| Course | NURS 753 Psychotherapeutic Theories, Frameworks, and Modalities (NURS753) |
|---|---|
| Module/Week | 4 |
| Assignment | Case Analysis Evaluation 1 on Harm-Focused OCD in a New Father |
| Paper type | Case analysis evaluation (assessment, diagnosis, therapeutic intervention and treatment plan, at least 5 references) |
| Length | about 1,503 words, 5 double-spaced pages plus title page and references. Course guide: a case analysis of a chronic mental health symptom covering assessment, diagnosis, therapeutic intervention and treatment plan, applying evidence-based psychotherapy, with at least 5 references in current APA format, which may include the course textbook |
| Format | APA 7 student paper |
| Points | 100 |
| School | Liberty University Online |
| Program | DNP |
| Where it sits | Module/Week 4 in Liberty's published NURS 753 course guide; current sections can differ |
| Updated | October 2026 |
Free sample paper for NURS 753 Week 4
He Will Not Hold the Knife or the Baby: A Case Analysis of Harm-Focused Obsessive-Compulsive Disorder in a New Father and a Plan for Exposure and Response Prevention
[Student Name]
School of Nursing, Liberty University
NURS 753: Psychotherapeutic Theories, Frameworks, and Modalities
Case Analysis Evaluation 1
[Instructor Name]
[Date]
The patient is a composite written as a model case; the diagnostic manual, textbook and studies cited are real.
He Will Not Hold the Knife or the Baby: A Case Analysis of Harm-Focused Obsessive-Compulsive Disorder in a New Father and a Plan for Exposure and Response Prevention
Case Presentation
Mr. D., a 31-year-old software engineer, was referred by his family nurse practitioner ten weeks after the birth of his first child. Three weeks after the birth, while bathing his son, he had a sudden thought of holding the baby under the water. He was horrified. Since then the thoughts have returned many times a day: images of drowning the baby, of dropping him down the stairs, of stabbing him with a kitchen knife. He has stopped bathing the baby, will not carry him on the stairs, has put the knives in a locked drawer and checks that the baby is breathing several times a night. He asks his wife many times a day whether she thinks he is a danger, and he searches online whether people who have such thoughts act on them. He finally told his family nurse practitioner, fearing he would be reported and his son taken away.
He has no psychiatric or substance history, no history of violence and no psychotic symptoms. He is close to his parents, who live nearby, and he and his wife describe their marriage as strong, though strained by his constant questions. He returned to work after four weeks of leave and has been able to concentrate there, which is where he feels safest because the baby is not present. He attends church with his wife and has avoided taking the baby to the nursery for fear of being alone with him in the changing room. He reports that as a teenager he had a period of "checking things" that resolved. He is sleeping five hours a night and feels "ashamed and exhausted," but still enjoys time with his son when he is not alone with him.
Assessment
Safety Assessment
The first task was to determine whether the thoughts represented risk. I asked directly about intent, plans and urges and about how he felt when the thoughts occurred. He described the thoughts as unwanted, repugnant and contrary to everything he wants for his son, and he has responded to them by avoiding the baby rather than by any approach behavior. He has no history of aggression, psychosis or substance use. This pattern is characteristic of obsessions: the thoughts are ego-dystonic and produce avoidance and neutralizing, not intent. Research supports this distinction. Intrusive thoughts of intentionally harming one's infant are common in both mothers and fathers; in a study of prepartum and postpartum couples who listened to recorded infant crying, 44% of postpartum parents reported intrusive harm thoughts afterward, and mothers and fathers did not differ in the likelihood or number of such thoughts (Fairbrother et al., 2019). In a prospective cohort of birthing parents, even unwanted intrusive thoughts of infant-related sexual harm were not associated with harmful behavior, adding to evidence that such thoughts do not increase the risk of actually harming the infant (Beck et al., 2026).
