- Email: [email protected]
Cognitive behavioral treatment of obsessive-compulsive disorders: A commentary
408
Cognitive Behavioral Treatment of Obsessive-Compulsive Disorders: A Commentary D a v i d A. C l a r k , University o f N e w B r u n s w i c k This commentary discusses a number of issues that arise from the papers published in this special issue on cognitive behavioral treatment (CBT) of obsessive-compulsive disorders (OCD). The reasons for the recent shift toward a more cognitive perspective in the theory and treatment of OCD are discussed. A theoretical framework is proposed for understanding the concepts found in various cognitive theories of OCD. Furthermore, the common, core ingredients of CBT for obsessive and compulsive p~vblems are presented. The pitfalls and difficulties encountered by the clinician who offers CBT to individuals with OCD are discussed, and I conclude with a comment on the empirical status of the therapy.
BSESSIVE-COMPULSIVE DISORDERS (OCD) are a g r o u p o f anxiety disorders that can take a chronic a n d debilitating course with 1-year prevalence rates rep o r t e d as high as 2.1% for the general p o p u l a t i o n (Regier et al., 1993), a l t h o u g h Antony, Downie, a n d Swinson (1998) question w h e t h e r this estimate is too high because structured interviews, like the Diagnostic Interview Schedule, p r o d u c e m o r e false positives when diagnosing OCD. T h e distinguishing diagnostic criteria for OCD is the p r e s e n c e o f obsessions a n d / o r compulsions that cause significant distress o r i m p a i r m e n t in f u n c t i o n i n g (American Psychiatric Association, 1994). A c c o r d i n g to the Diagnostic and Statistical M a n u a l of Mental Disorders (DSM-1V,, A m e r i c a n Psychiatric Association, 1994), obsessions are "persistent ideas, thoughts, impulses, o r images that are e x p e r i e n c e d as intrusive a n d i n a p p r o p r i a t e a n d that cause m a r k e d anxiety or distress" (p. 418), whereas compulsions are "repetitive behaviors o r mental acts, the goal of which is to p r e v e n t o r r e d u c e anxiety or distress, n o t to provide pleasure or gratification" (p. 418). Typical examples o f obsessions are unwanted, intrusive a n d egodystonic (i.e., uncharacteristic o f the person) thoughts, images, o r impulses involving themes o f dirt, contamination, sex, accidents, aggression, dishonesty, blasphemy; a n d the like. Compulsions typically involve some ritualistic behavior such as washing, checking, o r d e r i n g , o r h o a r d i n g . Earlier behavioral theories o f OCD viewed obsessions as noxious c o n d i t i o n e d stimuli that elicit a significant d e g r e e o f anxiety o r distress, with compulsions serving as strategies for r e d u c i n g o r neutralizing the anxiety caused by the o c c u r r e n c e o f the obsession (Rachman & H o d g s o n , 1980).
O
Cognitive and Behavioral Practice 6, 4 0 8 - 4 1 5 , 1999
107%7229/99/408-41551.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. Continuing Education Quiz located on p. 469.
In the 1970s a behavioral t r e a t m e n t o f OCD was develo p e d based on this early l e a r n i n g m o d e l o f obsessions a n d compulsions. T h e t r e a t m e n t involved systematic exposure to the obsessions a n d any stimuli that would evoke them, as well as prevention o f any compulsive o r neutralizing behaviors that m i g h t be used to r e d u c e anxiety. T h e central tenet o f e x p o s u r e a n d response p r e v e n t i o n (ERP) t r e a t m e n t was that anxiety caused by the obsession would naturally habituate a n d so the frequency of the obsession a n d associated compulsive ritual would significantly decline with r e p e a t e d e x p o s u r e to the fear stimulus (i.e., obsession). ERP did prove to be a very successful form o f t r e a t m e n t for OCD, especially for those with washing and, to a lesser extent, checking rituals. O u t c o m e studies o f ERP indicate that a p p r o x i m a t e l y 70% to 80% of OCD patients who c o m p l e t e t r e a t m e n t show significant symptom i m p r o v e m e n t (Stanley & Turner, 1995). In a metaanalysis o f 24 o u t c o m e studies, Abramowitz (1996) rep o r t e d that ERP p r o d u c e d large effect sizes indicating that most patients e x p e r i e n c e d substantial reductions in OCD symptoms. If ERP has b e e n such an effective form o f t r e a t m e n t for OCD, why i n t r o d u c e a cognitive c o m p o n e n t to this t r e a t m e n t regimen? Is the shift from a behavioral to a cognitive focus justified, given the effectiveness o f ERP? Can we expect cognitive-behavior t h e r a p y (CBT) to significantly improve o n the effectiveness o f established behavioral t r e a t m e n t a p p r o a c h e s to OCD? A n u m b e r o f researchers have discussed reasons for advocating a cognitive perspective on theory, research, a n d t r e a t m e n t in OCD (Salkovskis, 1985; Whittal & McLean, 1999). First, a significant n u m b e r o f patients (20% to 30%) refuse to begin ERP o r t e r m i n a t e t r e a t m e n t p r e m a t u r e l y (Stanley & Turner, 1995). Second, long-term follow-up studies indicate that for many patients residual OCD symptoms r e m a i n even after an intensive course o f CBT (Whittal & McLean). Third, ERP has b e e n less effective with certain subtypes o f OCD, such as those with p u r e ob-
CBT of OCD Commentary sessions a n d no overt compulsions (Freeston & Ladouceur, 1999) o r individuals with compulsive h o a r d i n g (Frost & Steketee, 1999). Fourth, a significant n u m b e r o f individuals (20% to 30%) a p p e a r to be t r e a t m e n t resistant (Sookman & Pinard, 1999), failing to show significant i m p r o v e m e n t from either CBT o r p h a r m a c o t h e r a p y . Fifth, t h e r e are a variety o f psychological factors, such as low motivation, negative expectancies for t r e a t m e n t success, procrastination, a n d n o n c o m p l i a n c e , that may interfere with response to ERP. And, finally, the promin e n c e o f cognitive biases, dysfunctional beliefs, a n d e r r o n e o u s thinking in the d i s o r d e r suggests that the cognitive c o m p o n e n t o f OCD s h o u l d be addressed m o r e directly in any t r e a t m e n t regimen. This special series o f Cognitive and Behavioral Practice is devoted to the description, application, a n d discussion o f cognitive behavioral t r e a t m e n t o f OCD. T h e five p a p e r s in the series all focus on the d e v e l o p m e n t a n d application of different variants of CBT for t r e a t m e n t of OCD, or specific subtypes o f OCD. Each o f the p a p e r s presents new, innovative, a n d very p r o m i s i n g a p p r o a c h e s to the t r e a t m e n t o f OCD. However, given that CB t r e a t m e n t for OCD is still in its infancy, relatively few systematic controlled o u t c o m e studies have b e e n c o n d u c t e d to verify the effectiveness o f the interventions advocated in these papers. Nevertheless, most clinicians will agree that new a n d innovative psychological interventions for OCD are n e e d e d , a n d so these papers p r e s e n t the r e a d e r with the very latest original ideas for the cognitive t r e a t m e n t o f obsessive a n d compulsive problems. In the r e m a i n d e r of this c o m m e n t a r y I would like to draw o u t some of the similarities in theory, issues, a n d t r e a t m e n t that cut across these various papers. Despite differences in the OCD symptomatology targeted a n d in the particular intervention strategies emphasized, I will argue that t h e r e is a c o m m o n o r s t a n d a r d CBT theory a n d t r e a t m e n t perspective that can be d i s c e r n e d in these papers.
Cognitive Theory o f OCD O n e of the first impressions one obtains from r e a d i n g the papers in this special series is the critical role that theory plays in cognitive-behavioral t r e a t m e n t of OCD. Freeston a n d L a d o u c e u r (1999) p r e s e n t their cognitive m o d e l o f obsessive thoughts, S o o k m a n a n d Pinard (1999) describe a cognitive-developmental perspective o f OCD, Frost a n d Steketee (1999) discuss a cognitivebehavioral formulation for compulsive hoarding, and Whittal a n d McLean (1999) explain the theoretical tenets o f their g r o u p CBT, drawing on the theoretical work o f Salkovskis (1985, 1996), van O p p e n a n d Arntz (1994), a n d Freeston, Rhdaume, a n d L a d o u c e u r (1996). This very close link between theory a n d t h e r a p y is integral to the practice of CBT for OCD.
409
Cognitive behavioral t r e a t m e n t for OCD is n o t defined in terms o f a u n i q u e set of intervention strategies d e v e l o p e d exclusively for the t r e a t m e n t o f obsessions a n d compulsions. Instead, t h e r a p e u t i c tasks such as exposure, response prevention, construction of a fear hierarchy, self-monitoring, cognitive restructuring, a n d behavioral e x p e r i m e n t s are "borrowed" f r o m established cognitive a n d behavioral t r e a t m e n t packages a p p l i e d to o t h e r disorders. However, CBT does r e p r e s e n t a u n i q u e way o f conceptualizing obsessive a n d compulsive p r o b l e m s . It is the theoretical perspective o r how one u n d e r s t a n d s OC pheCBT cannot be n o m e n a that is u n i q u e to CBT. implemented W h a t follows in CBT, then, is the i m p l e m e n t a t i o n o f this simply by following m o d e l in each therapy session. a treatment This also means that treatmanual. Rather, m e n t manuals o f CBT m u s t at the outset devote considerthe clinician using able space to a fairly detailed CBT for OCD must exposition o f the cognitive have an advanced m o d e l o f OCD so that the clinician is able to e d u c a t e the understanding of client into the CB m o d e l bethe cognitive basis fore any specific interventions of obsessiveare i n t r o d u c e d . T h e r e are a n u m b e r o f imcompulsive plications that follow from this phenomena in very tight c o u p l i n g o f theory order to conduct a n d practice. First, a t h o r o u g h assessment a n d case formulathe treatment tion is necessary before impleeffectively. m e n t i n g a t r e a t m e n t strategy. Each of the authors in the p r e s e n t series e m p h a s i z e d the necessity o f a detailed assessment, especially of the cognitive a n d behavioral processes that u n d e r l i e OC p h e n o m e n a . Cognitive theory o f OCD informs the clinician of the cognitive constructs that must be identified d u r i n g the assessment process, which are then used to develop a viable t r e a t m e n t program. Second, the cognitive m o d e l o f OCD guides a n d directs the i m p l e m e n t a t i o n of CBT for each patient. T h e initial sessions are devoted to e d u c a t i n g the p a t i e n t a b o u t the cognitive m o d e l o f OCD. A n u m b e r o f the authors e m p h a s i z e d the i m p o r t a n c e o f this c o m p o n e n t o f the t r e a t m e n t package. We know from clinical e x p e r i e n c e a n d research on cognitive therapy for depression o r panic d i s o r d e r that patients must "buy into" a cognitive e x p l a n a t i o n for their symptoms if they are to benefit from cognitive intervention strategies. Thus, in CBT, cognitive t h e o r y is so i m p o r t a n t that it is directly a n d explicitly taught to the p a t i e n t at the outset o f treatment. A third implication of this tight c o u p l i n g between theory a n d practice is that the cognitive behavioral therapist
410
Clark Table 1 Summary of the Central Constructs Shared by Cognitive Models of OCD 1. Normality of intrusions: assumption that normal and pathological
intrusive thoughts lie on a continuum 2. Fault), appraisals of intrusions: the core problem in OCD is the
faulty appraisal of unwanted intrusive thoughts or obsessions 3. Neutralization and avoidance: presence of overt or covert
neutralizing strategies will increase the salience of the obsession, and avoidance will reinforce faulty interpretations of the intrusive thought. 4. Dysfunctional beliefs: the faulty appraisals of the obsession-prone individual are rooted in latent maladaptive beliefs or schemas involving themes of threat, dangm; responsibility, uncertainty, importance of control, perfectionism, and the like.
