Cognitive-Behavioral Therapy for OCD [Paperback]

I found this book to be well-written and well researched. I pretty much stopped doing therapy with OCD years ago because I found strict behavior therapy to be inadequate for most cases. Clark proves the value of cognitive-behavioral approach, backing it up with empirical findings. His treatment of the literature is objective--presenting both positive and negative findings and attempting to make sense out of it. Started using Clark's approach recently and found it to be helpful. I'm sure there are ongoing refinements since he wrote this book, but if you are treating OCD I would consider this book to be a must-read.

Clark's book must be read by anyone who is interested in the etiology and psychotherapy of OCD because it is full of much valuable research and clinical findings and therapy strategies based on them. But Clark also explains that the current understanding of the etiology of this disorder and the results of its treatment are not sufficiently satisfactory, as exemplified by his statements quoted in the next paragraph. It is shown in this review of his book that the research results and the therapy strategies based on them constitute a mixture of rights and wrongs because an invalid hypothesis is used in research, which causes the misinterpretation of the results of research. Therefore, a new research hypothesis is generated and is used in the interpretation and evaluation of existing research findings and therapy strategies that are currently based on the misinterpretations of those findings.

"Yet there are many inconsistent findings that leave us with more questions than answers" (p. 115). "It is entirely possible that the faulty appraisals and beliefs noted by Rachman, Salkovskis, and others is a consequence, rather than a cause, of obsessive-compulsive symptoms" (p. 115). "At present too few studies have investigated the therapeutic ingredients of CBT [Cognitive-Behavioral Therapy] to draw firm conclusions about the mechanisms in this new treatment approach" (p. 281). "Despite the advances in our understanding of the cognitive basis of obsessions and compulsions, further research is needed ." (p. 282). "Together, cognitive theory, research, and practice clearly have much to offer in the treatment of OCD. Yet the present discussion reveals many important gaps in our theories and research of this disorder. The treatment innovations that characterize the new cognitive-behavioral therapy of OCD have yet to receive empirical verification. Moreover, the application of cognitive and behavioral interventions to obsessions and compulsions continues to present extraordinary challenges to even the most experienced practitioners" (p. 284).

In reality, psychologists have done much better in the study of OCD than they did in the study of mental disorders in general. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), it is said:

"DSM-IV . . . distinguishes those mental disorders that are due to a general medical condition from those that are substance induced and those that have no specified etiology. The term primary mental disorder is used as a shorthand to indicate those mental disorders that are not due to a general medical condition and that are not substance induced" (p. 165).

This means that the etiologies of primary mental disorders are not known, as more clearly expressed in DSM-III-R thus: "For most of the DSM-III-R disorders, however, the etiology is unknown" (p. xxiii), the exceptions being organically caused and drug induced mental disorders. This evaluation covers OCD too and makes it a primary mental disorder because it is considered a psychological-behavioral disorder, not an organic one. Consequently, the causes of the unsatisfactory results of OCD research and therapy need to be looked for in the study and therapy of mental disorders in general. And because scientific investigation consists of framing a hypothesis and testing it, the basic hypothesis and the general method of testing used in the study of mental disorders need to be scrutinized. This is important especially because therapy can be sufficiently effective only if it is based on the correct understanding of etiology.

I showed elsewhere that the hypotheses that made possible the construction of the grand theories of physics have been generated by likening the studied phenomenon to a better known one on the grounds that they have some observed common features and then assuming that the former shares also some other observed features of the latter although this is not obvious. This assumption constitutes a hypothesis that needs to be tested empirically. This is how hypotheses are generated in physics and gave birth to grand theories. This is also how all hypotheses are generated, although not always fully consciously. The definition of mental disorder given in DSM exposes the general hypothesis that is used in the study and therapy of mental disorders:

"Each of the mental disorders is conceptualized as a clinically significant [i.e., harmful] behavioral or psychological syndrome or pat¬tern . . . . Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biologi¬cal dysfunction in the individual."

