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Cognitive Behavioral Treatment of Obsessive-Compulsive Disorders:
A Commentary
David A. Clark, University of New Brunswick
This commentary discusses a number of issues that arise from the papers published in this special issue on cognitive behavioral treat-
ment (CBT) of obsessive-compulsive disorders (OCD). The reasons for the recent shift toward a more cognitive perspective in the the-
ory and treatment of OCD are discussed. A theoretical framework is proposed for understanding the concepts found in various cogni-
tive theories of OCD. Furthermore, the common, core ingredients of CBT for obsessive and compulsive p~vblems are presented. The
pitfalls and difficulties encountered by the clinician who offers CBT to individuals with OCD are discussed, and I conclude with a
comment on the empirical status of the therapy.
BSESSIVE-COMPULSIVE DISORDERS (OCD) are a In the 1970s a behavioral treatment of OCD was devel-
O group of anxiety disorders that can take a chronic oped based on this early learning model of obsessions
and debilitating course with 1-year prevalence rates re- and compulsions. The treatment involved systematic ex-
ported as high as 2.1% for the general population posure to the obsessions and any stimuli that would evoke
(Regier et al., 1993), although Antony, Downie, and Swin- them, as well as prevention of any compulsive or neutral-
son (1998) question whether this estimate is too high be- izing behaviors that might be used to reduce anxiety. The
cause structured interviews, like the Diagnostic Interview central tenet of exposure and response prevention (ERP)
Schedule, produce more false positives when diagnosing treatment was that anxiety caused by the obsession would
OCD. The distinguishing diagnostic criteria for OCD is naturally habituate and so the frequency of the obsession
the presence of obsessions and/or compulsions that and associated compulsive ritual would significantly de-
cause significant distress or impairment in functioning cline with repeated exposure to the fear stimulus (i.e.,
(American Psychiatric Association, 1994). According to obsession). ERP did prove to be a very successful form of
the Diagnostic and Statistical Manual of Mental Disorders treatment for OCD, especially for those with washing
(DSM-1V,, American Psychiatric Association, 1994), obses- and, to a lesser extent, checking rituals. Outcome studies
sions are "persistent ideas, thoughts, impulses, or images of ERP indicate that approximately 70% to 80% of OCD
that are experienced as intrusive and inappropriate and patients who complete treatment show significant symp-
that cause marked anxiety or distress" (p. 418), whereas tom improvement (Stanley & Turner, 1995). In a meta-
compulsions are "repetitive behaviors or mental acts, the analysis of 24 outcome studies, Abramowitz (1996) re-
goal of which is to prevent or reduce anxiety or distress, ported that ERP produced large effect sizes indicating
not to provide pleasure or gratification" (p. 418). Typical that most patients experienced substantial reductions in
examples of obsessions are unwanted, intrusive and ego- OCD symptoms.
dystonic (i.e., uncharacteristic of the person) thoughts, If ERP has been such an effective form of treatment
images, or impulses involving themes of dirt, contamina- for OCD, why introduce a cognitive component to this
tion, sex, accidents, aggression, dishonesty, blasphemy; treatment regimen? Is the shift from a behavioral to a
and the like. Compulsions typically involve some ritualis- cognitive focus justified, given the effectiveness of ERP?
tic behavior such as washing, checking, ordering, or Can we expect cognitive-behavior therapy (CBT) to sig-
hoarding. Earlier behavioral theories of OCD viewed ob- nificantly improve on the effectiveness of established be-
sessions as noxious conditioned stimuli that elicit a signif- havioral treatment approaches to OCD? A number of
icant degree of anxiety or distress, with compulsions serv- researchers have discussed reasons for advocating a
ing as strategies for reducing or neutralizing the anxiety cognitive perspective on theory, research, and treatment
caused by the occurrence of the obsession (Rachman & in OCD (Salkovskis, 1985; Whittal & McLean, 1999).
