Clinical Psychology

To provide another example of an exposure-
based empirically supported treatment, Box 14-3
presents an overview of the treatmentexposure plus
response preventionfor obsessive-compulsive disorder.
Exposure plus response prevention is the most
successful psychological treatment for obsessive-
compulsive disorder (Emmelkamp, 2004; Rosa-
Alcazar et al., 2008).

Behavior Rehearsal

Included under this broad heading are a variety of
techniques whose aim is to enlarge the patient’srep-
ertoire of coping behaviors. Clearly,behavior rehearsal

is not a new concept; it has been around in one form

or another for many years. For example, Moreno

(1947) developed psychodrama, a form of role-

playing, to help solve patients’problems, and Kelly

(1955) used fixed-role therapy. However, it is impor-

tant to note that such forms of role-playing or behav-

ior rehearsal have purposes that depart from

behavioral goals. For Moreno, role-playing provided

a therapeutic release of emotions that was also diag-

nostic in identifying the causes of the patient’s

problems. For Kelly, role-playing was a method of

altering the patient’s cognitive structure. Again, we

are reminded that specific therapeutic techniques are

not the exclusive province of one theoretical frame

BOX14-3 Focus on Clinical Applications

Behavior Therapy for Obsessive-Compulsive Disorder: Exposure Plus Response Prevention

Obsessive-compulsive disorder (OCD) is an Axis I dis-

order characterized by recurrent intrusive thoughts,

impulses, or images (obsessions) that generate great

anxiety and distress. Repetitive behavior or ritualistic

mental acts aimed at counteracting obsessions or

otherwise preventing or reducing anxiety often are

present as well (American Psychiatric Association,

2000). Once thought to be largely intractable,

research results over the past few decades indicate

that a particular form of behavior therapy,

exposure plus response prevention, can be par-

ticularly effective in treating OCD symptoms

(Emmelkamp, 2004).

As noted by Foa (1996), this treatment is based on

the assumption that obsessions produce marked anxi-

ety and distress, while compulsions serve to reduce this

anxiety. Further, even though compulsions temporarily

reduce anxiety, obsessional anxiety is maintained

because no habituation develops. Compulsive behavior

continues because it is reinforced by the reduction in

anxiety. Exposure plus response prevention aims to

disrupt this pattern by (a) exposing the patient to

situations that lead to obsessional distress and (b) pre-

venting the patient from engaging in compulsive

behaviors that are typically emitted in the face of this

distress. Ideally, in this way, (a) habituation to the

obsessional thoughts, images, or impulses will develop

(and thus, the level of anxiety produced by these will

be reduced) and (b) compulsive behaviors will no

longer be reinforced because they will be prevented.

Foa (1996) provides an overview of a typical

exposure plus response prevention treatment for OCD:

1. Fifteen 2-hour exposure sessions are conducted
   over the course of three weeks.


2. During these sessions, patients are“exposed”to
   the situations or objects that seem to trigger the
   obsessions. For example, a patient who obsesses
   about dirt and germs might be asked to rub
   newspaper print all over his arms and face.


3. In addition, patients are asked to imagine that the
   tragic consequences they anticipate occurring if
   they do not engage in compulsive behavior did
   occur. In this way, patients can begin thinking
   about these“catastrophes”without being
   markedly fearful.


4. Homework is assigned and involves repeating
   these exposure experiences.


5. At the same time that exposure is introduced, the
   therapist ensures that ritualistic compulsions that
   typically occur in the face of the obsessional fear
   do not occur. For example, the patient who
   obsesses about dirt and germs and engages in
   excessive hand washing or showering would not
   be allowed to engage in these behaviors. At a
   later point in time,“normal”hand washing and
   showering will be introduced.


6. Finally, a maintenance phase of treatment
   involves about ten office visits or phone calls
   aimed at encouraging the patient and reinforcing
   the therapeutic gains.

408 CHAPTER 14