478 TREATMENT OF SPECIFIC ANXIETY DISORDERS
to hold or remove the thought are signaled by the client and recorded by the therapist.
This exercise is useful for demonstrating the futility of our efforts to intentional control
unwanted thoughts. The potential for rebound effects once suppression efforts cease can
also be discussed with clients. Together these exercises, which are introduced early in
treatment, emphasize the importance of cognitive change in the client’s interpretation
and control of obsessional concerns.
Clinician Guideline 11.7
Educating the client into cognitive therapy of OCD requires an acceptance of the normal-
ity of unwanted intrusive thoughts, the primary role of faulty appraisals, and the negative
effects of neutralization and other mental control efforts.Distinguishing Appraisals from Obsessions
Educating the client on how to distinguish between the obsession and her appraisal
of the obsession can be difficult because individuals with OCD have often spent years
preoccupied with their obsessional concerns. Moreover, the concept of metacognition,
or “thinking about thinking,” will seem rather abstract and esoteric to some clients.
However, it is critical to the success of cognitive therapy that clients become aware of
the maladaptive meaning that they give to the obsession. In fact it is difficult for therapy
to proceed with modification of faulty appraisals if the client is not fully cognizant of
her “metacognitive appraisals” of the obsession.
A number of interview questions can be used to ease the client into the concept of
metacognitive appraisal. The following are some probes that we have used with OCD
clients:
••“What makes this thought [the obsession] important to you?”
••“What’s so significant about this thought? Does the thought reflect anything
about you—your character or values?”
••“Is there anything frightening or upsetting about the thought? Are you concerned
about any possible negative consequences? When you think about your obses-
sional concerns, what’s the worst that could happen?”
••“Is there anything about the thought that draws your attention to it, makes it
hard to ignore?”
••“What would happen if you couldn’t get the thought out of your mind or you
couldn’t avoid or complete your compulsive ritual?”After careful probing with clients about the special meaning or significance of the
obsession, the therapist and client together compose a brief narrative about what makes
the obsession a highly significant personal threat to the client. Together with a copy of
the cognitive appraisal model of obsessions (Figure 11.1) and a sheet that defines the key
appraisals and beliefs of OCD (see Table 11.2 or Appendix 10.1 in D. A. Clark, 2004),
the therapist and client review the “significance narrative” and pick out various types of
specific faulty appraisals (e.g., responsibility, TAF, need for control, perfectionism) that
characterize the narrative. This can be followed by a homework assignment in which