40 COGNITIVE THERAPY IN CLINICAL PRACTICE

T: How did you try to keep in control? P: Sort of mentally.

T: Right, so that you tried to stop yourself jumping out by keeping mental control of yourself. Is that what you usually do? P: All the time. Otherwise I think I might do-it [jump].

T: Is there anything else you do?

P: I walk further away from the pavement edge.

The therapist at this point formed the hypothesis that the patient’s fears were being maintained by the avoidant behaviour described. From here, the therapist went on to discuss this possibility with the patient. To illustrate how this might work, he used the example of the apprentice builder who is asked by his workmates to hold a wall up while they have a break; the wall is actually perfectly secure, but the apprentice does not know this. Whilst they are gone, he worries about his responsibility, and pushes against the wall harder and harder, becoming more and more concerned about the consequences of letting the wall go. When his workmates come back, he discovers the wall To be quite secure when he lets it go; only by letting it go is he able to determine the true risk of the wall falling (or not). The patient was asked whether the apprentice was helping his worries when holding the wall up; this discussion was directed towards allowing the patient to arrive at the conclusion that unnecessary avoidance behaviour serves to focus the mind on the feared disaster and leads to an unrealistic (if understandable) perception of the risks involved, rather than giving any peace of mind. The patient agreed with the point, but thought it was possible that his situation was different, because in his instance the risk seemed more likely. He also agreed that the apprentice would say something similar. This led on to consideration of whether it was possible to check it out for his particular situation. The therapist and patient did this by conducting an experimental exposure session where both went to a main road, stood on the edge, and ‘tried to lose control’ for half an hour! Discussion of this last exercise showed that the patient did not feel ‘loss of control’ increasing during this behavioural experiment, however hard he tried to make himself lose control. One possible explanation for this is that there are no ‘mental muscles’ which can be employed in this situation. Having made this discovery, the patient was then able repeatedly to go down the street he feared without exerting ‘control’. He quickly lost his fear of this situation without any more exposure than had previously been occurring in the normal course of events. Thus, exposure had been adapted in a way which specifically changed the patient’s belief that it is possible to come to harm because of spontaneously losing control of one’s behaviour. This generalised to a wide range of situations, including social situations where the patient had believed that he constantly ran the risk of losing control.

Dealing with negative automatic thoughts

The way in which negative automatic thoughts of obsessional patients are challenged and tested does not substantially differ from the style adopted in other problems. Factors identified on p. 62 need to be borne in mind, particularly the way in which negative automatic thoughts concern responsibility for harm arising as a result of inaction following an intrusive thought, image, or impulse. In general, care should be taken to ensure that the thought being challenged is an evaluation of the intrusive thought rather than the intrusive thought itself. Arguing with obsessionals about the rationality of the intrusion is a time-honoured and highly unsuccessful approach, however attractive it may seem when the patient describes doubts about some improbable disaster.

For example, a 27-year-old woman worked part time in a clothes shop. Her principal complaint was of checking, particularly late at night before going to bed. Checking was always carried out with her husband or daughter looking on. Some degree of checking had always been present, but she dated the worsening of her problem to a specifie incident. She awoke to the smell of smoke, and managed to escape with her young son just before the entire house was engulfed by flames. She was subsequently troubled each night by images of her family being horribly burnt; these images led her to the extensive checking of her house and all electrical appliances in it. During exposure she was able to identify this occurrence of the image and her appraisal which went: This image shows what might happen. I can’t risk it in any way.’ In the course of exposure she was taught to identify negative automatic thoughts which represented appraisals of responsibility, and to answer these. The patient devised a striking example for herself when she was unable to resist checking her cooker. On the third night that resisting this was her target (she had failed the previous two nights), she asked herself, ‘What is really the worst thing that could happen?’ and concluded, ‘I will have a bigger electric bill.’ She went straight back to sleep, and stopped checking the cooker from then on, with no subsequent discomfort.

The cognitive model of obsessions gives the perception of responsibility for harm to self or others a key role in obsessional problems. Treatment should aim to change the patient’s views about responsibility by demonstrating that the taking of previously avoided responsibility does not have dire consequences. There are three principal ways in which exposure to responsibility can be implemented: (1) by getting the patient to undertake previously avoided activities involving elements of responsibility (Salkovskis and Kirk 1989); (2) by demonstrating the effects of, and then preventing, reassurance seeking (Salkovskis and Westbrook 1987; Salkovskis and Warwick 1988); (3) by getting the patient to seek out responsibility actively

OBSESSIONS AND COMPULSIONS 41

without revealing any details to others (including the therapist) so that the patient alone is responsible (Salkovskis and Westbrook 1987).

