482 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Response Prevention
Response prevention is an important therapeutic element in all cognitive treatment for
OCD. In fact continued reliance on compulsive rituals or other forms of neutralization
will undermine the effectiveness of cognitive therapy for obsessions. In Chapter 7 we
discussed seven steps for implementing response prevention. It is important that therapy
focus not only on preventing compulsive rituals but also any neutralization or mental
control strategy that functions to reduce anxiety, prevent some dreaded outcome, or
divert attention away from the obsession. Naturally, the effectiveness of exposure to
the obsessional fear will be diluted if compulsions and other control strategies are not
prevented.
It is likely that clients will be reluctant to engage in response prevention when anxi-
ety is very high, so the therapist usually begins with preventing compulsions and neu-
tralization responses to situations that elicit moderate anxiety in the midrange of the
exposure hierarchy. It is preferable that the therapist start with in- session exposure and
response prevention to ensure that the client blocks all compulsions and other forms of
neutralization. This also gives the cognitive therapist an opportunity to discuss appro-
priate coping responses that can be used during response prevention and to deal with
any negative beliefs or appraisals the client may have about exposure and response
prevention. Effective ERP sessions are usually 60–90 minutes in duration and the client
is always encouraged to daily practice the ERP homework assignments. Clients should
record the frequency, duration, and outcome of their ERP homework on self- monitoring
forms so the effectiveness of the intervention can be tracked. With Richard, response
prevention focused on refraining from pulling down his sweater or checking that his
shirt was tucked in or attempting to convince himself that no one was looking at his
back (i.e., self- reassurance control strategy).
Clinician Guideline 11.11
Response prevention is one of the main therapeutic ingredients in cognitive therapy of OCD.
It directly challenges the secondary appraisals and beliefs about need to control the obses-
sion and its anxiety.Behavioral Experimentation
Most of the behavioral experiments used in cognitive therapy for OCD involve some
form of sustained exposure to the obsession and its associated anxiety. However, the
main difference between behavior therapy and cognitive therapy is that in the latter
case exposure is used to modify faulty appraisals and beliefs about the perceived sig-
nificance and dangerousness of the obsession. Exposure-based behavioral experiments
are introduced early in treatment, often guided by the fear hierarchy. After educating
the client into the cognitive model and various cognitive interventions aimed at high-
lighting the important role of appraisals and beliefs in the persistence of obsessions, the
therapist introduces within- session and between- session exposure exercises as a method
of empirically testing the validity of OC-related beliefs. D. A. Clark (2004, Table 11.1)
describes a number of specific behavioral exercises that can be used with clients to
modify appraisals and beliefs of threat, responsibility, control, intolerance of uncer-