32 COGNITIVE THERAPY IN CLINICAL PRACTICE

For example, Mr Johnstone was an obsessional patient who was troubled by the thought that he had offered activities to the devil. (His treatment is described in detail on pp. 63 ff. below.) He described aspects of his strict Roman Catholic upbringing in the following way: ‘I was brought up in a convent school; we used to put at the top of our essays JMJ (Jesus, Mary & Joseph). By putting that there, you offered your work as a form of prayer or worship. You could do the essay without this, the pure act, but this offering made it different. Your whole life can become a prayer. So, when you sin, you can make this evil act a prayer to the devil by your attitude or offering. You are not just sinning, but you are committing a far worse sin.’

He went on to describe how, as a young child, he was extensively warned about the dangers of impure thoughts, and of the awful punishment which would follow from ‘sin by thought’; the punishment could, however, be averted, by adopting a contrite attitude of mind. During his late teens he rebelled against these ideas, and behaved very much as he wanted. He was troubled a great deal by guilt; as he settled down, he began to believe that he had offered his ‘wild living’ to the devil. As this thought grew, he began to have another thought—that he would offer everyday activities to the devil. This thought increasingly occurred at times when he was in a state that he believed to be sinful, such as when he was angry or thinking ‘lustful thoughts’. He tried to neutralise these thoughts (‘put them right’) by making ‘a firm purpose of amendment’, by saying prayers in ritualised ways, and by depriving himself of things he would enjoy (such as food, watching television). He became increasingly preoccupied with the idea of offering things to the devil.

This example illustrates the way in which an apparently innocuous attitude (that everyday activities can be transformed by an associated intention or thoughts into intrinsically good or bad acts) can lead to difficulties when intrusive thoughts occur which seem to run counter to the individual’s particular beliefs. Similar and related beliefs led the patient to attempt to resist the occurrence of the thoughts and, when this did not succeed, to neutralise them. This increase in neutralising was associated with a progressive worsening of the patient’s distress.

The role of cognitive and behavioural factors in the maintenance of obsessional disorders

Thus, the patient’s attitudes and beliefs (particularly those concerning responsibility, blame, and blamelessness) lead the patient to negative appraisals of their intrusive thoughts. When this appraisal (which manifests in the content of negative automatic thoughts) includes a major element of both threat and responsibility for future harm, the patient will show a propensity to attempt some kind of corrective action. Such attempts to neutralise the implications of one’s own thoughts will prevent reappraisal of the true risks, and have the effect of further amplifying pre-existing beliefs about responsibility. When issues of responsibility hinge on the occurrence of intrusive thoughts and the possible harm associated with not reacting to them, the effect of the neutralising behaviour will be to focus attention more closely on the subject of the original intrusion. This can take patients into seemingly never-ending sequences of intrusion-appraisal of responsibility-neutralising-intrusion- appraisal…and so on. That is, the effort towards neutralising leads to increasing preoccupation with the intrusion and its appraisal. The importance of responsibility in the ideation of obsessional patients clarifies several previously inexplicable aspects of their behaviour, particularly the way in which obsessions are not troublesome where it is possible for the patient to spread or pass on responsibility. This could be accomplished by avoidance (getting others to carry out tasks such as locking or checking) and by the seeking of reassurance. Reassurance seeking spreads responsibility by making another person aware of the details of the patient’s recent actions or thoughts (usually someone in a position of repsonsibility, such as the therapist) (Warwick and Salkovskis 1985). Treatment is focused on aspects of the maintaining factors identified here and in Salkovskis (1985); on reducing avoidance behaviour and increasing exposure to problem situations and thoughts; on the modification of attitudes concerning responsibility; on modification of the appraisal of intrusive thoughts; on preventing neutralising which follows the appraisal of responsibility; and on increasing exposure to responsibility, by direct exposure and stopping reassurance seeking.

Applications of the cognitive model

Cognitive techniques can be used with obsessional patients in a wide range of ways. These include procedures designed to facilitate the behavioural approach to treatment (exposure and response prevention) as well as techniques more specifically intended to change the thoughts and beliefs which are directly involved in the production of distress in obsessional patients. The first category includes strategies which (1) facilitate assessment; (2) prevent treatment drop-outs; (3) improve compliance;

(4) maximise the effectiveness of exposure and response prevention. In general, these techniques work by reducing the degree of distress experienced by patients, with the same amount of exposure, or even increasing exposure. The second category involves the use of techniques intended to allow the patients to modify negative evaluations of the obsessional thoughts, and to bring about more general changes in beliefs concerning responsibility. In practice, the most effective approach to the treatment of obsessional patients involves a combination of both cognitive and behavioural strategies (Salkovskis and Warwick 1988). Behavioural techniques are a particularly efficient way to bring about belief changes; designing and conducting behavioural interventions integrated with cognitive elements (for instance, as behavioural experiments as described on p. 70) can shorten