More on the role of ERP in CT for OCD

In discussing Cognitive Therapy with OCD in the upcoming second edition of Clinical Applications of Cognitive Therapy, Barbara Fleming writes:

In keeping with the attitude of acceptance discussed earlier, the goal of treatment for OCD is not to eliminate intrusive thoughts, images, or impulses. Instead, the goal is for the client to be able to accept and cope with them effectively and not make them worse than necessary by struggling to fight them. The most commonly discussed and researched behavioral treatment for Obsessive Compulsive Disorder is exposure and response prevention. This can be seen in cognitive terms as the behavioral experiment of refraining from the obsessive-compulsive behavior as a test of whether or not the feared consequences occur. Treatment generally involves repeated, prolonged confrontation with the situations that cause anxiety. In addition, the client must refrain from performing any of the rituals that have served in the past to reduce the anxiety. Exposure can be conducted in reality (in vivo exposure) or in imagery. It can be conducted gradually or all at once (flooding).

This intervention approach is appropriate and useful for both cognitive as well as behavioral rituals which are anxiety-reducing in nature. When the individual is using rituals to avoid anxiety, preventing the rituals serves to help the client confront his or her fears. For example, if a compulsive hand-washer is prevented from washing his or her hands even though he or she feels contaminated, the anxiety will initially increase substantially, then peak, and begin to subside with no catastrophe following. In this manner, the client has challenged his or her idea that the germs and feelings of contamination are dangerous and that the only way to make these feelings go away is to repeatedly wash his or her hands. The client thus discovers that the hand-washing is unnecessary and that his or her anxiety can be reduced more effectively by confronting the fears.

Numerous studies of exposure and response prevention have found that approximately 75% of clients have responded to treatment at follow-up (Foa & Kozak, 1996). For a detailed discussion of how to implement these procedures, see Steketee and Foa (1985).

Although the initial exposure and response prevention session may be done in the presence of the therapist, a single exposure session is not sufficient to constitute the entire treatment. The procedure needs to be repeated regularly between sessions as homework and prevention of the subtler rituals, as well as the more obvious ones, needs to be incorporated into the treatment. Clients may also need to be taught basic rules for ?normal? behavior, since they may not have a clear idea what is normal in terms of hand-washing or checking. Relapse prevention is especially important with OCD, since stressful situations often lead to anxiety and urges to ritualize in the future. Acceptance of OCD as a chronic disease that can be managed effectively is crucial. It may be helpful to include some sessions with significant others present so that they can also understand this illness and learn how to be helpful and not inadvertently enable obsessive-compulsive behavior.

Despite the effectiveness of exposure and response prevention with compulsions that are anxiety-reducing in nature, these same methods would not be appropriate for obsessions which are anxiety-evoking (such as, "I could hurt my baby!"). For the treatment of anxiety-evoking obsessions, flooding with feared cognitions is necessary. These thoughts are maintained by the individual's fears and horror at the thoughts, and attempts at preventing these thoughts through procedures such as thought-stopping could serve to reinforce the view that the thoughts are indeed terrible and such procedures could inadvertently make the disorder worse. If the client is induced repeatedly to confront the feared thoughts, images, or impulses and sufficient time is allowed for his or her anxiety to come to a peak and then subside, he or she discovers that they are unpleasant but not dangerous. This helps to break the cycle that perpetuates them.

When obsessions are not accompanied by compulsions, the exposure focuses less on overt response prevention and more on exposure to the obsessional thoughts. This can be implemented by scheduling a daily ?obsession time,? when the client deliberately focuses on the obsessive thoughts without any attempt at avoidance. The therapist will need to be vigilant for any mental rituals, which could defeat the value of the exposure. Making a loop tape of the obsessions which plays over and over again without stopping can be useful. Another strategy is to teach the client to make the conscious choice to obsess, but to change the way in which he or she obsesses. First, the client needs to recognize that he or she has started to obsess, but instead of fighting the obsession, the client practices acceptance rather than avoidance. The client can learn to apply a variety of strategies to change the process of the obsessing: write the obsession down, sing it, change the image, etc. Once the scheduled obsession time is ended, clients are taught to temporarily put the obsessions away until the scheduled time the next day, becoming more mindful of their current life in the meantime. In order for clients to successfully postpone their obsessions until the next scheduled obsession time, it is necessary to teach them to be mindfully present in the reality of the moment.

