14

Approaches to Common Obstacles in the Exposure-Based Treatment of Obsessive-Compulsive Disorder

J o n a t h a n S. A b r a m o w i t z , M a y o Clinic M a r t i n E. F r a n k l i n a n d S h a w n P. Cahi l l , University o f P e n n s y l v a n i a School o f Medic ine

Treatment manuals have proven extremely useful in implementing exposure and ritual prevention (EX/RP) with patients with obsessive-compulsive disorder (OCD). Nevertheless, treatment manuals cannot possibly attend to all possible situations encountered in therapy, especiaUy with OCD patients who have such a diverse range of presentations. In this article we address four commonly en- countered issues not explicitly described in the widely used EX/RP treatment manuals, lqrst, we offer suggestions on how to help pa- tients understand their OCD symptoms in ways that f i t into the theoretical framework of the treatment procedures. Second, we address how to manage excessive reassurance-seeking behavior that is often obse~-oed in patients with particularly severe symptoms. Third, we describe the importance of consistent exposure during (and after) treatment. Fourth, we discuss clinical decision-making regarding the implementation of dtual prevention.

M EYER AND COIJJ~AGUES ' (Meyer, 1966; Meyer & Levy, 1973) early reports on the benefits of expo-

sure and ritual prevent ion (EX/RP) for what is now known as obsessive-compulsive d i sorder (OCD) gener- a ted considerable interest in this form of t reatment . OCD was at the t ime cons idered highly refractory to available psychotherapies . Therefore , the appa ren t success of E X / RP offered new hope that p rocedures based on learning principles could be used to reduce these symptoms. Since then, numerous studies have suppor ted the efficacy of E X / R P (e.g., Lindsay, Crino, & Andrews, 1997), with sub- stantial short- and long-term symptom reduct ion for the vast majori ty of pat ients who receive it (Foa & Kozak, 1996; Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000). Given that EX/RP is now an empirical ly suppor ted treat- men t for OCD, and des ignated by the APA Division 12 Task Force on Promot ion and Disseminat ion of Psycho- logical Procedures as a "well-established" t reatment (Chain- bless et al., 1998), a t tent ion has focused more recently on how to make it more widely available (Greist, 2000).

Trea tment manuals , cons idered by many experts to be essential to ou tcome research studies (Foa & Meadows, 1997), are used to p romote the s tandardizat ion of ther- apy p rocedures across therapists and patients. Optimally, manuals should de l inea te the essential pr inciples of treat- men t and provide clinicians with session-by-session pro- cedural guidelines. The chal lenge in developing such a manual is to specify abstract pr inciples of t r ea tment in sufficient detail that they can be appl ied to a variety of

Cognitive and Behavioral Practice 10, 14 -22 , 2003 1077-7229/03/14-2251.00/0 Copyright © 2003 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

patients, but not in so much detail that the manual be- comes too cumbersome. This is an especially relevant issue in the t reatment of OCD as this d isorder is character- ized by except ional heterogeneity. Indeed , no t rea tment manual could adequately address the implementa t ion of EX/RP across the countless possible presentat ions of OCD (e.g., themes of obsessions, compulsions, and avoidance behaviors) . In this article, we presen t some clinically de- rived suggestions for handl ing commonly e n c o u n t e r e d obstacles in the t rea tment of OCD that may not be explic- itly descr ibed in widely used EX/RP t rea tment manuals (e.g., Kozak & Foa, 1997).

We begin by offering suggestions on how clinicians can help patients to unders tand their obsessive-compulsive symptoms in ways that fit into the conceptual f ramework of the EX/RP t rea tment procedures . We find that pa- tients come to therapy with a wide range of thoughts and beliefs (some useful and others not so useful) about themselves, psychotherapy, and their disorder. Compli- ance with t rea tment r ecommenda t ions can be enhanced when pat ients master the fundamenta l theoret ical tenets of therapy. Second, we address how to manage excessive reassurance-seeking behavior that is often observed in pa- tients with part icularly severe symptoms. Offer ing unreal- istic guarantees of safety dur ing exposure can sabotage such exercises, leading to a t tenua ted outcome. Third, we descr ibe the impor tance of consistent exposure dur ing (and after) treatment, and differentiate between two forms of practice: that which is specifically assigned to the pa- tient by the therapist ( "programmed" exposure) , and that which involves making decisions to conf ront obsessional situations as they arise in everyday life ("lifestyle" expo- sure). Finally, we discuss clinical decis ion-making regard- ing the implementa t ion of ritual prevent ion. M t h o u g h

Treatment of OCD 15

comple te abst inence from compulsive ri tualizing is the ul t imate goal, it may be necessary in some instances to i m p l e m e n t r i tua l p r even t i on on a m o r e g radua l basis to minimize failures and reinforce compliance.

Psychoeducation

Recent EX/RP t rea tment manuals (e.g., Kozak & Foa, 1997) descr ibe an i n f o r m a t i o n - g a t h e r i n g / t r e a t m e n t - p lann ing phase dur ing which the therapis t collects data on the pat ient ' s specific fear cues, rituals, and avoidance patterns. It is also dur ing this phase that a h ierarchy of sit- uat ions to be conf ron ted dur ing exposure (i.e., the treat- men t plan) is collaboratively developed. To design a use- ful t r ea tment plan, it is necessary for the therapis t to unde r s t and the funct ional relat ionships among the pa- t ient 's idiosyncratic obsessional, compulsive, and avoid- ance symptoms. However, we have found that many OCD patients themselves do not unde r s t and these funct ional relat ionships very well, and hence have a difficult t ime identifying subtle symptoms that are necessary to address in t rea tment (e.g., subtle menta l rituals). Patients may also be unaware that various facets of OCD, such as logi- cal errors in thinking, serve to mainta in their symptoms. Awareness of these more subtle aspects of OCD can often enhance the pat ient ' s ability to grasp the core theoret ical basis of their t r ea tment and thereby get the most benefi t f rom E X / R P procedures . Given pa t ien t heterogeneity, it is difficult in an OCD t rea tment manual to clearly expli- cate how to he lp patients become aware of the disorder 's subtleties, yet clinically this very process may set the stage for successful outcome. In our clinics, we often appeal to the vast research l i terature on OCD symptoms to en- l ighten patients about such processes. We have observed, in both clinical and research settings, that such educa- t ional efforts may help pat ients to be t te r c o m p r e h e n d the ra t ionale for using EX/RP, leading to be t te r compli- ance and ou tcome (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002). Below, we descr ibe the psychoeduca- t ional p rocedures we most commonly use with patients.