Structured Assessment
His Yale-Brown Obsessive Compulsive Scale score was 26, in the severe range, with obsessions occupying three or more hours a day and compulsions, mainly checking, reassurance seeking and mental reviewing, about two hours. His PHQ-9 was 11, reflecting sleep loss, guilt and low energy, without suicidal ideation. With his permission, I interviewed his wife, who confirmed that he has been loving and gentle with the baby, that he avoids being alone with him and that the reassurance questions have become constant. Insight was good: he recognizes that the thoughts are probably products of anxiety, though in the moment they feel dangerous.
Diagnosis
| Diagnosis | For | Against |
|---|---|---|
| Obsessive-compulsive disorder | Recurrent, intrusive, unwanted harm thoughts; checking, reassurance seeking, avoidance; over an hour a day; severe distress | None |
| Postpartum depression | Low energy, guilt, poor sleep | Mood symptoms follow the obsessions; PHQ-9 moderate; anhedonia absent |
| Postpartum psychosis | Thoughts of infant harm | No delusions, hallucinations or confusion; thoughts recognized as his own and unwanted |
| Generalized anxiety disorder | Worry, poor sleep | Content is specific intrusive images with compulsions, not diffuse worry |
Mr. D. meets DSM-5 criteria for obsessive-compulsive disorder, with good or fair insight (American Psychiatric Association, 2013): he has obsessions, recurrent and persistent unwanted intrusive thoughts and images causing marked anxiety that he attempts to suppress or neutralize, and compulsions, repetitive checking, reassurance seeking and mental reviewing aimed at preventing a dreaded event, which take more than an hour a day and cause clinically significant distress. Depressive symptoms will be monitored as secondary to the OCD.
Therapeutic Intervention: Exposure and Response Prevention
Formulation
In the cognitive behavioral model, intrusive thoughts are normal experiences that most people dismiss. People with OCD interpret them as meaningful and dangerous, believing that having the thought means they might act on it or that they are bad people for having it. That interpretation produces anxiety, which the person reduces through avoidance and compulsions. Each act of avoidance or reassurance brings short-term relief but confirms the belief that the thought was dangerous, so the cycle strengthens (Wheeler, 2014). Mr. D.'s avoidance of bathing and holding the baby, his locked knives and his reassurance seeking all maintain his OCD.
Why Exposure and Response Prevention
Exposure and response prevention, the core cognitive behavioral treatment for OCD, asks the patient to face feared thoughts and situations in graded steps while refraining from compulsions. The evidence is strong and durable. Öst et al. (2026) pooled 47 studies with 2,817 participants and found very large within-group effects on OCD severity after treatment and at follow-up averaging 2.5 years, response rates of 70% after treatment and 69% at follow-up, recovery in about half of patients, and no significant difference between exposure and response prevention, cognitive therapy and their combination. They also found that the amount of change during initial treatment strongly predicted long-term results, which argues for doing exposure thoroughly rather than briefly. I will combine exposure with cognitive work on the meaning of the thoughts.
Exposure Hierarchy
| Step | Exposure | Predicted distress (0 to 100) |
|---|---|---|
| 1 | Reading the word "drown" and writing a sentence about his fear | 30 |
| 2 | Holding the baby in the living room with his wife present | 35 |
| 3 | Leaving one kitchen knife in the drawer, unlocked | 45 |
| 4 | Holding the baby alone while his wife is in another room | 55 |
| 5 | Using a knife to cut food with the baby in a bouncer nearby | 60 |
| 6 | Carrying the baby up and down the stairs | 65 |
| 7 | Bathing the baby with his wife in the bathroom | 70 |
| 8 | Writing and recording a script of his feared drowning image and listening to it daily | 80 |
| 9 | Bathing the baby with his wife in the next room | 85 |
| 10 | Bathing the baby alone, then putting him to bed without checking his breathing | 95 |
Session Plan
Treatment will run sixteen weekly sessions of fifty minutes, with exposure practice at home every day. Sessions 1 and 2 provide psychoeducation, including the normality of intrusive thoughts and the evidence that they do not predict harm, build the formulation and the hierarchy, and introduce self-monitoring of obsessions and compulsions. Sessions 3 through 12 move through the hierarchy, beginning each step in session and assigning it as homework, with Mr. D. remaining in the situation until his distress falls by about half or until the session ends, without checking, reviewing or seeking reassurance. Cognitive work runs alongside exposure, examining beliefs such as "having this thought means I might do it." Imaginal exposure to the drowning script begins around session 8. Sessions 13 through 16 address relapse prevention, including what to do when thoughts return during stressful periods such as the baby's illnesses or a second pregnancy.