must have a t h o r o u g h u n d e r s t a n d i n g of cognitive theory o f OCD. CBT c a n n o t be i m p l e m e n t e d simply by following a t r e a t m e n t manual. Rathe1; the clinician using CBT for OCD must have an advanced u n d e r s t a n d i n g o f the cognitive basis o f obsessive-compulsive p h e n o m e n a in ord e r to c o n d u c t the t r e a t m e n t effectively. A n u m b e r of writers have p r e s e n t e d cognitive models of OCD (Clark & P u r d o n , 1993; Freeston et al., 1996; Rachman, 1997, 1998, Salkovskis, 1985, 1989, 1996; van O p p e n & Arntz, 1994; Wells & Matthews, 1994). Alt h o u g h there are some distinctive features a m o n g these different accounts, there is a r e m a r k a b l e d e g r e e of consensus on the essential c o m p o n e n t s for a theoretical framework on which the various cognitive m o d e l s o f OCD are constructed. This theoretical framework is evid e n t in the c u r r e n t series o f papers. T h e following constructs, then, can be f o u n d in most cognitive models of OCD. These have b e e n s u m m a r i z e d in Table 1. The Normality o f Intrusions Most CBT models begin by recognizing that u n w a n t e d intrusive thoughts, images, a n d impulses occur as a normal p a r t o f h u m a n e x p e r i e n c e (i.e., R a c h m a n & de Silva, 1978). ~rhat distinguishes n o r m a l from a b n o r m a l obsessions is a m a t t e r o f d e g r e e r a t h e r than kind. Faulty Appraisals o f Intrusions A c c o r d i n g to cognitive theories, the core p r o b l e m in OCD is the faulty appraisal of u n w a n t e d intrusive thoughts, images, o r impulses. A variety o f pathological appraisal o r interpretative processes have b e e n implicated in the pathogenesis o f obsessions. These include appraisals o f inflated p e r s o n a l responsibility, i m p o r t a n c e o f thoughts, thought-action fusion, overestimation o f threat or danger, negative consequences of ineffective t h o u g h t control, i n t o l e r a n c e o f uncertainty, a n d perfectionistic standards. W h i c h particular appraisal process is e m p h a s i z e d in a m o d e l will d e p e n d on the theorist a n d
the particular OC p h e n o m e n a u n d e r consideration. For example, faulty appraisals o f personal responsibility may be most salient with "loss o f control" obsessions involving aggressive or i n a p p r o p r i a t e sexual behavior, whereas perfectionistic standards in the form o f indecisiveness may be most p r o m i n e n t in h o a r d i n g (Frost & Steketee, 1999). However, what makes all o f these appraisal processes pathological is that they offer evaluations that exaggerate the sense of personal significance a n d threat o f u n w a n t e d intrusive thoughts, t h e r e b y l e a d i n g to an escalation in the frequency, intensity, a n d salience o f the intrusions (Rachman, 1997, 1998). Neutralization and Avoidance Cognitive m o d e l s o f OCD c o n t i n u e to recognize that neutralization, w h e t h e r in the form o f t h o u g h t control strategies, o r behavioral or mentalistic rituals, plays an i m p o r t a n t role in the onset a n d persistence of OCD. T h e r e is some d i s a g r e e m e n t over w h e t h e r neutralization strategies function to r e d u c e anxiety o r o n e o f the appraisal processes such as an inflated sense o f responsibility. Whatever the case, there is b r o a d a g r e e m e n t a m o n g CBT researchers that neutralization a n d o t h e r compulsive behavior increases the salience of the u n w a n t e d obsessive thought. Avoidance of situations or stimuli will also increase the salience o f obsessions by reinforcing the faulty i n t e r p r e t a t i o n s o f the p a t i e n t (e.g., "I feel b e t t e r when avoiding public washrooms, so these must be dangerous places"). Dysfunctional Beliefs or Schemas Each o f the authors in this series r e c o g n i z e d that underlying maladaptive beliefs may be responsible for the faulty appraisals obsession-prone individuals g e n e r a t e in response to their u n w a n t e d intrusive thoughts. T h e content of these maladaptive beliefs matches the focus evid e n t in the appraisal processes. Thus, themes o f threat, danger, perfectionism, uncertainty, responsibility, and loss of control characterize the dysfunctional beliefs of the obsessive-compulsive individual. However, it must be r e c o g n i z e d that the c o n t e n t o f the dysfunctional beliefs associated with different subtypes o f OCD may be u n i q u e to that particular subtype, such as the collecting a n d discarding beliefs of h o a r d e r s (Frost & Steketee, 1999). Currently an international g r o u p o f OCD researchers is working on the d e v e l o p m e n t o f measures to assess dysfunctional beliefs a n d appraisals in OCD (ObsessiveCompulsive Cognitions Working Group, 1997).
Cognitive Behavior Therapy for OCD Despite nuances in the various CBT t r e a t m e n t app r o a c h e s described by the authors in this series, we d o
CBT of OCD Commentary
Table 2 Common Therapeutic Ingredients in Cognitive-Behavioral Treatments of OCD 1. Education on the cognitive model', initially the client is provided with a cognitive explanation for the persistence of obsessions and compulsions as well as the treatment rationale. 2. Identification offaulty appraisals, neutralization, and avoidance: clients are trained to recognize their faulty interpretations of the obsession as well as any neutralizingstrategies and avoidance behaviors intended to minimize the distressing quality of the obsession. 3. Cognitive restructuring offaulty appraisals: through collaboration and guided discovery clients are taught to cognitivelychallenge their erroneous appraisals and maladaptive beliefs of the obsession. 4. Behavioral experimentation: exposure, response prevention, and other behavioral interventionsare used to test out the exaggerated importance and catastrophic consequences clients impute to the obsession. 5. Alternative interpretations for the obsession: clients are taught to accept a more adaptive and realistic alternative explanation for the obsession. 6. Cc~rreetingdysfunctional beliefs: treatment gaius can be maintained only if the latent core dysfunctional beliefs that give rise to the faulty appraisals of the obsession are modified. 7. Relapse prevention: clients are taught self-help strategies to implement in the face of an anticipated resurgence of obsessive and compulsive symptoms
see a n u m b e r of c o m m o n elements in their t r e a t m e n t packages. Of course these elements take a different orie n t a t i o n or focus d e p e n d i n g o n the obsessive-compulsive p h e n o m e n a u n d e r consideration. Having said this, the following are some c o m m o n therapeutic ingredients that are f o u n d in most cognitive-behavioral interventions for OCD. A s u m m a r y of these seven c o m m o n therapeutic c o m p o n e n t s can be f o u n d in Table 2.
Educating the Client to the Cognitive Model As n o t e d previously, each of the authors emphasizes the i m p o r t a n c e of educating the patient to the cognitive m o d e l of OCD. It is critical that this educational aspect of CBT n o t degenerate into an intellectual exercise; rather, the m o d e l should be illustrated using the patient's own obsessions, appraisals, beliefs, a n d neutralizing strategies (Freeston & Ladouceur, 1999). If patients "buy into" the cognitive explanation for their obsessions a n d compulsions, then they are more likely to be motivated for treatment, collaborate in the identification of dysfunctional thinking, a n d complete homework assignments. O n the other hand, it will be very difficult for patients to adopt a collaborative stance o n interventions that focus o n the identification a n d modification of cognitions if they rem a i n skeptical over the relevance of the cognitive m o d e l for their condition. In addition, Freeston a n d L a d o u c e u r (1999) n o t e d
that a n o t h e r reason for p r e s e n t i n g the cognitive m o d e l is to normalize patients' experience of obsessions by showing t h e m the c o n n e c t i o n between pathological obsessions a n d the u n w a n t e d intrusions that occur in the normal population. However, one should n o t u n d e r e s t i m a t e how difficult it may be to convince s o m e o n e that the onset a n d persistence of their obsessions is affected by their faulty interpretations. Many patients come into therapy . . . . /' with strongly held behefs that their OCD as a d~sease stemm i n g from a "chemical imbalance" or "genetic deficit." For these patients, the educational phase of CBT may take considerably l o n g e r t h a n o n e to two sessions described in the t r e a t m e n t manuals. Educating the client into the cognitive m o d e l of OCD will also include a n i n t r o d u c t i o n to the c o n c e p t of "faulty appraisals" of the obsession. At this initial stage of therapy, the client is simply i n t r o d u c e d to the idea of appraisals or "giving i m p o r t a n c e to the obsession" as the primary reason for the thought's persistence. In educati n g the client, the clinician will also refer to the different types of appraisals that u n d e r l i e obsessional p h e n o m ena, a n d will suggest to the client the possibility that these appraisals are faulty or incorrect. However, n o att e m p t is m a d e to persuade clients that their appraisals are faulty. Rather, in tile second phase o f treatment, the clinician uses collaboration a n d guided discovery in order for clients to test o u t the realistic or faulty basis of their appraisals. Identifying Faulty Interpretations, Neutralizing Strategies, and Avoidance Patterns All of the authors emphasize that patients must be trained to recognize the faulty appraisals a n d futile neutralizing behavior a n d thought-control strategies they engage in once an obsessional t h o u g h t intrudes into consciousness. Freeston a n d L a d o u c e u r (1999) use daily selfm o n i t o r i n g a n d other exercises to help clients learn the external a n d i n t e r n a l factors, such as anxiety, avoidance, magical thinking, a n d reassurance seeking, that strengthen a faulty appraisal process. Whittal a n d McLean (1999) note that it is i m p o r t a n t that patients be trained to distinguish between the intrusive t h o u g h t a n d the appraisals or interpretations they generate a b o u t the intrusion. This distinction will be difficult for some patients who have become utterly preoccupied with the obsessional thought. Frost a n d Steketee (1999) c o m m e n t e d that hoarders may find it particularly difficult to identify the triggering intrusive t h o u g h t a n d its interpretation. I n addition, all of the authors n o t e d that the identification of covert or overt neutralizing rituals, avoidance patterns, a n d other maladaptive coping strategies is a critical c o m p o n e n t of CBT for obsessions a n d compulsions. Behavioral change is still an i m p o r t a n t part of CBT, despite the increased emphasis o n cognitive factors.
