484 TREATMENT OF SPECIFIC ANXIETY DISORDERS
The Role of Core Beliefs and Relapse Prevention
The long-term maintenance of treatment effects will be increased if the later phase of
cognitive therapy targets individual’s maladaptive core beliefs and builds into termina-
tion some relapse prevention strategies. Wilhelm and Steketee (2006) suggest that the
core beliefs relevant in OCD often revolve around the same themes as noted in the
appraisals and beliefs of obsessions. Core beliefs of personal helplessness and vulner-
ability are related to overestimated threat, beliefs about weakness and lack of control
are linked to thought control appraisals, and core assumptions of inferiority and incom-
petence are related to perfectionism. Over the course of therapy the client can be encour-
aged to keep a record of experiences that directly challenge these core beliefs about the
self. For example, the person who believes she is particularly lacking in “willpower and
strong mental control” could keep a record of her experiences of “mental discipline.”
This information could be used to readjust her core belief to a healthier self-view such
as “I obviously have more mental fortitude than I think” and “I am no better or worse
than the average person in my ability to direct my thought processes.”
The last couple of therapy sessions are devoted to relapse prevention, which has
been shown to improve treatment maintenance in CBT for OCD (e.g., Hiss, Foa, &
Kozak, 1994). A number of intervention strategies have been described to improve
relapse prevention. Tolin and Steketee (2007) suggest that in the latter therapy sessions
responsibility for exposure should shift from the therapist to the client (e.g., “What kind
of exposure could you now do that would be most helpful?”) and individuals should be
encouraged to develop permanent life-style changes so they are frequently challenging
their fear and avoidance as a natural part of daily living. In addition educating the client
about the likelihood of future relapses and identifying high-risk situations are an impor-
tant part of relapse prevention (D. A. Clark, 2004; Tolin & Steketee, 2007). The client
and therapist should develop a written protocol for how to cope with relapse (Freeston
& Ladouceur, 1999). The introduction of basic problem- solving skills, support groups,
and how to handle changes in medication are also recommended (Wilhelm & Steketee,
2006). Finally, fading treatment sessions and scheduling occasional booster sessions can
improve the long-term effects of treatment.
Clinician Guideline 11.13
Given the chronicity of OCD, it is important to focus on modifying core beliefs as well as
issues of future relapse during the latter sessions of cognitive therapy. This will help encour-
age the generalizability and long-term maintenance of treatment effects.effiCaCy of Cognitive therapy of oCDA number of well- designed randomized control trials have clearly demonstrated the
immediate and long-term effectiveness of exposure and response prevention (ERP) for
OCD (for reviews, see Foa & Kozak, 1996; Foa, Franklin, & Kozak, 1998; Kozak &
Coles, 2005; Rowa, Antony, & Swinson, 2007). CBT which includes both ERP and cog-
nitive therapy is now recommended as the treatment of choice, either alone or in combi-
nation with SRI medication, for all OCD in adults (March, Frances, Carpenter, & Kahn,
1997). In this brief review, we adopt the current custom of referring to ERP as treatment