Obsessive– Compulsive Disorder 481
that exposing his back to others would be dangerous (i.e., “find any known record that
someone was horribly disgusted by the sight of a red spot on his lower back”), (2) his
insistence that he feel certain that someone is not disgusted when looking at him, and
(3) his failure to recognize the negative consequences of trying too hard to control any
trace in his mind of the “lower back rash obsession.”
Clinician Guideline 11.9
Cognitive restructuring is introduced early in treatment to weaken dysfunctional beliefs in
the personal significant threat and importance of the obsession, its need for control, and the
perceived negative effects of exposure and response prevention.Alternative Explanation
Cognitive restructuring interventions should encourage clients with OCD to question
their beliefs that obsessions are highly dangerous threats for which they have personal
responsibility to control. But cognitive restructuring should also guide clients toward
adopting healthier, more adaptive perspectives on the obsession and its control. The
goal of cognitive therapy is for clients with OCD to adopt the following perspective on
their obsessions and compulsions.
Obsessions are meaningless, benign intrusions that have no particular personal significance.
They are a normal manifestation of an active, creative mind. The thought has become
highly frequent and distressing because of “catastrophic misinterpretations of significant
threat” and excessive attempts at neutralization and control. Mental control is elusive at
the best of times so that the most effective approach is to cease all compulsions, neutraliza-
tion, or other mental control responses. Efforts to control the obsession and its associated
anxiety may lead to immediate relief but it is only temporary. Over time the obsession only
grows in frequency and intensity. A passive, accepting approach to the obsession is the best
cure for my anxiety.To facilitate acceptance of this alternative perspective, the cognitive therapist should
work collaboratively with clients to write out their own healthy narrative of the obses-
sions and compulsions. Clients are more likely to accept the alternative explanation
if it is expressed in their own words and punctuated with examples from their own
experience. The client should be given a copy of the alternative explanation and daily
implementation of this perspective would become one of the primary goals of therapy.
In the case of Richard, the alternative explanation focused on giving up his efforts to
control the obsession and tolerating some initial anxiety in order to achieve long-term
reductions in his obsessional concerns and anxiety.
Clinician Guideline 11.10
The alternative explanation normally emphasizes that an obsessional intrusion is a mean-
ingless mental nuisance whose frequency and anxiety- provoking properties will fade if all
efforts at control or neutralization cease.