Normality of Intrusive Thoughts Patients with OCD are often u n d e r the impress ion

that they have someth ing wrong with their mind, or they are "going crazy" because of their unwanted thoughts (e.g., "I might rape my daughter") . The i r fears often con- cern engaging in harmful behavior, inc luding the behav- ior of th inking "bad" thoughts. However, f indings from research studies suggest that unwanted thoughts are a normal and universal exper ience: 90% of the genera l popula t ion , even those without OCD, r epo r t ed these kinds of thoughts (e.g., Rachman & de Silva, 1978; Sal- kovskis & Harrison, 1984). Rachman and de Silva (1978), for example , found that menta l hea l th professionals

could not dist inguish between the con ten t of intrusive thoughts of OCD patients and those o f nonpat ients . When pat ients express ho r ro r over the con ten t of their intrusions, we often describe this study and even review the list of "normal" obsessional thoughts p resen ted in the publ i shed article. We also encourage therapists to share their own intrusive thoughts with pat ients to fur ther nor- malize this p h e n o m e n o n .

Learn ing that unwanted thoughts are a c o m m o n phe- n o m e n o n , ra ther than the p roduc t of an " inherent ly evil person ' s mind," often comes as a re l ief to patients, who can then begin to see their p rob lem (and themselves) as much less threatening. From this in format ion abou t nor- mative funct ioning it follows that reduc ing the f requency and intensity of obsessions and the distress they cause, ra ther than e l iminat ing unwanted thoughts altogether, is the goal of EX/RP. This knowledge might also he lp pa- tients to refrain f rom neutral iz ing behaviors (e.g., com- pulsions, avoidance) that paradoxical ly mainta in distress associated with obsessions.

The Thought Suppression Paradox Being terr if ied of thei r intrusive, upset t ing thoughts

and ideas, OCD patients often develop habits of a t tempt- ing to force unwanted thoughts out of their mind, a pro- cess known as thought suppression. However, research suggests that trying to suppress thoughts (under some circumstances) results in an increase in the f requency of that thought (for a review, see Abramowitz, Tolin, & Street, 2001). For patients who are unaware of this para- doxical effect of thought suppression, the inabili ty to sup- press may be ext remely scary, leading to fur ther maladap- tive beliefs (e.g., "My mind is out of control ," "Maybe I want it to happen") that main ta in mis in terpre ta t ions of intrusive thoughts.

For the therapist , it may be useful to discuss the nega- tive effects of suppression a t tempts with patients. One helpful way of demons t ra t ing this pa radox is to engage the pa t ien t in the following br ie f exper iment :

"I'd like you to try not to th ink of a p ink e l ephan t for three minutes. You can th ink of anything else you want, bu t whatever you do , ju s t don ' t th ink of a p ink e lephant . Okay? Start when I tell you to, and raise your hand if you h a p p e n to th ink of a p ink e l e p h a n t . . . "

Invariably, the pat ient will have pink e lephant thoughts and admit that it is impossible to suppress them fully (the authors have never had this expe r imen t fail!). Fol lowing the exper iment , the pa t ien t can be asked about how this p h e n o m e n o n applies to their OCD symptoms. Such a dis- cussion should focus on how thought suppression attempts are unnecessary because thoughts are not inherently dan- gerous. However, attempts to suppress are d o o m e d to fail

16 Abramowitz et al.

and the re fo re exace rba te feel ings that the d r e a d e d thoughts are uncont ro l lab le , repetit ive, or the sign of a dangerous or perver ted mind. In addi t ion, it is impor t an t to po in t out that the more effort the pat ient puts into trying to cont ro l or suppress, the more the unwanted thoughts will come up. Giving extra a t tent ion to such thoughts also s t reng thens the be l ie f that the thoughts are threatening: After all, why else would someone go th rough the t rouble to try to dismiss thei r thoughts?

The exercise descr ibed above, and the knowledge that intrusive thoughts occur normal ly and are not danger- ous, leads nicely into present ing a cohe ren t ra t ionale for imaginal exposure. In imaginal exposure, patients are in- s t ructed to purposely conf ront their unwanted thoughts by e labora t ing on them in o rde r to weaken the connec- tions between such thoughts and anxiety. Indeed, these thoughts themselves are not harmful and the associated anxiety will dissipate with r epea ted practice, especially as the feared consequences cont inual ly fail to occur in real- ity. We often use metaphors , such as the following, for imaginal exposure: Imaginal exposure is very much like weight t ra ining for athletes. Both require comple t ion of exercises that are above and beyond what one might en- coun te r on the playing field or in real life, such as lifting large barbells in the case of the baseball player, or elabo- ra t ing on a scenario in which con tamina t ion leads to seri- ous harm for the OCD patient . At the same time, comple- tion of these difficult exercises invariably s t rengthens the a t h l e t e / p a t i e n t to do what needs to be done and in- creases the chances of a positive outcome. For the athlete it is running , batt ing, etc., and for the OCD pat ient it is al- lowing the spontaneous intrusions to l inger while simul- taneously refra ining f rom any neutral iz ing behavior.

