For understanding CBT management of OCD a clear understanding of Cognitive Behavioral conceptualization of the OCD disorder is cornerstone of success for both patient and more importantly for any CBT therapist. It highlights the areas on which both are going to work. Without a route a ship in voyage is a terrifying idea.
To start with modern cognitive behavioral conceptualization of OCD, here it means trying to understand more essentially the maintaining factors of the disease than looking out for etiological factors we are mentioning the key maintaining factors of OCD in terms of CBT conceptualization:
a) Negative appraisals or interpretation
b) Faulty maladaptive coping strategies by patients to their symptoms; which is again divided in two ways;
i) Avoidance behaviors
ii) Compulsive acts itself
Now to illuminate in brief the above mentioned maintain factors, we will start with Negative appraisals which consists bedrock of Cognitive Model (not Cognitive Behavioral Model). It rests on premise that intrusive thoughts are essentially universal human experience. Rachman & Silva (1978) initially reported that over 90% of a community samples reported occasional intrusive, repugnant, unwanted thoughts, images or impulses. Salkovskis & Harrison (1984) reported that thought of non OCD sample did not differ in content from those experienced by people diagnosed with OCD. However, what did differ was the meaning attributed to the intrusive thought. Non OCD people appraised the intrusive thoughts as having no special significance, whereas people diagnosed with OCD appraised these thoughts as threatening meaning and personally relevant. The threat simultaneously produces emotional distress and the urge to engage in overt or compulsive acts that functions to reduce both threat and distress (Carr; 1974, Mc Fall 1979 & Salkovskis, 1985). For example one thought being affected by disease by seeing a death of someone. A non OCD person would not place any special significance on this thought but a OCD people may appraise the same thought as indicative of future danger and lesson for him to take some firm steps. If he ignores then devastating consequence may happen to him. This threatening appraisal would clearly lead to anxiety and the urge to take necessary steps in order to be contamination free. The threatening appraisal is what initially maintains behavior, without it, the emotional distress would be minimal or nonexistent and the urge to engage in a behavior that functions to decrease the threat would be unnecessary.
Many researchers & clinicians mentioned types of such faulty negative appraisals which are of importance to OCD out of which six are considered highly replicated. Out of these, Salkovskis reasoned Inflated Responsibility appraisals are of central importance. Salkovskis (1996) regards responsibility as “the belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes”. Obsessive Compulsive Cognitions Working Group (OCCWG) has suggested five appraisals domain in addition to responsibility (OCCWG, 2001). The beliefs are;
i) Over importance of thoughts
ii) Control over thoughts
iii) Overestimation of threat
iv) Intolerance of uncertainty
v) Perfectionism
Overimportance of thoughts can be summarized as giving a thought merit because it was experienced (i.e., the thought was important which is why it occurred and it is thought about because it is important). The reasoning behind overimportance of thoughts is circular (Whittal et.al, 2001). An additional concept is thought action fusion (TAF) (Rachman & Shafran, 1998). TAF is thought to be operating when thoughts and action s are inappropriately fused together. There are two suggested component; moral TAF and likelihood TAF. In moral TAF, having the thought and engaging in the action are seen as the same (e.g., having an intrusive unwanted sexual thought is equivalent to carrying out the act). Likelihood TAF entails a higher probability of an event happening because the thought occurred (the probability of diseases increases because of an intrusive thought of contamination). Both cause extreme guilt, shame & severe distress hence one does anything everything which decreases anxiety or such like compulsion or avoidance which are reinforcing in nature.
Control over thoughts, another faulty type of appraisals, is similar to previous domain in which the distress is hypothesized to be produced by the perceived catastrophic consequences if the intrusive thoughts are not controlled (Clark & Purdon, 1993). A typical response to intrusive uncontrollable thoughts is an effort to suppress it, while it actually increases the frequency of such thoughts in more severe form and in result and one more tries to further suppress and so on a escalation in more circular form happens and one becomes more frustrated and distressed.
