Cognitive-based therapy for OCD: Role of behavior experiments and exposure processes

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Highlights

  • We describe the pragmatics for conducting behavioral experiments in Cognitive Therapy (CT) for OCD.

  • Behavioral experiments serve to modify maladaptive interpretations and produce symptom reduction.

  • We outline how to prepare for, and operationalize, the behavioral experiment.

  • We describe patient and therapist-related behaviors that will facilitate the experiment’s success.

  • We discuss how to integrate other CT strategies to process the findings of the behavioral experiment.

Abstract

The current manuscript describes the rationale and pragmatics for conducting exposures (termed “behavioral experiments”) in Cognitive Therapy (CT) for OCD. Given that the cognitive model of OCD focuses upon the assumptions and belief systems (e.g., threat perception) that underlie the misinterpretation of unwanted intrusions, CT employs cognitive strategies, such as behavioral experiments, to modify maladaptive interpretations and produce symptom reduction. We outline how to prepare for behavioral experiments through psychoeducation and empirically supported assessment procedures. Next, we describe how to operationalize the behavioral experiment and propose patient and therapist-related behaviors that will facilitate (or interfere with) the experiment׳s success. Lastly, we discuss how to process the findings of the behavioral experiment by integrating other CT strategies, such as calculation of harm and the downward arrow, to consolidate learning and ultimately strengthen and generalize skills use.

Section snippets

Cognitive-based therapy for OCD: role of behavior experiments and exposure processes

Cognitive models of Obsessive Compulsive Disorder (OCD) propose that maladaptive beliefs and interpretations about unwanted intrusive thoughts play a major role in the pathogenesis and maintenance of OCD (e.g., Rachman, 1997, Salkovskis, 1985). Thus, Cognitive Therapy (CT) does not require the use of prolonged in-vivo exposure and response prevention techniques, as used in behavioral therapies. Despite this, even cognitive models of OCD carry unique implications for the exposure process, as

Description of the theoretical model

In the cognitive model, unwanted intrusive thoughts, images, or impulses (e.g., harming a loved one with a knife) are considered normal and common occurrences (Rachman & de Silva, 1978). Research has consistently demonstrated that nearly everyone has disturbing intrusions that do not align with one׳s goals, values, or ideals (Rachman and de Silva, 1978, Rachman, 1997, Rachman, 1998, Rassin et al., 2007, Salkovskis, 1985). Our minds naturally generate a variety of thoughts, regardless of their

Responsibility/threat estimation

Individuals with an inflated sense of responsibility and an overestimation of threat consider themselves responsible for averting danger, or causing severe harm by mistake or inaction (Obsessive Compulsive Cognitions Working Group, 1997, Obsessive Compulsive Cognitions Working Group, 2003, Obsessive Compulsive Cognitions Working Group, 2005). In addition, they tend to overestimate the chances of disaster and assume the worst outcome from even small risks. For example, a mother who works in a

Empirical evidence supporting CT for OCD

Multiple treatment trials have demonstrated the efficacy of CT as an intervention for OCD (e.g., Emmelkamp and Beens, 1991, van Oppen et al., 1995, Wilhelm et al., 2005, Wilhelm et al., 2009). Most recently, results from an open trial (Wilhelm et al., 2005), waitlist controlled trial (Wilhem et al., 2009), and randomized-controlled trial (Whittal, Thordarson, & McLean, 2005), indicated that CT is associated with a significant reduction in patients’ maladaptive obsessive beliefs, as well as OCD

Mechanisms of change in CT for OCD

Given that CT has consistently been shown to reduce OCD symptom severity, recent research has sought to examine the processes by which these changes occur. Investigating the mechanisms of change can highlight why the treatment worked and identify the relevant processes which maximize patient improvement (Johannson & Høglend, 2007). Woody, Whittal, and McLean (2011) investigated whether changes in certain obsessive beliefs mediated treatment response in CT for OCD. Results indicated that a

Preparing for a behavioral experiment

Prior to selecting a behavioral experiment, it is essential that patients are administered an assessment of their dysfunctional beliefs and interpretations and subsequently provided psychoeducation regarding how the cognitive model informs treatment. We will walk through these steps to aid clinicians in establishing the foundation for which CT, specifically behavioral experiments, can be most effectively delivered.

Once the clinician has performed an adequate assessment of OCD symptoms

Behavioral experiment “set up”

The first step of setting up the behavioral experiment is to present the patient with a strong rationale. The patient should be informed that the purpose of a behavioral experiment is to take on the role of a scientist and treat beliefs and interpretations as testable hypotheses. Gathering information (i.e., data) which tests the validity of the patient’s predictions highlights the discrepancy between the expected and experienced outcomes. In this way, a behavioral experiment differs from an

Behavioral experiment “Do’s and Don’ts”

During the behavioral experiment, there are various prescribed and proscribed therapist behaviors (see Table 1). An overarching principle is that the behavioral experiments are collaborative and the patient considers him/herself to be a co-investigator. Thus, it is recommended for the first behavioral experiment that the therapist accompany the patient to ensure that the goals are being met, offer objective observations, and provide moral support. We recommend that the therapist either follow

Ending behavioral experiments

A behavioral experiment is considered “complete” when the behavioral goals have been met and the length of time given to any predicted outcomes has ended (e.g., Monica predicted that she would feel nauseous and/or vomit within 24 h and that she would develop immediate symptoms of a cough or skin rash). Given that office visits are typically limited to 50-min sessions, it would be impossible to wait the full 24 h to test all predictions. At the end of the exercise, the therapist and patient should

Conclusion

In the cognitive model of OCD, special emphasis is placed upon the assumptions and belief systems (e.g., exaggerated threat perception) that underlie the misinterpretation of unwanted thoughts, images, impulses or ideas (Rachman, 1997, Rachman, 1998). Given their theoretical importance to the model, CT for OCD utilizes a variety of empirically supported cognitive strategies to modify the maladaptive interpretations. Research has demonstrated that CT for OCD yields short- and long-term gains

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