mar mechanic. 5% approaching car. 20%. Fig. 1. Illustration of 'pie-technique' .... OCD patients it is doubtful whether self-instructional training is the most suitable ... Practical application of cognitive therapy for obsessive-compulsive disorder.
Behov. Res. Ther. Vol. 32, No. I, pp. 79-81, Printed in Great Britain. All rights reserved
COGNITIVE
1994
0005-7967/94
56.00
+ 0.00
Copyright 0 1993Pergamon Press Ltd
THERAPY
FOR OBSESSIVE-COMPULSIVE DISORDER
PATRICIA VAN OPPEN’*
and ARNOUD ARNTZ’
’ Department of Psychiatry at the Amsterdam Psychiatric Centre, Free University, Valeriusplein 9, 1075 BG Amsterdam, The Netherlands 2Department of Medical Psychology/Experimental Psychopathology, Limburg University, P.O.B. 616, 6200 MD Maastricht, The Netherlands (Received
2 December
1992)
Summary-This paper discusses three cognitive models for the obsessive-compulsive disorder (OCD). Further, a cognitive formulation of OCD which stresses the importance of the perception of danger and responsibility is described. Several specific cognitive interventions, which address the estimation of catastrophes and the perception of personal responsibility, are presented and illustrated with patient material. Furthermore, problems with cognitive therapy with OCD patients are described and some solutions for these pitfalls are discussed. Finally, the findings of controlled studies into cognitive therapy with OCD are given.
INTRODUCTION
“A therapeutic technique that maximizes the patient’s opportunity for acquiring new subjective estimates of the probability of unfavourable outcomes would be a welcome advance in the treatment of compulsive problems that to date have proved most resistant to existing therapies” (Carr, 1974, p. 317). Obsessive-compulsive disorder (OCD; APA, 1987) is long considered as a condition resistant to therapy. The introduction of behaviour therapy, i.e. exposure in vivo with response prevention, has radically changed this. The efficacy of behavioural treatment of obsessive-compulsive problems has been well established now (Rachman 8z Hodgson, 1980; Emmelkamp, 1982; Marks, 1987; Steketee & Cleere, 1990). It is striking that until now techniques to change the patient’s subjective estimates of the probability of unfavourable outcomes, as was recommended by Carr (1974), have been underdeveloped, particularly in view of the recent rise of cognitive therapy for mood and anxiety disorders. Progress has been made in identifying the characteristics of the emotional memories and selfschemata associated with depression and anxiety disorders, but research in the area of OCD is scarce. Compared to other anxiety disorders, for which numerous studies have evaluated the effectiveness of cognitive therapy (e.g. Hollon dz Beck, 1986), little research on cognitive treatment with OCD has been done. This is remarkable since OCD is characterized by several forms of cognitive dysfunction. Cognitions seem to play an important role in the triggering of compulsions. For example, during the execution of washing rituals, cognitions about possible contamination play a prominent role and control rituals seem to be provoked by ideas concerning harming others or oneself (Emmelkamp, 1987). In addition, obsessive-compulsives are characterized by unrealistic threat appraisal and overestimation of one’s own responsibility (Rachman, 1992). This paper discusses cognitive models of OCD. Further, several specific cognitive interventions for obsessiv=ompulsive problems are presented. Finally, specific problems of cognitive therapy with OCD patients are described and some solutions for these difficulties are proposed. COGNITIVE
MODELS
OF
OCD
The model of Carr
A first attempt to conceptualize OCD in a cognitive model was made by Carr (1974). Carr emphasized the unrealistic threat appraisals in OCD. This threat appraisal is an individual’s *Author for correspondence. BKT 32,1--F
79
80
PATRICIAVAN OPPEN and ARNOUD ARNTZ
evaluations of a situation in terms of its harmful implications. He assumed that obsessive-compulsives experience a high degree of threat because they overestimate both the probability and the cost of the occurrence of undesired outcomes. Carr based this model on the finding that obsessivecompulsives have an abnormally high subjective estimate of the probability of occurrence of an unfavourable outcome. This idea was supported by findings that obsessive-compulsive patients were more cautious of getting involved in risk-taking activities than other groups of psychiatric patients (Steiner, 1972). The model of Carr was based on Lazarus’ (1966) concept of ‘threat appraisal’, which is an individual’s evaluation of a situation in terms of its harmful implications. Carr assumed that threat is some multiplicative function of the subjective cost of an event and its subjective probability. Because of the high subjective estimate of the probability of the undesired outcome, a number of situations will lead to a high level of anxiety; obsessive-compulsive rituals are developed, in order to lower the subjective probability of the unfavourable outcome. Consequently, these activities are threatreducing. This strategy is reinforced by anxiety reduction and is successful in averting the unfavourable outcome. Unfortunately, in this model it remains unclear why obsessive-compulsive patients have high subjective estimates of the probability of unfavourable events and of the subjective
costs.