Another faulty reasoning process of overestimation of threat is likely common as in case of other anxiety disorders. This appraisal is highly restructured and dealt in case of both cognitive & behavioral approach of Exposure techniques which we will discuss later.
Intolerance of uncertainty, though mostly associated with generalized anxiety disorder even in case of OCD especially in symmetry based compulsion it is perhaps more stronger. It is usual with OCD patients that they know the behavior (e.g., locking the car) was done. However, because it doesn’t ‘feel right’ or they are not absolutely certain, the behaviour must be repeated. Even a small seed of doubt is unacceptable likely due to consequences associated with it.
Another faulty appraisal associated more strongly with symmetry compulsions are of need of perfectionism. It is the “tendency to believe there is perfect solution to every problem, that doing something perfectly (i.e., mistake free) is not only possible but also necessary, and that even minor mistakes will have serious consequences” (OCCWG, 2001). Strive for this escalates compulsive acts which perhaps have no limit.
Now let’s understand the other maintaining factors which are more behavioral in nature but further fuels the faulty cognitive part of the patient.
Obsessive thoughts, impulses and images usually concern themes which are personally relevant, repugnant and build imaginable catastrophic fears. Subsequently when obsessions occur then it is understandingly accompanied by feelings of discomfort or anxiety, the more personally unacceptable the more uncomfortable one becomes on its occurrence. Then the individual tries to find something which is aimed either to decrease such elevated anxiety or distress or to neutralize the imaginary consequences these are attached with. And such acts often take form of either or both compulsion or avoidance.
Compulsions are usually carried in stereotyped or idiosyncratic which brings temporary anxiety relief and the expectation that had these not been carried out then the anxiety has increased or the dreadful consequences would have been inevitable.
Patients also develop avoidance behaviors, keeping away from situations or objects which trigger obsessions. For example patient with contamination fears may avoid public toilets, places; patient with sexual thoughts may avoid looking opposite gender, people with pathological doubt (checking) may avoid shopping and buying things for his own. For patient this acts on a principle that of “prevention is better than cure or for them avoidance is better than cure.”
In both the acts, compulsions and avoidance, gives temporarily relief. This “relief” is reinforcing in nature. Imagine a situation in your occupational setting where you are given reward for something. Then it will motivate you do the same work for which you got it. Similarly these temporally relief acts as such reward on reinforcement, so when ever in future obsessions happens the patients uses the method that which gave him success. But he is not aware that these acts of temporary relief strengthen his faulty fears in a long run, hence making the disease stronger on each acts of this.
In summary, “avoidance prevents exposure to the feared thoughts, and compulsions terminate exposure; both types of behavior prevent the patient from confronting (being exposed to) his feared thoughts and situations” (Salkovskis, 1997). Compulsions and avoidance thus prevent reappraisal: if the patient stops these behaviors, he discovers that the things he is afraid of do not actually happen. Thus these two own way of coping the problem by patients makes the disorder more firm and habitual in manner.
As we have mentioned earlier the first and perhaps most important step of CBT of OCD is understanding and communicating the patient that what are the maintaining factors of their OCD and how their own “coping acts” are maintain the problem and their own role is foremost building block of their success in overcoming it. In short rationale of treatment has to be communicated efficiently i.e., how each of the step is actually going to give them success.
Exposure and response prevention (ERP): For the past 35 years, the psychosocial treatment of choice has been exposure and response prevention. Treatment using this approach involves developing a hierarchy of presenting symptoms, from least fear producing to most, and then guiding the client through exposure to items on the hierarchy until the highest level items are readily tolerated at the same time response prevention is included, whereby the client is asked to refrain from completing the compulsions that would otherwise eliminate the anxiety or distressing emotional reaction (Rowa et al., 2007).
ERP can be delivered in two ways.