Thought-Action Fusion Patients with OCD often make errors in the ways they

appraise unwanted (but harmless) obsessional thoughts. The cognitive theory of emot iona l d isorders (e.g., Beck, Rush, Shaw, & Emery, 1979) posits that these errors lead to the ex t reme distress associated with the thoughts and the urges to ritualize, avoid, or thought-suppress to es- cape from distress. A specific logical e r ror that is often observable in people with OCD is thought-action fusion (TAF). First descr ibed by Shafran, Thordarson , and Rachman, (1996), TAF refers to the mistaken bel ief that thoughts are equivalent to actions. Indeed, if a person with OCD believes that her thoughts about yelling curse words in church are the moral equivalent of actually do ing so, she will init iate efforts to dismiss or neutral ize this thought . Similarly, if a man with intrusive unwanted thoughts of hur t ing his child believes that having such thoughts will increase the probabi l i ty that he will take such action, he will be likely to employ similar ritualistic or avoidance be- haviors. A goal of E X / R P is to demons t ra te that thoughts

(even dis turbing and repeti t ive ones) do not pose realis- tic threat. That is, th inking about someth ing is a pure ly menta l event, which, alone, can not directly cause some- th ing bad to h a p p e n in the world.

A discussion of the TAF fallacy is often useful in iden- tifying and beg inn ing to modify this mistake in affected patients. For example , Gordon was a col lege-aged pa t ien t who had unwanted thoughts about s tabbing others. He avoided using knives a r o u n d o ther people and became convinced that it was only a mat te r of t ime before he lost control and s tabbed his best friends. As is the case with many OCD patients with aggressive obsessions, Gordon was a gent le young man who had no history of violence of any kind. To help Gordon identify this TAF mistake, he was asked to th ink very ha rd abou t s tanding up out of his chair while trying to remain seated. Gordon was in- s tructed to visualize s tanding up, pray about standing, and even say out loud, "I want to stand up." Of course, Gordon d id not s tand up dur ing the exper iment . This ex- ercise can be used to il lustrate how people have to con- sciously decide to act, and that their thoughts do not auto- matically translate to impulsively engaging in i m p r o p e r behaviors. This (and o the r similar exercises) often pro- vides a robust demons t ra t ion of the logical error, and pa- tients frequently feel more willing to engage in E X / R P exercises that help to modify dysfunctional beliefs about the relat ionship between unwanted thoughts and actions. Gordon , himself, genera ted a part icularly useful expo- sure that he carr ied out successfully: using a knife while purposely th inking about s tabbing the person sitting next to him.

Sometimes, OCD patients r epor t fears that they will be responsible for someth ing terr ible occurr ing (e.g., an ac- cident) simply because they had a thought about such an occurrence. One patient, Norah, feared that her thoughts of he r husband dying in a p lane crash would increase the l ike l ihood of such a tragedy. Norah found herself having such terrifying ideas whenever he r husband traveled, and would spend hours paralyzed, engaged in at tempts to neutral ize the thoughts (i.e., "canceling them out" in he r mind) and praying that such an accident would not occur. She also t racked the progress of he r husband 's p lane on the World Wide Web, and p h o n e d the des t ina t ion re- peatedly to be sure he had arrived safely. On quest ioning, Norah stated that she felt "responsible for having bad thoughts about the plane."

In addi t ion to a discussion about the normalcy of in- trusive upset t ing thoughts, Norah was asked to conduc t a br ie f expe r imen t in the session that inc luded looking out the window and purposely th inking about specific cars on the road crashing. At one point , a pedes t r ian crossed the street and Norah, with the therapist , wished for this indi- vidual to be struck (fortunately, these mishaps d id not occur!). This demonst ra t ion nicely illustrated the mistake

Treatment of OCD 17

she was making and fur ther o p e n e d the doo r to working on this p rob l em using more difficult exposure exercises.

As with many patients, Norah could th ink about acci- dents to strangers fairly easily; yet when she was asked to th ink about he r husband, the task el ici ted high levels of anxiety. In fact, she r e sponded to the idea by asking why she would ever want to purposely th ink of such a thing. Often patients resist exposure exercises that seem (to them) riskier than what "normal people" would do. In this case, the therapis t should po in t out that the treat- men t exercises are not des igned on the basis of what most people would do, bu t ins tead (as we describe above) are designed to weaken unrealist ic beliefs about danger a n d connect ions between harmless thoughts and anxiety. The tendency for patients with OCD to show TAF in some specific si tuations but not others is f requent ly observed a n d speaks volumes about the na ture of this condi t ion. Indeed , patients should be made aware of the fact that they are willing and able to use good logic in certain situ- at ions but no t in others.

I n t o l e r a n c e f o r U n c e r t a i n t y

Anothe r logical e r ror p resen t in OCD is the intoler- ance for uncertainty. Indeed, some compulsive rituals can

be conceptua l ized as a t tempts to gain 100% certainty in feared situations. Cons ider the woman who washes he r l aundry three times fear ing that the first two washes d o n ' t remove all of the germs, or the man who rereads his let- ters (even open ing sealed envelopes) over and over to be complete ly cer tain he d id not write anything obscene by mistake. It is as if pat ients believe that in the absence of absolute certainty, dange r or ha rm is likely (in contrast, most peop le assume a si tuation is safe in the absence of clear danger cues). Interestingly, this bias is only appl ied in certain situations: those that are OCD-relevant. This p h e n o m e n o n can be i l lustrated for pat ients using a br ie f demons t ra t ion . We often ask pat ients who struggle with uncer ta in ty to tell us whether or not their spouse or par- en t (known to be living) is alive at that very moment . In most instances (even if the pa t ien t has obsessional fears of relatives dying), pat ients automatical ly respond, "Of course they ' re alive." The therapis t then asks the more difficult quest ion, "How do you know for sure?" Patients explain that they don ' t know f o r sure, but they assume

things are okay unless they find out otherwise. Thus, a l though pat ients have the ability to tolerate un-

certainty when it comes to thoughts of some tragedies, they have difficulty do ing so in OCD-relevant situations, part icularly when the uncer ta in ty is cued by intrusive ob- sessional doubts. It remains unc lear as to whether prob- lems with uncer ta in ty are a cause or effect of anxiety or fear. However, the p h e n o m e n o n can be used therapeut i - cally to po in t out how this mistake serves to mainta in OCD symptoms in terms of urges to pe r fo rm compulsive

rituals in o rder to obtain reassurance. A discussion of how the p rocedures of E X / R P are des igned to he lp pat ients feel more comfor table with uncertainty, and less like they need comple te reassurance of safety (as they are able to do in non-OCD-rela ted situations), is useful in "selling" the cognit ive-behavioral mode l of OCD and rat ionale for t rea tment .

