Obsessive– Compulsive Disorder 477
included in the education component of cognitive therapy for OCD, the therapist also
highlights the normalcy of unwanted intrusive thoughts, the role of faulty metacognitive
appraisals, and the long-term deleterious effects of neutralization and other attempts
at mental control. The objective of educating the client is to facilitate acceptance of the
treatment rationale, that is, that reduction in obsessive or compulsive symptoms is best
achieved by modifying how the obsession and its control are appraised.
An important part of the education process is to normalize the experience of
unwanted intrusive thoughts, images, and impulses so the critical role of exaggerated
appraisals of significance is highlighted (Salkovskis & Wahl, 2003). Clients can be
shown a list of common unwanted intrusive thoughts that have been collected from
nonclinical samples (for lists, see D. A. Clark, 2004; Rachman & de Silva, 1978; Wil-
helm & Steketee, 2006). Individuals with OCD are often surprised that nonclinical
individuals frequently report thoughts or images that are similar in content to their own
obsessions. When demonstrating the role of appraisals the therapist can ask the client
to select one or two intrusions that are not problematic and discuss how the thought
could be interpreted so it becomes a highly significant threat. This can be contrasted
with their own more benign interpretation that reduces the intrusion to an insignificant,
even trivial, intrusion into the stream of consciousness. After this the therapist is ready
to select the client’s primary obsession from the list and explore with the client how
she “has turned this intrusion into a highly significant personal threat.” The long-term
negative effects of neutralization can be demonstrated by the “camel effect” (Freeston
& Ladouceur, 1997b). The client is instructed to purposefully hold the thought or image
of a camel for 2 minutes and then to suppress the camel thought for 2 minutes. Failures
table 11.4. therapeutic Components of Cognitive therapy for oCD
Therapy component Description
Educating Client Treatment rationale based on the role of appraisals and neutralization in
the persistence of obsessions and compulsions.
Distinguishing appraisals
and obsessions
Clients are taught how to identify their faulty evaluations that lead to
misinterpretations of the personal significance of the obsession.Cognitive restructuring Evidence gathering, cost–benefit analysis, decatastrophizing, and cognitive
error identification are used to weaken belief in the dangerousness of the
obsession and increase willingness to engage in exposure-based behavioral
experiments.
Alternative explanation A more benign, accepting interpretation of the obsession and its control is
encouraged.
Response prevention Strategies are introduced to block or prevent compulsive rituals, safety
behaviors, avoidance, neutralization, and other mental control strategies.
Behavioral experimentation Within- and between-session exposure exercises are employed to modify
faculty appraisals and beliefs.
Modify core beliefs Core beliefs about the dangerousness and control of thoughts and personal
vulnerability are addressed later in therapy.
Relapse prevention Effective response to symptom relapse and recurrence is addressed in the
final sessions of therapy.