486 TREATMENT OF SPECIFIC ANXIETY DISORDERS
for CBT (van Oppen, de Haan et al., 1995). It would appear that group CBT for OCD
is less effective than individual therapy (Fisher & Wells, 2005; McLean et al., 2001;
O’Connor, Freeston, et al., 2005).
Even if CBT versus ERP alone are considered equivalent, this is not an inconsequen-
tial finding because it could be argued that the addition of cognitive interventions might
detract from the potency of ERP by reducing the amount of exposure patients receive in
therapy (see arguments by Kozak, 1999). Kozak and Coles (2005) concluded from their
review of the outcome literature that the addition of cognitive therapy interventions to
intensive, therapist- supervised exposure and rigorous abstinence from compulsive ritu-
als was not warranted because it might actually detract from the effectiveness of behav-
ior therapy. However, Fama and Wilhelm (2005) point out that an insufficient number
of studies have directly compared CBT versus ERP and suboptimal cognitive therapy
protocols may have been utilized in some of the studies included in literature reviews.
Moreover, Fama and Wilhelm argue that given the recent advent of cognitive therapy for
OCD, further refinements and elaboration in cognitive interventions should be encour-
aged rather than prematurely discarded as ineffective.
A number of studies have shown that cognitive interventions with no explicit
instructions to engage in exposure or response prevention can lead to significant
improvement in obsessive and compulsive symptoms in their own right. In one study
65 OCD outpatients who were randomly assigned to 20 sessions of cognitive therapy
or 20 hours of intensive ERP showed equivalent response at posttreatment and follow-
up (Cottraux et al., 2001). Wilson and Chambless (2005) provided cognitive therapy
without ERP to six patients with OCD and reported that two out of six recovered at
posttreatment. Freeston, Léger, and Ladouceur (2001) employed cognitive therapy that
specifically targeted the six appraisals and beliefs of OCD discussed in this chapter
and obtained significant posttreatment improvement in four out of six patients with
pure obsessions without overt compulsions. Previous multiple case studies indicated
that cognitive therapy alone can produce clinically significant change in patients with
compulsive checking rituals (Ladouceur, Léger, Rhéaume, & Dubé, 1996; Rhéaume &
Ladouceur, 2000). Compared to a wait list control group, Jones and Menzies (1998)
reported that patients with compulsive washing rituals who received their DIRT treat-
ment protocol that specifically focuses on cognitive interventions without exposure to
anxiety- provoking stimuli showed significant pre– posttreatment symptom reductions.
In a later study, four of five patients with intractable OCD who failed to respond to ERP
showed significant symptom improvement with DIRT (Krochmalik, Jones, & Menzies,
2001). Together these studies indicate that cognitive interventions alone can have a
significant effect on symptom reduction, although the effect sizes may be smaller when
compared to intensive ERP (Abramowitz et al., 2002).
Clinician Guideline 11.14
Individual cognitive therapy is an effective treatment for OCD that may eventually prove to
be particularly beneficial for certain subtypes of OCD such as individuals with pure obses-
sions without overt compulsions. Cognitive interventions should be introduced in the early
sessions with frequent and intense exposure-based behavioral exercises employed through-
out the course of treatment.