By Milton Spett

In his new book, Cognitive-Behavioral Therapy for OCD (Guilford, 2004), David Clark provides an excellent, comprehensive review of generally accepted CBT theory and treatment for obsessive-compulsive disorder. He argues that maladaptive cognitions are the core of OCD and cognitive change is the key to symptom remission. According to Clark, the purpose of behavioral interventions is to effect cognitive change. He also discusses at least one new and powerful cognitive intervention for treating obsessions.

CBT Treatment of Obsessions

A widely-accepted principle in CBT is that patients’ attempts to reduce the frequency and distress of their obsessive thoughts actually increase the intensity of these thoughts. For many years, the effective and widely accepted CBT treatment for obsessions has been exposure. OCD patients have been assigned to think or write about their obsessions frequently and for prolonged periods. Obsessive patients have also been assigned to record their obsessions on loop tapes, and then listen to their own voices, endlessly repeating their obsessive thoughts. Exposure has been assumed to work through the process of extinction -- the assumption that when patients intentionally obsess for long periods, whatever had been reinforcing their obsession will not be present and so the frequency of their obsessions will decrease.

According to Clark, the effectiveness of exposure is probably best explained not by the behavioral concept of extinction, but rather by the concept of cognitive restructuring: patients changing their negative appraisals of their obsessive thoughts. The more patients intentionally experience these thoughts, the easier it is for patients to accept the thoughts without judging themselves or their thoughts as defective or immoral.

A Powerful, New Intervention for Obsessions

The most important and powerful intervention described in the book is a cognitive technique developed by Salkovskis for treating obsessions. Salkovskis argues that when patients complain of intrusive, obsessive thoughts, their key problem is not the thought but their negative appraisal of the thought. Most people occasionally have fleeting thoughts of violence or danger or sexuality. But OCD patients’ negative appraisals of these thoughts cause the thoughts to become obsessive rather than fleeting. The key problem of these patients is their belief that they are defective or immoral because they have such thoughts. The key element in treating obsessions is to convince OCD patients to change their negative appraisals of their obsessive thoughts.

To help normalize OCD patients’ appraisals of their obsessive thoughts, Clark suggests telling obsessive patients that “90% of people report that they have … unwanted intrusive thoughts of contamination, dirt, sex, aggression, mistakes, dishonesty, religion, making rude or embarrassing remarks, causing accidents or injury to self or others, or losing control.” Clark includes a table of typical obsessive thoughts and the percent of non-clinical subjects who report having experienced these thoughts. This table can be copied and shown to subjects. Some examples of common negative thoughts are:

Causing a fire by not turning an appliance off: 70%

Leaving the door unlocked: 71%

Swerving my car into oncoming traffic: 52%

Having sex in public: 61%

Slitting my wrists or throat with a knife: 21%

CBT Treatment of Compulsions

An important point in Clark’s book is that OCD patients must give up their efforts to control their obsessions (much like panic patients must give up their efforts to control their symptoms). Clark views compulsions as counterproductive attempts to control obsessions by neutralization. For example, repeatedly consulting doctors and undergoing medical tests are attempts to neutralize the obsession of having a serious medical illness.

For many years, the effective and widely accepted CBT treatment for compulsions has been exposure and response prevention – exposure to the stimuli that evoke the compulsive behavior and response prevention of the compulsive behavior. Compulsions are usually viewed as an attempt to reduce the anxiety caused by an obsessive fear. For example, an obsessive fear of contamination causes anxiety, and handwashing reduces the contamination anxiety. But this anxiety reduction reinforces the compulsive handwashing and increases its future frequency. When the compulsive behavior is not performed (response prevention), it is not reinforced by anxiety reduction and the compulsive behavior gradually extinguishes.

In treating compulsions the focus should therefore be on disrupting the compulsive behavior, encouraging the patient to make some change in his or her compulsive ritual. Patients are often unwilling or unable to completely stop their compulsive behavior, but they can make a small change in that behavior. For example assume that before a patient can leave his house, he compulsively checks his oven ten times to make sure the gas is turned off. The standard treatment would be to ask him to change this ritual, perhaps to check the gas only five times. Another technique for disrupting compulsions is to ask the patient to delay performing the compulsive behavior for a specific amount of time. For example, to leave the house for 30 seconds without checking, and then return to check the gas or the lock or whatever. By delaying the compulsive behavior, the patient’s anxiety usually diminishes, reducing the urge to perform the compulsion, and enabling the patient to further reduce or delay the compulsive behavior.

Additional Techniques Described by Clark:

1. Socratic Questioning. Adopt a collaborative rather than a confrontational style. Patients’ obsessive beliefs include thought-action fusion, inflated responsibility, intolerance of uncertainty, perfectionism, intolerance of anxiety, and faulty appraisals of danger. Instead of disputing these obsessive beliefs, Clark recommends asking patients a series of questions that will force them to evaluate the reasonableness of their beliefs. For example, suppose a patient believes that he must always do exactly what God wants him to do. Instead of arguing that this goal is unreachable or unknowable, Clark advises asking the patient what is the likelihood that this belief is true? What is the percent of people who know what God wants them to do? Suppose God wanted you to do something for fifteen minutes each day and you did it for ten minutes one day, do you think God would punish you?

2. Withhold Reassurance. Some obsessive patients constantly seek reassurance -- for example, reassurance that they have not contracted a serious illness. Clark views this reassurance-seeking as a compulsion, an attempt to reduce the anxiety caused by a contamination obsession. Reassuring these patients that they are not sick does temporarily reduce their anxiety, but this anxiety reduction reinforces their compulsive reassurance seeking. Rather than trying to reassure these patients, Clark advises trying to convince them to stop seeking reassurance (response prevention).

3. Begin With Cognitive Interventions. Clark points out that patients may initially be reluctant to complete anxiety- producing behavioral assignments. Therefore treatment should begin with an explanation of the cognitive view of OCD and the rationale for behavioral assignments. While this is certainly true for many patients, other patients are more willing to carry out behavioral assignments than to change their negative appraisals of their obsessive thoughts.

Concluding Comments

Clark points out that OCD patients must learn to view their unwanted thoughts as insignificant, meaningless, and requiring no control efforts. Following this concept of normalizing obsessive thoughts, I would suggest that referring to obsessive thoughts as “intrusive” is illogical and counter-therapeutic. The word “intrusive” has a pathological connotation, but most thoughts are intrusive, that is, they come to the thinker unbidden. Very few thoughts are produced intentionally. Pointing this out to patients and not referring the obsessive thoughts as “intrusive” helps to normalize patients’ appraisals of their thoughts and of themselves. Instead of referring to unwanted thoughts as “intrusive,” I refer to them as “silly.” This adjective is more benign that “intrusive,” further helping to depathologize unwanted thoughts.

Another normalizing technique I like to use with OCD patients is to point out that thoughts are not wishes and wishes are not acts. Most patients who feel guilty about their thoughts or wishes will accept the concept that a violent or forbidden sexual thought is not as “bad” as a wish, and a wish is not as “bad” as an act.

This is a valuable book and an outstanding guide to treating OCD, but it is often tedious. Clark tends to repeat points over and over, delineate interventions in exhausting detail, and draw meticulous distinctions between theoretical positions that have no clinical significance. But what would you expect from a book on OCD?

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