Reducing Reassurance
His wife will attend sessions 2, 6 and 12. Reassurance is a compulsion, and her well-meant answers maintain his doubt. Together we will agree on a supportive response she can give instead, such as "That sounds like the OCD; I know this is hard, and I'm here," and on a gradual reduction rather than an abrupt refusal. Clinicians often respond to intrusive harm thoughts in ways that worsen them; in a survey of 94 perinatal practitioners given a postpartum case of infant-harm obsessions, almost 70% failed to identify the symptoms as obsessive-compulsive, and most endorsed at least one contraindicated management strategy (Mulcahy et al., 2020). Removing the father from the baby or reassuring him repeatedly would be such a strategy here. Treatment for this father succeeds when he can bathe his son without being sure the thought will not come.
Medication
Because his OCD is severe and his sleep and mood are affected, I discussed adding a selective serotonin reuptake inhibitor, which has evidence in OCD, while continuing exposure therapy. He preferred, after hearing the options, to begin with therapy alone and revisit medication if his Y-BOCS has not fallen meaningfully by session 8. We agreed on that decision point.
Treatment Plan and Evaluation
Barriers were discussed in advance: his work schedule, the baby's sleep and the temptation to skip exposures on hard days. We built exposure practice into existing routines, such as the evening bath and diaper changes, so that it would not require extra time, and agreed that skipped practice would be discussed without judgment. Goals, agreed with Mr. D., are to bathe and care for his son alone, to stop nightly breathing checks and to reduce reassurance seeking to near zero. Outcomes will be measured with the Y-BOCS at baseline and sessions 4, 8, 12 and 16, with a target score below 14 and a reduction of at least 35%; the PHQ-9 monthly; and a daily log of compulsions. His family nurse practitioner will receive a letter, with his consent, explaining that the thoughts are obsessional and do not indicate risk, so that no unnecessary report is made. Follow-up visits at one, three and six months after treatment will support maintenance. Because the thoughts often return briefly during stress, the relapse prevention plan names early warning signs, such as a new urge to check the baby's breathing, and the first exposure he will repeat if they appear, so that a return of thoughts is treated as a cue to practice rather than as a failure of treatment.
Conclusion
Mr. D.'s unwanted thoughts of harming his son are obsessions, not intentions, and his avoidance, checking and reassurance seeking maintain them. After a safety assessment and a structured evaluation, he meets criteria for obsessive-compulsive disorder with good insight. Exposure and response prevention, delivered through a graded hierarchy over sixteen sessions with cognitive work and his wife's partnership, offers durable improvement, with medication held in reserve.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Beck, Q. M., Sachet, J., Cargnelli, C., Lathrop, B., Challacombe, F. L., & Fairbrother, N. (2026). Unwanted intrusive thoughts of infant-related sexual harm: Prevalence and assessment of safety. The Journal of Clinical Psychiatry, 87(1). https://doi.org/10.4088/JCP.25m15985
Fairbrother, N., Barr, R. G., Chen, M., Riar, S., Miller, E., Brant, R., & Ma, A. (2019). Prepartum and postpartum mothers' and fathers' unwanted, intrusive thoughts in response to infant crying. Behavioural and Cognitive Psychotherapy, 47(2), 129-147. https://doi.org/10.1017/S1352465818000474
Mulcahy, M., Rees, C., Galbally, M., & Anderson, R. (2020). Health practitioners' recognition and management of postpartum obsessive-compulsive thoughts of infant harm. Archives of Women's Mental Health, 23(5), 719-726. https://doi.org/10.1007/s00737-020-01026-y
Öst, L. G., Andersson, E., Clefberg, L., Fladvad, A., Havnen, A., Riise, E., Wahlund, T., & Wergeland, G. J. (2026). Long-term follow-up of cognitive behavior therapy for obsessive-compulsive disorder in adults and children: A systematic review and meta-analysis. Cognitive Behaviour Therapy. Advance online publication. https://doi.org/10.1080/16506073.2026.2696809
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing.
