusive harm-related thoughts. Methods: This case study describes a 22-year-old male who presented with obsessions such as “What if I break his neck?”, fears of poisoning others, and associated compulsive checking and avoidance behaviors. He completed 30 sessions of CBT and ERP integrated with the 4T Psychoeducation Model, a framework derived from the Islamic intellectual tradition. The model distinguishes involuntary cognitive processes – imagination (tahayyul), baseless assumption/suspicion (tewehhum) and reasoning (taakkul) – from voluntary confirmation (tasdiq). Results: Standardized measures, including the Yale–Brown Obsessive Compulsive Scale (Y-BOCS), Padua Inventory, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI), were administered during treatment and at six-month follow-up. Results showed a clinically significant reduction in obsessive-compulsive symptoms (46% decrease in Y-BOCS), along with decreases in depression and anxiety. Qualitative feedback indicated that the 4T model helped the client differentiate intrusive images from responsible beliefs (confirmations), reducing thought–action fusion and excessive sense of responsibility. Conclusions: By the end of treatment, intrusive thoughts still occurred but were no longer perceived as threatening. This case highlights the value of integrating 4T psychoeducation into standard CBT protocols. Although initially developed for religious obsessions, the model provides a compelling cognitive framework for reconceptualizing thought-action relationships, emphasizing that thought processes are not inherently linked to actions, thereby emerging as an effective tool for improving treatment outcomes in harm-related OCD.