Obsessive– Compulsive Disorder 479
the client records occurrences of the obsession, what made the obsession significant at
the time, and which faulty appraisals were present in that specific instance of evaluating
the obsession (see also Purdon, 2007).
Clinician Guideline 11.8
Ensure that clients can distinguish their appraisals of the obsession from their obsessional
content before proceeding with cognitive or behavioral interventions aimed at modifying
faulty appraisals and beliefs.Cognitive Restructuring
Chapter 6 provided an extensive discussion of cognitive interventions like evidence gath-
ering, cost– benefit analysis, decatastrophizing, and error identification that are used to
challenge anxious thoughts and beliefs. These same strategies can be used to challenge
faulty appraisals and beliefs about obsessions and their control with some adaptation
for OCD. However, it is important that the cognitive interventions focus on the apprais-
als of the obsession and not on modifying the obsessional content itself. Salkovskis
(1985, 1989) warns that cognitive strategies will not be effective in persuading clients
to abandon their obsessional fears. Instead cognitive strategies are used to reeducate
clients that their exaggerated evaluation of the significance of the obsession is faulty.
For example, in our case example Richard could not be convinced that people would
not see “the red spot on his lower back” and be disgusted by it (i.e., his obsessional con-
tent). Instead we used evidence gathering, behavioral experimentation, and alternative
explanations to challenge his exaggerated threat appraisal about public exposure of the
lower back red spot.
Cognitive restructuring should be tailored to target the seven faulty appraisals and
beliefs that are crucial to OCD (i.e., overestimated threat, importance of thoughts or
TAF, control of thoughts, inflated responsibility, intolerance of uncertainty, perfec-
tionism, and thought control failures). The cognitive therapist will devote more time to
appraisals that are particularly important in the individual’s OCD. We mention here a
few cognitive restructuring strategies that can be used with each of the appraisals (see
D. A. Clark, 2004; Purdon, 2007; Purdon & Clark, 2005; Rachman, 2003; Wilhelm &
Steketee, 2006, for more detailed descriptions). The downward arrow technique, calcu-
lating the probability of harm, and surveys of others’ estimates of harm can be used to
challenge overestimated threat appraisals. A pie chart in which the client assigns per-
centages of responsibility for an outcome to various factors including the self can be used
to challenge inflated personal responsibility beliefs (Salkovskis & Wahl, 2003). Socratic
questioning is useful in highlighting the circularity and faulty reasoning involved in
importance of thought appraisals (i.e., “Is the obsession important because it occurs so
frequently or is it frequent because we assume it’s important?”). Wilhelm and Steketee
(2006) discuss the “courtroom technique” in which evidence for and against the “impor-
tance of the obsession” can be presented. Purdon and Clark (2005) recommended having
clients think about all the times when they had the obsessive thought and it never led to
the dreaded deed or outcome, indicating that the obsessive thought may not be as impor-
tant as assumed. For intolerance of uncertainty appraisals, a cost– benefit cognitive inter-