In Classical Habituation model, ERP involves exposing the patients to the anxiety triggering stimuli in a graded manner, starting with the item that illicit at least moderate level of anxiety or distress. It should be explained the patient that often people think that the anxiety will continue and becomes intolerable, rather it does not increases to intolerable levels and after subsides more rapidly than they might expect. Sometimes within ten minutes, at times may be half an hour or an hour, but it will. It is also to be explained that they will notice that after they have done exposure two or three times, the amount of discomfort they get at first becomes less and less. This is the best indication of how the treatment is working, as time goes on, they will find that they are able to do the exposure and get no discomfort at all.
Even in a single session, when ERP is about to be started it is advisable to take SUD rating (out of 100) of the patient of how uncomfortable he/she feels at that moment, then after every 10 minutes same can be asked him to re rate out of 100, this should continue till he feels less anxious or score on SUD rating significantly lower. On in a rule of thumb it should last 45 minutes at least. This subjective experience of decreasing anxiety will be counterproductive to his past belief that “anxiety is intolerable and will escalate forever” and also will be self reinforcing in nature.
ERP as Cognitive Restructuring Tool: Aside of using as habituation tool, here what we do is that we invite patient (after rationale and conceptualization) to challenge the obsessions without doing avoidance and compulsions and observe whether their feared anticipatory consequences actually happens or not. For example one involving in repeated washing of hand would be asked to soil his hand deliberately and make him seat without washing 1 hour and observe in 12 hour basis whether he or family has been in any disease, or modification that only immediately wash soiled hand for only one minute and go on touching his family members and see whether in 12 hour check period has any one fallen ill.
On basis of that they are encouraged to restructure the beliefs that repeated washing is not needed or even one minute is enough for it. It’s better to demonstrate few ERP sessions with therapist in beginning but key lies in multiple home work sessions to be carried out. We basically involve family member in treatment session so they can push and motivate patient for homework sessions. Another thing it has be to clearly stated that in every session at beginning he will feel intense discomfort and anxiety so he is not to be afraid of.
Some data suggest that ERP is more effective if it includes not only habituation but also discussion of feared consequences and dysfunctional beliefs (Freeston, 1997). The method of delivery is important with in vivo therapist– assisted ERP, in conjunction with imagery, reported to produce the greatest change in symptom severity.
Success rates for treatment completers are approximately 80% (Foa & Kozak, 1996). Treatment gains are typically maintained over the long term (Foa & Kozak, 1996). A similar or slightly higher efficacy of ERP therapy as compared to SSRIs was found in several clinical trials (Mawson & Marks, 1984) and in several meta analyses (Van, 1994; Abramowitz, 1997; Kobak, 1998), having been definitively consolidated as the first choice treatment when rituals prevail and the symptoms have mild to moderate intensity.
Since ERP is reported to be a difficult treatment to tolerate where drop-out and refusal rates range are seen the clinician has to supplement with additional techniques to support his cause for success. What we do is integrate these motivational interviewing methods and supportive techniques aimed with humanistic orientation. Even on minor success, how trivial it may be, we try to give as practical examples can like, situation of infant when he starts babbling or imitating human speech, does he ever leave that well I will only speak when I master at it? Does he (patient) when started to learn cycle leave it when he fall down while learning?
The concerns with classical ERP led to the development of alternate theories that would more directly address the changes that were thought to account for a decrease in the severity of OCD symptoms. It was consensually proposed that OCD patients attach a threatening meaning to the intrusions, whereas those without OCD appraise similar thoughts in a more neutral fashion (Carr;1974, Mc Fall 1979, Salkovskis, 1985). It is the appraisal that produces the emotional distress and the urge to neutralize the intrusive thought and these faulty appraisals are distributed in six domains: tendency to overestimate the risk and the responsibility; the importance and the power of thoughts and the need of controlling them; the need of certainty; and perfectionism (Salkovskis, 1985).