Psychoeducat ional p rocedures such as those elabo- ra ted u p o n above can be used at all points dur ing EX/RP. Dur ing the informat ion-ga ther ing phase it is often help- ful to identify and discuss how logical mistakes are re la ted to OCD symptoms, and explain how E X / R P can be help- ful in modifying these cognitive errors. This may serve to normal ize the symptoms and allow the pa t ien t to recog- nize that the therapis t unders tands this seemingly "crazy" or "bizarre" problem. We inform patients that E X / R P re- quires an unde r s t and ing the symptoms of OCD and the condi t ions that mainta in those symptoms, ra ther than an under s t and ing of the initial causes the disorder. Thus, these psychoeducat ional discussions also serve to rein- force this focus.

Awareness of the cognitive biases discussed above also helps the pa t ien t identify when the errors are occur r ing a n d how influential they can be. Fur the rmore , present- ing these concepts in a way that is consis tent with the ra- t i o n a l e for E X / R P allows the pa t ien t to see how the treat- men t procedures can be used to modify these maladaptive strategies. Ano the r excel lent t ime to re i terate psychoedu- cational informat ion is dur ing exposure exercises while the pa t ien t is conf ront ing feared situations and experi- encing obsessional thoughts. Here, such discussions can be used to re inforce new and more funct ional me thods of hand l ing obsessional doubts and fear-evoking situa- tions. However, it is impor t an t that such psychoeduca- t ional efforts are not used to reassure the pa t ien t of safety. Indeed , the issue of providing reassurance often arises when working with OCD patients, and therefore it is dis- cussed below.

P r o v i d i n g R e a s s u r a n c e i n E X / R P

Cognitive-behavioral conceptual izat ions of OCD view compulsive rituals as providing escape f rom anxiety or distress, thereby serving to mainta in connec t ions be- tween obsessional stimuli and distress. In many cases, the distress is associated with doubts and uncer ta in ty over whe ther or no t a d r e a de d outcome will occur (e.g., "Will I get sick?" "Will it cause a fire?"). In large part , a goal of E X / R P is to teach peop le with OCD to become more comfor table with an acceptable level of uncertainty. This need for a guarantee and the to lerance for uncer ta in ty seem to vary across pat ients with OCD. Some pat ients recognize thei r excessive doub t ing a n d are willing to at- t empt to tolerate no t knowing for sure about obsessionally

18 Abramowitz et al.

feared outcomes. The ability to complete ly abstain from compulsive rituals is often a good indica tor of this impor- tant at tr ibute. Othe r patients, however, may have an ex- t raordinar i ly difficult t ime not be ing reassured of safety. The persis tence of rituals such as subtle checking, and not-so-subtle question-asking, is often a sign of high levels of in to lerance for uncertainty.

To illustrate, we descr ibe the part icularly severe case of Joe, who had fears of con tamina t ion f rom pesticides. When p lann ing confronta t ion with places that had been sprayed with pes t ic ides ,Joe insisted that he and the ther- apist meet with an exper t on pesticides to define what is a safe level of exposure. I n d e e d , J o e r epor t ed having previ- ously sought such informat ion, but said that he was unsat- isfied with the qualifications of the five o ther pest icide "experts" he had interviewed. Th roughou t t reatment , Joe wrote copious notes about each fear-evoking situation that arose between sessions (e.g., hear ing someth ing that sounded like someone spraying pesticides) and how he hand led it. Dur ing exposure exercises, Joe asked fie- quently for assurances from the therapist (e.g., "Are you sure this is safe?" "Would you ho ld your baby or eat with- out washing your hands after doing this?") and a t tempted to engage in more subtle forms of reassurance seeking such as pe r fo rming crude risk analyses and trying to re- call the pe rcen t of bug spray (parts per 100) that contains the active ingredient .

Just like pe r fo rming more classic rituals such as wash- ing and checking, these forms of reassurance seeking in- terfere with progress in E X / R P because they prevent di- rect exposure to the actual feared situation, which involves be ing uncer ta in about the consequences. Patients with OCD must learn to reduce their fears of uncer ta inty and urges for a t ta ining certainty. Thus, a t tempts to gain reas- surance are funct ional ly equivalent to compulsive rituals and should be e l iminated. Howevm, excessive reassur- ance seeking must be hand led with caut ion because mis- communica t ions can derai l therapy. Below we descr ibe some useful ways to address these problems.

Appeals to Authority It is most consistent with the principles of EX/RP for

pat ients to engage in exposure exercises without having to check with "experts" about the safety of such tasks. Un- necessary reassurances of safety impinge on the match between the pat ient ' s fear and the exposure situation and reinforce the (excessive) need for such an op in ion in everyday life (which is not practical) . Requests for such a consul ta t ion should be cons idered and discussed in light of whether or not they will be helpful for moving the pa- t ient toward overcoming their need for certainty. In some instances, it may be useful to allow a single consul ta t ion visit with an expert , for example , if do ing so would pre- vent the pat ient from d r o p p i n g out of t reatment . How-

ever, the therapist should supervise such a consul ta t ion to ensure that excessive ri tualizing does not take place. Fur- thermore , the pa t ien t should agree to ask only b road questions about risk since the goal of such a consul ta t ion is to establish guidel ines about safety, not to inquire about every possible si tuation that may arise. Such ques- tions should be agreed upon pr ior to the mee t ing with the expert , because pat ients will often want to inquire about specific feared situations. If possible, this should be prevented and pat ients should instead be taught that learn ing the ability to apply j u d g m e n t about risk ( ra ther than know for sure about the probabi l i ty of harm) in spe- cific feared situations is a must for overcoming OCD. The t rea tment of pat ients with scrupulosity (religious OCD symptoms) often necessitates consul ta t ion with a reli- gious authori ty to establish boundar ies about what is and what is not religious sin (Abramowitz, 2001).

