42 COGNITIVE THERAPY IN CLINICAL PRACTICE

occurred’, by just letting the thought drift through. If he felt the urge to respond to the thought by neutralising build up, then he would mentally shout ‘stop’ and, if necessary, switch into a pre-arranged thought sequence (e.g. he would imagine eating his favourite meal). If, despite this cognitive thought stopping he still began to neutralise, he would then undo the neutralising as thoroughly as he could, e.g. by offering the same thing to the devil again then using the same procedures. Note that the complicated sequence described here was to cover contingencies; although the thought-stopping based cognitive response prevention was sometimes used, the other procedures were very seldom required. The procedures were first taught in the context of the patient describing a particularly troublesome blasphemous sexual image onto an audiotape loop, then exploring the use of the response prevention techniques with the help of the therapist. Daily homework practice with the audiotape played on a personal stereo was used; this structured practice was successfully generalised from home to work and leisure activities within a period of 6 weeks. The patient reported that the audiotaped practice in the range of settings helped considerably with the application of cognitive response prevention when the obsessional thoughts occurred unprompted.

Relapse prevention

Relapse prevention is best accomplished by ensuring that all rituals (overt and covert) have been fully response prevented, and the patient has a clear idea of how they might react if the obsessions were to recur. Discussing hypothetical situations in which this might happen can be helpful. The therapist points out that one of the things which has been helpful in therapy has been identifying problems, and that a great deal has been learned from problems which have arisen; any setbacks in the future will provide similarly useful information. This goes with the idea that having a setback is not the same as having a relapse, but is an ideal opportunity to practise the skills the patient has learned during therapy. The patient writes down as part of a homework exercise towards the end of treatment a list of (1) what they have learned from treatment; (2) how to recognise an obsessional thought and how to recognise neutralising behaviours; (3) how they would advise a friend to set about tackling upsetting thoughts which had just started to occur, and were causing some upset to them. Having reviewed these with the therapist and discussed the range of potentially problematic situations with the therapist, the patient then makes up a ‘setback package’, which includes the material they have written and the audiotape of the session in which how to deal with future stress and setbacks was discussed. Sometimes, the patient will identify some residual problems which require more specific attention.

For example, towards the end of treatment, Mr Johnstone reported that his obsessional problem had ceased to trouble him in most respects. However, there were occasions when he would still experience the obsessional thoughts and go on to ritualise. These were not associated with extreme discomfort, but were occasions when he was enjoying himself; for instance, when he was sitting in his garden relaxing with a beer. At that time, he would feel a sense of loss or emptiness, and deliberately offer something to the devil so that he could then have the opportunity to ritualise. Rather than giving him a sense of relief from anxiety, he said that the feeling was one of comfort, and that he wanted to be able to retain this sense of comfort and closeness to his religion. He did not regard this behaviour as a problem. The therapist agreed that it was not necessary to stop this behaviour in its own right, so that one possibility would simply be to allow this to continue. However, given that this was the last trace of his obsessional problem, another possibility would be that this could form something of a focus for relapse if he became stressed (depressed or anxious) for some other reason. The therapist and patient discussed alternative strategies Mr Johnstone could use when he had that feeling, and settled on the occasional saying of prayers as a way of obtaining ‘indulgence’, so that the whole sequence was a positive one and did not have to involve a revival of his obsession.

Finally, it is often helpful to discuss with the patient the factors which might be helpful in predicting setbacks. These usually include factors which previously served to exacerbate the obsessional problem, including stress and anxiety arising from external sources, depressed mood, extra responsibilities, and being tired. Being able to predict setbacks in this way is consistent with the model which has been presented to the patient, and helps him to strengthen his belief that the problem is upsetting thoughts and not the threatened disasters. That is, when a setback occurs, rather than focusing on the content of the upsetting thoughts themselves, the patient is able to attribute correctly the distress they are experiencing to their thoughts.

Conclusions

This chapter has outlined the ways in which cognitive strategies can be used in conjunction with exposure and response prevention. There would be little point in applying cognitive therapy separately from exposure, given the good outcome obtained in behavioural treatment. The need for the addition of cognitive strategies to behaviour therapy for obsessional problems lies principally in the limitations which are apparent in the poor treatment acceptance and compliance rates. It is nevertheless encouraging to note that Emmelkamp and his colleagues have been able to demonstrate that cognitive procedures are as effective as exposure treatment in two controlled trials (see Emmelkamp 1987). Work on the relationship between normal intrusive thoughts, obsessional behaviour, and mood has opened up an exciting area of development, suggesting that an

OBSESSIONS AND COMPULSIONS 43

understanding of the basis of obsessional problems may improve understanding of a range of other psychological problems (e.g. Warwick and Salkovskis, this volume), and perhaps of much wider aspects of cognitive functioning in non-clinical populations (Edwards and Dickerson 1987; Salkovskis 1988).

Acknowledgements

The author is grateful to the Medical Research Council of the United Kingdom for their support, to Joan Kirk for help with some of the material in this chapter, and to Hilary Warwick for help with the material and for comments on an earlier version.

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