Hodgson, 1980). First, a significant number of patients (20% to 30%)
refuse to begin ERP or terminate treatment prematurely
Cognitive and Behavioral Practice 6, 408-415, 1999 (Stanley & Turner, 1995). Second, long-term follow-up
107%7229/99/408-41551.00/0 studies indicate that for many patients residual OCD
Copyright © 2000 by Association for Advancement of Behavior symptoms remain even after an intensive course of CBT
Therapy. All rights of reproduction in any form reserved. (Whittal & McLean). Third, ERP has been less effective
Continuing Education Quiz located on p. 469. with certain subtypes of OCD, such as those with pure ob-
CBT of OCD Commentary 409
sessions and no overt compulsions (Freeston & Ladou- Cognitive behavioral treatment for OCD is not de-
ceur, 1999) or individuals with compulsive hoarding fined in terms of a unique set of intervention strategies
(Frost & Steketee, 1999). Fourth, a significant number of developed exclusively for the treatment of obsessions and
individuals (20% to 30%) appear to be treatment resis- compulsions. Instead, therapeutic tasks such as exposure,
tant (Sookman & Pinard, 1999), failing to show signifi- response prevention, construction of a fear hierarchy,
cant improvement from either CBT or pharmacotherapy. self-monitoring, cognitive restructuring, and behavioral
Fifth, there are a variety of psychological factors, such as experiments are "borrowed" from established cognitive
low motivation, negative expectancies for treatment suc- and behavioral treatment packages applied to other dis-
cess, procrastination, and noncompliance, that may in- orders. However, CBT does represent a unique way of
terfere with response to ERP. And, finally, the promi- conceptualizing obsessive and compulsive problems. It is
nence of cognitive biases, dysfunctional beliefs, and the theoretical perspective or
erroneous thinking in the disorder suggests that the cog- how one understands OC phe- CBT cannot be
nitive component of OCD should be addressed more nomena that is unique to CBT. implemented
directly in any treatment regimen. What follows in CBT, then, is
This special series of Cognitive and Behavioral Practice is the implementation of this simply by following
devoted to the description, application, and discussion of model in each therapy session. a treatment
cognitive behavioral treatment of OCD. The five papers This also means that treat- manual. Rather,
in the series all focus on the development and applica- ment manuals of CBT must at
tion of different variants of CBT for treatment of OCD, or the outset devote consider- the clinician using
specific subtypes of OCD. Each of the papers presents able space to a fairly detailed CBT for OCD must
new, innovative, and very promising approaches to the exposition of the cognitive have an advanced
treatment of OCD. However, given that CB treatment for model of OCD so that the cli-
OCD is still in its infancy, relatively few systematic con- nician is able to educate the understanding of
trolled outcome studies have been conducted to verify client into the CB model be- the cognitive basis
the effectiveness of the interventions advocated in these fore any specific interventions of obsessive-
papers. Nevertheless, most clinicians will agree that new are introduced.
and innovative psychological interventions for OCD are There are a number of im- compulsive
needed, and so these papers present the reader with the plications that follow from this phenomena in
very latest original ideas for the cognitive treatment of very tight coupling of theory order to conduct
obsessive and compulsive problems. In the remainder of and practice. First, a thorough
this commentary I would like to draw out some of the assessment and case formula- the treatment
similarities in theory, issues, and treatment that cut across tion is necessary before imple- effectively.
these various papers. Despite differences in the OCD menting a treatment strategy.
symptomatology targeted and in the particular interven- Each of the authors in the
tion strategies emphasized, I will argue that there is a present series emphasized the necessity of a detailed as-
common or standard CBT theory and treatment perspec- sessment, especially of the cognitive and behavioral pro-
tive that can be discerned in these papers. cesses that underlie OC phenomena. Cognitive theory of
OCD informs the clinician of the cognitive constructs
Cognitive Theory of OCD that must be identified during the assessment process,
which are then used to develop a viable treatment pro-
One of the first impressions one obtains from reading gram. Second, the cognitive model of OCD guides and
the papers in this special series is the critical role that the- directs the implementation of CBT for each patient. The
ory plays in cognitive-behavioral treatment of OCD. initial sessions are devoted to educating the patient about
Freeston and Ladouceur (1999) present their cognitive the cognitive model of OCD. A number of the authors
model of obsessive thoughts, Sookman and Pinard emphasized the importance of this component of the
(1999) describe a cognitive-developmental perspective of treatment package. We know from clinical experience
OCD, Frost and Steketee (1999) discuss a cognitive- and research on cognitive therapy for depression or
behavioral formulation for compulsive hoarding, and Whit- panic disorder that patients must "buy into" a cognitive
tal and McLean (1999) explain the theoretical tenets of explanation for their symptoms if they are to benefit
their group CBT, drawing on the theoretical work of Sal- from cognitive intervention strategies. Thus, in CBT, cog-
kovskis (1985, 1996), van Oppen and Arntz (1994), and nitive theory is so important that it is directly and explic-
Freeston, Rhdaume, and Ladouceur (1996). This very itly taught to the patient at the outset of treatment. A
close link between theory and therapy is integral to the third implication of this tight coupling between theory
practice of CBT for OCD. and practice is that the cognitive behavioral therapist
410 Clark
Table 1 the particular OC phenomena under consideration. For
Summary of the Central Constructs Shared by example, faulty appraisals of personal responsibility may
Cognitive Models of OCD be most salient with "loss of control" obsessions involving
1. Normality of intrusions: assumption that normal and pathological aggressive or inappropriate sexual behavior, whereas per-
intrusive thoughts lie on a continuum fectionistic standards in the form of indecisiveness may
2. Fault), appraisals of intrusions: the core problem in OCD is the be most prominent in hoarding (Frost & Steketee, 1999).