Asking for Reassurance During Exposure As we discussed above, the goal of E X / R P is to reduce

the need for absolute certainty without having to resort to reassurance-seeking rituals. However, some patients are part icularly persis tent at ques t ioning the therapis t to ti T to gain assurance of safety, and have difficulty resisting this behavior even dur ing exposure exercises. In such in- stances, the first incl inat ion may be to ease patients with guarantees that they are not in any danger. However, this u n d e r m i n e s the goal of t each ing pa t ien ts to live with acceptable levels of risk and uncertainty. On the o ther hand, it is not necessary to try to convince pat ients that they are indeed put t ing themselves at high risk for nega- tive consequences. The most preferable response uses a compass iona te approach , focusing on how exposures are des igned to evoke uncertainty. It is of ten useful to explain to patients that a l though exposure exercises present low risk, there can never truly be an absolute guar- antee of safety.

The occasional pat ient will persistently ask the same questions again and again (perhaps in different ways), because they are reassured by hear ing the therapis t say that the risk of harm is low. This is an instance in which clinical j u d g m e n t is n e e d e d to assess whether the func- tion of the quest ioning truly is assurance seeking. A gen- eral rule to keep in mind is that quest ions about risk in a given situation should be answered only once. Addi t ional a t tempts to gain assurance should be po in ted out to the pat ient and addressed in an empath ic way, such as:

"It sounds like you ' re feeling uncomfor tab le and are searching for that guarantee r ight n o w - - a n d that 's your obsessional doubt ing. Since I a l ready answered that question, it would not be helpful for you if I answered it again. The best way to stop the obsessional doubts is for you to work on tolerat ing

Treatment of OCD ! 9

the distress and u n c e r t a i n t y . . . How can I he lp you to do that?"

Assurance seeking can also be more subtle, such as a pat ient ' s making a s ta tement about a homework expo- sure they are p lann ing ("Now that we've touched the trash bin, I 'm going to go home and play with my 2-year- old") and then scrutinizing the therapist 's facial expres- sion for signs of concern. In such instances the therapis t should make inquiry of the pa t ien t as to whether the s ta tement const i tuted assurance seeking, and then revisit the ra t ionale for not providing such assurances.

The authors have unfor tunate ly worked with some in- dividuals who were complete ly unable (or unwilling) to resist persis tent reassurance-seeking behavior in and be- tween sessions. Because fail ing to refrain f rom seeking assurance in terferes p ro found ly with E X / R P ( indeed, it is equivalent to refusing to abstain f rom any o ther rituals) and inevitably compromises ou tcome, therapy had to be suspended in these cases. As addressed in t r ea tment man- uals, suspension is the last resor t when pat ients refuse to comply with t reatment procedures. If this opt ion is chosen, it is impor tant to convey in the most sensitive and caring way why the therapis t r e c o m m e n d s d iscont inuat ion of t r ea tment at p resen t (i.e., because the pa t ien t is unable to carry out the t rea tment p rocedures in ways that would be beneficial) and what alternatives might be available.

"Programmed" vs. "Lifestyle" Exposure

Practicing in-session (therapist-supervised) exposure and carrying out exposure homework assignments are core features of most E X / R P programs. However, comple t ing only these prescr ibed assignments is no t sufficient: Imme- diate and long-term improvemen t requires consistent exposure practice across a variety of situations in o rde r to p romote general izat ion of learning. Whereas patients usually grasp the not ion of ri tual prevent ion as mean ing abst inence f rom compulsive rituals, it is not always as clear to them that they must also pract ice "avoidance pre- vention." Some patients comple te thei r assigned expo- sures and then p roceed to use avoidance strategies be- tween assignments, effectively d is regarding the purpose of exposure in the first place. Don, for example , com- p le ted 2 hours of assigned exposure in which he he ld his shoes in his lap, but then took precaut ions to avoid touching his pants because they had been in contact with his shoes! Not surprisingly, Don's anxiety about shoes re- ma ined high despi te his rel iable comple t ion of exposure and his refraining f rom rituals. Along with continual ly curtai l ing rituals, pat ients should be encouraged to en- gage in cont inual self-guided exposure. We suggest that pat ients th ink of E X / R P as lea rn ing a new lifestyle that is conducive to gaining control over, ra ther than be ing con- t rol led by, OCD.

In our t rea tment p rog ram we have found that distin- guishing between two categories of therapeut ic exposure helps patients to practice appropr ia te responses to anxiety- evoking situations that arise between sessions. When treat- men t p rocedures are discussed with patients, we descr ibe "p rogrammed" exposure as the systematic assignments that are prescr ibed by the therapis t for comple t ion within or between sessions. These are usually writ ten on home- work forms given to pat ients on which to record ratings of subjective anxiety (SUDs) dur ing the exercise. "Life- style" exposure, on the o the r hand, is descr ibed as mak- ing choices to take advantage of all possible oppor tuni t ies to practice the new ways of responding (i.e., confront ing ra ther than avoiding). Patients are encouraged to be op- portunist ic and view potent ial ly anxiety-evoking situa- tions not as something to be avoided or e ndu re d with great distress, but instead as occasions to practice EX/RP and work on fur ther reduc ing OCD symptoms. To this end, we emphasize the choices that patients have to e i ther conf ront or avoid, and that each t ime an anxiety-evoking si tuat ion is c on f ron t e d wi thout avoidance o r ri tualist ic behavior, OCD is be ing weakened. Alternatively, each t ime a decision is made to avoid a potent ia l lifestyle expo- sure situation, the OCD symptoms may be s t rengthened.

Whereas the concep t of lifestyle exposure is usually helpful, it is somet imes too much to expect that pat ients will con f ron t all OCD-relevant s i tuat ions f rom the start of therapy. Indeed , unti l the pa t ien t has comple t ed pro- g r a m m e d exposure to the most difficult i tems on the stimulus hierarchy, pat ients may not be part icular ly suc- cessful with lifestyle exposure to these items. If pat ients raise this issue, therapists should be flexible by encourag- ing exposure a t tempts in the "spirit" of t rea tment , while under s t and ing that confronta t ion with more difficult sit- uat ions may at first be avoided. Indeed , if such lifestyle exposure to the most difficult si tuations has a l ike l ihood of result ing in excessive ritualizing, the therapis t may cons ider proscr ib ing activities that could lead to such nat- uralistic exposures until the pa t ien t has had success with p r o g r a m m e d exposure to the relevant situations. The purpose of such temporary avoidance of the most diffi- cult i tems is to minimize violations of response preven- tion and prevent fur ther s t rengthening of existing rituals. As suggested by Kozak and Foa (1997), a collaborat ive t rea tment plan that involves a (flexible) session-by-session list of exposure situations can be used to de t e rmine when more difficult situations will be confronted . As we will see below, an analogous si tuation requi r ing flexibility also exists with imp lemen t ing ritual prevent ion.