The model of McFall and Wollersheim The model of McFall and Wollersheim is based on the work of Lazarus (1966) and Carr (1974). McFall and Wollersheim (1979) proposed that cognitions have a mediating role in the performance of compulsions. This model emphasizes factors which influence the unrealistic subjective estimates of catastrophic outcomes. According to McFall and Wollersheim the threat is generated by an immediate cognitive primary appraisal process whereby the individual estimates the danger of an event relative to the perceived resources to cope with it. After a primary appraisal of threat, anxiety raises and obsessive-compulsive behaviour is initiated on the basis of the person’s secondary appraisal of the likely consequence of his or her efforts to cope with the threat. The unreasonable beliefs which are considered to influence the primary appraisal process of the OCD are: (1) one should be perfect; (2) making mistakes result in punishment or condemnation; (3) one is powerful enough to initiate or prevent the occurrence of disastrous outcomes; and (4) certain thoughts and feelings are unacceptable and could lead to a catastrophe (McFall & Wollersheim, 1979). They further formulate a number of unreasonable beliefs that negatively influence the secondary appraisals including the following: (1) if something is or may be dangerous, one should be terribly upset by it; (2) magical rituals or obsessive ruminating will circumvent feared outcomes; (3) it is easier and more effective to carry out a magical ritual or to obsess than it is to confront one’s feelings/thoughts directly; and (4) feeling of uncertainty and loss of control are intolerable, should make one afraid, and something must be done about them. Because of these beliefs obsessive-compulsives experience themselves as helpless to cope with perceived threat. They perform rituals to prevent the foreseeable catastrophic outcomes. Although obsessions and compulsions are themselves distressing, the obsessive-compulsive patients prefer these over the distress associated with the unfavourable outcomes which may occur if the rituals are not performed. Patients perceive these rituals as being more tolerable than the guilt feelings which are related to the unacceptable impulses (see also Rosen, 1975). McFall cognitive
and
Wollersheim
recommended
Rational
Emotive
procedures
(Ellis,
1962) for
structuring.
