36COGNITIVE THERAPY IN CLINICAL PRACTICE

2.Behaviours which have the effect of reducing or passing on actual responsibility to others; e.g. asking others to carry out specific tasks.

3.Questioning others (seeking reassurance) in a way which ensures that responsibility for harm is reduced.

4.The occurrence of covert neutralising and avoidance (mental ritualising and avoidance); e.g. when the thought of someone dying occurs, trying to think of the same person alive.

5.Attitudes concerning responsibility; e.g. ‘Having a thought about doing something is as bad as carrying out the action’; ‘sin by thought’.

The transcript of the therapy session with Mr Johnstone (pp. 63 ff.) illustrates the way this type of assessment is developed, using techniques such as the downward arrow to gain access to the patient’s fears.

Treatment

Engagement and ensuring compliance

As outlined in the section on style of treatment, problems can arise when the patient’s view of the nature of their difficulties is not fully consistent with the therapist’s perception of the problem. Where this situation occurs, it usually leads to problems with engaging the patient in treatment as a collaborative effort, and can lead to the situation where a patient reluctantly goes along with parts of the programme, but feels unable to comply fully with the more stressful or threatening components. A cognitive analysis of this situation will usually lead to the conclusion that the patient is not convinced by the therapist’s formulation of their problem; e.g. they may be unsure whether the basis of their problem truly lies with anxiety or is actually with contamination. The patient will have such reservations because they are unconvinced by the available evidence. This is dealt with in two principal ways: first, the therapist makes explicit the two alternatives which could account for their distress (that their worries occur as a result of anxiety, or that their worries are the result of an actual and realistic danger), then elicits from the patient the evidence for each perspective; for convenience, these are placed in two columns (see Salkovskis and Warwick 1985 and 1988 for some examples of this). Having elicited the evidence, each item is discussed and the belief rated. Finally, belief in each of the two possibilities is rated. As far as possible, the therapist ensures that they are not engaged in discussing the original intrusive thought or directly involved in providing reassurance.

Sometimes this still leaves a major element of doubt, which is rather more difficult to dispel. This situation often arises once treatment has already begun and shown some signs of progression, and can lead to a halt in further progress. In the following example, the earlier stages of treatment had dealt only with one aspect of the obsession. Mr Johnstone was a 29- year-old married civil servant, referred with religious obsessions. At the time of referral, the obsessions involved having the thought ‘I am going to offer what I am doing to the devil’; when this thought occurred, he would make a ‘firm purpose of amendment’ then ritualise, usually by repeating prayers ‘until I am satisfied’ and denying himself some pleasure later in the day. He initially responded well to exposure with response prevention, but improvement began to slow down within six sessions, and further progress ceased. He reported that he was able to stop ritualising in some instances but not others. The transcript below is taken from session ten.

T: You have doubts as to whether the thoughts are true or whether they are obsessions.

P:The main problem I had with previous treatment was that I was given techniques to change the direction of my thoughts when I was ritualising and I thought I could be killing my conscience by learning a trick. I worry about the harm that I had done by offering things to the devil or thought I had offered things to the devil and not put right; I would have to put them right when I thought that way. Rationalising things as just obsessions could be killing my conscience. Where things to me

are real, I can’t think of them as irrational. T: And therefore—

P: Then I haven’t the confidence to stop putting right, you’ve got to do the absolution. T: If you do kill your conscience, then what?

P: Then I’ll be living an anti-religious life, I really will be offering things to the devil because I haven’t neutralised it.

T:So that leaves us with two possibilities. Either that the thoughts are correct and you could be living the life of an antichrist; or that you have an obsessional problem. Are these the two possibilities you see, and swing between?

P:Yes, sometimes I can say ‘this is my stupidity’, then there are things I really feel guilt for and the ritual has to be done because it seems I really have offered things to the devil. I lose my temper or have impure thoughts, then think I’m going to offer that to the devil and still give in. That makes it more real, because by implication I wanted to commit the sin, I chose to do it. Other times the thought comes when I am walking through a door, then that’s not a problem in the same way; that seems like it really is an intrusion. Guilt from a real, chosen sin makes it very real so I have to put it right then.

