Workshop 7

Focussed cognitive-behavioural treatment of Obsessive-compulsive:  beyond exposure and response prevention.

Paul Salkovskis, Institute of Psychiatry, UK

Cognitive-behavioural theory indicates that anxiety is related to the perception of threat or impending danger to oneself and/or others. Obsessive-compulsive disorder results when people misinterpret intrusive thoughts as a sign not only that harm may occur, but that they may be responsible for it through what they do or fail to do. People thus develop obsessional problems because they interpret normal intrusive thoughts as a sign that they may be responsible for harm if they fail to take preventative action. The preventative action (compulsive behaviour) is motivated by the way in which the person interprets intrusions as indicating that they may be responsible for harm to themselves or other people. However, the reactions which are motivated in this way can and do have two effects. Firstly, they can increase the occurrence of intrusive cognitions and secondly, maintain or even increase the person’s beliefs about threat and their responsibility for it.

The cognitive-behavioural treatment that has been developed from this theory has several components, but one primary focus.  Therapy seeks to help the patient understand their problem as one of anxiety rather than danger and to react accordingly. In this workshop a multi-stage treatment will be described with the main focus being on providing practical clinical details of cognitive-behavioural treatment as applied to obsessional problems. Clinical strategies which allow the application of a personalised combination of the following components and stages in each patient:

1. Helping the person to identify the intrusions, the way these are interpreted and the specific vicious circles involved in the maintenance of both. The aim of this aspect of treatment is to give the person a new (and less frightening) way of thinking about their problem and what they can do about it. Subsequent treatment components draw upon and build up this re-conceptualisation of their obsessional problem. This is a crucial stage as the remainder of therapy is driven by this therapeutic conceptualisation.
2. Strategies to normalise the experience of intrusions and help the person to interpret them in a less threatening way, so that they are better able to react less or not at all to them.
3. Strategies which modify both (a) the general beliefs which lead the person to misinterpret intrusions (e.g. “thinking something is as bad as doing it”) and (b) the specific interpretations (e.g. “I had the thought I hoped my mother would die; this means I want to kill her”) which arise from the general beliefs and motivate the counter-productive reactions.
4. Techniques designed to normalise the experience of intrusions and help the person to see that they do not need to engage in compulsive behaviour.
5. Helping the person to devise, carry out and make sense of behavioural experiments with which they can test the accuracy of their new way of thinking about their problem.
6. Helping the person to understand the counter-productive effects of safety seeking behaviours, particularly overt and covert compulsions. This allows therapist and patient to negotiate a programme of exposure to feared stimuli combined with prevention of compulsive behaviours. This programme is tailored in ways which help the person discover (a) that their anxiety can and will be reduced without resorting to compulsive behaviours and (b) where appropriate, that the consequences they fear were not being prevented by the compulsions. Although similar to exposure and response prevention, the emphasis is quite different and specific cognitive strategies (e.g. the use of metaphor) are used to achieve the required results.
7. Helping the person to re-establish important non-obsessional aspects of their life (their social life, education, occupational issues and so on).
8. Identify relapse prevention strategies, and anticipate how these could best be activated if the person were to find their problem recurring.
9. The importance of treatment flexibility and integrity will be emphasised; detailed supervision is the best strategy to ensure these.

Each stage will be illustrated through practical clinical case material. The treatment described has recently been evaluated as being effective in two randomised controlled trials, which will be briefly described.

Key Objectives:  On completion of the workshop participants should:

1. Have a good understanding of the way in which cognitive behavioural theory is applied to the treatment of obsessive compulsive disorder
2. Know how to conduct an assessment which will lead to a shared understanding
3. Engage in a range of cognitive procedures including normalising and challenging of the beliefs which motivate compulsive behaviour
4. Be able to devise and implement a range of behavioural experiments including, but not confined to, exposure
5. Understand how to challenge assumptions
6. Understand and be able to implement goal-setting in a flexible way taking account of patient values and aspirations