Hazards of cognitive therapy in OCD

A hazard of cognitive therapy in inexperienced hands is that the therapist becomes engaged in subtle requests for reassurance and arguments about minor probabilities. In such cases, it is especially important to use Socratic dialogue to help the patient generate the information needed by a behavioural experiment, or to ask the patient how a colleague or relative would think or act.

Most problems in CBT for OCD stem from two failures: challenging the content of intrusive thoughts rather than the patient’s appraisal of them or the cognitive process; and not spending enough time on exposure and behavioural experiments.

Always relate requests for reassurance or more information to the patient’s formulation and the cognitive–behavioural model of OCD, with an emphasis on the effect of various cognitive processes and behaviours.

Key good practice points for using CBT are summarised in Box 5 and further reading is suggested in Box 6.

Box 5 Good practice points in CBT for OCD

* Patients should have clearly defined problems and goals for therapy
* There should be a shared formulation of the problem that provides a neutral explanation of the symptoms and of how trying to avoid and control intrusive thoughts and urges maintains the patient’s distress and disability
* Do not become engaged in the content of obsessions and requests for reassurance, and do not argue about the likelihood of a bad event happening – help patients to use their formulation and the cognitive–behavioural model of OCD, and use a Socratic dialogue to focus on the process and consequences of their actions
* Do not give up using exposure and response prevention: integrate it with the cognitive approach in the form of behavioural experiments to make predictions
* Ensure that patients do not incorporate new appraisals or self-reassurance as another compulsion or way of neutralising

Box 6 Further reading

* Antony, M. M., Purdon, C. & Summerfeldt, L. J. (eds) (2007) Psychological Treatment of Obsessive–Compulsive Disorder: Fundamentals and Beyond. American Psychological Association.
* Salkovskis, P. M. & Kirk, J. (2007) Obsessional disorders. In Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide (eds K. Hawton, P. M. Salkovskis, J. Kirk, et al), pp. 129–168. Oxford University Press.
* Veale, D. & Willson, R. (2005) Overcoming Obsessive Compulsive Disorder: A Self-Help Guide Using Cognitive Behavioral Techniques. Constable & Robinson.
* Wells, A. (2000) Emotional Disorders and Metacognition, pp. 179–199. John Wiley & Sons.

David Veale
David Veale is an honorary senior lecturer at the Institute of Psychiatry, King’s College London and a consultant psychiatrist in cognitive–behavioural therapy at the South London and Maudsley Trust (Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, 99 Denmark Hill, London SE5 8AF. Email: [email protected]; website: http://www. veale.co.uk) and the Priory Hospital North London. He is President of the British Association of Behavioural and Cognitive Psychotherapies, was a member of the National Institute for Health and Clinical Excellence group that produced guidelines on treating obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) and runs a national specialist unit at the Bethlem Royal Hospital for refractory OCD and BDD.