Dealing with concurrent depression

The association between obsessions and depression is an important component of the cognitive model. Depressed or anxious mood can affect the likelihood of intrusive thoughts, of negative evaluation of those thoughts, and the likelihood that that evaluation will contain an element of personal responsibility for harm and therefore have implications for neutralising behaviour. Clinically, these phenomena have been identified as the cause of treatment failure (Foa 1979) and of worsening of obsessions (Gittleson 1966). Such associations have led to the suggestion that tricyclic antidepressant medication is indicated where severe concurrent depression complicates an obsessional problem. This view is supported by outcome trials such as the MRC study (Marks et al. 1980). There has been some argument as to the relative merits of clomipramine in the treatment of obsessional problems, with the MRC study suggesting that the drug effects are purely antidepressant, whilst others suggest a more specific antiobsessive effect (Christensen et al. 1987). This issue could be clarified by a trial of cognitive therapy focused on depression in obsessional patients with severe concurrent depression, given the evidence that cognitive treatment of severe primary depression is as effective as tricyclic antidepressant medication in the short term (Blackburn et al. 1987) and more effective at follow-up. Treatment of depression in obsessional patients should follow similar lines to that employed with patients with primary depression; an additional focus would be on episodes where depressed affect contributed to obsessional problems and vice versa. (See Salkovskis and Warwick 1988.)

Dealing with obsessions not accompanied by compulsive behaviour

Early behavioural treatments were considered particularly suitable for obsessive-compulsive disorder because of the prominence of overt avoidance and distressing compulsive behaviours. Consistent with learning theories current at that time, it was assumed that if obsessions with compulsions could be dealt with effectively, then the knowledge so gained would be easily generalised to obsessions without compulsions, which have the appearance of a less complicated variant of the same problem. This quite reasonable expectation has not been fulfilled. Rachman (1983) stated that ‘the main obstacle to the successful treatment of obsessions is the absence of effective techniques’. We have argued elsewhere (Salkovskis and Westbrook 1987; Salkovskis and Warwick 1988) that this pessimism is based more on methodological grounds than actual difficulty. That is, the emphasis on overt behaviour served to mask the extent to which covert ritualising and avoidance behaviours are involved. Obsessions without overt compulsions are characterised by mental rituals. When ritualising becomes covert, this can have the effect of making the obsessional problem more severe and particularly resistant to treatment. This is because mental rituals are more difficult to identify (by both patient and therapist), more ‘portable’ in the sense that mental ritualising can be carried out almost anywhere, usually without fear of social embarrassment, and are often briefer and therefore potentially more frequent. Where response prevention is initiated, the scope for ‘sneaky ritualising’ is greater. Finally, making the occurrence of obsessional stimuli (thoughts) predictable can be particularly difficult when exposure is to thoughts alone. Unpredictability tends to retard habituation.

Despite these complicating factors, the solution to the problem of treatment of obsessional thoughts is principally to be found in the careful application of both cognitive and behavioural treatment techniques used in obsessive-compulsive disorder, following the principles outlined earlier in this chapter. Obsessions without overt compulsions present problems of predictability of stimuli and difficulties in implementing response prevention. Salkovskis and Kirk (1989) and Salkovskis and Westbrook (1989) provide detailed solutions for the more specific problems. Avoidance of particular situations or stimuli is discovered and reversed. Predictability of exposure to obsessional thoughts can be increased by getting patients to record their obsessional thoughts on loop audiocassette tapes, then play them back in situations which increasingly approximate to those in which the obsessional thoughts usually occur. Response prevention requires careful instruction in the rationale for stopping covert neutralising; the audiotape procedure can then be used as a way of pin-pointing and overcoming difficulties in the detection of neutralising responses and the implementation of response prevention (Salkovskis 1983). The audiotape also helps to detect covert avoidance and neutralising, because it provides an opportunity to present obsessional thoughts under controlled conditions.

In the case of Mr Johnstone, described above, covert neutralising persisted for some considerable time after overt ritualising and avoidance had been eliminated. The patient still experienced occasions in which he would be troubled by having the thought that he was going to offer his behaviour (such as being angry) to the devil, not being able to suppress either the thought or the behaviour, then neutralising by ‘making a firm purpose of amendment’, usually with mental ritualising including prayers. Quite often he would experience this as prolonged sequences of intrusive thought, neutralising, further intrusive thought, neutralising, and so on. The patient was instructed in the use of thought-stopping techniques for the neutralising thought. Whenever the intrusive thoughts occurred, he would first try to deal with them ‘as if they hadn’t