Implementing Ritual Prevention

Dismant l ing studies of E X / R P have f o u n d that in combina t ion with exposure, patients must curtail their

20 Abramowitz et al.

compulsive r i tualizing in o rde r to achieve max imum short- and long-term benefit . In fact, there is a degree of specificity between the t rea tment componen t s and OCD symptoms, with exposure result ing in a greater reduct ion of obsessional anxiety and ritual prevent ion result ing in a greater reduct ion in time spent ritualizing (Foa, Steketee, & Milby, 1980). However, the co r re spondence between the exposure and ritual prevent ion e lements of treat- men t with anxiety and t ime spent r i tualizing is not per- fect, in that exposure alone can result in some reduct ion in compuls ions and ritual prevent ion can result in some anxiety reduct ion. A meta-analysis also found that EX/RP programs incorpora t ing complete ritual abst inence pro- duced be t te r outcomes than d id those employing partial ritual prevent ion (Abramowitz, 1996). Thus, ritual pre- vent ion is a critically impor tan t c o m p o n e n t of EX/RP and the ra t ionale for this p rocedure should be p resen ted to the pat ient very early and re i tera ted th roughou t the course of therapy. The rat ionale provided should empha- size that this p rocedu re helps patients to learn that the ant ic ipated negative consequences of exposure do not occur, leading to the realization that one does not need to ritualize to pro tec t themselves or others from danger. Kozak and Foa (1997) suggest the use of self-monitoring forms on which pat ients record any violations of ritual prevent ion instructions.

However, the implemen ta t ion of ritual prevent ion is not always straightforward, and thus is sometimes misun- ders tood. Because it is general ly self-governed (i.e., con- duc ted by the pa t ien t between sessions), pe rsuad ing the cl ient to choose no t to ritualize is a necessary first step for good outcomes and underscores the need to have pa- tients set a goal of complete , as opposed to only partial, ritual abst inence. Indeed , experts suggest that part ial rit- ual prevent ion is a fairly c o m m o n p rob lem in t rea tment and, as indica ted above, a potential ly serious i m p e d i m e n t to good outcome (Kozak & Foa, 1997). Therapists are encouraged to r e m i n d patients of the impor t an t role of refraining from rituals, but also caut ion them against ex- cessive self-criticism founded on unrealist ic perfect ion- ism as at least some violations of response prevent ion are b o u n d to occur. In such instances, patients should be taught to counter the occasional r i tualizing with inten- t ional re-exposure or take some o ther measure to "spoil" the ritual. Gordon , for example , f requent ly engaged in the ritual of saying or th inking "God forbid" in o rde r to prevent terr ible things from h a p p e n i n g to friends or fam- ily. Because this ri tual was so quick, easy to perform, and socially acceptable , it was difficult for Gordon to consis- tently refrain from engaging in it. He was, however, able to recognize when it happened and then spoil it by counter- thinking "God willing" the terrible event should happen.

Given the re la t ionship between ritual prevent ion and eventual reduct ion of the frequency and intensity of OCD

symptoms, it would seem impor t an t to encourage pa- tients to target comple te abst inence early on in treat- ment. At times, however, this goal may be inconsis tent with that of systematic, g raded exposure using a hierar- chy. Indeed, pat ients may have chance encounte rs with f r ightening stimuli, which evoke high urges to ritualize, but which have not yet been pract iced in session. A re- lated difficulty is that pat ients could become demora l i zed if they feel overwhelmed, or think that they cannot achieve comple te ritual abst inence immediately. An alternative to full r i tual prevent ion is a graded approach in which ritual prevent ion instructions paral lel the progress up the ex- posure hierarchy, with the goal be ing comple te ri tual ab- s t inence midway into t reatment . Below, we illustrate the use of this app roach for a pat ient with severe washing and c leaning rituals who likely would have d iscont inued treat- men t had the therap is t insisted u p o n comple t e r i tual prevent ion from the start of therapy, as descr ibed in the t rea tment manual (Kozak & Foa, 1997).

Lori was contaminat ion-fearful , had clinically signifi- cant OCD since high school, and had expe r i enced a gradual worsening of he r symptoms over the last 5 years such that he r general funct ioning was largely impaired , especially in nonwork domains. To make matters worse, Lori worked in a medical context in which hand washing between patients was required , and she had ready access to Betadine, an abrasive cleanser that she used with great f requency both at home and at work. She managed to funct ion at work by wearing tr iple gloves, which went un- chal lenged by coworkers. Unlike most OCD patients with con tamina t ion fears who worry about con tamina t ion from the environment , the source of con tamina t ion was herself: Lori feared con tamina t ing others with he r "nega- tive essence" that was especially concen t ra t ed in the lower half of her body. As a medical professional she rec- ognized that this concern was illogical and unfounded , yet she was so fearful of the possibility of ha rming others that she was entirely unwilling to take such a risk. The ex- tent of avoidance and rituals was remarkable : At intake Lori r epo r t ed that she had not touched the lower half of he r body in 5 years without some sort of bar r ie r (e.g., glove) to prevent direct contact with he r skin.