411
412
Clark
Cognitive Restructuring of Faulty Appraisals Freeston a n d L a d o u c e u r (1999), Whittal a n d McLean (1999), a n d Frost a n d Steketee (1999) all discuss various a p p r o a c h e s that can be used to cognitively challenge the faulty appraisals a n d maladaptive beliefs that constitute the cognitive basis to the patient's obsessions a n d compulsions. All emphasize that the use of logical persuasion or "cognitive challenge" must be d o n e in a collaborative For a h o m e w o r k m a n n e r with the use o f Socratic dialogue a n d g u i d e d assignment, he discovery. Whittal and McLean was to s p e n d 30 provide patients with a list o f minutes each day questions that they can use to cognitively challenge the vafocused on the lidity of their interpretations murderous thought when intrusive thoughts ocand to avoid any cur. My own clinical experience in c o n d u c t i n g CBT with attempt to obsessional patients is that suppress the they can be very rigid, narrow, thought. After 1 a n d inflexible when trying to explore alternative perspecweek he reported tives a n d a r g u m e n t s to their a dramatic interpretations and beliefs. For reduction in the this reason, cognitive correction of faulty interpretations frequency and a n d beliefs may play a secondlevel of distress ary role to the use of behavassociated with ioral experiments or what Beck a n d colleagues refer to as the murderous "empirical hypothesis-testing" thought; he did (Beck, Rush, Shaw, & Emery, not feel an increase 1979). This is n o t to imply that in murderous "cognitive" p r o c e d u r e s are impulses. less useful in treating obsessions a n d compulsions than e x p o s u r e tasks. Instead, exposure-based strategies may be necessary to challenge core dysfunctional beliefs a b o u t the i m p o r t a n c e o f the obsessional thought. How the clinician explains the o u t c o m e o f the e x p o s u r e exercise to the client will d e t e r m i n e w h e t h e r it facilitates change in dysfunctional OCD beliefs (e.g., "Notice that when you did n o t check, n o t h i n g terrible h a p p e n e d to you, a n d your distress eventually abated"). In this way, both "cognitive" a n d "behavioral" interventions are necessary to modify core dysfunctional belief stnmtures in OCD. Behavioral "Experiments" Despite the limitations o f ERP n o t e d previously, there can be little d o u b t that exposure a n d response prevention are vital to CBT o f OCD. T h e a m o u n t o f therapy time devoted to ERP will vary d e p e n d i n g on the particu-
lar OCD subtype, with, for example, ERP playing a very p r o m i n e n t role in the t r e a t m e n t o f compulsive washers. However, the function o f ERP in CBT is different than the function it plays in behavior therapy. In CBT, exposure a n d response p r e v e n t i o n exercises are c o n s i d e r e d critical for testing o u t faulty appraisals a n d maladaptive beliefs. This is n o t to d e n y that h a b i t u a t i o n to anxiogenic obsessions may also occur. However, in CBT, e x p o s u r e is used to challenge existing ideas a b o u t the i m p o r t a n c e a n d c o n s e q u e n c e of obsessions a n d compulsions. To illustrate this point, a few years ago I treated a m a n who h a d very upsetting intrusive thoughts o f losing control a n d m u r d e r i n g his wife with a hammer. H e believed that the m o r e he h a d this thought, the m o r e likely it would be that he would lose control a n d c o m m i t m u r d e r (i.e., appraisals o f overestimated threat, inflated responsibility, thought-action fusion, and i m p o r t a n c e of thoughts). F o r a h o m e w o r k assignment he was to s p e n d 30 minutes each day focused on the m u r d e r o u s t h o u g h t a n d to avoid any a t t e m p t to suppress the t h o u g h t (exposure a n d response prevention). After 1 week he r e p o r t e d a dramatic r e d u c t i o n in the frequency a n d level of distress associated with the m u r d e r o u s thought. More importantly, he noticed that despite s p e n d i n g m o r e time with the obsessive thought, he d i d n o t feel an increase in m u r d e r o u s impulses. In fact, he got b o r e d with the exercise a n d ceased to do it after a few days. This e x p e r i e n c e p r o v i d e d clear behavioral evidence that his belief a n d i n t e r p r e t a t i o n a b o u t the dangerousness of his obsessive t h o u g h t was incorrect. It should be n o t e d that ERP is n o t the only effective behavioral intervention for challenging faulty cognitions. Freeston a n d L a d e u c e u r (1999) describe the "camel exercise" to challenge beliefs in the controllability o f intrusive thoughts, Frost a n d Steketee (1999) use an exercise called the "purgatory table" to identify a n d challenge beliefs a n d interpretations a b o u t discarding possessions, Whittal a n d McLean (1999) have patients survey friends a n d colleagues to challenge the patient's estimation of threat associated with a particular situation, a n d Sookm a n a n d Pinard (1999) m e n t i o n the use o f affect expression to challenge the belief that strong negative affect must be avoided. In sum, behavioral exercises a n d empirical-hypothesis testing may be particularly critical in CBT, n o t only to address the extensive neutralizing rituals a n d avoidance patterns that may be present, b u t also to prevent therapy sessions from slipping into a destructive form o f defensive intellectualization (i.e., an academic discussion of the cognitive m o d e l a n d its application to o n e ' s condition).
Development of Alternative Interpretations T h e r e can be little d o u b t that o n e o f the most overl o o k e d c o m p o n e n t s o f CBT is the realization that the CB
CBT of OCD C o m m e n t a r y therapist must work with patients on the d e v e l o p m e n t of alternative, h e a l t h i e r m o d e s o f thinking. Whittal a n d McLean (1999) d i d note that they s p e n d time in the latter p a r t of their t r e a t m e n t p r o g r a m on the d e v e l o p m e n t of alternative appraisals a n d beliefs. It is n o t e n o u g h for t h e r a p y to challenge the faulty appraisals a n d maladaptire beliefs o f the obsessional patient. T r e a t m e n t effects will last only to the e x t e n t that obsession-prone individuals develop s t r o n g e r beliefs in m o r e functional interpretations o f their intrusive thoughts. F o r example, if a patient begins to d o u b t that "thinking a b o u t stabbing a f r i e n d means that I could stab him," t h e n that individual must a d o p t a different i n t e r p r e t a t i o n o f the intrusive thought. If the t h o u g h t is n o t an i n d i c a t i o n o f latent homicidal tendencies, then where d o these thoughts c o m e from? W h a t do they mean? Why d o we have them? A credible alternative e x p l a n a t i o n for these intrusions m u s t be available to patients if they are to a b a n d o n their maladaptive thinking patterns.
Correcting Dysfunctional Beliefs A n u m b e r of authors note that CBT does n o t focus only o n the appraisals o f obsessions but, later in treatment, o n e must shift the t h e r a p e u t i c a g e n d a to the identification a n d c o r r e c t i o n o f the maladaptive beliefs that l e a d to faulty appraisals. Work is currently in progress to isolate the core, critical beliefs o f OCD a n d to develop valid a n d reliable measures o f these beliefs (ObsessiveCompulsive Cognitions Working G r o u p , 1997). We assume that t r e a t m e n t gains from CBT will be m a i n t a i n e d only if the core u n d e r l y i n g maladaptive beliefs are modified. Thus the correction of dysfunctional OCD beliefs a n d assumptions may be necessary to r e d u c e relapse a n d r e o c c u r r e n c e o f OC symptoms.
Relapse Prevention Relapse prevention must be w o r k e d into CBT programs if t r e a t m e n t gains are to be maintained. Neziroglu, Stevens, Yaryura-Tobias, a n d H o f f m a n (1999) identified a n u m b e r of factors that may be associated with p o o r response to treatment. Whittal a n d McLean (1999) provide patients with a list o f strategies they can use to deal with intrusive thoughts after t h e r a p y has ceased. Given the c h r o n i c n a t u r e o f OCD, relapse p r e v e n t i o n must be built into each CBT regimen.
Pitfalls in Cognitive-Behavioral Treatment of OCD Several of the authors in this series raise a n u m b e r o f interesting p r o b l e m s that can arise when e m p l o y i n g cognitive-behavioral a p p r o a c h e s to OCD (Freeston & Ladouceur, 1999; Frost & Steketee, 1999; Neziroglu et aL, 1999; Whittal & McLean, 1999; see also c o m m e n t s by van Op-
413
p e n & Arntz, 1994). I would like to briefly h i g h l i g h t t h r e e of the complications. First, the therapist must identify occasions when patients turn t h e r a p e u t i c interventions into neutralizing strategies. As an example, I treated a y o u n g m a n who suffered with obsessional r u m i n a t i o n s involving u n w a n t e d sex a n d violence. H e e x p e r i e n c e d a significant r e d u c t i o n in the frequency a n d intensity o f his obsessions after b e i n g t a u g h t to cognitively challenge the faulty appraisal that "these violent thoughts m e a n that t~a m a dangerous p e r s o n who m i g h t b e c o m e violent." However, a few years later he again contacted me, r e p o r t i n g that the violent thoughts h a d r e t u r n e d . Interestingly, he was compulsively m o n i t o r i n g these thoughts a n d c h a l l e n g i n g t h e m each time they occurred. T h e p r o b l e m is that the cognitive restructuring was now b e i n g used as a thoughtcontrol strategy, a n d as such increased the salience of the viCB therapists must olence thoughts. So the first be vigilant that p o i n t o f intervention was to discontinue the use o f cognitheir therapeutic tive restructuring. Freeston a n d interventions are Ladeuceur (1999) offer some not converted by very practical advice on how therapists can distinguish bepatients into s o m e tween responses that are in form of neutralizing aid of neutralizing a n d those ritual, thoughtthat constitute a healthy evaluation of the intrusion. control strategy, A s e c o n d c o m p l i c a t i o n in or reassurance. c o n d u c t i n g CBT for obsessional p r o b l e m s is the possibility that patients will use the t h e r a p e u t i c support, advice, a n d o t h e r cognitive interventions as reassurance against the threat or d a n g e r they perceive from the obsession. Freeston a n d L a d o u c e u r (1999) note that reassurance seeking is a form of neutralization that can increase the perceived i m p o r t a n c e o f the intrusive thought. W h e n patients directly solicit reassurance f r o m the therapist o r significant others, Freeston a n d L a d o u c e u r suggest that individuals r e s p o n d to the p a t i e n t in a calm, nonaggressive manner, emphasizing that they will n o t provide the reassurance the p a t i e n t seeks. Whittal a n d M c L e a n (1999) c o m m e n t that patients can turn a healthy, alternative appraisal into a form o f reassurance. Thus, CB therapists must be vigilant that their t h e r a p e u t i c interventions are n o t converted by patients into some form o f neutralizing ritual, thought-control strategy, or reassurance. Finally, a n u m b e r o f authors discuss the p r o b l e m o f low motivation a n d n o n c o m p l i a n c e with h o m e w o r k assignments, which will u n d e r m i n e the t r e a t m e n t integrity of CBT (see Frost & Steketee, 1999; Nezrioglu et al., 1999). These p r o b l e m s are n o t u n i q u e to OCD o r CBT. Low motivation a n d n o n c o m p l i a n c e will r e d u c e the effectiveness of any psychological intervention. However, it
414
Clark
m a y be that t h e s e p r o b l e m s are especially p r o m i n e n t in obsessive a n d c o m p u l s i v e disorders. O C D is a very c h r o n i c c o n d i t i o n a n d so individuals will o f t e n restructure t h e i r lives a r o u n d t h e i r symptomatology. Thus, t h e r e d u c t i o n o r e l i m i n a t i o n o f obsessive-compulsive sympt o m s m i g h t b e p e r c e i v e d as a n attack o n an i n t e g r a l p a r t o f o n e ' s p e r s o n a l identity. If o n e adds to this the very h i g h level o f f e a r a n d anxiety associated with obsessions a n d t h e situations t h a t t r i g g e r t h e m , t h e n it is u n d e r s t a n d a b l e why s o m e p a t i e n t s with O C D find it difficult to c o m m i t t h e m s e l v e s to therapy. A t the very least, t h e CB t h e r a p i s t m u s t d e a l directly with low m o t i v a t i o n a n d n o n c o m p l i a n c e o f h o m e w o r k a s s i g n m e n t s by i d e n t i f y i n g a n d chall e n g i n g the t h o u g h t s a n d beliefs that m i g h t u n d e r l i e amb i v a l e n c e for t r e a t m e n t .
