476 TREATMENT OF SPECIFIC ANXIETY DISORDERS
anxiety was interpreted as further proof that he was increasing the risk of offending
others with exposure of his lower back. Although Richard acknowledged that his obses-
sion was unusual, the intensity of his anxiety convinced him that other people probably
would be disgusted by the sight of the red spot on his lower back.
Throughout the course of therapy a number of core beliefs became apparent. Rich-
ard believed that “people are easily offended and so it is his responsibility to ensure that
this does not happen.” He also believed that “anxiety was intolerable” and that “certain
thoughts are dangerous and must be controlled or they will lead to a life of misery and
torment.” As a result he believed that what he needed “was greater control over his
thoughts and emotions” in order to achieve stability and calm in his life. Richard’s case
formulation led to a number of treatment goals.
- Modify his exaggerated threat appraisal of public exposure of his lower back.
- Reformulate his control beliefs so that he relinquishes efforts to control the
obsession. - Increase his tolerance for anxiety.
- Prevent compulsive rituals associated with the obsession such as checking his
lower back and repeatedly pulling at and retucking his shirts and sweaters. - Eliminate safety behaviors such as wearing loose clothing or putting ointment
on his lower back. - Reduce avoidance of “back exposure” situations such as bending, walking in
front of people, swimming, and so on.
DesCription of Cognitive therapy for oCDMany clinical researchers now argue that cognitive interventions should be incorpo-
rated into the standard behavioral treatment of exposure and response prevention (ERP)
in psychotherapy for OCD (e.g., D. A. Clark, 2004; Freeston & Ladouceur, 1997b;
Rachman, 1998; Salkovskis & Warwick, 1988; van Oppen & Arntz, 1994). In cognitive
therapy improvement in obsessive and compulsive symptoms and alleviation of anxiety
is achieved by modifying the faulty appraisals and beliefs of the obsession as well as the
individual’s efforts to control the obsession. The cognitive model of OCD provides the
theoretical framework and guiding principles for the therapy. However, ERP is still a
central therapeutic ingredient in cognitive therapy for OCD, with cognitive interven-
tions often utilized to prepare the client for exposure-based homework. Below we pres-
ent an overview of the eight treatment components of cognitive therapy for obsessions
and compulsions. A number of more detailed cognitive- behavioral treatment manuals
for OCD are now available (e.g., D. A. Clark, 2004; Purdon & Clark, 2005; Rachman,
2003, 2006; Salkovskis & Wahl, 2004; Wilhelm & Steketee, 2006). Table 11.4 presents
a summary of the key therapeutic components of cognitive therapy for OCD.
Education Phase
In Chapter 6 we discussed the central role that education plays in cognitive therapy and
how the therapist should inform clients of the nature of anxiety, the cognitive explana-
tion for the persistence of anxiety, and the treatment rationale. Although these issues are