The model of Salkovskis A third cognitive model for OCD was proposed by Salkovskis (1985, 1989). He argued that the model of McFall and Wollersheim is unable to distinguish between threat appraisals in obsessive-compulsives and threat-appraisals in other patients. Salkovskis’ model is based on the same model of emotions as that used in the cognitive model of Beck for depression and for anxiety (Beck, 1976; Beck, Emery & Greenberg, 1985). The central
81
Cognitivetherapy for OCD
theme within this model is the idea that not an event, but rather people’s interpretation of an event, leads to a specific emotional response. The response to particular stimuli (thoughts, situations or events) occurs as a result of negative automatic thoughts. Salkovskis emphasized the difference between intrusions and automatic thoughts. The negative automatic thoughts are relatively autonomous, idiosyncratic, experienced as reasonable and egosyntonic as opposed to the obsessions, which are intrusive thoughts that evoke negative automatic thoughts leading to neutralizing by the obsessional. As a consequence of this neutralizing activity, intrusive thoughts become more salient and frequent, and they evoke more discomfort, so that the probability of further neutralizing increases (Salkovskis, 1985). More recently, Salkovskis proposed that the negative automatic thoughts of OCD are related to ideas of personal responsibility (Salkovskis, 1989). He argued that if the appraisal does not include an element of responsibility, the person is likely to be anxious or depressed rather than having an obsessional problem. Several experiments (Rtiper, Rachman & Hodgson, 1973; Riiper & Rachman, 1976; Rachman & Hodgson, 1980) demonstrated the significance of the sense of responsibility in determining compulsive checking. These data showed that stimuli which normally cause discomfort and provoke checking rituals caused little or no checking rituals when the experimenter was present. Presumably, because of the presence of the experimenter, the responsibility for the act is divided between the patient and the experimenter or totally moved to the experimenter, which might cause little distress (Rachman & Hodgson, 1980). Recently, Freeston, Ladouceur, Thibodeau and Gagnon (1992) found evidence for the hypothesis of Salkovskis (1985) that an inflated perception of responsibility is linked to neutral~ation. Using a questionnaire they found a five-factor solution; including the factor ‘evaluation’. This factor, ‘evaluation’, which involves responsibility, disapproval and guilt, was the only significant predictor of compulsive activity scores and was more correlated with avoidance responses than other factors. Thus, these results support Salkovskis’ model of OCD. In all recent formulations of OCD discussed above the importance of cognitive processes has been stressed (Carr, 1974; McFall & Wollersheim, 1979; Rachman & Hodgson, 1980; Salkovskis, 1985). The following account of the development of compulsions is a comprehensive summary of these various cont~butions. fn OCD it is assumed that the pathological cognitive processes involve evaluative processes linking the intrusion and the compulsion (cf. Arntz, 1992). Two such evaluative processes can be assumed to take place: the perception of danger, and the appraisal of personal responsibility. When an intrusion occurs this is hypothesized to lead to a perception of danger. Further, it is important whether or not the person perceives personal responsibility. When the person believes that he or she should do something in order to prevent or reduce the danger or the perceived personal responsibility this eventually will result in the compulsion. ~i~~Iarities and d@erences
between OCD, other anxiety d~orders
and depression
There has been some discussion about the issue whether OCD is truly an anxiety disorder. Though there are undoubtedly similarities, it has been pointed out that there are also similarities between OCD and depression (Rachman & Hodgson, 1980; Insel, Zahn & Murphy, 1985). Not only do OCD patients often suffer from depressed mood or from full-blown depressive disorders, but their preoccupations with guilt, failure, worthlessness and responsibility also resemble the themes that are characteristic of depressed patients. A cognitive fo~ulation of OCD which stresses the importance of both the perception of danger and of responsibility makes it understandable why OCD patients often impress as having characteristics of both anxiety and depressive disorders (Arntz, 1992). The following matrix may illustrate this. In this matrix danger and responsibility are represented by separate dimensions. On the danger dimension, distinction is made between a dangerous event that has led to a catastrophe in the past and a dangerous event that may occur in the future. On the responsibility dimension, a distinction is made between high and low responsibility for the act. A number of psychopatholo~cal problems can be placed in this matrix: (i) low self-esteem, guilt and depression are defined by the combination of perceived high responsibility for an event that took place in the past and which is evaluated as very negative (catastrophic); (ii) resentment is defined by a low perceived personal responsibility (responsibility is attributed to others) about a catastrophe that has happened to the S; (iii) phobias and other anxiety disorders are defined by
82
PATRICIA VAN OPPEN and ARNOUD ARNTZ
the expectations of a catastrophe in the future, but the S perceives little responsibility for the event; (iv) OCD is defined by perceived high responsibility for a future catastrophe. Table 1 may be illustrated by some negative automatic thoughts specific for the different disorders: Depression: OCD: Resentment: Phobias:
I have ruined my whole life. If I do not wash the trousers separately, my daughter will get cancer. If the driver didn’t drink so much my daughter would not have been run over. My heart beats too fast and this means that I could get a heart-attack.