Conclusion T h e p a p e r s in this series d e s c r i b e the a p p l i c a t i o n o f c o g n i t i v e - b e h a v i o r a l i n t e r v e n t i o n for t h e t r e a t m e n t o f obsessive a n d c o m p u l s i v e s y m p t o m s . D e s p i t e the t r e a t m e n t i n n o v a t i o n a n d p r o m i s e r e p r e s e n t e d in t h e s e papers, it m u s t b e r e a l i z e d t h a t the effectiveness a n d clinical utility o f CB t r e a t m e n t f o r O C D is n o t yet p r o v e n . We d o have s o m e case r e p o r t s that this t r e a t m e n t a p p r o a c h can be effective (Frost & S t e k e t e e , 1999; L a d o u c e m ; F r e e s t o n , G a g n o n , T h i b o d e a u & D u m o n t , 1995; K e a r n e y & Silverm a n , 1990; Salkovskis & Warwick, 1985; S o o k m a n & Pinard, 1999). As well, a few clinical o u t c o m e studies have b e e n p u b l i s h e d w h i c h a g a i n s u p p o r t the clinical effectiveness o f C B T for obsessive a n d c o m p u l s i v e s y m p t o m s (Emm e l k a m p & Beens, 1991; E m m e l k a m p , Vissel; & H o e k stra, 1988; F r e e s t o n et al., 1997). T h e r e are also a n u m b e r o f clinical o u t c o m e trials o f C B T in p r o g r e s s (see Frost & Steketee, 1999; Whittal & M c L e a n , 1999), so we s h o u l d b e in a m u c h b e t t e r p o s i t i o n within the n e x t c o u p l e o f years to j u d g e the effectiveness o f C B T for obsessivec o m p u l s i v e disorders. In t h e i n t r o d u c t i o n I a r g u e d that the cognitive innovations r e p o r t e d in these p a p e r s r e p r e s e n t an i m p o r t a n t dev e l o p m e n t for the t r e a t m e n t o f O C D . However, at this p o i n t we d o n o t have any systematic e m p i r i c a l e v i d e n c e that the cognitive c o m p o n e n t o f C B T adds significantly to the effectiveness o f psychological t r e a t m e n t for O C D bey o n d t h e established effects o f ERP. In addition, we d o n o t k n o w w h e t h e r CBT significantly r e d u c e s the t r e a t m e n t refusal a n d d r o p o u t rates s e e n with ERP, n o r is t h e r e any evi d e n c e that C B T p r o d u c e s m o r e c o m p l e t e remission o f obsessive-compulsive s y m p t o m s o r r e d u c e s relapse a n d reo c c u r r e n c e rates. It is also n o t known w h e t h e r CBT is effective with obsessional patients w h o are drug-refractory o r t r e a t m e n t resistant, a l t h o u g h the results o f S o o k m a n a n d P i n a r d (1999) are e n c o u r a g i n g . N o r is it k n o w n w h e t h e r C B T can r e a d d r e s s factors that u n d e r m i n e treat-
m e n t effectiveness like low m o t i v a t i o n a n d n o n c o m p l i a n c e with ERP. Clearly, t h e r e is a g r e a t deal o f e m p i r i c a l research, t h e o r e t i c a l e l a b o r a t i o n , a n d clinical r e f i n e m e n t that is n e e d e d b e f o r e C B T b e c o m e s an established f o r m o f t r e a t m e n t for O C D . Until then, the c u r r e n t w o r k suggests that C B T offers a r e f r e s h i n g a n d highly p r o m i s i n g n e w perspective o n the t r e a t m e n t o f O C D .
References Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A metaanalysis. Behavior Therap3; 27, 583-600. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Antony, M. M., Downie, E, & Swinson, R. R (1998). Diagnostic issues and epidemiology in obsessive-compulsive disorder. In R. R Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessivecompulsive disorder: Theory, research and treatment (pp. 3-32). New York: Guilford Press. Beck, A. T., Rush, A.J., Shaw, B. E, & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Clark, D. A., & Purdon, C. (1993). New perspectives for a cognitive theory of obsessions. Australian P~ychologist, 28, 161-167. Emmelkamp, R M. G., & Beens, H. (1991). Cognitive therapy with obsessive-compulsive disorder: A comparative evaluation. Behavior Research and Therapy, 29, 293-300. Emmelkamp, R M. G., Visser, S., & Hoekstra, R.J. (1988). Cognitive therapy vs. exposure in vivo in the treatment of obsessive compulsives. Cognitive Therapy and Research, 12, 103-114. Freeston, M. H., & Ladouceur, R. (1999). Exposure and response prevention for obsessional thoughts. Cognitive and Behavioral Practice, 6, 362-383. Freeston, M. H., Ladoucem; R., Gagnon, E, Thibodeau, N., Rhaume, J., Letarte, L., & Bujold, A. (1997). Cognitive-behavioral treatment of obsessive thought.s: A controlled study. Journal of Consulting and Clinical Psychology, 65, 405-413. Freeston, M. H., Rhfiaume, J., & Ladouceur, R. (1996). Correcting fault), appraisals of obsessive thoughts. BehaviourResearch and Therapy, 13, 459-470. Frost, R. O., & Steketee, G. (t999). Issues in the treatment of compulsive hoarding. Cognitive and Behavioral Practiee, 6, 397-407. Kearney, C. A., & Silverman, W. K. (1990). Treatment of an adolescent with obsessive-compulsive disorder by alternating response prevention and cognitive therapy: An empirical analysis. Journal of Behavior Th.erapy &Experimental Psychiat~?~, 21, 39-47. Ladouceur, R., Freeston, M. H., Gagnon, E, Thibodeau, N., & Dumont, J. (1995). Cognitive-behavioral treatment of obsessions. Behavior Modification, 19, 247-257. Neziroglu, E, Stevens, K. R, ~aryaara-Tobias, J. A., & Hoffman, J. H. (1999). Assessment, treatment parameters and prognostic indicators for patients with obsessive-compulsive spectrum disorders. Cognitive and Behavioral Practice, 6, 345-350. Obsessive-Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder: Behaviour Research and Therapy, 35, 667-682. Rachman, S.J. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793-802. Rachman, S.J. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36, 385-401. Rachman, S., & de Silva, E (1978). Abnormal and normal obsessions. Behaviour Resea~ch and Therapy, 16, 233-248. Rachman, S.J., & Hodgson, R.J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall. Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B.Z., & Goodwin, E K. (1993). The de facto US Mental and Addictive Disorders Service System: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85 - 94.
Series R e s p o n s e : C o m p l i a n c e a n d U n d e r s t a n d i n g OCD Stanley, M. A., & Turner, S. M. (1995). Current status of pharmacological and behavioral treatment of obsessive-compulsive disorder. Behavior Therapy, 26, 163-186. Van Oppen, R, & Arntz, A. (1994). Cognitive therapy for obsessivecompulsive disorder. Behaviour Researeh and Therapy, 32, 79-88. Wells, A., & Matthews, G. (1994). Attention and emotion: A elinicalperspecrive. Hove, UK: Lawrence Erlbaum. Whittal, M. L., & McLean, R D. (1999). CBT for OCD: The rationale, protocol, and challenges. Cognitive and Behavioral Practice, 6, 383396.
Salkovskis, R M. (1985). Obsessive-compulsive problems: A cognitivebehavionral analysis. Behaviour Research and Therapy, 23, 571-583. Salkovskis, R M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682. Salkovskis, E M. (1996). Cognitive-behavioural approaches to the understanding of obsessional problems. In R. Rapee (Ed.), Current controversies in the anxiety disorders (pp. 103-133). New York: Guilford. Salkovskis, R M., & Warwick, H. M. C. (1985). Cognitive therapy of obsessive-compulsive disorder: Treating treatment failures. Behavioural Psychotherapy, 13, 243-255. Salkovskis, E M., & Westbrook, D. (1989). Behaviour therapy and obsessional rumination: Can failure be turned into success? Behaviour Research and Therapy, 27, 149-160. Sookman, D., & Pinard, G. (1999). Integrative cognitive therapy for obsessive-compulsive disorder: Focus on multiple schemas. Cognitive and Behavioral Practice, 6, 351-362.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
415
Address correspondence to David A. Clark, Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, E3B 6E4 Canada; e-maih [email protected]. Received: June 18, I998 Accepted: October8, 1998
•
•
•
•
•
•
¢,
•
•
4,
•
•
•
•
•
Series Response: Compliance and Understanding OCD Jonathan
B. G r a y s o n , A n x i e t y & Agoraphobia Treatment Center, B a l a Cynwyd, P e n n s y l v a n i a
This response to the series focuses on the differentiation between research and clinical work, reminding the reader that research protocols are not treatment protocols and treatment protocols are guidelines, not cookbooks. 7"00 often we stray from the ideal of the scientist/practitioner model, in which practitioners are influenced by research and researchers by clinicians. Within this context three broad areas will be addressed: (1) the role of treating the whole person versus their OCD only; (2) the use of group treatments; and (3) the art of how we explain OCD to ourselves and to those suffering from it.
ARNING h o w to d o b e h a v i o r t h e r a p y is fairly simple; o b t a i n i n g p a t i e n t c o m p l i a n c e is an art. C o g n i t i v e b e h a v i o r therapy's excessive focus o n t e c h n o l o g y is t h e result o f its g r e a t e s t s t r e n g t h : r e l i a n c e u p o n e m p i r i c i s m . H o w e v e r , as r e s e a r c h e r s , t h e r e are times we f o r g e t t h a t t h e t r e a t m e n t o f f e r e d in a c o n t r o l l e d study is o f t e n n o t t r e a t m e n t ; that a research p r o t o c o l d e s i g n e d for t h e purp o s e o f c o n s t r a i n t a n d c o n t r o l is n o t a treatment p r o t o c o l . F o r p s y c h o l o g y to a d v a n c e as a s c i e n c e a n d a service, res e a r c h a n d clinical p r a c t i c e m u s t c o m m i n g l e . It is t h e clin i c i a n ' s task to take t h e results o f r e s e a r c h a n d m o d i f y t h e i r use for u n c o n t r o l l e d c o n d i t i o n s with p o p u l a t i o n s n o t s e l e c t e d by study criteria. Similarly, in g e n e r a t i n g n e w hypotheses, t h e creative r e s e a r c h e r n e e d s to l o o k b e y o n d t h e r e s e a r c h to e x a m i n e w h a t i n t e r v e n t i o n s s e e m useful in clinical p r a c t i c e a n d t h e n i n c o r p o r a t e t h e s e i n t o t h e i r studies a n d r e s e a r c h designs. T h e a u t h o r s in this series have ambitiously c r e a t e d t h e r a p y p r o g r a m s that go b e y o n d the o n e - d i m e n s i o n a l b e h a v i o r a l t r e a t m e n t o f obsessivec o m p u l s i v e d i s o r d e r ( O C D ) a n d obsessive-compulsive
E
Cognitive and Behavioral Practice 6, 4 1 5 - 4 2 1 , 1999 1077-7229/99/415-42151.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
s p e c t r u m disorders. Clark's (1999) s u m m a r y o f the series p r o v i d e s an e x c e l l e n t i n t e g r a t i o n a n d synthesis o f everyo n e ' s w o r k - - w h i c h leaves m e f r e e to f o c u s o n art a n d compliance. W i t h r e g a r d to c o m p l i a n c e , t h r e e issues will b e discussed, two raised by t h e series a n d o n e w h i c h I f o u n d to b e i n a d e q u a t e l y c o v e r e d by t h e series: (1) t h e role o f t r e a t i n g t h e w h o l e p e r s o n versus t h e i r O C D only; (2) t h e use o f g r o u p t r e a t m e n t s ; a n d (3) t h e art o f h o w we explain O C D to ourselves a n d to t h o s e s u f f e r i n g f r o m it. Alt h o u g h m o s t o f this p a p e r ' s a t t e n t i o n will be s p e n t u p o n the last, all r e p r e s e n t d i f f e r e n t p i e c e s o f w h a t constitutes the best t r e a t m e n t for the individual s u f f e r i n g f r o m O C D . T r e a t m e n t refusal a n d d r o p o u t s w e r e a m o n g t h e c o m p l i a n c e issues raised by a few o f the series' a u t h o r s . T h e d r o p o u t rate at o u r c e n t e r is n o t as large as r e p o r t e d elsew h e r e (Stanley & Turner, 1 9 9 5 ) - - p r e s u m a b l y f o r the reasons discussed below. O n t h e o t h e r h a n d , we d o n ' t k n o w h o w m a n y O C D sufferers c h o o s e n o t to c o m e to o u r c e n ter b e c a u s e t h e y k n o w a m a j o r c o m p o n e n t o f t h e i r treatm e n t will b e e x p o s u r e a n d r e s p o n s e p r e v e n t i o n (ERP). A l t h o u g h ERP is a c e n t r a l c o m p o n e n t o f o u r O C D treatm e n t p r o g r a m , we d o treat t h e w h o l e p e r s o n . F o r s o m e o f o u r clients, O C D is t h e o n l y p r e s e n t i n g p r o b l e m , while f o r others, O C D m a y simply b e t h e m o s t obviously dis-
Cognitive Behavioral Treatment of Obsessive-Compulsive Disorders: A Commentary D a v i d A. C l a r k , University o f N e w B r u n s w i c k This commentary discusses a number of issues that arise from the papers published in this special issue on cognitive behavioral treatment (CBT) of obsessive-compulsive disorders (OCD). The reasons for the recent shift toward a more cognitive perspective in the theory and treatment of OCD are discussed. A theoretical framework is proposed for understanding the concepts found in various cognitive theories of OCD. Furthermore, the common, core ingredients of CBT for obsessive and compulsive p~vblems are presented. The pitfalls and difficulties encountered by the clinician who offers CBT to individuals with OCD are discussed, and I conclude with a comment on the empirical status of the therapy.
