OBSESSIONS AND COMPULSIONS 35

T:Well, I can’t say for sure that your worries are exactly the same because I don’t know much about yours, but they sound similar. For instance, it sounds a bit like someone I saw recently who had thoughts that she might lose control of herself and hurt her children; sometimes, she thought she might even want to hurt them. She was so upset about it, and that’s a really important clue as to what’s going on. If she really wanted to hurt her children, do you think that she would have been upset?

P: No, I’d never thought of that, no.

T: Right, but supposing she didn’t want to have the thoughts and fought them off; what would happen then? P: I don’t know.

T: OK, will you try a little experiment for me? You remember the waiting room? P: Yes.

T:Right. Just for a minute, I want you to do your best not to think about the waiting room. Try really hard, close your eyes, that’s right. [Pause] What happened?

P: I couldn’t get the waiting room out of my mind.

T: Right. Do you begin to see what I mean?

P: You’re showing me that these thoughts can come because you don’t want them?

T: Right.

Note here that the therapist is doing several things; he is beginning the process of educating the patient into a model of how intrusive thoughts work even before he has details of the content of the thinking. The particular intention is to account for the discomfort experienced in a less threatening way. Notice that the illustration used did not initially refer to the patient’s obsessional thoughts, but used other thoughts as a close analogy. Having gained an initial impression as to the likely content of the patient’s obsession, the therapist provides a similar example from his own experience, thus reinforcing the idea that this is a familiar problem. In this example, the interview developed further in the following way after an example of harming obsessions had been outlined:

T: Supposing you did tell me about your thoughts; what is the worst thing which could happen? P: You might take my children away from me.

T: Because of the thoughts? P: Yes.

T:Right. From what you’ve told me so far, that seems very unlikely. I have never even considered it when people have upsetting thoughts of the type I described. Are your thoughts very different from the ones we just talked about?

After the interaction above, the patient disclosed that she had thoughts of strangling her children. It may sometimes be useful to engage the patient in more discussion of hypothetical examples and further clarify the nature of obsession.

It can also be helpful to discuss other examples of people horrified by their thoughts, explaining that the nature of obsessions is such that only a religious person would be upset by blasphemous thoughts, a meticulous person by thoughts of contamination, a gentle person by thoughts of violence, and so on. A further useful strategy would be to ask the patient how they thought a truly violent person would react to thoughts of harming others; usually patients will decide that an evil person would be pleased by violent thoughts. A further helpful piece of information is to discuss the incidence of what appear to be obsessional thoughts in the normal population (Rachman and de Silva 1978; Salkovskis and Harrison 1984). Demonstrating that intrusive thoughts are a frequently experienced but seldom discussed phenomenon can relieve worries about the intrinsic abnormality of the problem.

Note that many of these interventions not only facilitate assessment, but can form the basis of the rationale for subsequent treatment. In some milder cases, these discussions with some further brief instruction in response prevention can be sufficent to resolve the obsessional problem.

Broadening the cognitive focus of assessment

The focus in routine assessment of obsessive-compulsive disorder is on the form and content of the obsession itself, and on discovering factors which may be maintaining the obsession and associated discomfort (see Salkovskis and Kirk 1989 for a full account of behavioural assessment). These maintaining factors include mood and behaviours which the patient uses to prevent them from being exposed to their obsession (avoidant behaviours) and/or behaviours which terminate exposure once it has occurred. The cognitive model indicates that a variety of other factors need to be assessed. These are:

1.The extent to which the patient makes specific evaluations (negative automatic thoughts) of their intrusive thoughts and the meaning of these; e.g. when a violent thought occurs, then having the negative automatic thought, ‘If I have that thought it may mean that deep down I want to be violent, and could be if I am not vigilant’.