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Chapter 11
Cognitive Therapy
of Obsessive– Compulsive Disorder
Once you consent to some concession, you can never cancel it
and put things back the way they are.
—ho w a r d hu g h e s (American entrepreneur, 1905–1976)Richard was a 47-year-old government office clerk who had suffered for more
than 20 years with OCD. He had multiple obsessions involving fear of contam-
inating others with germs that would make them sick, blasphemous thoughts
of cursing God, and concern that others would see a red spot on his lower back
that would cause disgust and disapproval. He engaged in compulsive hand-
washing and took long showers to ensure he was clean. There was no overt
compulsion associated with the religious obsession but he would wear long
loose shirts and continually check whether he might be exposing his lower back
in response to the “red spot” obsession.
Previously Richard had shown a partial response to a trial of behavior
therapy (i.e., exposure and response prevention) for his contamination symp-
toms. He reluctantly agreed to seek further treatment in response to consider-
able family pressure. Assessment revealed a moderately severe primary diag-
nosis of OCD (Clark–Beck Obsessive Compulsive Inventory Total Score = 61)
with a secondary social phobia. Richard indicated that his preoccupation with
the lower back red spot was now his primary obsession and so this became the
target for treatment. Self- monitoring revealed a high daily rate of “red spot”
obsessions (average daily rate of over 25 occurrences) that occurred primarily
in the work environment. He refused to engage in any exposure assignments
even though we started at the lowest end of his fear hierarchy. Thus therapy
took a primarily cognitive approach consisting of education into the cognitive
therapy model, reappraisal of his biased threat estimation of public exposure