BSESSIVE-COMPULSIVE DISORDERS (OCD) are a g r o u p o f anxiety disorders that can take a chronic a n d debilitating course with 1-year prevalence rates rep o r t e d as high as 2.1% for the general p o p u l a t i o n (Regier et al., 1993), a l t h o u g h Antony, Downie, a n d Swinson (1998) question w h e t h e r this estimate is too high because structured interviews, like the Diagnostic Interview Schedule, p r o d u c e m o r e false positives when diagnosing OCD. T h e distinguishing diagnostic criteria for OCD is the p r e s e n c e o f obsessions a n d / o r compulsions that cause significant distress o r i m p a i r m e n t in f u n c t i o n i n g (American Psychiatric Association, 1994). A c c o r d i n g to the Diagnostic and Statistical M a n u a l of Mental Disorders (DSM-1V,, A m e r i c a n Psychiatric Association, 1994), obsessions are "persistent ideas, thoughts, impulses, o r images that are e x p e r i e n c e d as intrusive a n d i n a p p r o p r i a t e a n d that cause m a r k e d anxiety or distress" (p. 418), whereas compulsions are "repetitive behaviors o r mental acts, the goal of which is to p r e v e n t o r r e d u c e anxiety or distress, n o t to provide pleasure or gratification" (p. 418). Typical examples o f obsessions are unwanted, intrusive a n d egodystonic (i.e., uncharacteristic o f the person) thoughts, images, o r impulses involving themes o f dirt, contamination, sex, accidents, aggression, dishonesty, blasphemy; a n d the like. Compulsions typically involve some ritualistic behavior such as washing, checking, o r d e r i n g , o r h o a r d i n g . Earlier behavioral theories o f OCD viewed obsessions as noxious c o n d i t i o n e d stimuli that elicit a significant d e g r e e o f anxiety o r distress, with compulsions serving as strategies for r e d u c i n g o r neutralizing the anxiety caused by the o c c u r r e n c e o f the obsession (Rachman & H o d g s o n , 1980).
O
Cognitive and Behavioral Practice 6, 4 0 8 - 4 1 5 , 1999
107%7229/99/408-41551.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. Continuing Education Quiz located on p. 469.
In the 1970s a behavioral t r e a t m e n t o f OCD was develo p e d based on this early l e a r n i n g m o d e l o f obsessions a n d compulsions. T h e t r e a t m e n t involved systematic exposure to the obsessions a n d any stimuli that would evoke them, as well as prevention o f any compulsive o r neutralizing behaviors that m i g h t be used to r e d u c e anxiety. T h e central tenet o f e x p o s u r e a n d response p r e v e n t i o n (ERP) t r e a t m e n t was that anxiety caused by the obsession would naturally habituate a n d so the frequency of the obsession a n d associated compulsive ritual would significantly decline with r e p e a t e d e x p o s u r e to the fear stimulus (i.e., obsession). ERP did prove to be a very successful form o f t r e a t m e n t for OCD, especially for those with washing and, to a lesser extent, checking rituals. O u t c o m e studies o f ERP indicate that a p p r o x i m a t e l y 70% to 80% of OCD patients who c o m p l e t e t r e a t m e n t show significant symptom i m p r o v e m e n t (Stanley & Turner, 1995). In a metaanalysis o f 24 o u t c o m e studies, Abramowitz (1996) rep o r t e d that ERP p r o d u c e d large effect sizes indicating that most patients e x p e r i e n c e d substantial reductions in OCD symptoms. If ERP has b e e n such an effective form o f t r e a t m e n t for OCD, why i n t r o d u c e a cognitive c o m p o n e n t to this t r e a t m e n t regimen? Is the shift from a behavioral to a cognitive focus justified, given the effectiveness o f ERP? Can we expect cognitive-behavior t h e r a p y (CBT) to significantly improve o n the effectiveness o f established behavioral t r e a t m e n t a p p r o a c h e s to OCD? A n u m b e r o f researchers have discussed reasons for advocating a cognitive perspective on theory, research, a n d t r e a t m e n t in OCD (Salkovskis, 1985; Whittal & McLean, 1999). First, a significant n u m b e r o f patients (20% to 30%) refuse to begin ERP o r t e r m i n a t e t r e a t m e n t p r e m a t u r e l y (Stanley & Turner, 1995). Second, long-term follow-up studies indicate that for many patients residual OCD symptoms r e m a i n even after an intensive course o f CBT (Whittal & McLean). Third, ERP has b e e n less effective with certain subtypes o f OCD, such as those with p u r e ob-
CBT of OCD Commentary sessions a n d no overt compulsions (Freeston & Ladouceur, 1999) o r individuals with compulsive h o a r d i n g (Frost & Steketee, 1999). Fourth, a significant n u m b e r o f individuals (20% to 30%) a p p e a r to be t r e a t m e n t resistant (Sookman & Pinard, 1999), failing to show significant i m p r o v e m e n t from either CBT o r p h a r m a c o t h e r a p y . Fifth, t h e r e are a variety o f psychological factors, such as low motivation, negative expectancies for t r e a t m e n t success, procrastination, a n d n o n c o m p l i a n c e , that may interfere with response to ERP. And, finally, the promin e n c e o f cognitive biases, dysfunctional beliefs, a n d e r r o n e o u s thinking in the d i s o r d e r suggests that the cognitive c o m p o n e n t o f OCD s h o u l d be addressed m o r e directly in any t r e a t m e n t regimen. This special series o f Cognitive and Behavioral Practice is devoted to the description, application, a n d discussion o f cognitive behavioral t r e a t m e n t o f OCD. T h e five p a p e r s in the series all focus on the d e v e l o p m e n t a n d application of different variants of CBT for t r e a t m e n t of OCD, or specific subtypes o f OCD. Each o f the p a p e r s presents new, innovative, a n d very p r o m i s i n g a p p r o a c h e s to the t r e a t m e n t o f OCD. However, given that CB t r e a t m e n t for OCD is still in its infancy, relatively few systematic controlled o u t c o m e studies have b e e n c o n d u c t e d to verify the effectiveness o f the interventions advocated in these papers. Nevertheless, most clinicians will agree that new a n d innovative psychological interventions for OCD are n e e d e d , a n d so these papers p r e s e n t the r e a d e r with the very latest original ideas for the cognitive t r e a t m e n t o f obsessive a n d compulsive problems. In the r e m a i n d e r of this c o m m e n t a r y I would like to draw o u t some of the similarities in theory, issues, a n d t r e a t m e n t that cut across these various papers. Despite differences in the OCD symptomatology targeted a n d in the particular intervention strategies emphasized, I will argue that t h e r e is a c o m m o n o r s t a n d a r d CBT theory a n d t r e a t m e n t perspective that can be d i s c e r n e d in these papers.
Cognitive Theory o f OCD O n e of the first impressions one obtains from r e a d i n g the papers in this special series is the critical role that theory plays in cognitive-behavioral t r e a t m e n t of OCD. Freeston a n d L a d o u c e u r (1999) p r e s e n t their cognitive m o d e l o f obsessive thoughts, S o o k m a n a n d Pinard (1999) describe a cognitive-developmental perspective o f OCD, Frost a n d Steketee (1999) discuss a cognitivebehavioral formulation for compulsive hoarding, and Whittal a n d McLean (1999) explain the theoretical tenets o f their g r o u p CBT, drawing on the theoretical work o f Salkovskis (1985, 1996), van O p p e n a n d Arntz (1994), a n d Freeston, Rhdaume, a n d L a d o u c e u r (1996). This very close link between theory a n d t h e r a p y is integral to the practice of CBT for OCD.
409
Cognitive behavioral t r e a t m e n t for OCD is n o t defined in terms o f a u n i q u e set of intervention strategies d e v e l o p e d exclusively for the t r e a t m e n t o f obsessions a n d compulsions. Instead, t h e r a p e u t i c tasks such as exposure, response prevention, construction of a fear hierarchy, self-monitoring, cognitive restructuring, a n d behavioral e x p e r i m e n t s are "borrowed" f r o m established cognitive a n d behavioral t r e a t m e n t packages a p p l i e d to o t h e r disorders. However, CBT does r e p r e s e n t a u n i q u e way o f conceptualizing obsessive a n d compulsive p r o b l e m s . It is the theoretical perspective o r how one u n d e r s t a n d s OC pheCBT cannot be n o m e n a that is u n i q u e to CBT. implemented W h a t follows in CBT, then, is the i m p l e m e n t a t i o n o f this simply by following m o d e l in each therapy session. a treatment This also means that treatmanual. Rather, m e n t manuals o f CBT m u s t at the outset devote considerthe clinician using able space to a fairly detailed CBT for OCD must exposition o f the cognitive have an advanced m o d e l o f OCD so that the clinician is able to e d u c a t e the understanding of client into the CB m o d e l bethe cognitive basis fore any specific interventions of obsessiveare i n t r o d u c e d . T h e r e are a n u m b e r o f imcompulsive plications that follow from this phenomena in very tight c o u p l i n g o f theory order to conduct a n d practice. First, a t h o r o u g h assessment a n d case formulathe treatment tion is necessary before impleeffectively. m e n t i n g a t r e a t m e n t strategy. Each of the authors in the p r e s e n t series e m p h a s i z e d the necessity o f a detailed assessment, especially of the cognitive a n d behavioral processes that u n d e r l i e OC p h e n o m e n a . Cognitive theory o f OCD informs the clinician of the cognitive constructs that must be identified d u r i n g the assessment process, which are then used to develop a viable t r e a t m e n t program. Second, the cognitive m o d e l o f OCD guides a n d directs the i m p l e m e n t a t i o n of CBT for each patient. T h e initial sessions are devoted to e d u c a t i n g the p a t i e n t a b o u t the cognitive m o d e l o f OCD. A n u m b e r o f the authors e m p h a s i z e d the i m p o r t a n c e o f this c o m p o n e n t o f the t r e a t m e n t package. We know from clinical e x p e r i e n c e a n d research on cognitive therapy for depression o r panic d i s o r d e r that patients must "buy into" a cognitive e x p l a n a t i o n for their symptoms if they are to benefit from cognitive intervention strategies. Thus, in CBT, cognitive t h e o r y is so i m p o r t a n t that it is directly a n d explicitly taught to the p a t i e n t at the outset o f treatment. A third implication of this tight c o u p l i n g between theory a n d practice is that the cognitive behavioral therapist
410
Clark Table 1 Summary of the Central Constructs Shared by Cognitive Models of OCD 1. Normality of intrusions: assumption that normal and pathological
intrusive thoughts lie on a continuum 2. Fault), appraisals of intrusions: the core problem in OCD is the
faulty appraisal of unwanted intrusive thoughts or obsessions 3. Neutralization and avoidance: presence of overt or covert
neutralizing strategies will increase the salience of the obsession, and avoidance will reinforce faulty interpretations of the intrusive thought. 4. Dysfunctional beliefs: the faulty appraisals of the obsession-prone individual are rooted in latent maladaptive beliefs or schemas involving themes of threat, dangm; responsibility, uncertainty, importance of control, perfectionism, and the like.