When the ra t ionale for voluntary ri tual abst inence was presented in the first t r ea tment session, Lori immedia te ly burst into tears, saying, "There 's jus t no way I can possibly do that." The therapis t assured her that many peop le feel this way before beg inn ing the therapy and that gradual exposure to feared situations and thoughts would allow for t i tration of anxiety; yet this informat ion was only mildly helpful. Lori correctly po in ted out that once her use of barr iers was e l iminated, comple te f looding would ensue and she would then have to wipe herself after uri- na t ing and defecating, scratch itches, and dress herself without any pro tec t ion against con tamina t ing the u p p e r

Treatment of OCD 21

half of he r body and then con tamina t ing o the r people . Addi t ional discussion with the therapis t fur ther under- scored the distance between her cur ren t funct ioning and the des i red ri tual abst inence. Even at home, she was using abrasive cleaners, t r iple gloves, and engaging in an extensive laundry ri tual that r educed her fears of becom- ing con tamina ted by the lower half of he r body and spreading con tamina t ion with he r hands.

The therapis t bel ieved that this pa t ien t was correct in he r assessment and would be unable to negot ia te this dra- matic ad jus tment in he r r i tual ized rout ine without be- coming overwhelmed. Thus, a revised ri tual prevent ion plan was contrived. Accord ing to this plan, she would e l iminate the th i rd set of gloves in the home environ- m e n t after the first session and e l iminate the second pair of gloves at home and the th i rd set of gloves at work after session two. Gradual removal of rituals and avoidance would cont inue unti l she was wearing no gloves and do ing no washing in he r home or work environment . Ad- ditionally, it was acceptable for Lori to use single gloves after defecat ing and ur ina t ing until such t ime that these items were conf ron ted on the stimulus hierarchy. Only after she had virtually re f ra ined f rom rituals for two con- secutive days were exposures to directly contac t ing skin on the lower half of he r body implemented .

The gradual nature of the ri tual prevent ion schedule would delay accidental exposures to i tems at the top of the s t imulus hierarchy, which the p r o t o c o l suggests should be conf ron ted at the end of the first week of daily therapist-assisted EX/RP. This is to ensure sufficient prac- tice with these most difficult i tems within the 3Vz-week t ime frame of the t r ea tment protocol . Again, ra ther than be ing a hard-and-fast rule that must be h e e d e d regardless of circumstance, the stated goal of reach ing the top of the hierarchy by the end of the first week is der ived f rom the genera l pr inc ip le of leaving sufficient t ime and op- por tun i ty for hab i tua t ion and cognit ive change. This gradual ri tual prevent ion d id necessitate a delay in reach- ing this highest i tem and requ i red addi t ional homework assignments in the final week to ensure habi tua t ion be- fore the end of the t reatment . On the o the r hand, it was inconceivable to the pa t ien t (and to the therapist) how the top of the h ierarchy could possibly have been ad- dressed any ear l ie r given the severity of the pa t ien t ' s symptoms. At the end of t rea tment , Lori told the thera- pist that she was p r e p a r e d to d rop out of E X / R P after the first session upon hear ing about the goal of comple te and immedia te ritual abst inence, and had come to the second session only as a courtesy. Upon hear ing that this treat- men t goal could indeed be shifted, she engaged fully in the t reatment : She was highly compl ian t with in-session exposure, comple t ed exposure homework faithfully, and was di l igent in he r adhe r ing to the revised ri tual preven- t ion program.

C o n c l u s i o n

We have a t t empted to h ighl ight several issues that may conf ront therapists who are conduc t ing E X / R P using re- cent t r ea tment manuals on the topic (e.g., Kozak & Foa, 1997). O u r aim is to assist therapists in flexibly applying these t r ea tment p rocedures to fit the needs of individual patients. We chose to focus first on psychoeducat ion for OCD, as we believe that the pat ient ' s unde r s t and ing of the theoret ical founda t ion for the t r ea tment sets the stage for good outcome. We then shifted to several spe- cific p rob lems often encoun te r ed in clinical practice, yet se ldom discussed in detail in t rea tment manuals. These include curtai l ing assurance seeking, encourag ing pa- tients to take advantage of spontaneous oppor tun i t ies to pu t the t rea tment pr inciples into practice, and dec id ing when and how to adjust r i tual prevent ion instruct ions with severely ill patients.

However, the topics we addressed are by no means ex- haustive. There are countless o the r issues that arise in the t rea tment of OCD that may requi re tai lor ing of manual- ized t r ea tment procedures , exercise of sound clinical j u d g m e n t on a case-by-case basis, and an openness to learn ing "on the fly" from patients we interact with. The t rea tment of OCD will be ref ined and improved with ex- pe r imen ta t ion using novel approaches to present ing and imp lemen t ing EX/RP. Indeed , more recen t t r ea tment manuals (e.g., Steketee, 1998) advocate the use of cogni- tive therapy p rocedures not explicitly descr ibed in previ- ous E X / R P protocols. Research examin ing the efficacy of these newly deve loped and promis ing p rocedures is cur- rently u n d e r way. Thus, we highly encourage fur ther clin- ical case reports i l lustrating useful techniques for imple- men t ing E X / R P that may not be descr ibed in the existing t rea tment manuals.

R e f e r e n c e s

Abramowitz, J. s. (1996). Variants of exposure and response preven- tion in the treatment of obsessive-compulsive disorder: A meta- analysis. Behavior Therapy, 27, 583-600.

Abramowitz,J. S. (2001). Treatment of scrupulous obsessions and com- pulsions using exposure and response prevention: A case report. Cognitive and Behavioral Practice, 8, 79-85.

Abramowitz, J. S., Franklin, M. E., Zoellner, L. A., & DiBernardo, C. (2002). Treatment compliance and outcome in obsessive compul- sive disorder. Behavior Modification, 26, 447-463.

Abramowitz,J. S., Tolin, D. E, & Street G. P. (2001). Paradoxical effects of thought suppression: A meta-analysis of controlled studies. Clinical Psychology Review, 21, 683-703.

Chambless, D. L., Baker, M.J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., Daiuto, A., DeReubis, R., Detweiler, J., Haaga, D. A. E, Johnson, S. B., McCurry, S., Mueser, IL T., Pope, I~ S., Sanderson, W. C., Shoham, V., Stickle, T., Williams, D. A., & Wooddy, S. R. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.