This means that symptoms are considered harmful manifestations of dysfunction, and this amounts to saying, "Something is wrong here." The problem is to discover what is wrong, or what the dysfunction is. The basic hypothesis that is currently used in the study and therapy of mental disorders based on the idea of "something is wrong" is that symptoms are not only caused by dysfunctions and constitute manifestations of those dysfunctions but are themselves harmful dysfunctions. Concerning OCD, biological dysfunction is ruled out because this disorder is not known to be organically caused and is therefore a primary mental disorder caused by psychological-behavioral dysfunction which needs to be discovered. Consequently, researchers look for psychological-behavioral dysfunctions and interpret their findings as such. Some of the "dysfunctions" that they discovered are intrusive thoughts, inflated responsibility, dysfunctional assumptions, thought-action fusion, moral perfectionism, preexisting dysfunctional cognitive beliefs and biases, anxiety proneness, faulty appraisals, ironic monitoring process, and so forth. Compulsive behaviors are readily observed symptoms of OCD.

In reality, considering the symptoms of primary mental disorders, including OCD, as dysfunctional is a self-contradictory thought. The reason is that, if all hypotheses are generated as explained above, psychologists must have likened the symptoms of primary mental disorders to some better-known symptoms, which appear to be the symptoms of organic illnesses interpreted without making any research. In fact, many symptoms of organic illnesses are seen as, and are, harmful manifestations of organic dysfunctions, and this fits the idea of "Something is wrong here." But there are also symptoms of organic illnesses that do not constitute dysfunctions, because they are found to have self-protective functions. For example, the rise in the body temperature caused by infections has self-protective function: it facilitates the fight against the microbes in many ways, including the hindering of their reproduction. Pain is a very common symptom of organic illnesses and has a self-protective function: it warns consciousness about an organic dysfunction. Ordinary pain too warns consciousness about a harm suffered by a part of the body. Pain can do even more than warning consciousness for realizing self-protection. For example, pain caused by a cracked leg bone prevents walking and thus facilitates the mending of the crack in the bone. In fact, this is what a doctor does to a leg with a cracked bone.

There are also symptoms that are not caused by any organic defect and have self-protective functions. For example, fear warns consciousness about a danger and prepares the organism mentally and physiologically to cope with the danger. Fear has this function both when it is a symptom of mental disorder, e.g., phobia, and an ordinary mental response. Freud found through linguistic analysis that anxiety is a "danger signal," a particular type of fear that prepares the person to detect and cope with dangers about which sufficient information is not available. Clark too mentions this function of anxiety: "The central function of anxiety is `to facilitate the detection of danger or threat in potentially threatening environments' (M. V. Eysenck, 1992)" (p. 82).

Now, because hypotheses are generated by likening a studied phenomenon to a better known one on the grounds that they have some common features, it makes more sense to liken all symptoms of primary mental disorders, including the symptoms of OCD, to some symptoms of some primary disorders that have functions, instead of likening them to the non-functional symptoms of some organic illnesses. This makes more sense because (a) a particular symptom of a primary mental disorder has, or can be expected to have, more common features with the symptoms of other primary mental disorders than with the symptoms of organic illnesses, (b) the results of research and therapy based on the dysfunction hypothesis have not been satisfactory, (c) some symptoms of organic illnesses have self-protective functions, (d) some symptoms of primary mental disorders too are functional, (e) many automatic responses are seen to be functional, and symptoms too are, or can be considered, automatic responses, and (f) automatic responses are, or can be considered, as created by evolution which is directed to realize self-protection, success, and survival.

A definition of the symptoms of primary mental disorders, including OCD, based on the above-mentioned facts and the fact that consciousness too seeks to realize self-protection can be formulated as follows: The symptoms of primary mental disorders are automatic responses which have self-protective functions and are produced when consciousness fails to realize sufficient self-protection for any reason. This definition of symptoms can be used as the basic hypothesis in the research and therapy of all primary mental disorders, and it is used below in interpreting and evaluating the research and therapy results related in Clark's book.

Compulsive behaviors, intrusive thoughts, inflated responsibility, thought-action fusion, moral perfectionism , anxiety proneness, and so forth, serve to incite consciousness to be more careful and diligent in trying to realize self-protection by terminating and preventing the failures. Dysfunctional assumptions, preexisting dysfunctional cognitive beliefs and biases, and faulty appraisals are wrong ideas resulting from the invalid hypothesis of dysfunction. "There is, however, a second cognitive process, called ironic monitoring process, which is much more automatic and continuous, operating in the background of consciousness. This automatic monitoring process is ironic in that it searches for mental incidents that signal failure to achieve the desired mental state" (p. 119). The researchers should be congratulated for having discovered this process, except that they misinterpreted it as dysfunctional like all other automatic responses. This process is the automatic response of the unconscious to the failures of consciousness, which warns consciousness about its failures so that it can try to terminate and prevent them. There is nothing ironic in it, this idea being again a consequence of seeing the products of the unconscious, i.e., the symptoms, as dysfunctions.