must have a t h o r o u g h u n d e r s t a n d i n g of cognitive theory o f OCD. CBT c a n n o t be i m p l e m e n t e d simply by following a t r e a t m e n t manual. Rathe1; the clinician using CBT for OCD must have an advanced u n d e r s t a n d i n g o f the cognitive basis o f obsessive-compulsive p h e n o m e n a in ord e r to c o n d u c t the t r e a t m e n t effectively. A n u m b e r of writers have p r e s e n t e d cognitive models of OCD (Clark & P u r d o n , 1993; Freeston et al., 1996; Rachman, 1997, 1998, Salkovskis, 1985, 1989, 1996; van O p p e n & Arntz, 1994; Wells & Matthews, 1994). Alt h o u g h there are some distinctive features a m o n g these different accounts, there is a r e m a r k a b l e d e g r e e of consensus on the essential c o m p o n e n t s for a theoretical framework on which the various cognitive m o d e l s o f OCD are constructed. This theoretical framework is evid e n t in the c u r r e n t series o f papers. T h e following constructs, then, can be f o u n d in most cognitive models of OCD. These have b e e n s u m m a r i z e d in Table 1. The Normality o f Intrusions Most CBT models begin by recognizing that u n w a n t e d intrusive thoughts, images, a n d impulses occur as a normal p a r t o f h u m a n e x p e r i e n c e (i.e., R a c h m a n & de Silva, 1978). ~rhat distinguishes n o r m a l from a b n o r m a l obsessions is a m a t t e r o f d e g r e e r a t h e r than kind. Faulty Appraisals o f Intrusions A c c o r d i n g to cognitive theories, the core p r o b l e m in OCD is the faulty appraisal of u n w a n t e d intrusive thoughts, images, o r impulses. A variety o f pathological appraisal o r interpretative processes have b e e n implicated in the pathogenesis o f obsessions. These include appraisals o f inflated p e r s o n a l responsibility, i m p o r t a n c e o f thoughts, thought-action fusion, overestimation o f threat or danger, negative consequences of ineffective t h o u g h t control, i n t o l e r a n c e o f uncertainty, a n d perfectionistic standards. W h i c h particular appraisal process is e m p h a s i z e d in a m o d e l will d e p e n d on the theorist a n d
the particular OC p h e n o m e n a u n d e r consideration. For example, faulty appraisals o f personal responsibility may be most salient with "loss o f control" obsessions involving aggressive or i n a p p r o p r i a t e sexual behavior, whereas perfectionistic standards in the form o f indecisiveness may be most p r o m i n e n t in h o a r d i n g (Frost & Steketee, 1999). However, what makes all o f these appraisal processes pathological is that they offer evaluations that exaggerate the sense of personal significance a n d threat o f u n w a n t e d intrusive thoughts, t h e r e b y l e a d i n g to an escalation in the frequency, intensity, a n d salience o f the intrusions (Rachman, 1997, 1998). Neutralization and Avoidance Cognitive m o d e l s o f OCD c o n t i n u e to recognize that neutralization, w h e t h e r in the form o f t h o u g h t control strategies, o r behavioral or mentalistic rituals, plays an i m p o r t a n t role in the onset a n d persistence of OCD. T h e r e is some d i s a g r e e m e n t over w h e t h e r neutralization strategies function to r e d u c e anxiety o r o n e o f the appraisal processes such as an inflated sense o f responsibility. Whatever the case, there is b r o a d a g r e e m e n t a m o n g CBT researchers that neutralization a n d o t h e r compulsive behavior increases the salience of the u n w a n t e d obsessive thought. Avoidance of situations or stimuli will also increase the salience o f obsessions by reinforcing the faulty i n t e r p r e t a t i o n s o f the p a t i e n t (e.g., "I feel b e t t e r when avoiding public washrooms, so these must be dangerous places"). Dysfunctional Beliefs or Schemas Each o f the authors in this series r e c o g n i z e d that underlying maladaptive beliefs may be responsible for the faulty appraisals obsession-prone individuals g e n e r a t e in response to their u n w a n t e d intrusive thoughts. T h e content of these maladaptive beliefs matches the focus evid e n t in the appraisal processes. Thus, themes o f threat, danger, perfectionism, uncertainty, responsibility, and loss of control characterize the dysfunctional beliefs of the obsessive-compulsive individual. However, it must be r e c o g n i z e d that the c o n t e n t o f the dysfunctional beliefs associated with different subtypes o f OCD may be u n i q u e to that particular subtype, such as the collecting a n d discarding beliefs of h o a r d e r s (Frost & Steketee, 1999). Currently an international g r o u p o f OCD researchers is working on the d e v e l o p m e n t o f measures to assess dysfunctional beliefs a n d appraisals in OCD (ObsessiveCompulsive Cognitions Working Group, 1997).
Cognitive Behavior Therapy for OCD Despite nuances in the various CBT t r e a t m e n t app r o a c h e s described by the authors in this series, we d o
CBT of OCD Commentary
Table 2 Common Therapeutic Ingredients in Cognitive-Behavioral Treatments of OCD 1. Education on the cognitive model', initially the client is provided with a cognitive explanation for the persistence of obsessions and compulsions as well as the treatment rationale. 2. Identification offaulty appraisals, neutralization, and avoidance: clients are trained to recognize their faulty interpretations of the obsession as well as any neutralizingstrategies and avoidance behaviors intended to minimize the distressing quality of the obsession. 3. Cognitive restructuring offaulty appraisals: through collaboration and guided discovery clients are taught to cognitivelychallenge their erroneous appraisals and maladaptive beliefs of the obsession. 4. Behavioral experimentation: exposure, response prevention, and other behavioral interventionsare used to test out the exaggerated importance and catastrophic consequences clients impute to the obsession. 5. Alternative interpretations for the obsession: clients are taught to accept a more adaptive and realistic alternative explanation for the obsession. 6. Cc~rreetingdysfunctional beliefs: treatment gaius can be maintained only if the latent core dysfunctional beliefs that give rise to the faulty appraisals of the obsession are modified. 7. Relapse prevention: clients are taught self-help strategies to implement in the face of an anticipated resurgence of obsessive and compulsive symptoms
see a n u m b e r of c o m m o n elements in their t r e a t m e n t packages. Of course these elements take a different orie n t a t i o n or focus d e p e n d i n g o n the obsessive-compulsive p h e n o m e n a u n d e r consideration. Having said this, the following are some c o m m o n therapeutic ingredients that are f o u n d in most cognitive-behavioral interventions for OCD. A s u m m a r y of these seven c o m m o n therapeutic c o m p o n e n t s can be f o u n d in Table 2.
Educating the Client to the Cognitive Model As n o t e d previously, each of the authors emphasizes the i m p o r t a n c e of educating the patient to the cognitive m o d e l of OCD. It is critical that this educational aspect of CBT n o t degenerate into an intellectual exercise; rather, the m o d e l should be illustrated using the patient's own obsessions, appraisals, beliefs, a n d neutralizing strategies (Freeston & Ladouceur, 1999). If patients "buy into" the cognitive explanation for their obsessions a n d compulsions, then they are more likely to be motivated for treatment, collaborate in the identification of dysfunctional thinking, a n d complete homework assignments. O n the other hand, it will be very difficult for patients to adopt a collaborative stance o n interventions that focus o n the identification a n d modification of cognitions if they rem a i n skeptical over the relevance of the cognitive m o d e l for their condition. In addition, Freeston a n d L a d o u c e u r (1999) n o t e d
that a n o t h e r reason for p r e s e n t i n g the cognitive m o d e l is to normalize patients' experience of obsessions by showing t h e m the c o n n e c t i o n between pathological obsessions a n d the u n w a n t e d intrusions that occur in the normal population. However, one should n o t u n d e r e s t i m a t e how difficult it may be to convince s o m e o n e that the onset a n d persistence of their obsessions is affected by their faulty interpretations. Many patients come into therapy . . . . /' with strongly held behefs that their OCD as a d~sease stemm i n g from a "chemical imbalance" or "genetic deficit." For these patients, the educational phase of CBT may take considerably l o n g e r t h a n o n e to two sessions described in the t r e a t m e n t manuals. Educating the client into the cognitive m o d e l of OCD will also include a n i n t r o d u c t i o n to the c o n c e p t of "faulty appraisals" of the obsession. At this initial stage of therapy, the client is simply i n t r o d u c e d to the idea of appraisals or "giving i m p o r t a n c e to the obsession" as the primary reason for the thought's persistence. In educati n g the client, the clinician will also refer to the different types of appraisals that u n d e r l i e obsessional p h e n o m ena, a n d will suggest to the client the possibility that these appraisals are faulty or incorrect. However, n o att e m p t is m a d e to persuade clients that their appraisals are faulty. Rather, in tile second phase o f treatment, the clinician uses collaboration a n d guided discovery in order for clients to test o u t the realistic or faulty basis of their appraisals. Identifying Faulty Interpretations, Neutralizing Strategies, and Avoidance Patterns All of the authors emphasize that patients must be trained to recognize the faulty appraisals a n d futile neutralizing behavior a n d thought-control strategies they engage in once an obsessional t h o u g h t intrudes into consciousness. Freeston a n d L a d o u c e u r (1999) use daily selfm o n i t o r i n g a n d other exercises to help clients learn the external a n d i n t e r n a l factors, such as anxiety, avoidance, magical thinking, a n d reassurance seeking, that strengthen a faulty appraisal process. Whittal a n d McLean (1999) note that it is i m p o r t a n t that patients be trained to distinguish between the intrusive t h o u g h t a n d the appraisals or interpretations they generate a b o u t the intrusion. This distinction will be difficult for some patients who have become utterly preoccupied with the obsessional thought. Frost a n d Steketee (1999) c o m m e n t e d that hoarders may find it particularly difficult to identify the triggering intrusive t h o u g h t a n d its interpretation. I n addition, all of the authors n o t e d that the identification of covert or overt neutralizing rituals, avoidance patterns, a n d other maladaptive coping strategies is a critical c o m p o n e n t of CBT for obsessions a n d compulsions. Behavioral change is still an i m p o r t a n t part of CBT, despite the increased emphasis o n cognitive factors.