Thus, both OCD and other anxiety disorders involve ruminations about future catastrophic events; however, OCD differs from the other anxiety disorders in perceived responsibility. OCD resembles depression with respect to the personal responsibility for the catastrophic event, but differs from depression on the time dimension. Consequently, OCD can be described as a condition in which the S tries to avoid the depressive position of being guilty, being worthless or having failed, by performing rituals. COGNITIVE
THERAPY
OF
OCD
Cognitive therapy with OCD as presented in the following is essentially based on cognitive therapy with depression and anxiety disorders. The general strategies are: firstly, to consider the intrusions as stimuli, secondly, to identify the distressing thoughts (negative automatic thoughts), thirdly, to challenge these automatic thoughts, and finally, to change the distressing thoughts into non-distressing thoughts. An important general cognitive technique used by the therapist to challenge the automatic thoughts is the Socratic dialogue. Patients are also instructed to monitor and challenge automatic thoughts in diaries. The general cognitive strategies are not described in this paper because these are discussed elsewhere (Beck, 1976; Beck et al., 1985). In this paper we will focus on the more specific cognitive techniques applied in cognitive treatment of OCD. The formulation above (illustrated by Table 1) implicates that OCD should not be treated as a pure anxiety disorder. Depressive issues related, for example, to self-worth, guilt and failure should also be addressed in (cognitive) treatment. Consequently, cognitive therapy with obsessive-compulsives has to deal with estimation of catastrophes on the one hand, and with perceived personal responsibility on the other.
The estimation of catastrophe First, we will describe the cognitive interventions focusing on changing the irrational estimation of danger. It may be useful for patient and therapist to investigate collaboratively two aspects of the danger as perceived by the patient: (i) whether the patient overestimates the chance of danger; and (ii) whether the patient overestimates the extent or the consequences of the danger. Examples of overestimated chances commonly seen in OCD are: “If I come into contact with a tramp I will get a disease”, and “If I do not extinguish my cigarette my house will burn down”. Examples of the second type of overestimation are: “If I get this disease, I will infect my pregnant friend and her unborn child will be physically deformed”, and “If I write an incorrect bank account number of a transfer by bank, the money will reach the wrong person and I will never get my money back, and I will have to live in poverty for the rest of my life”. In cognitive therapy these estimations of danger may be addressed by various techniques derived from cognitive therapy of depression and anxiety (Beck, 1976; Beck et al., 1985). One cognitive technique is the calculation of the probability of the catastrophe. In this procedure the original chance estimation is compared with the chance estimation based on an analysis of the sequence Table I. OCD compared with depression and (other) anxietv disorders Catastrophe in oast
Catastrophe in future
Hinh responsibility
Low self-esteem Guilt Depression
OCD
Low responsibility
Resentment
Anxiety Phobias
Cognitive 2.
Table
Calculation
therapy for OCD
of the probability
step
I.
I did not extinguish
2.
A
3.
The
4.
The carpet
5.