The identification of dysfunctional beliefs in OCD patients has led some authors to propose and adapt cognitive techniques for the treatment of OC symptoms (Salkovskis, 1985, 1989, 1998; Rachman, 1997). In parallel, some clinical trials have proven the effectiveness of using cognitive therapy alone for the treatment of OCD (Emmelkamp,1988). Similar efficacy was seen between cognitive and ERP therapies (van Oppen, 1995; Cottraux, 2001; McLean, 2001; Whittal, 2005).
Here, like other CBT oriented methods, after explaining model of the next step is ti discuss the rationale for treatment. Given that intrusive thoughts are nearly universal the obsessions are not the target for treatment. It would be near to impossible to stop thoughts that are normal experience of being human. However, it is reasonable to target the way in which these intrusive thoughts are interpreted.
The insight that the content of thoughts are universal in nature can be encouraged by asking patients to conduct survey of the frequency of intrusive thoughts amongst their friends and/or family members. To accomplish the task list of intrusive thoughts reported by non clinical samples can be given to them (Rachman & de Silva, 1978).
Apart from normalization another important task is make patient learn to distinguish appraisals from obsessions. There has been some disagreement among CBT therapist on when cognitive interventions should be introduced. We are in favor that we may start with cognitive tactics aimed at faulty appraisals and then introduce ERP both as habituation and restructuring techniques because cognitive interventions are usually less threatening than ERP sessions and client can be mentally and cognitively prepared for challenging behavioral work to follow.
To make client learn to distinguish appraisals from obsessions many authors have suggested that appraisals can be described as “your interpretation of the obsession”, “what the obsessions means to you,” “what you think of obsessions,” or “the importance given to thoughts,” “What makes this a significant thought for you?” “What’s so upsetting about this thought?” “What is that makes it to difficult to ignore you?” (Freeston & Ladouceur, 1997; Whittal & McLean, 1999).
Once a client has explained his view on the importance of the intrusive thought, the therapist must then focus on identifying the different types of faulty appraisals involved in the client’s understanding of the importance of the thought. Then therapist can provide required cognitive skills in challenging these appraisals as required.
Salkovskis argues that responsibility appraisals, perhaps is central most in OCD. It can be discovered during a downward arrow analysis. Freeston et. al (1996) suggested courtroom procedure where an individual patient takes the roles of both the prosecuting and defence attorneys. This helps client think critically about the reasoning behind their OCD beliefs as they are required to put forward the arguments that are evidence based than emotional based.
Pie chart technique is another technique to directly challenge excessive responsibility appraisals. The client is asked to identify a situation involving personal responsibility and to give a rating as to how responsible he or she felt for causing this situation (e.g., “My cousin in my family got sick. I am 95% responsible because I wore dirty socks, and last time I did this someone also got sick”). The client is then asked to think all possible contributors to this situation. A circle is drawn (i.e., pie chart), and the client is asked to place all of the possible contributions to the pie, with an estimate of the percentage of importance or responsibility of each contributor for the situation. The therapist can then compare the client’s initial responsibility estimate with the final estimate represented in the pie after taking all other possible factors. This exercise highlights on drawing attention of the clients’ automatic tendency to exaggerate his or personal responsibility, emphasizing the multifaceted and dimensional nature of responsibility, and highlighting the difficulty in portioning overall responsibility for any negative situation because of multiple interacting contributors (Salkovskis, 2003).
The downward arrow technique can be used to cognitively challenge all the faulty appraisals of obsessions. In this exercise the client begins with the obsessive thought and then the therapist probes with the question. As the client answers responds to each probe, the therapist is able to peel back the layers, to uncover successively more basic dysfunctional appraisals. Once the therapist exposes the core fear, then he can summarize by stating that, “So your fear is that if the obsession is true, then this awful outcome will occur.” If at this point the client agrees that the appraisals of threat are biased and unrealistic then the therapist can propose a series of ERP tasks that involve his fears.
