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Section 15
Cognitive-Behavioral Treatment Part Two

Question 15 | Test | Table of Contents

Assessment
It is important to develop a comprehensive inventory of the obsession content, all ameliorative strategies used to cope with the distress it evokes, and the situations, people, places, and so forth that are avoided because of it. Patients who have OCD are often reluctant to admit the content of their obsessions, especially repugnant ones, especially after they have been told that the therapist is obligated to break confidentiality if he/she believes the client is a danger to self or others. Gentle, nonjudgmental inquiry about the basic content of the obsessions is important.

It is helpful to clients to monitor their obsessions, compulsions, and avoidance every day for a week, recording the occurrence of each on a form. Clients typically require some instruction about how to identify and distinguish all three. We have found it useful to define obsessionsas "thoughts that keep coming back to you, even though you do not want them, and that are distressing and/or disturbing." Compulsionsare defined as "mental or behavioral coping strategies you feel compelled to perform in order to try to reduce the distress or discomfort caused by the obsession and/or to prevent a bad outcome."

Avoidanceis "any person, place, object, color, sensation, or situation you avoid in order to reduce the chance of having the obsession or to reduce the amount of distress you might feel if you were to have the obsession." Examples are provided of each, drawing from the diagnostic assessment (e.g., the target obsessions and compulsions on the Yale- Brown Obsessive-Compulsive Scale (Y-BOCS) or the client’s verbal report).

We use two self-report measures of obsessional beliefs and appraisals. The Obsessional Beliefs Questionnaire (OBQ) and the Interpretation of Intrusions Inventory (III) have items designed to assess the range of cognition implicated as important in cognitive behavioral models. The measures have been validated in clinical and nonclinical samples and have demonstrated good psychometric properties (OCCWG, 2001). The OBQ contains items framed in the form of general beliefs, whereas the III contains a subset of items from the OBQ that are framed in terms of situational, immediate appraisal of each occurrence of the obsession. For the purposes of treatment, the III is probably more useful as it assesses situational appraisal.

When assessing violent and sexual obsessions, ensuring that the "obsession" is truly an obsession, and not a thought characteristic of a paraphilia or violent behavior, is of course important. People who have exploitative paraphilias or antisocial tendencies in fact act on thoughts about committing the action. To establish a differential diagnosis determining the extent to which the thought is ego-dystonic is important. This can be accomplished by asking whether the person has ever voluntarily generated fantasies about committing the act and which, if any, acts that are consistent with the thoughts (e.g., violent behavior, sexually exploitative behavior) he/she may have committed. In the case of sexual obsessions the therapist should also ask whether the individual has ever become sexually aroused by the thoughts or has masturbated in response to them.

It is also important to determine whether the primary focus of the concern about having the thought reflects self-interest (e.g., acting it out and getting caught) or concern for the "victim" (e.g., harming someone). Often individuals who have exploitative paraphilias and/or antisocial tendencies have significant difficulty appreciating the destructive impact of their act on the victim. Individuals who have OCD, on the other hand, are exquisitely sensitive to the potential for harm to the victim were the act to be committed, and this sensitivity makes the thought especially upsetting and repugnant. Individuals who have OCD are also most likely to avoid situations that might evoke action consistent with the thought, whereas individuals who have antisocial tendencies or exploitative paraphilias may well seek out situations in which they could potentially act it out. One individual I assessed wondered whether he was a pedophile and had actually tested himself by tickling a little girl he encountered at the grocery store on the chest to determine whether he found it arousing. When it doubt, and when possible, forensic assessments can be helpful in making differential diagnoses.

Educating the Client to the Model
We begin by educating the client about the cognitive-behavioral model of OCD, using the data the client has collected to piece together the roles appraisal, compulsive rituals, avoidance, and thought suppression play in the persistence of the disorder. These data elucidate the internal logic of the problem and its solution. Often clients feel much less "crazy" when they understand the problem, and the treatment itself then makes more sense to them. Furthermore, therapeutic rapport is much stronger when the client is confident that the therapist truly understands her/his fears. If family members are involved in the ritual (e.g., if they are regularly asked to provide reassurance), arranging for them to sit in for part of the session, explaining the treatment rationale to them, and telling them that they will be asked to stop providing reassurance are often helpful. They are often concerned and want to know what they should do instead.
-Purdon, Christine. Wiley Periodicals, Inc. J Clin Psychol/In Session 60, 2004.

Personal Reflection Exercise #8
The preceding section contained information about cognitive-behavioral treatment of repugnant obsessions. Write three case study examples regarding how you might use the content of this section in your practice.

Update
Efficacy of Remotely-Delivered
Cognitive Behavioural Therapy
for Obsessive-Compulsive Disorder:
An Updated Meta-Analysis
of Randomised Controlled Trials

Salazar de Pablo, G., Pascual-Sánchez, A., Panchal, U., Clark, B., & Krebs, G. (2023). Efficacy of remotely-delivered cognitive behavioural therapy for obsessive-compulsive disorder: An updated meta-analysis of randomised controlled trials. Journal of affective disorders, 322, 289–299. https://doi.org/10.1016/j.jad.2022.11.007

Peer-Reviewed Journal Article References:
Barrera, T. L., McIngvale, E., Lindsay, J. A., Walder, A. M., Kauth, M. R., Smith, T. L., Van Kirk, N., Teng, E. J., & Stanley, M. A. (2019). Obsessive-compulsive disorder in the Veterans Health Administration. Psychological Services, 16(4), 605–611.

McKay, D., Abramowitz, J. S., & Storch, E. A. (2021). Mechanisms of harmful treatments for obsessive–compulsive disorder. Clinical Psychology: Science and Practice, 28(1), 52–59.

Solomonov, N., Kuprian, N., Zilcha-Mano, S., Muran, J. C., & Barber, J. P. (2020). Comparing the interpersonal profiles of obsessive-compulsive personality disorder and avoidant personality disorder: Are there homogeneous profiles or interpersonal subtypes? Personality Disorders: Theory, Research, and Treatment. Advance online publication.

QUESTION 15
How does Purdon define avoidance? To select and enter your answer go to Test.

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