What the NURS 753 Week 4 instructions ask
In NURS 753 the first Case Analysis Evaluation comes in Module/Week 4, when the readings in Wheeler and the Kaplan and Sadock Synopsis turn to cognitive and behavioral psychotherapies. According to the course guide, each of the three case analyses works through a long-standing psychiatric symptom from assessment and diagnosis to therapeutic intervention and a plan of care, and expects students to apply knowledge of evidence-based psychotherapies to the management of the disorder. At least five references in current APA are required, and the course textbook may be one of them. What distinguishes these analyses from the diagnostic evaluations in NURS 751 is the therapy: the plan must show how the psychotherapy will actually be delivered.
How this NURS 753 Week 4 example is built
The analysis begins with the case: a software engineer referred by his family nurse practitioner after confessing to his wife that he has had thoughts of drowning their son during baths. A safety assessment follows, then a structured assessment with the Y-BOCS, depression screening and an interview with his wife. A differential compares OCD with postpartum depression, psychosis and generalized anxiety, and the DSM-5 diagnosis is stated with its insight specifier. The heart of the paper is the therapy: a cognitive behavioral formulation, a ten-step exposure hierarchy, a session plan for sixteen weeks, a protocol for reducing reassurance, the role of medication and how progress will be measured.
NURS 753 Week 4 grading rubric: where the points go
Case analysis evaluations are generally scored on the thoroughness of the assessment, the accuracy of the diagnosis and the reasoning of the differential, the selection of an evidence-based psychotherapy that fits the case, the specificity of the therapeutic intervention, a complete treatment plan with follow-up and outcome measures, and APA and reference requirements. In this course, instructors look most closely at whether the therapy is described as it would be delivered, with sessions, techniques, homework and what the clinician says, rather than named. Safety reasoning is essential whenever a patient reports thoughts of harm, and graders expect to see it before the diagnosis rather than after it.
NURS 753 Week 4 help: mistakes that cost points
Case analyses that reach the right diagnosis often lose points in the treatment section, where the psychotherapy appears as a single sentence such as "refer for CBT." Write the therapy out: the formulation that explains the symptom, the techniques you will use, a sample hierarchy or session agenda, homework and how you will know it is working. With intrusive harm thoughts, show that you can tell obsessions from intent, and avoid responses that reinforce the cycle, such as removing the patient from the baby or offering repeated reassurance. Use the DSM-5 for criteria, the textbook for method and recent studies for outcomes, and name the measures you will repeat so the reader can see how success will be judged.
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NURS 753 Week 4 questions, answered
What is the NURS 753 Case Analysis Evaluation?
One of three written case analyses in NURS 753, due in Module/Weeks 4, 6 and 7 for 100 points each, each carrying a case from assessment and diagnosis to an evidence-based psychotherapy and plan, with at least five sources.
Where can I find a free NURS 753 Week 4 sample paper?
The complete NURS 753 Week 4 case analysis of harm-focused OCD in a new father, including the ten-step exposure ladder, the sixteen-week session outline and every source, can be read here at no cost.
Are intrusive thoughts of harming a baby dangerous?
Research consistently finds that unwanted, intrusive harm thoughts are common in new parents and are not associated with harming the infant; the distress they cause reflects that they conflict with the parent's values.
What is exposure and response prevention?
A cognitive behavioral therapy for OCD in which the person gradually faces feared thoughts and situations while refraining from compulsions, so that anxiety falls and the feared outcome is not confirmed.
How effective is CBT for OCD in the long term?
A 2026 meta-analysis of 47 studies found response rates of about 70% after treatment and 69% at follow-up averaging 2.5 years, with no difference between exposure, cognitive therapy and combined approaches.
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