I notice
little
spark
wall-to-wall
immediately anything
my cigarette
falls on the floor carpet
starts notice
will
to burn
covering
catch
fire
and I do not
of the catastrophe Chance
Cumulative
l/IO
l/IO
l/IO
l/l00
chance
l/IO
l/l000
l/l00
I/lCO,OOO
l/l00
I/I o,OOO,OOo
the fire
the fire too late, so I cannot about
83
do
it
of events that lead to catastrophe (Hoekstra, 1989). First, patients and a therapist analyse the sequence of events that lead to the catastrophe. Second, the patient estimates the chance of each event separately. Finally, the cumulative chance is computed, and compared with the original estimate of catastrophe of the patient. The patient is invited to reduce any uncertainty that is left about the chance or the sequence itself in order to optimize the analysis. This analysis can be written on a blackboard or flashcard, so that it can be used on the spot. In Table 2 this cognitive procedure is illustrated. It concerns a patient who checks over and over again whether her cigarette is really extinguished. Her original chance estimation of the catastrophe that her house will burn down if she did not put out her cigarette is 20%. The first event in the calculation of the probability of the catastrophe is: “I did not extinguish my cigarette”. The next event of the sequence for this patient is: “A little spark falls on the floor covering”. The third event in her analysis that leads to the unfavourable outcome is: “The wall-to-wall carpet will catch fire”. The following event is: “The carpet starts to burn and I do not immediately notice the fire”. Finally, the last event that leads to catastrophe is: “I notice the fire too late, so I cannot do anything about it”. The patient’s estimation of the probability of the first three steps was 10% for each step separately. She estimated the chance of the last two steps of the sequence of events at 1%. As can be seen from Table 2, in a sequence of events the cumulative chance is computed by multiplying the chances l/10 x l/10 x l/10 x l/100 x l/100). So, on the average she has to smoke 10,000,000 cigarettes to expect one fatal fire. Due to the overestimation of danger the final chance calculation differs dramatically from what the patients estimated originally. As we compared the original estimation vs the final chance calculation for the patient described above, we obtained 20% vs 0.00001%. As noted above, patients also overestimate the extent of the consequences of the danger. For example, a patient who checks his bank transfers over and over again provoked by the thought “If I write an incorrect bank account number on a transfer by bank, the money will reach the wrong person and I will never get my money back, and I will have to live in poverty for the rest of my life”. Several beliefs underlie his overestimation of the consequences of writing a wrong bank account number or a wrong amount, including: (i) if I make an error in the bank account number the transfer will be remitted automatically to the wrong person (even if the bank account number and the person’s name do not match); (ii) if I make an error in the amount of the transfer I have no legal rights to get the money back; (iii) regardless of the amount of the bank transfer the money will always be remitted (even when the amount is $50,000; (iv) if I make an error in the bank transfer I will never get my money back. To test out the empirical basis of the estimation of consequences it can be useful to ask the patient to solicit information from an expert. For example, this patient wrote a letter to the bank with all these questions precisely formulated. Another useful method for testing the empirical basis of estimation of the consequences of danger is a behavioural experiment (e.g. Beck er al., 1985). An example of a behavioural experiment for the patient who checks his bank transfers a number of times is: deliberately write an incorrent bank account number on the transfer (for example, with a small amount) and see whether the money is remitted to the incorrect person, and if so, whether it is possible to get the money back. Another possible behavioural experiment is to transfer a large amount to the account number of the patient’s wife to test out whether this amount will be transferred. He can also investigate what happens if he makes a transfer of a small amount with a name and number which do not match each other. The patient’s hypothesis is that the amount will be transferred and the alternative hypothesis is that the bank will not transfer the amount.
84
PATRICIA VAN OPPEN and ARNOUD ARNTZ
The overestimation
of responsibility
In the beginning of cognitive therapy for OCD attention focused on the overestimation of danger. However, patients often improved considerably in that respect, but still had OCD problems. Athough the chance of catastrophe is perceived by the patients as very low, a number of OCD patients still want to perform his or her rituals. For OCD patients, even though the chance may be very low, the risk remains very high if the perceived consequence is high. The formula generally used for the computation of risk is: risk = chance x consequence. Thus, as long as the consequence is perceived as unacceptably high, the risk remains unacceptably high. Consequently, the therapist should not only focus on the overestimation of danger, but also on what makes the consequence so unacceptable for the patient. Usually, this has to do with the issue of responsibility. The perceived consequences of having been responsible for an aversive event are often directly related to the core assumptions of the patient, and are similar to depressogenic assumptions: they usually concern worthlessness, guilt and total rejection by other people. As with overestimation of danger, two aspects of responsibility should be addressed in this phase of therapy: (i) whether the patient overestimates the amount of responsibility; and (ii) whether the patient overestimates the perceived consequences of having been responsible. Examples of overestimation of the amount of responsibility are: “If my sister, who is pregnant, gets toxoplasmosis this is my fault”; and “If my bicycle falls on the street and a car crash happens this is my fault”. Examples of the overestimation of perceived consequences of having been responsible are: “If my daughter gets cancer, everybody will condemn me and I will have no friends anymore”; and “If my house does not look very tidy everybody will blame me and nobody will visit me anymore”. Techniques Several cognitive techniques for challenging overestimation of the amount of responsibility can In this procedure, all factors contributing to be used. One useful technique is the ‘pie-technique’. the catastrophic event are listed. After a circle (a pie) is drawn, the patient fills in pieces of the pie differing in size, relative to the importance of each contributing factor. All factors should be pieces of the pie and it should be noticed that the patient’s own contribution should be drawn at last. This technique was applied to a man who is afraid that because of his carelessness a terrible car crash on the street will happen if his bicycle fell on the street. The patient thought that he alone would be responsible if his bicycle fell on the street and the driver of a car would neither be able to brake nor to get out of the way of the bicycle. Figure 1 illustrates this ‘pie-technique’. First, factors were listed which contributed to a car crash. He mentioned: driver, weather, approaching
driver 45%
myself 5% mar mechanic 5%
weather 25%
approaching 20% Fig. 1. Illustration
of ‘pie-technique’
of factors
which contributed
car
to the car crash.