faulty appraisal of unwanted intrusive thoughts or obsessions However, what makes all of these appraisal processes
3. Neutralization and avoidance: presence of overt or covert pathological is that they offer evaluations that exaggerate
neutralizing strategies will increase the salience of the obsession, the sense of personal significance and threat of unwanted
and avoidance will reinforce faulty interpretations of the intrusive thoughts, thereby leading to an escalation in the
intrusive thought.
4. Dysfunctional beliefs: the faulty appraisals of the obsession-prone frequency, intensity, and salience of the intrusions (Rach-
individual are rooted in latent maladaptive beliefs or schemas man, 1997, 1998).
involving themes of threat, dangm; responsibility, uncertainty,
importance of control, perfectionism, and the like.
Neutralization and Avoidance
Cognitive models of OCD continue to recognize that
must have a thorough understanding of cognitive theory neutralization, whether in the form of thought control
of OCD. CBT cannot be implemented simply by follow- strategies, or behavioral or mentalistic rituals, plays an
ing a treatment manual. Rathe1; the clinician using CBT important role in the onset and persistence of OCD.
for OCD must have an advanced understanding of the There is some disagreement over whether neutralization
cognitive basis of obsessive-compulsive phenomena in or- strategies function to reduce anxiety or one of the ap-
der to conduct the treatment effectively. praisal processes such as an inflated sense of responsibil-
A number of writers have presented cognitive models ity. Whatever the case, there is broad agreement among
of OCD (Clark & Purdon, 1993; Freeston et al., 1996; CBT researchers that neutralization and other compul-
Rachman, 1997, 1998, Salkovskis, 1985, 1989, 1996; van sive behavior increases the salience of the unwanted ob-
Oppen & Arntz, 1994; Wells & Matthews, 1994). Al- sessive thought. Avoidance of situations or stimuli will
though there are some distinctive features among these also increase the salience of obsessions by reinforcing the
different accounts, there is a remarkable degree of con- faulty interpretations of the patient (e.g., "I feel better
sensus on the essential components for a theoretical when avoiding public washrooms, so these must be dan-
framework on which the various cognitive models of gerous places").
OCD are constructed. This theoretical framework is evi- Dysfunctional Beliefs or Schemas
dent in the current series of papers. The following con- Each of the authors in this series recognized that un-
structs, then, can be found in most cognitive models of derlying maladaptive beliefs may be responsible for the
OCD. These have been summarized in Table 1. faulty appraisals obsession-prone individuals generate in
The Normality of Intrusions response to their unwanted intrusive thoughts. The con-
Most CBT models begin by recognizing that unwanted tent of these maladaptive beliefs matches the focus evi-
intrusive thoughts, images, and impulses occur as a nor- dent in the appraisal processes. Thus, themes of threat,
mal part of human experience (i.e., Rachman & de Silva, danger, perfectionism, uncertainty, responsibility, and
1978). ~rhat distinguishes normal from abnormal obses- loss of control characterize the dysfunctional beliefs of
sions is a matter of degree rather than kind. the obsessive-compulsive individual. However, it must be
recognized that the content of the dysfunctional beliefs
Faulty Appraisals of Intrusions associated with different subtypes of OCD may be unique
According to cognitive theories, the core problem in to that particular subtype, such as the collecting and dis-
OCD is the faulty appraisal of unwanted intrusive carding beliefs of hoarders (Frost & Steketee, 1999). Cur-
thoughts, images, or impulses. A variety of pathological rently an international group of OCD researchers is
appraisal or interpretative processes have been impli- working on the development of measures to assess dys-
cated in the pathogenesis of obsessions. These include functional beliefs and appraisals in OCD (Obsessive-
appraisals of inflated personal responsibility, importance Compulsive Cognitions Working Group, 1997).
