28 COGNITIVE THERAPY IN CLINICAL PRACTICE

Postscript

John was markedly improved at the end of our regular sessions, but soon after he suffered a severe panic, driving towards a bridge with his wife en route to a week’s vacation at the beach. He called me from his car phone: he could not cross the bridge.

John’s automatic thoughts, while circling before the bridge, weeping, were an amalgam of fears he had expressed previously: ‘I’ll fall apart [emotionally] on the bridge.’ ‘I’m all alone. No one loves me.’ ‘I’ll be far away from my parents; what if I need medical help?’ And finally, ‘I have to feel closer to my wife before I attempt these things.’ Together, we developed some ‘rational responses’: ‘I’ve already ‘fallen apart’—at least I’m pretty upset. What worse can happen?’ ‘I’m not really in medical danger—anyway, there are hospitals at the beach.’

The matters of love and closeness were harder to test. To gather some evidence on the point, I asked to speak to his wife. Yes, she was trying to be supportive (though a little frustrated with the length of the trip). Yes, she would hug and kiss him and tell him she loved him. ‘Put John back on now’, I said; and to John, ‘Doesn’t that mean someone loves you?’ ‘But it’s not enough!’ said John.

‘But that’s as good as love gets!’ said I.

‘But I don’t think she feels what I feel—I’m all alone!’

‘How can she feel it? Your body is racked with fear and anxiety, and she is calm. Still, she’s been frightened before, and she can understand what you feel. Check it out.’ He did, and she confirmed this.

‘But I have to feel close to her before I go over.’

‘That will never happen—you’ll only feel close after you cross. Call me when you do!’

Half an hour after this dialogue, a triumphant John called from the other side of the bridge—feeling euphoric, close to his wife, and very appreciative of cognitive therapy!

References

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders, New York: International Universities Press.

Beck, A.T. and Emery, G.D., with Greenberg, R.L. (1985) Anxiety Disorders and Phobias: A Cognitive Perspective, New York: Basic. Beck, A.T. and Greenberg, R.L. (1988) ‘Cognitive therapy of panic disorders’, American Psychiatric Association Annual Review of Psychiatry

7.

Clark, D.M., Salkovskis, P.M., and Chalkley, A.J. (1985) ‘Respiratory control as a treatment for panic attacks’. Journal of Behaviour Therapv and Experimental Psychiatry 16:23–30.

Salkovskis, P.M., Jones, D.R.O., and Clark, D.M. (1986) ‘Respiratory control in the treatment of panic attacks: replication and extension with concurrent measurement of behaviour and pCO2’, British Journal of Psychiatry 148: 526–32.

Chapter three

Obsessions and compulsions

Paul M.Salkovskis

Introduction

Obsessional disorders are characterised by the occurrence of intrusive and upsetting thoughts which the patient usually regards as senseless, and which are accompanied by the urge to ‘put right’ or neutralise. Compulsive, overt behaviour such as repetitive washing or checking is the most obvious form of neutralising, but neutralising may also take the form of cognitive behaviours, such as thinking a ‘good thought’ whenever an obsessional intrusion occurs. Neutralising behaviour, either cognitive or overt, usually occurs repetitively and is often identified as the principal problem leading to the patient seeking treatment. For example, a patient was referred because of repetitive hand washing. On interview, he reported that two years previously he had read about a toddler dying after drinking from a bottle of domestic bleach. Since that time, he had been troubled by the thought that he had become contaminated by bleach and could harm others as a result. This led him to wash his hands repeatedly, taking up to an hour at a time, several times every day. When he tried to stop, he had the thought, ‘What if I missed some bleach and touched my baby son?’ When this thought occurred, he had a terrifying image of his son’s face, horribly distorted, and his wife reproaching him for his carelessness and the death of their child. He would then have the thought, ‘I can’t risk it, just for the sake of washing for five minutes.’

This sequence of a thought leading to distress or discomfort, then to disturbed behaviour, further upsetting thoughts and more distress and disturbed behaviour in a vicious spiral is characteristic of obsessional problems. Similar observations have led to the formulation of cognitive models and treatment of other anxiety disorders (see Beck 1976; Greenberg, this volume; Warwick and Salkovskis, this volume). However, the treatment of choice for obsessive-compulsive disorder is behaviour therapy; little attention has been paid to cognitive approaches to treatment. A brief inspection of the literature suggests that this is because behaviour therapy is so successful that cognitive approaches have not been considered necessary. However, more careful examination of reports of outcome studies reveals important shortcomings. While success rates of up to 85 per cent (median 75 per cent) have been reported (Foa and Goldstein 1978; Marks 1987), these figures may not reflect the typical outcome of out-patient treatment in routine clinical practice. Almost all of the outcome studies have been carried out in carefully selected research populations, and in centres of excellence, using a team of highly trained staff in an intensive in-patient setting. Even in this context, 25 per cent of patients screened as suitable refuse treatment when it is explained; a further 12 per cent drop out when treatment starts. Longer-term relapse rates are unknown; there is certainly some evidence that relapses do occur (Espie 1986). These figures lead to the conclusion that, in a research setting, true success rates are less than 50 per cent of the patients who seek treatment and are judged to be suitable. Furthermore, behavioural treatment is associated with high levels of distress, sometimes making treatment a prolonged and difficult matter. For some patients distress may be so intolerable as to lead to refusal to proceed with further exposure, or even withdrawal from treatment. Exposure programmes have been developed so that flooding with 24-hour response prevention is used (Foa and Goldstein 1978); it is difficult to envisage more intensive exposure. Most authors now agree that the most substantial gains lie in developing techniques intended to alter the beliefs which give rise to difficulties in exposure treatments and the obsessions themselves (Foa et al. 1983; Rachman 1983).

Thus, the major problem which has yet to be adequately dealt with is patients who do not respond to exposure treatment. Foa et al. (1983) have identified the major problems; these are patients who refuse or drop out of treatment, patients who are convinced that their worries are sensible (described as ‘overvalued ideas’), patients with severe concurrent depression and patients with obsessions without accompanying compulsive behaviour.

Cognitive therapy could therefore be useful in three major areas: in developing techniques which can be used to allow behaviour therapy to be carried out, to make behaviour therapy more effective when it is carried out, and as a treatment in its own right, particularly for patients who are known not to respond to behavioural techniques (‘treatment failures’). This chapter briefly describes the behavioural model upon which exposure treatment of obsessions is based and goes on to describe the cognitive-behavioural hypothesis of the nature of obsessive-compulsive disorder, including some discussion of the