411
412
Clark
Cognitive Restructuring of Faulty Appraisals Freeston a n d L a d o u c e u r (1999), Whittal a n d McLean (1999), a n d Frost a n d Steketee (1999) all discuss various a p p r o a c h e s that can be used to cognitively challenge the faulty appraisals a n d maladaptive beliefs that constitute the cognitive basis to the patient's obsessions a n d compulsions. All emphasize that the use of logical persuasion or "cognitive challenge" must be d o n e in a collaborative For a h o m e w o r k m a n n e r with the use o f Socratic dialogue a n d g u i d e d assignment, he discovery. Whittal and McLean was to s p e n d 30 provide patients with a list o f minutes each day questions that they can use to cognitively challenge the vafocused on the lidity of their interpretations murderous thought when intrusive thoughts ocand to avoid any cur. My own clinical experience in c o n d u c t i n g CBT with attempt to obsessional patients is that suppress the they can be very rigid, narrow, thought. After 1 a n d inflexible when trying to explore alternative perspecweek he reported tives a n d a r g u m e n t s to their a dramatic interpretations and beliefs. For reduction in the this reason, cognitive correction of faulty interpretations frequency and a n d beliefs may play a secondlevel of distress ary role to the use of behavassociated with ioral experiments or what Beck a n d colleagues refer to as the murderous "empirical hypothesis-testing" thought; he did (Beck, Rush, Shaw, & Emery, not feel an increase 1979). This is n o t to imply that in murderous "cognitive" p r o c e d u r e s are impulses. less useful in treating obsessions a n d compulsions than e x p o s u r e tasks. Instead, exposure-based strategies may be necessary to challenge core dysfunctional beliefs a b o u t the i m p o r t a n c e o f the obsessional thought. How the clinician explains the o u t c o m e o f the e x p o s u r e exercise to the client will d e t e r m i n e w h e t h e r it facilitates change in dysfunctional OCD beliefs (e.g., "Notice that when you did n o t check, n o t h i n g terrible h a p p e n e d to you, a n d your distress eventually abated"). In this way, both "cognitive" a n d "behavioral" interventions are necessary to modify core dysfunctional belief stnmtures in OCD. Behavioral "Experiments" Despite the limitations o f ERP n o t e d previously, there can be little d o u b t that exposure a n d response prevention are vital to CBT o f OCD. T h e a m o u n t o f therapy time devoted to ERP will vary d e p e n d i n g on the particu-
lar OCD subtype, with, for example, ERP playing a very p r o m i n e n t role in the t r e a t m e n t o f compulsive washers. However, the function o f ERP in CBT is different than the function it plays in behavior therapy. In CBT, exposure a n d response p r e v e n t i o n exercises are c o n s i d e r e d critical for testing o u t faulty appraisals a n d maladaptive beliefs. This is n o t to d e n y that h a b i t u a t i o n to anxiogenic obsessions may also occur. However, in CBT, e x p o s u r e is used to challenge existing ideas a b o u t the i m p o r t a n c e a n d c o n s e q u e n c e of obsessions a n d compulsions. To illustrate this point, a few years ago I treated a m a n who h a d very upsetting intrusive thoughts o f losing control a n d m u r d e r i n g his wife with a hammer. H e believed that the m o r e he h a d this thought, the m o r e likely it would be that he would lose control a n d c o m m i t m u r d e r (i.e., appraisals o f overestimated threat, inflated responsibility, thought-action fusion, and i m p o r t a n c e of thoughts). F o r a h o m e w o r k assignment he was to s p e n d 30 minutes each day focused on the m u r d e r o u s t h o u g h t a n d to avoid any a t t e m p t to suppress the t h o u g h t (exposure a n d response prevention). After 1 week he r e p o r t e d a dramatic r e d u c t i o n in the frequency a n d level of distress associated with the m u r d e r o u s thought. More importantly, he noticed that despite s p e n d i n g m o r e time with the obsessive thought, he d i d n o t feel an increase in m u r d e r o u s impulses. In fact, he got b o r e d with the exercise a n d ceased to do it after a few days. This e x p e r i e n c e p r o v i d e d clear behavioral evidence that his belief a n d i n t e r p r e t a t i o n a b o u t the dangerousness of his obsessive t h o u g h t was incorrect. It should be n o t e d that ERP is n o t the only effective behavioral intervention for challenging faulty cognitions. Freeston a n d L a d e u c e u r (1999) describe the "camel exercise" to challenge beliefs in the controllability o f intrusive thoughts, Frost a n d Steketee (1999) use an exercise called the "purgatory table" to identify a n d challenge beliefs a n d interpretations a b o u t discarding possessions, Whittal a n d McLean (1999) have patients survey friends a n d colleagues to challenge the patient's estimation of threat associated with a particular situation, a n d Sookm a n a n d Pinard (1999) m e n t i o n the use o f affect expression to challenge the belief that strong negative affect must be avoided. In sum, behavioral exercises a n d empirical-hypothesis testing may be particularly critical in CBT, n o t only to address the extensive neutralizing rituals a n d avoidance patterns that may be present, b u t also to prevent therapy sessions from slipping into a destructive form o f defensive intellectualization (i.e., an academic discussion of the cognitive m o d e l a n d its application to o n e ' s condition).
Development of Alternative Interpretations T h e r e can be little d o u b t that o n e o f the most overl o o k e d c o m p o n e n t s o f CBT is the realization that the CB
CBT of OCD C o m m e n t a r y therapist must work with patients on the d e v e l o p m e n t of alternative, h e a l t h i e r m o d e s o f thinking. Whittal a n d McLean (1999) d i d note that they s p e n d time in the latter p a r t of their t r e a t m e n t p r o g r a m on the d e v e l o p m e n t of alternative appraisals a n d beliefs. It is n o t e n o u g h for t h e r a p y to challenge the faulty appraisals a n d maladaptire beliefs o f the obsessional patient. T r e a t m e n t effects will last only to the e x t e n t that obsession-prone individuals develop s t r o n g e r beliefs in m o r e functional interpretations o f their intrusive thoughts. F o r example, if a patient begins to d o u b t that "thinking a b o u t stabbing a f r i e n d means that I could stab him," t h e n that individual must a d o p t a different i n t e r p r e t a t i o n o f the intrusive thought. If the t h o u g h t is n o t an i n d i c a t i o n o f latent homicidal tendencies, then where d o these thoughts c o m e from? W h a t do they mean? Why d o we have them? A credible alternative e x p l a n a t i o n for these intrusions m u s t be available to patients if they are to a b a n d o n their maladaptive thinking patterns.
Correcting Dysfunctional Beliefs A n u m b e r of authors note that CBT does n o t focus only o n the appraisals o f obsessions but, later in treatment, o n e must shift the t h e r a p e u t i c a g e n d a to the identification a n d c o r r e c t i o n o f the maladaptive beliefs that l e a d to faulty appraisals. Work is currently in progress to isolate the core, critical beliefs o f OCD a n d to develop valid a n d reliable measures o f these beliefs (ObsessiveCompulsive Cognitions Working G r o u p , 1997). We assume that t r e a t m e n t gains from CBT will be m a i n t a i n e d only if the core u n d e r l y i n g maladaptive beliefs are modified. Thus the correction of dysfunctional OCD beliefs a n d assumptions may be necessary to r e d u c e relapse a n d r e o c c u r r e n c e o f OC symptoms.
Relapse Prevention Relapse prevention must be w o r k e d into CBT programs if t r e a t m e n t gains are to be maintained. Neziroglu, Stevens, Yaryura-Tobias, a n d H o f f m a n (1999) identified a n u m b e r of factors that may be associated with p o o r response to treatment. Whittal a n d McLean (1999) provide patients with a list o f strategies they can use to deal with intrusive thoughts after t h e r a p y has ceased. Given the c h r o n i c n a t u r e o f OCD, relapse p r e v e n t i o n must be built into each CBT regimen.
Pitfalls in Cognitive-Behavioral Treatment of OCD Several of the authors in this series raise a n u m b e r o f interesting p r o b l e m s that can arise when e m p l o y i n g cognitive-behavioral a p p r o a c h e s to OCD (Freeston & Ladouceur, 1999; Frost & Steketee, 1999; Neziroglu et aL, 1999; Whittal & McLean, 1999; see also c o m m e n t s by van Op-
413
p e n & Arntz, 1994). I would like to briefly h i g h l i g h t t h r e e of the complications. First, the therapist must identify occasions when patients turn t h e r a p e u t i c interventions into neutralizing strategies. As an example, I treated a y o u n g m a n who suffered with obsessional r u m i n a t i o n s involving u n w a n t e d sex a n d violence. H e e x p e r i e n c e d a significant r e d u c t i o n in the frequency a n d intensity o f his obsessions after b e i n g t a u g h t to cognitively challenge the faulty appraisal that "these violent thoughts m e a n that t~a m a dangerous p e r s o n who m i g h t b e c o m e violent." However, a few years later he again contacted me, r e p o r t i n g that the violent thoughts h a d r e t u r n e d . Interestingly, he was compulsively m o n i t o r i n g these thoughts a n d c h a l l e n g i n g t h e m each time they occurred. T h e p r o b l e m is that the cognitive restructuring was now b e i n g used as a thoughtcontrol strategy, a n d as such increased the salience of the viCB therapists must olence thoughts. So the first be vigilant that p o i n t o f intervention was to discontinue the use o f cognitheir therapeutic tive restructuring. Freeston a n d interventions are Ladeuceur (1999) offer some not converted by very practical advice on how therapists can distinguish bepatients into s o m e tween responses that are in form of neutralizing aid of neutralizing a n d those ritual, thoughtthat constitute a healthy evaluation of the intrusion. control strategy, A s e c o n d c o m p l i c a t i o n in or reassurance. c o n d u c t i n g CBT for obsessional p r o b l e m s is the possibility that patients will use the t h e r a p e u t i c support, advice, a n d o t h e r cognitive interventions as reassurance against the threat or d a n g e r they perceive from the obsession. Freeston a n d L a d o u c e u r (1999) note that reassurance seeking is a form of neutralization that can increase the perceived i m p o r t a n c e o f the intrusive thought. W h e n patients directly solicit reassurance f r o m the therapist o r significant others, Freeston a n d L a d o u c e u r suggest that individuals r e s p o n d to the p a t i e n t in a calm, nonaggressive manner, emphasizing that they will n o t provide the reassurance the p a t i e n t seeks. Whittal a n d M c L e a n (1999) c o m m e n t that patients can turn a healthy, alternative appraisal into a form o f reassurance. Thus, CB therapists must be vigilant that their t h e r a p e u t i c interventions are n o t converted by patients into some form o f neutralizing ritual, thought-control strategy, or reassurance. Finally, a n u m b e r o f authors discuss the p r o b l e m o f low motivation a n d n o n c o m p l i a n c e with h o m e w o r k assignments, which will u n d e r m i n e the t r e a t m e n t integrity of CBT (see Frost & Steketee, 1999; Nezrioglu et al., 1999). These p r o b l e m s are n o t u n i q u e to OCD o r CBT. Low motivation a n d n o n c o m p l i a n c e will r e d u c e the effectiveness of any psychological intervention. However, it
414
Clark
m a y be that t h e s e p r o b l e m s are especially p r o m i n e n t in obsessive a n d c o m p u l s i v e disorders. O C D is a very c h r o n i c c o n d i t i o n a n d so individuals will o f t e n restructure t h e i r lives a r o u n d t h e i r symptomatology. Thus, t h e r e d u c t i o n o r e l i m i n a t i o n o f obsessive-compulsive sympt o m s m i g h t b e p e r c e i v e d as a n attack o n an i n t e g r a l p a r t o f o n e ' s p e r s o n a l identity. If o n e adds to this the very h i g h level o f f e a r a n d anxiety associated with obsessions a n d t h e situations t h a t t r i g g e r t h e m , t h e n it is u n d e r s t a n d a b l e why s o m e p a t i e n t s with O C D find it difficult to c o m m i t t h e m s e l v e s to therapy. A t the very least, t h e CB t h e r a p i s t m u s t d e a l directly with low m o t i v a t i o n a n d n o n c o m p l i a n c e o f h o m e w o r k a s s i g n m e n t s by i d e n t i f y i n g a n d chall e n g i n g the t h o u g h t s a n d beliefs that m i g h t u n d e r l i e amb i v a l e n c e for t r e a t m e n t .