If clients are not ready for ERP another approach can be tried to bring more conviction. Double-column evidence gathering technique introduced by Beck can be used. For example, a client having fear of contaminated would be ask how many people have died as they have sat in public places, how many times in past you have fallen ill for it before this OCD started, does similar things happen to your family members when they do such?
Over importance to one’s thoughts takes a faulty circular reasoning. My having the thoughts means it is important. My having the thought increases the probability of action. Finally, my having the thought and engaging in the action are more equivalent. Examples of circular reasoning involved in appraising the thought as over important and the process by which it is developed are discussed. Dwelling on thought provides evidence that it is indeed important. Clients here can be told to adapt a come and go style and test it in a behavioural experiment. On alternative days clients are asked to let intrusive thoughts “come and go” and on the other days to engage in their typical “fight and dwell style”. The outcome measures that patients are asked to record is the time spent engaging in obsessive thinking. Typically what patient report is lower frequency, intensity, and duration of obsessions on the “come and go” days.
Cognitive interventions for likelihood TAF bias will be very similar to the strategies discussed in regard to overestimated threat because Likelihood TAF involves the erroneous view that the obsession increases the probability that feared outcome will occur. Freestone (1996) illustrates use of downward arrow technique to expose Likelihood TAF associated with harm and accident obsessions. Freestone again recommended similar technique to expose the core dysfunctional thinking underlying Moral TAF (e.g., “that I am an evil person, a pervert for having thoughts that maybe I would sexually touch a child”). “Once the highly critical self judgement is clearly articulated with the client, the therapist proposes to test the view that, “the way we think determines our true moral character”. Socratic questioning can be used to introduce doubt in the client’s global, rigid, and absolutistic belief that having bad thoughts is the basis of bad character (Clark, 2004).
“Have you ever changed your mind about someone you at first thought were highly moral but now you find is not so moral? What happened that caused you to change your mind? Was it what that person thought or what the person did?” (Clark, 2004). The therapist could give an example from news reports of clergy accused of sexually assaulting children. “If morality is mainly determined by what we think, how many bad thoughts must a person have to be immoral?” “Is one terribly immoral thought equal to 100 slightly immoral thoughts?” These questions are intended to suggest that judgments of morality cannot be rigid and absolutistic and that person’s behavior is more valid measure of moral character than his or her thoughts.
Therapist can also explore whether a person’s will plays any role in moral value. Consider a person who intentionally runs down a pedestrian versus a person who accidentally runs over someone who has run out in front of traffic. Freeston et al. (1996) suggest that the client can be asked to talk to close friends or family about their strange thoughts as way of normalizing unwanted, even abhorrent, intrusive thoughts. The purpose of this cognitive intervention is to help clients to be aware of when they engage in the faulty appraisal of Moral TAF, to realize that moral value is not primarily determined by our thoughts, and that morality is based on deliberate choice of action.
Clark summarizes two main aims here that are to demonstrate the negative consequences associated with both types of appraisal and to show that a state of certainty and perfection is rarely, if ever achieved.
Freestone (1996) proposes that both should work on a list of advantages and dis advantages to the high need for certainty and perfection. Clients are asked to recall the most memorable times in which they were certain of a action or decision, or when they acted perfectly. Each certain and perfect incident is evaluated in terms of the advantages and disadvantages of such appraisals. Clients can then be asked to recall important occasions on which certainty or perfection was not achieved and they had to live with doubt. Again Socratic questioning, the therapist probes the positive and negative consequence of tolerating uncertainty and imperfection. The therapist should explore the frequency with which certainty and perfection are achieved. The cognitive restructuring exercise should conclude with cost/benefit analysis: “Is striving for certainty was worthwhile?” “On balance, do the costs far outweigh the benefits?”
In above discussions we have tried to present the fundamental CBT mechanisms of OCD patients in a nutshell manner for sake of brevity. In addition to these there are many other numerous behavioral experiments and works which are supplemented with these description of all those in a single chapter may not do a proper justice, in order to get detailed overview of it readers are encouraged to go through CBT specific books on OCD.