Academic journal article American Journal of Psychotherapy

What's Broken with Cognitive Behavior Therapy Treatment of Obsessive-Compulsive Disorder and How to Fix It

Academic journal article American Journal of Psychotherapy

What's Broken with Cognitive Behavior Therapy Treatment of Obsessive-Compulsive Disorder and How to Fix It

Article excerpt

Cognitive Behavior Therapy (CBT) is the evidence-based treatment of choice for Obsessive-Compulsive Disorder (OCD). The central technique of this approach is Exposure and Response Prevention (EX/RP). Examination of EX/RP treatment of OCD reveals severe shortcomings. The technique, while generally quite effective, cannot deal with patients who are unable to comply with EX/RP's difficult regime, resulting in a significant percentage of patients who refuse treatment and dropouts. Also, for optimal results, the therapist should be present while the patient carries out EX/RP therapy. This severely reduces the therapist's resources since leaving the clinic and being personally present during EX/RP in the patient's real life circumstances is not something therapists can do easily. These limitations acutely compromise the applicability of this technique to clinical practice. Research into Cognitive Therapy without EX/RP does not show superiority to EX/RP. In this paper, I illustrate a Strategic/Behavioral Treatment (SBT) for OCD that easily and elegantly overcomes the limitations of Cognitive Behavioral Therapy (CBT) treatment (thereby increasing its effectiveness), present three case studies, and offer suggestions for further research.

KEYWORDS: obsessive-compulsive treatment; exposure/response prevention; strategic/behavior therapy; prescribing the symptom


One of the most notable achievements - if not the most notable - of psychiatry and psychology in the latter decades of the 20' century has been the significant improvement in treating Obsessive-Compulsive Disorder (OCD). Once considered as an intractable disorder (Black, 1974) in the 1970s, today OCD is one with several medical and psychological treatment options that have been shown empirically to bring at least some relief to the suffering of patients. In the realm of psychopharmacology, the advent of Selective Seritonin Reuptake Inhibitors have been helpful in bringing partial, and sometimes significant, relief in most cases of OCD. In the area of psychotherapy, professionals and professional associations recognize Cognitive Behavioral Therapy (CBT) as the state-of-the-art psychological treatment for OCD (Chambless, Baker, Baucom, Beutler, Calhoun, Crits-Christoph et al., 1998; March, Frances, Kahn & Carpenter, 1997). Much research has been devoted to demonstrating CBT effectiveness in symptom relief. It is one of the best evidence- based treatments in the field of psychotherapy.

In this article I examine Exposure and Response Prevention (EX/RP), the main CBT technique for treating OCD; review the acknowledged limitations of the technique; explain the reason for these limitations; address the issue of patient noncompliance; examine the contribution of Cognitive Therapy and its acknowledged shortcomings; describe a Strategic/Behavioral (SBT) technique that avoids these shortcomings; introduce the SBT therapeutic approach to clinical problems; report on three cases studies using these techniques and method; and propose suggestions for further research directions.


The main CBT technique used for symptom reduction has been Exposure and Response Prevention (EX/RP). The technique, originally reported by Meyer (1966), requires the patient to expose himself to situations that increase his anxiety (exposure), which, as a consequence, increases his urge to compulsively ritualize. He is then requested to refrain from ritualizing, i.e., from performing his compulsion (response prevention). Various studies report success rates of EX/RP in the 50% to 60% range (Fisher & Wells, 2005). "Success rates" in these studies focus on statistically significant symptom reduction, but as Abramowitz (1998) has pointed out, symptom reduction in and of itself does not necessarily mean clinically improved functioning. …

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