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Active Intervention: Exposure
In treatment of repugnant obsessions it can be difficult to determine the risk to which the client should be exposed. The treatment can be especially tricky when the client’s obsessions occur in the form of doubts and when the client experiences obsessions involving violence or exploitation of loved ones. A general rule is that clients should be exposed to what they fear. If they are afraid of a thought or image, expose them to the thought or image. This exposure can be accomplished by the client’s writing out the thought or scene in vivid detail, and reviewing it again and again, or writing it again and again. The therapist can also ask the client to read a detailed description of the image into a tape recorder and play the tape repeatedly. This method, also referred to as audiotaped habituation, is especially helpful for clients who use mental compulsions or neutralization such as rationalizing, saying ritualized prayers, or thinking a "good" thought, as the continuous repetition of the obsession prevents completion of the mental ritual. A client who is afraid of losing control and acting on an impulse should be exposed to the situation in which the impulse occurs. For example, if the urge is to swerve into the other lane while driving, the client should drive and experience the urge as often as possible without engaging in compulsions or avoidance. In cases of violent or exploitative obsessions, the goal is not to desensitize individuals to the idea of hurting a loved one or of a loved one’s being harmed. Take the example of an obsession of sexually molesting one’s child. The parent’s concerns about the consequences to the child of experiencing sexual abuse are quite rational. What is irrational about the obsession is the fear that the thought itselfis the vector by which harm might occur.
If the obsession is a doubt, then the client needs to be exposed to the sense of uncertainty without engaging the doubt. The client needs to experience the doubt without entertaining it as an idea that requires anykind of response: that is, go about their day with the sense of doubt but without doing anything at all to ameliorate it. Often people who have obsessional doubts ask how they are to know whether a doubt is real. We have found it useful to tell clients that if it feels like OCD, it is OCD. Second, we recommend that if the doubt is not strong enough to evoke an action consistent with the doubt it is unreasonable (e.g., the doubt as to whether you have accidentally hurt someone does not lead you to want to drive to the police station to confess). Third, if the concern driving the anxiety has been derived through more than one "what if," we deem it unreasonable. For example, "What if I left crumbs behind on the table and what if the next person who sits down has a peanut allergy and what if he/she touches my crumbs and has an anaphylactic reaction and does not have an epi-pen and dies—it would be my fault!"
Active Intervention: Cognitive Restructuring
Second, cognitive restructuring around the "truth" of the obsessional thought is likely to be quite unproductive (e.g., trying to prove categorically that someone is not a child molester): it is almost impossible to prove the null hypothesis. The problem in the preceding example is not that such individuals erroneously think they are child molesters, but rather that they think they could bechild molesters and that they must behave cautiously until they have 100% certainty that they are not, have not been, and never will be a danger to children (99% certainty is seldom good enough). By the time individuals enter treatment they probably have accumulated every iota of evidence for and against the idea that they are child molesters and use this balance sheet as a form of self reassurance or self-recrimination. Thus, cognitive restructuring aimed at establishing the validity of the doubt is at best fruitless; at worst it assists the client in the elaboration of the reassurance ritual. Salkovskis (1999) states the OCD problem that needs to be addressed quite eloquently: "Maybe you are not dangerous, but you are very worriedabout being dangerous" (p.S35).
Finally, when treating religious obsessions sensitivity to the client’s religious values is important. Treatment should focus on irrational and exaggerated concerns about the meaning of the thoughts, but not beliefs about religion itself. We also advocate involvement of the client’s spiritual leader as a means of establishing acceptable guidelines for religious practice (e.g., frequency of prayer and other religious practices), just as when treating contamination fears one might consult a medical professional to establish acceptable guidelines for maintaining good hygiene. The therapist and client can then agree to accept the spiritual leader’s guidelines for religious practice and use these standards when reducing rituals such as repetitive prayers.
The message is that the sense of certainty is absent or present, and that if it is absent, one is "off the hook" for compensating for the perceived transgression. Taking the doubt (e.g., "maybe I sinned") seriously by actually questioning reality (e.g., "Am I certain that I didn’t sin?") and attempting to determine whether or not the doubt is valid is prohibited.
This reasoning is similar to the notion of not allowing individuals who have OCD to try to prove the null hypothesis. With these caveats in mind, there are a number of specific restructuring techniques for OCD to address the kind of appraisal relevant to repugnant obsessions (see Freeston, Rheaume, & Ladouceur, 1996; Salkovskis, 1999; Steketee, 1999; van Oppen & Arntz,1994). The following case example illustrates the use of cognitive techniques in combination with exposure in treatment of repugnant obsessions.
Reflection Exercise #9