of thoughts, thought-action fusion, overestimation of
threat or danger, negative consequences of ineffective Cognitive Behavior Therapy for OCD
thought control, intolerance of uncertainty, and perfec-
tionistic standards. Which particular appraisal process is Despite nuances in the various CBT treatment ap-
emphasized in a model will depend on the theorist and proaches described by the authors in this series, we do
CBT of OCD Commentary 411
Table 2 that another reason for presenting the cognitive model is
Common Therapeutic Ingredients in Cognitive-Behavioral to normalize patients' experience of obsessions by show-
Treatments of OCD ing them the connection between pathological obses-
1. Education on the cognitive model', initially the client is provided with sions and the unwanted intrusions that occur in the nor-
a cognitive explanation for the persistence of obsessions and mal population. However, one should not underestimate
compulsions as well as the treatment rationale. how difficult it may be to convince someone that the on-
2. Identification of faulty appraisals, neutralization, and avoidance: set and persistence of their obsessions is affected by their
clients are trained to recognize their faulty interpretations of the faulty interpretations. Many patients come into therapy
obsession as well as any neutralizing strategies and avoidance .... /'
behaviors intended to minimize the distressing quality of the with strongly held behefs that their OCD as a d~sease stem-
obsession. ming from a "chemical imbalance" or "genetic deficit."
3. Cognitive restructuring of faulty appraisals: through collaboration For these patients, the educational phase of CBT may
and guided discovery clients are taught to cognitively challenge take considerably longer than one to two sessions de-
their erroneous appraisals and maladaptive beliefs of the scribed in the treatment manuals.
obsession. Educating the client into the cognitive model of OCD
4. Behavioral experimentation: exposure, response prevention, and will also include an introduction to the concept of
other behavioral interventions are used to test out the
exaggerated importance and catastrophic consequences clients "faulty appraisals" of the obsession. At this initial stage of
impute to the obsession. therapy, the client is simply introduced to the idea of ap-
5. Alternative interpretations for the obsession: clients are taught to praisals or "giving importance to the obsession" as the
accept a more adaptive and realistic alternative explanation for primary reason for the thought's persistence. In educat-
the obsession. ing the client, the clinician will also refer to the different
6. Cc~rreeting dysfunctional beliefs: treatment gaius can be maintained
only if the latent core dysfunctional beliefs that give rise to the types of appraisals that underlie obsessional phenom-
faulty appraisals of the obsession are modified. ena, and will suggest to the client the possibility that
7. Relapse prevention: clients are taught self-help strategies to these appraisals are faulty or incorrect. However, no at-
implement in the face of an anticipated resurgence of obsessive tempt is made to persuade clients that their appraisals
and compulsive symptoms are faulty. Rather, in tile second phase of treatment, the
clinician uses collaboration and guided discovery in or-
der for clients to test out the realistic or faulty basis of
see a number of common elements in their treatment their appraisals.
packages. Of course these elements take a different ori-
entation or focus depending on the obsessive-compulsive Identifying Faulty Interpretations, Neutralizing
phenomena under consideration. Having said this, the Strategies, and Avoidance Patterns
following are some common therapeutic ingredients that All of the authors emphasize that patients must be
are found in most cognitive-behavioral interventions for trained to recognize the faulty appraisals and futile neu-
OCD. A summary of these seven common therapeutic tralizing behavior and thought-control strategies they en-
components can be found in Table 2. gage in once an obsessional thought intrudes into con-
sciousness. Freeston and Ladouceur (1999) use daily self-
Educating the Client to the Cognitive Model monitoring and other exercises to help clients learn the
As noted previously, each of the authors emphasizes external and internal factors, such as anxiety, avoidance,
the importance of educating the patient to the cognitive magical thinking, and reassurance seeking, that strengthen
model of OCD. It is critical that this educational aspect of a faulty appraisal process. Whittal and McLean (1999)
CBT not degenerate into an intellectual exercise; rather, note that it is important that patients be trained to distin-
the model should be illustrated using the patient's own guish between the intrusive thought and the appraisals or
obsessions, appraisals, beliefs, and neutralizing strategies interpretations they generate about the intrusion. This
(Freeston & Ladouceur, 1999). If patients "buy into" the distinction will be difficult for some patients who have be-
cognitive explanation for their obsessions and compul- come utterly preoccupied with the obsessional thought.
sions, then they are more likely to be motivated for treat- Frost and Steketee (1999) commented that hoarders may
ment, collaborate in the identification of dysfunctional find it particularly difficult to identify the triggering in-
thinking, and complete homework assignments. On the trusive thought and its interpretation. In addition, all of
other hand, it will be very difficult for patients to adopt a the authors noted that the identification of covert or
collaborative stance on interventions that focus on the overt neutralizing rituals, avoidance patterns, and other
identification and modification of cognitions if they re- maladaptive coping strategies is a critical component of
main skeptical over the relevance of the cognitive model CBT for obsessions and compulsions. Behavioral change
for their condition. is still an important part of CBT, despite the increased
In addition, Freeston and Ladouceur (1999) noted emphasis on cognitive factors.
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