Beck, A. T., Rush, A.J., Shaw, B. E, & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Foa, E. B., & Kozak, M.J. (1996). Psychological treatments for obsessive-

2 2 H e m b r e e e t al.

compulsive disorder. In M. R. Mavissakalian & R. E Prien (Eds.), Long-term treatments of anxiety disorders (pp. 285-309). Washington, DC: American Psychiatric Press.

Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for post- traumatic stress disorder: A critical reviev~: Annual Review of Ps~v- chology, 48, 449-480.

Foa, E. B., Steketee, G., & Milby, J. B. (1980). Differential effects of exposure and response prevention in obsessive-compulsive washers. Journal of Consulting and Clinical Psychology, 48, 7 1-79.

Franklin, M. E., Abramowitz, J. S., Kozak, M.J., Levitt. J., & Foa, E. B. (2000). Effectiveness of exposure and ritual prevention far obsessive compulsive disorder: Randomized compared with non-randomized samples. Journal of Consulting and Clinical Psycholo~, 68, 594-602.

Greist, J. H. (2000). Effective behavioral therapy constrained: Dissem- ination is the issue. In M. Maj, N. Sartorius, A. Osasha, &J. Zohar (Eds.), WPA Series Evidence and Experience in Psychiat~ (Volume 4): Obsessive-compulsive disorder (pp. 116-118). West Sussex, U.K.: John Wiley & Sons.

Kozak, M.J., & Foa, E. B. (1997). Master), ofobsessi~,e-compulsive disorder: A eoKnitive-hehavioral approach (therapist guide). San Antonio, TX: Psychological Corporation.

Lindsay, M., Crino, R., & Andrews, G. (1997). Controlled trial of expo- sure and response prevention in obsessive-compulsive disorder. Bdtish Journal of Ps'fchiatry, 171. 135-139.

Meyer, V. (1966). Modification of expectations in cases with obses- sional rituals. Behaviour Research and Therapy, 4, 273-280.

Meyer, V., & Lew, R. (1973). Modification of behavior in obsessive- compulsive disorders. In H. E. Adams & P. Unikel (Eds.), Issues and trends in behaviorttwrapy (pp. 77-136). Springfield, IL: Charles C. Thomas.

Rachman, S., & de Silva, E (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233-248.

Salkovskis, E, & Harrison,J. (1984). Abnormal and normal obsessions: A replication. Behaviour Research and Therapy, 22, 549-552.

Shaft-an. R., Throdarson, D., & Rachman, S. (1996). Thought action fusion in obsessive-compulsive disordei: Journal of Anxiety Disor- ders, 10, 379-391.

Steketee, G. S. (1998). Overcoming obsessive-compulsive disorder." A behav- ioral and cognitive protocol for the treatment of OCD (therapist protocol). Oakland, CA: New Harbinger:

Address correspondence to Jonathan S. Abramowitz, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: abramowitz.jonathan@ mayo.edu.

Received: June 1, 2001 Accepted: November 13, 2001

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Beyond the Manual: The Insider's Guide to Prolonged Exposure Therapy for PTSD

E l i z a b e t h A. H e m b r e e , S h e i l a A. M. R a u c h , a n d E d n a B. F o a , University o f Pennsy lvan ia

Prolonged Exposure therapy (PE; Foa & Rothbaum, 1998) has strong empirical support for its efficacy in reducing trauma-related psychopathology in individuals with chronic PTSD (Rothbaum, Meadows, Resick, & Foy, 2000). In the process of providing PE to man~, clients and in training therapists in a variety of settings in its use, we at the Center for the Treatment and Study of Anxiety have amassed extensive experience with this therapy. This article extends the treatment guidelines provided in the PE treatment man- ual by sharing the knowledge and wisdom that years of experience have brought us. We emphasize the importance of fo~ging a strong therapeutic alliance and providing a thorough rationale for treatment, discuss wa~s to implement in-vivo and imaginal exposure so as to promote effective emotional engagement with traumatic memories, and conclude with some recommendations for how therapists who conduct PE for PTSD can take care of themselves while delivering a therapy that is very ren,arding and, at times, emotionally challe,¢ging.

S EVERAL cogni t ive-behaviora l therap ies (CBT) have

demons t r a t ed efficacy for the t rea tment o f P T S D - - f o r

example , P ro longed Exposure (PE), Cognit ive Processing

The rapy (CPT) , and Stress I n o c u l a t i o n Tra in ing (SIT; for

reviews see Foa & R o t h b a u m , 1998; R o t h b a u m , Meadows,

Resick, & Foy, 2000). PE, which involves r e p e a t e d imagi-

nal e x p o s u r e to the t r aumat ic m e m o r y ( t r auma rel iving) and r e p e a t e d in-vivO exposure to safe situations that are

avoided , has b e e n o n e o f the mos t inves t iga ted treat-

C o g n i t i v e a n d B e h a v i o r a l P r a c t i c e 1 0 , 2 2 - 3 0 , 2 0 0 3

1077-7229/03/22-3051.00/0 Copyright © 2003 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

men t s for PTSD. Its efficacy has b e e n d e m o n s t r a t e d with

a wide r ange o f popu la t ions , i n c l u d i n g f ema le sexual as-

sault survivors (Foa, R o t h b a u m , Riggs, & Murdock , 1991;

Foa et al., 1999), ma le c o m b a t ve te rans (e.g., Keane , Fair-

bank, Caddel l , & Zimer l ing , 1989), and m i x e d g e n d e r

samples exposed to a variety o f t r aumat ic e x p e r i e n c e s

(Devilly & Spence , 1999).

S o m e studies suggest that PE may e i t he r be m o r e effi-

cacious o r m o r e ef f ic ient than a l te rna t ive t r ea tmen t s fo r

PTSD. Foa et al. (1999) c o m p a r e d PE to SIT (anxiety-

m a n a g e m e n t t r a in ing focused on p o s t t r a u m a reac t ions)

and the i r c o m b i n a t i o n ( P E / S I T ) . T h e SIT t r e a t m e n t

used in this study was a d a p t e d f r o m V e r o n e n a n d Kil-

pat r ick 's (1983) SIT p r o g r a m . It i n c l u d e d t ra in ing in