OBSESSIONS AND COMPULSIONS 37

T:So some thoughts you can see are an obsession for sure; then there are thoughts which go with something which is really a sin, then you’re not so sure?

P:It means I really have offered things to the devil because I have the wrong attitude of mind; if I continue and say ‘Blow it’, there is a conscious decision on my part, therefore I must neutralise. I’m responsible for my actions then, no matter what.

T: But the other possibility is that the whole lot is part of your obsession?

P:Yes. But if I accept that, it’s easy for me to go throught life saying it’s all obsession; but it might be just that I’m learning a trick to kill my conscience. I can’t be confident.

T:Right, so we have two possibilities which really come into conflict in obsessions where your action could mean you have chosen to offer things to the devil. Let’s write these down [writes]: first, ‘my problem is obsessions’; second, ‘my problem is sin; calling this obsessions is killing my conscience’. Look at these; do you agree these are the possibilities?

P: Totally.

T:Right, now look at the first one; could you rate how likely that is to be true, using 0 to 100, where 0 is no truth at all, 100 is completely true.

P:Well: the first one, about 30 per cent now; when they happen, only 10 per cent. The second one, 70 per cent now, nearly 100 per cent when they happen.

T: OK, so you are not completely sure either way, although this can vary. Could both be true?

P: Definitely not. Only one of these can be correct.

T:That’s really useful to know. If the problem is obsessional thoughts, then the idea that the problem is sin will be untrue, or if the problem is sin, then it couldn’t be an obsession. I think that the main thing we need to work on today is to find a way of resolving this question, which is why I have written it down. How does that seem to ycu?

P:Yes, I agree that that’s what we should do. I don’t think I can stop putting things right unless I’m sure the thoughts really are an obsession.

T:OK, so look at the card where I have written the two ways of looking at your problem. Can you think of how we might be able to decide on this, between these possibilities?

P: Well, if I don’t commit sin, fine, there is no obsession. T: How likely is it that you won’t commit sin?

P: Very unlikely; I’ve been brought up to believe that you should always try to be free of sin, but that you always fall.

The therapist has thus pin-pointed one of the main obstacles to treatment, and has made deciding on the nature of the thoughts (and therefore resolving this obstacle) the target for the session. Leaving the card with the patient (and referring to it from time to time), the patient and therapist go on to examine the obsessional thoughts and how they occur. The thoughts can occur any time, and are always associated with urges to put right. The only difference that the patient can identify between obsessions associated with a sinful act or thought and those which are not is the context; when obsessions occur in the context of urges they are associated with increased belief in responsibility, while intrusive thoughts not associated with this type of behaviours are simply seen as an obsession.

P:I need that confidence; priests have often told me that, but the question keeps coming up, have they got it right on this occasion?

T:So it is important to identify whether the thought is an obsession; rather than trying to say on each occasion whether or not the thought is a sin, the alternative is to clarify whether the thoughts are obsessions.

P: Right. If I believed that I wouldn’t have to put right.

T: We need tests of the ideas on the card; do you have any evidence already?

P: Well, the very fact that I’m here; everybody apart from me says it’s an obsession, and that’s evidence. I’m not so sure. T: Right, but you think there is a small possibility that everybody could be wrong. Is there anything else?

Tests of this view carried out by the patient included attempts to exclude various non-obsessional thoughts from his mind and trying to gain certainty that various harmful events (such as being knocked down by a car) would not happen. These exercises served to illustrate the ‘mechanics’ of intrusive thoughts, and the impossibility of proving that something would not happen. A further component of treatment involved identifying and making explicit the thoughts of harm which were linked to the idea of not ‘putting right’.

Having thus elaborated on the evidence for and consequences of the thoughts as an obsessional problem, the therapist next asks the patient for further details of his beliefs about what it would mean if the thoughts really were sinful. Doing this means that the patient is unlikely to perceive the discussion as an attempt to ‘trick’ him. The therapist works out with the patient what would be bad about not neutralising the obsessional thoughts when he had offered some intentional act (such as lustful thoughts or being angry) to the devil. The technique used was the ‘downward arrow’, in which the therapist questions the patient about how bad each of a succession of steps would really be.