Cog@itive therapy for OCD
85
car and car mechanic.
Second, he drew all these contributions as pieces of the pie on the blackboard; respectively 45, 25, 20 and 5%. Finally, his own contribution to the ccident on the street was the left-over part of the pie. As can be seen from Fig. 1 only 5% o t the ‘pie’ was left. With the help of the ‘pie-technique’ the patient’s attention was focused on the contribution of other factors to the catastrophic event and he was able to see that his own responsibility was much smaller than he originally thought. For challenging the overestimation of the perceived consequences of having been responsible, the ‘double standard’ technique can be very effective. In this procedure the therapist asks the patient whether the patient would find someone else guilty when the event happens to the other person, and compare this with the case when the feared catastrophe occurs to him or her. This technique can be illustrated by the patient who believed that “If my daughter gets cancer everybody will condemn me and I will have no friends anymore”. First, the therapist investigates what the patient would do if a friend of hers had a child who is suffering from cancer. Would she also blame her friend for this? Would the same consequences happen? In this case, the patient did not evaluate her friend as bad and guilty if her daughter died from cancer. But if the same was to happen to herself this would be totally different. The therapist made this double standard explicit to her, discussed that this is difficult to handle, and investigated the reasons for maintaining this double standard. Lastly, behavioural experiments can be used to test out the empirical basis of the consequences of being responsible, as illustrated by a patient with cleaning rituals. This patient thought that nobody would visit her anymore if her house was not tidied up. A behavioural experiment for this patient existed of not cleaning her house for a week, after which she had to invite some friends around: she had to note if these friends did not come to visit her anymore because of the mess, the alternative hypothesis was that her friends took no notice of the mess, but visited her as frequently as before. Some pitfalls
of cognitive
therapy
with obsessive-compulsives
Several difficulties are seen during the cognitive therapy with OCD. First, some patients do not report any negative automatic thoughts at all. In such cases we recommend asking the patient what would happen if he or she did not perform his or her rituals. Sometimes patients only reported one central automatic thought (for example: “It has to be tidy”). In this case it is possible to challenge only this thought. During the course of this process, usually other ‘underlying’ thoughts will be detected. Another pitfall concerns unfruitfully challenging the intrusion rather than the negative automatic thoughts. Therefore, it is always important to differentiate between the intrusions and the automatic thoughts. Further, a serious problem involves patients who are inclined to argue with the therapist about every issue. Especially with this type of OCD patient it is particuarly important to use the Socratic dialogue. Another pitfall occurs when the challenging becomes a reassurance for the patient, thus not reducing anxiety in the long term. To prevent this, it is important as a therapist to make use of a number of different challenging techniques, rather than using the same cognitive interventions several times. In this manner the patient is ‘forced’ to reflect time after time on the negative automatic thought. Another manner for preventing this pitfall is to investigate the consequences of the expected event. For this, challenging the ‘so-what’ technique can be used. Furthermore, a problem sometimes appears when the patient’s expected consequences of a behavioural experiment, thus patient’s hypothesis, can only occur in the long term. Sometimes this difficulty can be overcome by ex ggerating the behavioural experiment, so the expected consequences of the experiment will oc ur in the near future. Finally, a pitfall may arise when the ”t erapist forgets or does not wish to address the issues of responsibility. As is illustrated by previous analysis it is clear that this issue is at least as central to OCD as the overestimation of danger. Therefore, therapists should not hesitate asking the patient what it would mean to him or h er wh en, for example, his or her daughter gets cancer.
