474 TREATMENT OF SPECIFIC ANXIETY DISORDERS
and the rated importance of preventing the outcome (see D. A. Clark, 2004, for record
form). The cognitive therapist should also assess the level of effort directed at preventing
or suppressing the obsessional intrusion as well as the client’s perceived success at con-
trolling the obsession. The role played by other primary appraisals in the persistence of
the obsession should be determined such as perceived responsibility, TAF, intolerance of
u nc er t a i nt y, p er fe c t ion i sm , i mp or t a nc e of t he t houg ht , it s sig n i fi c a nc e or p er son a l me a n-
ing, and need to control the thought. Furthermore, the client’s appraisal of his failure to
control the obsessions should be assessed to determine the role of secondary appraisals
in the pathogenesis of the obsession. It is unlikely that all information can be obtained
in the initial assessment session but as treatment progresses a more complete picture
of the cognitive basis of the obsession will emerge. Although some of the standardized
OCD cognition questionnaires such as the OBQ, III, TAF Scale, or RAS might be useful
at this stage, no doubt the most helpful approach is a well- informed interview and self-
monitoring records that are assigned as homework (for examples of appraisal recording
forms, see D. A. Clark, 2004; Purdon & Clark, 2005; Wilhem & Steketee, 2006).
Process- Oriented Assessment of Compulsions
Table 11.3 also presents various characteristics of compulsions and other forms of neu-
tralization that should be included in a cognitive assessment. As in behavioral treatment
of OCD, the development of a hierarchy of anxious situations that are avoided due to
obsessional concerns is an important part of the cognitive assessment. The previously
discussed situational analysis can be helpful in developing this hierarchy. In addition a
number of behavioral treatment manuals present record forms that are useful in con-
structing an avoidance hierarchy (e.g., Foa & Kozak, 1997; Steketee, 1993). The avoided
situations should be arranged hierarchically from the least distressing or avoided situ-
ation to the most avoided, distressing situation. Reduction or complete elimination of
the avoidance pattern can be incorporated into the treatment goals (Baer, 2000). For
example, one of the goals of a client with a cleaning compulsion might be to use public
washrooms in a shopping mall with only moderate anxiety, a situation that she cur-
rently avoids due to intense anxiety and fear of contamination.
It is also important to obtain self- monitoring data on the daily frequency of the
primary compulsion as well as ratings on the subjective urge associated with the com-
pulsion and degree of resistance exerted prior to capitulating to the compulsion. Some
individuals with OCD give into the urge almost immediately whereas others can expend
a considerable effort at resisting. It is also important to assess the clients’ perceived suc-
cess resisting their compulsions as well as the factors that might contribute to more suc-
cessful resistance. Given that individuals with OCD engage in neutralization and other
forms of mental control even more often than overt compulsive rituals, it is important
to assess the type, frequency, and perceived success of various neutralization and men-
tal control strategies. Appendix 11.2 presents a thought control form that can be used
for this purpose. Finally, insight into the excessive, unreasonable, or irrational nature
of the obsessions and compulsions should be determined. Questions should focus on
the extent to which clients believe that the imagined threat or negative consequence
associated with the obsessional fear is probable and whether the compulsive ritual or
other forms of neutralization are both necessary and effective in preventing the dreaded
outcome. For example, a client with poor insight believed that repeated reading and