The Treatment of Obsessions

The Treatment of Obsessions
[Book Reviews — Comptes rendus de lecture]
STEWART, SHERRY H.
Stanley J. Rachman is currently Professor Emeritus of Psychology at the University of British Columbia. He has published extensively on the subjects of fear, anxiety, anxiety disorders, and obsessive-compulsive disorder. He has written or edited more than 15 books and monographs and many additional journal articles and book chapters. Dr. Rachman received a Distinguished Scientist Award from the American Psychological Association (Division 12) in 1984 and was made a fellow of the Royal Society of Canada in 1989.
Sherry H. Stewart is Professor of Psychology, Psychiatry, and Community Health and Epidemiology at Dalhousie University and a Canadian Institutes of Health Research Investigator. She studies the co-morbidity of anxiety and substance use disorders. Her findings have been published in such journals as the Journal of Anxiety Disorders and Psychology of Addictive Behaviors. She also maintains a clinical practice as a cognitive-behavior therapist and is the Associate Coordinator of Dalhousie's doctoral training program in clinical psychology.
STANLEY RACHMAN The Treatment of Obsessions. New York: Oxford University Press, 2003, 160 pages (ISBN 0-19-851537-5, US$36.95 Paperback)
This treatment manual is part of Oxford's Cognitive Behavior Therapy: Science and Practice series edited by David Clark, Christopher Fairburn, and Steven Hollon. The goals of the book are to provide background theory and research, and to describe treatment techniques for a new cognitive-behavioural treatment for patients whose major or sole problem is obsessions (i.e., recurrent, unwanted thoughts, impulses, or images that the person finds unacceptable or disgusting).
As Rachman describes at the outset, until recently, progress in treating obsessions in obsessive-compulsive disorder (OCD) lagged far behind the progress made by cognitive-behavioural therapists in treating compulsions (i.e., repetitive, stereotypic behaviour). We have known since the early 1980s that we can successfully treat compulsive behaviors — like compulsive checking and cleaning — through exposure and response prevention (ERP). However, ERP was not designed to treat the cognitive symptom of obsessions, even though obsessions are the primary problem for nearly one-third of OCD patients. Rachman reviews the prior lack of success of procedures intended to treat obsessions (e.g., “thought-stopping”). Given the frequency of obsessions as the primary or only problem in OCD patients and the absence of effective prior treatments for obsessions, this manual is a welcome addition to the literature.
In the first two chapters, Rachman describes the nature of obsessions and background cognitive theory and rationale for his novel treatment. He acknowledges that he draws heavily on the work of David Clark (cognitive theory and therapy for panic disorder) and Paul Salkovskis (cognitive theory of obsessions). Rachman clearly describes the three types of classical obsessions — (a) Aggressive/harm obsessions, such as thoughts of harming children or elderly people; (b) Sexual obsessions, such as fears of sexually molesting a child; and (c) Blasphemous obsessions, such as fears of making sacrilegious gestures in a church. He reviews considerable data that indicate intrusive thoughts are a common and normal experience. He then clearly presents the cognitive theory of obsessions, which asserts that catastrophic misinterpretation of the meaning and significance of unwanted thoughts is the factor responsible for turning a nonclinical intrusive thought into a recurrent and troubling obsession. For example, a woman who has an intrusive thought of harming her child develops a harm obsession when she misinterprets her original unwanted thought as evidence that she is a dangerous and evil person. Rachman reviews the accumulating clinical and psychometric evidence for this cognitive theory gathered by his own team and by research groups worldwide. I found this section of the book to be clear, comprehensive, and current, while still managing to remain appropriately brief.
In the third chapter, Rachman reviews the importance of proper assessment of the obsessional problem for use in treatment planning, tracking progress (also covered in Chapter 8), and evaluating outcome. He recommends a specific set of tools (structured interviews, questionnaires, behavioral tests, and clinician ratings) for conducting a thorough assessment and suggests when they should be employed at various points in the therapy process. The specific set of tools allows the clinician to gather information about the frequency and specific content of the obsessions, the antecedents, safety behaviours (e.g., avoidance, neutralizing, concealing the thoughts from others), and maintaining factors, as well as associated emotional states (e.g., depression). Since this is a cognitive treatment, Rachman places particular emphasis on evaluating the personal significance or meaning the patient is attaching to obsessive thoughts via tools developed by his research team. A very helpful aspect of this section is that the relevant tools developed by his own research group are actually contained within the manual in Chapter 9 (“Therapist's Toolkit”). A limitation is that very little information is provided on the psychometric properties of the recommended tools.
The fourth through seventh chapters describe the content of the treatment and specific therapeutic strategies. The treatment is divided into two stages. Chapter 4 presents the first stage, which is psychoeducational (e.g., providing the patient with information on the high frequency of unwanted, intrusive thoughts in the general population; educating the patient about similarity in content and form between clinical and nonclinical intrusive thoughts; introducing the patient to the rationale for treatment). One of the strengths of this section is that useful tools for accomplishing these goals are provided in the Therapist's Toolkit. Specifically, Rachman has included a list of common intrusive thoughts gathered from nonclinical and clinical (obsessional) samples, which can be used to illustrate the similarities in form and content to the patient. Also, he has included a written description of the treatment rationale. This can be used to supplement the therapist's verbal explanation and to stimulate discussion about the therapy rationale to ensure patient understanding. I also appreciated suggestions for analogies that can be used (e.g., comparing the patient's true values and beliefs vs. obsessions to signal vs. noise, respectively, in a radio signal).
The next three chapters cover the second (cognitive-behavioral) stage of treatment. Rachman explains that the main goal of this stage of treatment is to eliminate the catastrophic misinterpretations of the meaning and significance of the obsessional cognitions and to replace these with satisfactory alternative interpretations (Chapters 5 and 7). An additional goal is to modify the associated abnormal safety behaviors (e.g., avoidance of or escape from situations that evoke the obsessions; concealment of the obsessions from others; engaging in neutralization or attempts to “put matters right”; suppressing or blocking the unwanted thoughts) which might serve to maintain the obsessions (Chapters 6 and 7). I found this section of the book to be the strongest and most helpful. It is filled with useful strategies for tackling such cognitive biases as an elevated sense of responsibility (e.g., transfer of responsibility exercise), and for challenging moral and probability “thought-action fusion.” The behavioural strategies for tackling self-defeating safety behaviors are very clearly described. Again, helpful tools to be used in accomplishing the goals of this portion of the therapy are provided in the Therapist's Toolkit (e.g., a worksheet for dealing with concealment by analyzing the reactions of friends to disclosure).
I have very few criticisms of this book. I found it a thoroughly enjoyable read, and very useful from both a science and practice perspective. I look forward to having the opportunity to employ this manual in my clinical practice and graduate teaching. I liked the use of chapter summaries in the first two chapters and wish that this feature had been maintained throughout. Although I very much appreciated that many of the necessary tools were included, I found the level of the language used in some of these to be quite high and likely unsuitable for patients with lower levels of education or intelligence. I found the incorporation of case material throughout the book very helpful and appreciated the inclusion of more detailed case examples in Chapter 10; I wondered if the latter might have been better placed earlier in the manual. My final criticism pertains to the fact that, as Rachman acknowledges, the causal role of catastrophic misinterpretation of intrusive thoughts in the etiology of obsessions has yet to be demonstrated experimentally, and there has yet to be an empirical test of the efficacy of this novel cognitive therapy. Hopefully, the publication of this manual will stimulate research on these missing links.
Accession Number: 00011346-200405000-00009
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