Cognitive interventions can also be used to address such issues as faulty estimation of danger or the exaggerated sense of personal responsibility often seen in OCD clients. Other useful foci for intervention include their perfectionistic attempts to control thoughts and actions, their closely related need for certainty, their unwillingness to tolerate ambiguity, their belief that all questions must have an all-or-nothing answer, and their belief that there is one ?right? choice in a situation. Three of the beliefs that are useful to challenge with OCD clients are:
1. I have to avoid the distressing situation or else my intense distress will continue forever;
2. The rituals will keep me (or others) safe;
3. I must ritualize to keep myself from going crazy.

Studies by Foa and her colleagues (Foa, Steketee, Grayson, Turner, & Latimer, 1984; Foa, Steketee, & Milby, 1980; Steketee, Foa, & Grayson, 1982) have shown that a combination of response prevention and prolonged exposure to obsessional cues was clearly superior to either component used alone for the treatment of OCD. In recent years, Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder have been published which conclude that these methods are the treatment of choice for OCD (March, Frances, Carpenter, & Kahn, 1997). The experts prefer to begin the treatment of OCD with either cognitive behavioral therapy alone or with a combination of cognitive behavioral therapy and medication. The likelihood that medication will be included in the recommendation varies with the severity of the OCD and the age of the client. In mild levels of OCD, cognitive-behavioral therapy alone is the initial preferred choice. As severity increases, the experts are more likely to add medications to cognitive-behavioral therapy or to use medication alone. In younger clients, the experts are more likely to use cognitive-behavioral therapy alone.

Outcome studies regarding OCD have been reviewed by Steketee, Pigott, and Schemmel (1999). Their conclusion is that both serotonin re-uptake inhibitor (SRI) medication and exposure and response prevention are effective within six months or less. Exposure and response prevention studies have found that 90 percent of clients were at least moderately improved after treatment, and at follow-up 76 percent remained improved. SRI medication was found to be similarly effective with 65 to 80 percent of clients improving with treatment. However, follow-ups of treatment with medication are not as promising as those with behavioral therapy. Research shows that as many as 90 percent of clients relapse within four weeks of discontinuing SRI medication.

Although most of the outcome studies regarding OCD have investigated treatment protocols focusing purely on exposure and response prevention, cognitive interventions have shown some success as well. One study (van Oppen, de Haan, van Balkom, Spinohoven, Hoogduin, & van Dyck, 1995) showed that challenging negative automatic thoughts was as effective as exposure and response prevention. Another study (Freeston et al., 1997) found an 84 percent success rate when Cognitive Therapy was combined with exposure and response prevention. In actual clinical practice, most therapists combine cognitive and behavioral techniques, and in the Expert Consensus Guidelines (March, Frances, Carpenter, & Kahn, 1997), the cognitive-behavioral treatment recommended includes a combination of exposure, response prevention, and cognitive restructuring. Kozak and Foa (1997) acknowledge that published descriptions of exposure procedures often fail to elucidate the cognitive elements in the procedures, and they conclude that, "there is ample justification for construing much of the exposure-based therapy as cognitive-behavioral" (p. 27).

The efficacy of this treatment approach was initially tested in intensive inpatient programs where exposure and response prevention were conducted for many hours per day, every day of the week. More recently, intensive outpatient treatment has become an alternative treatment of OCD that can make intensive, prolonged exposure and response prevention available without the expense of a full inpatient treatment program. Less research has been conducted on outpatient treatment conducted once or twice a week. However, clinical experience suggests that low-intensity outpatient treatment can be effective when clients follow through consistently on homework assignments.

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