The failures of consciousness to realize sufficient self-protection, which necessitates the automatic production of self-protective symptoms, can be considered the "dysfunctions" that cause the symptoms in accordance with the definition of mental disorders and their symptoms given in the DSM. But the symptoms themselves have to be seen as functional, unlike what is done in current research and therapy.

The invalid hypothesis of dysfunction and the misinterpretations of research results that are caused by it make therapy as well as research a mixture of rights and wrongs, which "present extraordinary challenges to even the most experienced practitioners" (p. 284). Examples are below.

"The efficacy and effectiveness of behavioral therapy (ERP) [Exposure and Response Prevention] for OCD is well established)" (p. 63). "ERP is better suited for the treatment of obsessive-compulsive disorders with a prominent behavioral component (i.e., overt compulsions) and is less effective in treating the cognitive component of the disorder (Foa et al., 1985; Rachman & Hogson, 1980; Reed, 1985)" (p. 66). "The therapist should not physically restrain the patient from carrying out a compulsion, but should instead use distraction, conversation, and encouragement to assist the patient in refraining from compulsive rituals (de Silva & Rachman, 1992)" (p. 58).

ERP is a self-contradictory and self-defeating method of therapy because it is a combination of rights and wrongs like all results of current research. Compulsions tell consciousness that it has to behave as illustrated by the compulsive act, because the person failed to act properly in the past and maybe also continues to act inadequately. Preventing this symptomatic behavior prevents the useful effect of the symptom and makes it even more needed. This happens especially when the compulsive act is prevented physically. When this is not done, ERP may be useful, but not because of distraction. The patient is exposed to an undesirable situation which caused harm in the past, he or she will suffer, and this can make his or her consciousness understand that he or she should avoid such situations or should try to terminate them if possible. Thus, exposure has therapeutic effect, whereas response prevention has negative effect but may be beneficial by intensifying the pain. No wonder the most experienced practitioners are perplexed. The correct treatment of all types of OCD is what can be called symptom rehearsal, similar to dream rehearsal which is known to have therapeutic effect. This consists of voluntarily acting and thinking as illustrated and requested by the symptoms. For example, the patient (a) can try to avoid the harmful situation voluntarily and in an exaggerated manner, (b) can perform the compulsive act and can produce the obsessive thought voluntarily and frequently when he or she is not automatically forced to do it, and (c) can voluntarily seek the harmful situation but being physically and mentally ready to cope with it, such as cleaning dirt using gloves, a mask, and other protective means. The voluntary production of an automatic response of any type can prevent its automatic production. For example, the best method of terminating hiccups is to produce them voluntarily especially at the times when one is expected to occur automatically. I used this method successfully in the treatment of OCD and other types of neurosis.

ATTENTION: The symptom rehearsal method should never be mixed with existing methods such as habituation, desensitization, etc., because this can make the symptoms even more needed and can thereby aggravate the illness by making consciousness look like it is antagonizing the self-protective efforts of the unconscious.

I recommend the use of the functionality hypothesis in interpreting and evaluating all research and clinical findings and views related in Clark's book. Symptoms can be interpreted correctly and precisely by integrating the functionality hypothesis with the life experiences of each patient. The fact that the language of the unconscious is concrete analogical has also to be taken into account. Therapy has to be conducted by cooperating with the symptoms and dreams of the patient, because dreams have the same origin and the same basic function as symptoms. However, in severe disorders, the solutions proposed by the unconscious through symptoms need to be scrutinized consciously, because the unconscious can overlook the needs of the society while trying to protect the individual. But this does not happen in OCD and other types of neurosis. The category of neurosis is eliminated from DSM because the editors could not see the common element in the various types of neurosis, because this common element is related to etiology and the etiology of no non-organic mental disorder is known. More information can be found in my books sold by Amazon.