Conclusion T h e p a p e r s in this series d e s c r i b e the a p p l i c a t i o n o f c o g n i t i v e - b e h a v i o r a l i n t e r v e n t i o n for t h e t r e a t m e n t o f obsessive a n d c o m p u l s i v e s y m p t o m s . D e s p i t e the t r e a t m e n t i n n o v a t i o n a n d p r o m i s e r e p r e s e n t e d in t h e s e papers, it m u s t b e r e a l i z e d t h a t the effectiveness a n d clinical utility o f CB t r e a t m e n t f o r O C D is n o t yet p r o v e n . We d o have s o m e case r e p o r t s that this t r e a t m e n t a p p r o a c h can be effective (Frost & S t e k e t e e , 1999; L a d o u c e m ; F r e e s t o n , G a g n o n , T h i b o d e a u & D u m o n t , 1995; K e a r n e y & Silverm a n , 1990; Salkovskis & Warwick, 1985; S o o k m a n & Pinard, 1999). As well, a few clinical o u t c o m e studies have b e e n p u b l i s h e d w h i c h a g a i n s u p p o r t the clinical effectiveness o f C B T for obsessive a n d c o m p u l s i v e s y m p t o m s (Emm e l k a m p & Beens, 1991; E m m e l k a m p , Vissel; & H o e k stra, 1988; F r e e s t o n et al., 1997). T h e r e are also a n u m b e r o f clinical o u t c o m e trials o f C B T in p r o g r e s s (see Frost & Steketee, 1999; Whittal & M c L e a n , 1999), so we s h o u l d b e in a m u c h b e t t e r p o s i t i o n within the n e x t c o u p l e o f years to j u d g e the effectiveness o f C B T for obsessivec o m p u l s i v e disorders. In t h e i n t r o d u c t i o n I a r g u e d that the cognitive innovations r e p o r t e d in these p a p e r s r e p r e s e n t an i m p o r t a n t dev e l o p m e n t for the t r e a t m e n t o f O C D . However, at this p o i n t we d o n o t have any systematic e m p i r i c a l e v i d e n c e that the cognitive c o m p o n e n t o f C B T adds significantly to the effectiveness o f psychological t r e a t m e n t for O C D bey o n d t h e established effects o f ERP. In addition, we d o n o t k n o w w h e t h e r CBT significantly r e d u c e s the t r e a t m e n t refusal a n d d r o p o u t rates s e e n with ERP, n o r is t h e r e any evi d e n c e that C B T p r o d u c e s m o r e c o m p l e t e remission o f obsessive-compulsive s y m p t o m s o r r e d u c e s relapse a n d reo c c u r r e n c e rates. It is also n o t known w h e t h e r CBT is effective with obsessional patients w h o are drug-refractory o r t r e a t m e n t resistant, a l t h o u g h the results o f S o o k m a n a n d P i n a r d (1999) are e n c o u r a g i n g . N o r is it k n o w n w h e t h e r C B T can r e a d d r e s s factors that u n d e r m i n e treat-
m e n t effectiveness like low m o t i v a t i o n a n d n o n c o m p l i a n c e with ERP. Clearly, t h e r e is a g r e a t deal o f e m p i r i c a l research, t h e o r e t i c a l e l a b o r a t i o n , a n d clinical r e f i n e m e n t that is n e e d e d b e f o r e C B T b e c o m e s an established f o r m o f t r e a t m e n t for O C D . Until then, the c u r r e n t w o r k suggests that C B T offers a r e f r e s h i n g a n d highly p r o m i s i n g n e w perspective o n the t r e a t m e n t o f O C D .
References Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A metaanalysis. Behavior Therap3; 27, 583-600. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Antony, M. M., Downie, E, & Swinson, R. R (1998). Diagnostic issues and epidemiology in obsessive-compulsive disorder. In R. R Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessivecompulsive disorder: Theory, research and treatment (pp. 3-32). New York: Guilford Press. Beck, A. T., Rush, A.J., Shaw, B. E, & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Clark, D. A., & Purdon, C. (1993). New perspectives for a cognitive theory of obsessions. Australian P~ychologist, 28, 161-167. Emmelkamp, R M. G., & Beens, H. (1991). Cognitive therapy with obsessive-compulsive disorder: A comparative evaluation. Behavior Research and Therapy, 29, 293-300. Emmelkamp, R M. G., Visser, S., & Hoekstra, R.J. (1988). Cognitive therapy vs. exposure in vivo in the treatment of obsessive compulsives. Cognitive Therapy and Research, 12, 103-114. Freeston, M. H., & Ladouceur, R. (1999). Exposure and response prevention for obsessional thoughts. Cognitive and Behavioral Practice, 6, 362-383. Freeston, M. H., Ladoucem; R., Gagnon, E, Thibodeau, N., Rhaume, J., Letarte, L., & Bujold, A. (1997). Cognitive-behavioral treatment of obsessive thought.s: A controlled study. Journal of Consulting and Clinical Psychology, 65, 405-413. Freeston, M. H., Rhfiaume, J., & Ladouceur, R. (1996). Correcting fault), appraisals of obsessive thoughts. BehaviourResearch and Therapy, 13, 459-470. Frost, R. O., & Steketee, G. (t999). Issues in the treatment of compulsive hoarding. Cognitive and Behavioral Practiee, 6, 397-407. Kearney, C. A., & Silverman, W. K. (1990). Treatment of an adolescent with obsessive-compulsive disorder by alternating response prevention and cognitive therapy: An empirical analysis. Journal of Behavior Th.erapy &Experimental Psychiat~?~, 21, 39-47. Ladouceur, R., Freeston, M. H., Gagnon, E, Thibodeau, N., & Dumont, J. (1995). Cognitive-behavioral treatment of obsessions. Behavior Modification, 19, 247-257. Neziroglu, E, Stevens, K. R, ~aryaara-Tobias, J. A., & Hoffman, J. H. (1999). Assessment, treatment parameters and prognostic indicators for patients with obsessive-compulsive spectrum disorders. Cognitive and Behavioral Practice, 6, 345-350. Obsessive-Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder: Behaviour Research and Therapy, 35, 667-682. Rachman, S.J. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793-802. Rachman, S.J. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36, 385-401. Rachman, S., & de Silva, E (1978). Abnormal and normal obsessions. Behaviour Resea~ch and Therapy, 16, 233-248. Rachman, S.J., & Hodgson, R.J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall. Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B.Z., & Goodwin, E K. (1993). The de facto US Mental and Addictive Disorders Service System: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85 - 94.
Series R e s p o n s e : C o m p l i a n c e a n d U n d e r s t a n d i n g OCD Stanley, M. A., & Turner, S. M. (1995). Current status of pharmacological and behavioral treatment of obsessive-compulsive disorder. Behavior Therapy, 26, 163-186. Van Oppen, R, & Arntz, A. (1994). Cognitive therapy for obsessivecompulsive disorder. Behaviour Researeh and Therapy, 32, 79-88. Wells, A., & Matthews, G. (1994). Attention and emotion: A elinicalperspecrive. Hove, UK: Lawrence Erlbaum. Whittal, M. L., & McLean, R D. (1999). CBT for OCD: The rationale, protocol, and challenges. Cognitive and Behavioral Practice, 6, 383396.
Salkovskis, R M. (1985). Obsessive-compulsive problems: A cognitivebehavionral analysis. Behaviour Research and Therapy, 23, 571-583. Salkovskis, R M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682. Salkovskis, E M. (1996). Cognitive-behavioural approaches to the understanding of obsessional problems. In R. Rapee (Ed.), Current controversies in the anxiety disorders (pp. 103-133). New York: Guilford. Salkovskis, R M., & Warwick, H. M. C. (1985). Cognitive therapy of obsessive-compulsive disorder: Treating treatment failures. Behavioural Psychotherapy, 13, 243-255. Salkovskis, E M., & Westbrook, D. (1989). Behaviour therapy and obsessional rumination: Can failure be turned into success? Behaviour Research and Therapy, 27, 149-160. Sookman, D., & Pinard, G. (1999). Integrative cognitive therapy for obsessive-compulsive disorder: Focus on multiple schemas. Cognitive and Behavioral Practice, 6, 351-362.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
415
Address correspondence to David A. Clark, Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, E3B 6E4 Canada; e-maih [email protected]. Received: June 18, I998 Accepted: October8, 1998
•
•
•
•
•
•
¢,
•
•
4,
•
•
•
•
•
Series Response: Compliance and Understanding OCD Jonathan
B. G r a y s o n , A n x i e t y & Agoraphobia Treatment Center, B a l a Cynwyd, P e n n s y l v a n i a
This response to the series focuses on the differentiation between research and clinical work, reminding the reader that research protocols are not treatment protocols and treatment protocols are guidelines, not cookbooks. 7"00 often we stray from the ideal of the scientist/practitioner model, in which practitioners are influenced by research and researchers by clinicians. Within this context three broad areas will be addressed: (1) the role of treating the whole person versus their OCD only; (2) the use of group treatments; and (3) the art of how we explain OCD to ourselves and to those suffering from it.
ARNING h o w to d o b e h a v i o r t h e r a p y is fairly simple; o b t a i n i n g p a t i e n t c o m p l i a n c e is an art. C o g n i t i v e b e h a v i o r therapy's excessive focus o n t e c h n o l o g y is t h e result o f its g r e a t e s t s t r e n g t h : r e l i a n c e u p o n e m p i r i c i s m . H o w e v e r , as r e s e a r c h e r s , t h e r e are times we f o r g e t t h a t t h e t r e a t m e n t o f f e r e d in a c o n t r o l l e d study is o f t e n n o t t r e a t m e n t ; that a research p r o t o c o l d e s i g n e d for t h e purp o s e o f c o n s t r a i n t a n d c o n t r o l is n o t a treatment p r o t o c o l . F o r p s y c h o l o g y to a d v a n c e as a s c i e n c e a n d a service, res e a r c h a n d clinical p r a c t i c e m u s t c o m m i n g l e . It is t h e clin i c i a n ' s task to take t h e results o f r e s e a r c h a n d m o d i f y t h e i r use for u n c o n t r o l l e d c o n d i t i o n s with p o p u l a t i o n s n o t s e l e c t e d by study criteria. Similarly, in g e n e r a t i n g n e w hypotheses, t h e creative r e s e a r c h e r n e e d s to l o o k b e y o n d t h e r e s e a r c h to e x a m i n e w h a t i n t e r v e n t i o n s s e e m useful in clinical p r a c t i c e a n d t h e n i n c o r p o r a t e t h e s e i n t o t h e i r studies a n d r e s e a r c h designs. T h e a u t h o r s in this series have ambitiously c r e a t e d t h e r a p y p r o g r a m s that go b e y o n d the o n e - d i m e n s i o n a l b e h a v i o r a l t r e a t m e n t o f obsessivec o m p u l s i v e d i s o r d e r ( O C D ) a n d obsessive-compulsive
E
Cognitive and Behavioral Practice 6, 4 1 5 - 4 2 1 , 1999 1077-7229/99/415-42151.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
s p e c t r u m disorders. Clark's (1999) s u m m a r y o f the series p r o v i d e s an e x c e l l e n t i n t e g r a t i o n a n d synthesis o f everyo n e ' s w o r k - - w h i c h leaves m e f r e e to f o c u s o n art a n d compliance. W i t h r e g a r d to c o m p l i a n c e , t h r e e issues will b e discussed, two raised by t h e series a n d o n e w h i c h I f o u n d to b e i n a d e q u a t e l y c o v e r e d by t h e series: (1) t h e role o f t r e a t i n g t h e w h o l e p e r s o n versus t h e i r O C D only; (2) t h e use o f g r o u p t r e a t m e n t s ; a n d (3) t h e art o f h o w we explain O C D to ourselves a n d to t h o s e s u f f e r i n g f r o m it. Alt h o u g h m o s t o f this p a p e r ' s a t t e n t i o n will be s p e n t u p o n the last, all r e p r e s e n t d i f f e r e n t p i e c e s o f w h a t constitutes the best t r e a t m e n t for the individual s u f f e r i n g f r o m O C D . T r e a t m e n t refusal a n d d r o p o u t s w e r e a m o n g t h e c o m p l i a n c e issues raised by a few o f the series' a u t h o r s . T h e d r o p o u t rate at o u r c e n t e r is n o t as large as r e p o r t e d elsew h e r e (Stanley & Turner, 1 9 9 5 ) - - p r e s u m a b l y f o r the reasons discussed below. O n t h e o t h e r h a n d , we d o n ' t k n o w h o w m a n y O C D sufferers c h o o s e n o t to c o m e to o u r c e n ter b e c a u s e t h e y k n o w a m a j o r c o m p o n e n t o f t h e i r treatm e n t will b e e x p o s u r e a n d r e s p o n s e p r e v e n t i o n (ERP). A l t h o u g h ERP is a c e n t r a l c o m p o n e n t o f o u r O C D treatm e n t p r o g r a m , we d o treat t h e w h o l e p e r s o n . F o r s o m e o f o u r clients, O C D is t h e o n l y p r e s e n t i n g p r o b l e m , while f o r others, O C D m a y simply b e t h e m o s t obviously dis-