PATRICIAVANOPPEN and ARNOUD ARNTZ
86
OUTCOME
STUDIES
The first controlled study with OCD and cognitive therapy was reported by Emmelkamp, van de Helm, van Zanten and Plochg (1980). This study investigated the additional effect of self-instructional training to exposure in uiuo. Self-instructional training did not increase the effectiveness of exposure in uivo. Because of the excessive self-talk, ruminations and doubting of OCD patients it is doubtful whether self-instructional training is the most suitable technique for obsessive-compulsive patients. Emmelkamp, Visser and Hoekstra (1988) investigated the value of rational-emotive therapy (RET). Results of this study showed that cognitive therapy has clinically beneficial effects on obsessive-compulsive patients. This study demonstrated that the effects of RET were about the same as self-controlled exposure in uiuo plus response prevention. Only on the depressive scale there was a specific effect of cognitive therapy: the cognitive therapy condition significantly improved whereas exposure in viuo with response prevention did not. More recently Emmelkamp and Beens (199 1) investigated two issues: (1) whether RET was as effective as exposure in vivo with response prevention; and (2) whether a combined package would be superior to exposure in vivo with response prevention only. No differences were found between RET and exposure in viuo. Cognitive therapy (RET) was as effective in treating OCD as exposure in viuo with response prevention and the combined treatment was no more effective than exposure only. To date, only one study compared cognitive therapy, along the lines of Beck and Salkovskis, with exposure in vivo and response prevention. Preliminary data of this study showed no significant differences between both therapies (van Oppen, de Haan, van Balkom, van Dyck, Hoogduin & Spinhoven, 1992). These findings demonstrate that this type of cognitive therapy is effective in dealing with obsessive-compulsive problems. CONCLUDING
REMARKS
There can be little doubt that there are numerous possibilities in carrying out cognitive therapy with OCD patients. A recent advance is the application of techniques which are especially suitable for OCD, instead of the more global RET. Efficacy will probably increase in the future with the development of new specific techniques. Do we need cognitive therapy for OCD patients, given the success of exposure in viva and response prevention? There are at least three groups of obsessive-compulsives in which cognitive therapy may be of value. First, patients who do not improve with exposure and response prevention. Second, generally about 30% of the patients, who are suitable for behavioural treatment, refuse to participate or are drop-outs of exposure and response prevention treatment (Foa, Steketee, Grayson & Doppelt, 1983). Third, cognitive therapy may be effective with patients with only obsessions. Until now the treatment of pure obsessions can be summarized as difficult and often unsuccessful. Rachman (1983) argued that this may be due to the cognitive nature of obsessions. For these three groups of obsessivecompulsives cognitive therapy may be an alternative treatment to exposure in viva with response prevention. Furthermore, many OCD patients have additional problems (for example, depression). Especially for these patients, cognitive therapy, as described above, may be a fruitful treatment. As a consequence of the cognitive formulation of OCD, which differentiates between the perception of danger and the perception of responsibility, further research is needed to compare the effect of addressing these issues separately. This may indicate which is the essential one in the treatment of OCD. A challenging task for further research is to investigate which patients profit from exposure with response prevention and which patients profit from cognitive treatment. Last, but not least, research is needed to investigate whether the relapse rate differs between exposure in vivo with response prevention on the one hand and cognitive therapy on the other. REFERENCES
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Cognitive therapy for OCD
87
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