The Uses and Misuses of Cognitive Therapy for OCD

I agree that attempts to dispute the rationality or probability of obsessional fears is not only likely to be ineffective, but they can actually reinforce the disorder by functioning as a reassurance compulsion.

It is important to acknowledge the POSSIBILITY (however remote) that your patient could be poisoned or contaminated by eating food prepared by his mother. He can never know for sure. His OCD is sustained because he is engaging in behaviors designed to create absolute certainty that he won't be harmed. As Jonathan Grayson points out, the essential problem is that "uncertainty is FEELING, not a fact." This is a critical meta-cognition for your patient to grasp. The key to your his recovery centers on his willingness to engage in behaviors which will temporarily INCREASE his experience of anxiety and uncertainty. Psychoeducation around the processes of habitutation and extinction can be very helpful in persuading the patient to do ERP (Exposure with Response Prevention).

I also wonder if your patients reluctance to take his medication on a regular basis might be related to harm-avoidance concerns. If this is the case, using administration of medication as an exposure exercise can be quite useful. I have had patients bring their pills to the office and take them during our sessions.

Phillipson has written eloquently on the use of CBT for OCD. His work can be found at:

http://www.ocdonline.com/definecbt.htm

One more point: so called "over-valued" obsessional concerns can appear quite bizarre (quasi-psychotic) and intractable. They can still be addressed through an appropriate regimen of behavior therapy.

Replies:

Re:The Uses and Misuses of Cognitive Therapy for OCD, by Helen, 08/02/03 Dr. Grayson, by Carl Robbins, 08/02/03 Re:Dr. Grayson, by Helen, 08/03/03

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