Obsessive– Compulsive Disorder 483
tainty, and the like (see also Purdon, 2007; Purdon & Clark, 2005; Rachman, 2003;
Wilhelm & Steketee, 2006; Whittal & McLean, 2002, for descriptions of behavioral
experiments for OCD).
Many of these behavioral experiments involve repeated and sustained exposure to
the obsession in a variety of avoided situations with response prevention of any form of
neutralization. The client is asked to monitor the outcome of these exposure exercises
in order to test firmly held beliefs such as anticipated threat, personal responsibility, or
need to control the obsession and prevent imagined dire consequences thought to occur
if control over the obsession falters. It is important that the cognitive therapist explore
with clients the outcome of their behavioral experiments at subsequent sessions in order
to consolidate evidence that challenges faulty appraisals and beliefs. For example, cli-
ents with a strong belief “that strict control over an obsession is necessary in order to
prevent being overwhelmed with anxiety” could be asked to alternate days (or times
of the day) when they expend great effort at controlling the thought versus other days
when they relinquish control of the thought. The cognitive therapist would then review
with clients their self- monitoring records. Some observations or probing questions that
would be important in modifying faulty control beliefs might be (1) “I notice from your
record form that you didn’t have more obsessions or anxiety on ‘low versus high con-
trol days.’ What does this tell you about your concern that the anxiety will get worse if
you don’t try to suppress the obsession?”; (2) “You predicted that not responding to the
obsession would be extremely difficult but what was you actual experience? From the
record it looks like you did quite well”; and (3) “I notice that you wrote down that the
control days were quite frustrating and exhausting for you compared to the ‘no control
days.’ What does that tell you about the personal costs of repeated neutralization and
efforts at mental control?” In cognitive therapy, then, exposure becomes one of the most
potent therapeutic tools for directly modifying the faulty appraisals and beliefs that
underlie obsessional thinking.
One behavioral experiment employed with Richard was to select periods of time
during his work day when he would intentionally bring the obsession to his mind (e.g.,
“Can other people see my lower back?”), and at the same time refrain from any shirt
tucking or self- reassurance. He also placed a Post-it note beside his computer monitor
with the words “GO BACK” written on it as a reminder to intentionally think about the
lower back rash. The imaginal component of this exposure exercise challenged Rich-
ard’s belief that the obsession was a significant threat because he would become over-
whelmed with anxiety. At the same time the written cue GO BACK was a type of situ-
ational exposure because it challenged Richard’s belief that any stimulus related to his
obsessional concern (i.e., the word “back”) would elicit anxiety- provoking queries from
his work colleagues. As it turned out Richard found the exercise moderately difficult to
complete because of his irrational belief that others would ask about his Post-it message
and would somehow find out about his lower back obsession.
Clinician Guideline 11.12
Exposure-based within- and between- session behavioral assignments are used as direct
empirical hypothesis- testing exercises to structure experiences that directly challenge obses-
sional appraisals and beliefs, leading to modification of the cognitive basis of obsessions and
compulsions.