The Treatment of Obsessions.

Models of treatment for obsessive-compulsive disorder (OCD) have undergone substantial revisions and refinements over the past 20 years, with particular focus on cognitive factors and, by association, specific cognitive therapy interventions. Previous approaches to treating OCD relied exclusively on exposure with response (ERP), a procedure that, while highly efficacious,1 is also extremely demanding for clients, with many dropping out either by early treatment termination or through noncompliance with treatment components.2 Cognitive therapy, on the other hand, is viewed as a more acceptable intervention, with lower dropout and lower demand vis-a-vis anxiety-producing within-and between-session exercises. Cognitive therapy has been available for quite some time. However, the approach originally developed was very general, neglecting conditions which had specific cognitive qualities that defied a general “negative automatic thought” framework; that is, there was a relative lack of attention to mechanisms that specifically defined particular psychological problems. Obsessions are notable in this regard. While it may be accurate to point out that individuals with obsessions struggle with negative automatic thoughts, time spent challenging these thoughts is an unproductive endeavor without attending to cognitive features that are specific to the condition. The Treatment of Obsessions presents a treatment manual for addressing the specific cognitive problems associated with obsessions without accompanying compulsions. Dr. Rachman, who has been studying OCD since the early development of ERP, has also contributed significantly to the evolution of current knowledge of how to conceptualize and treat obsessions. The book is brief, intended to introduce readers to the essentials necessary to assess and develop treatment plans for individuals suffering from obsessions. Dr. Rachman begins by providing a conceptual grounding in obsessions, particularly common cognitive features of the condition. Notably, the contemporary model of obsessions focuses on inflated responsibility and catastrophic interpretation of intrusive ideas. The conceptualization is based primarily on the original model of panic by Clark,3 in which anxiety results from catastrophic misinterpretations of physical changes. Rachman points out how obsessions follow a similar pattern, whereby an intrusive thought (e.g., “I could just kill Bill with this steak knife”) is followed by a catastrophic misinterpretation of the thought (i.e., “How could I have such a thought? Deep down, I must be a psychopath”). There are numerous corresponding cognitive biases present in such individuals, including thought-action fusion, overimportance of thoughts, and need for control over thoughts. Dr. Rachman cites Salkovskis4 as particularly influential in providing a template for the development of effective therapies for obsessions. The book is organized to lead readers from assessment to treatment planning and intervention. There are a number of very useful “Clinician Tools” to help readers utilize the assessment strategies in their practice, with illustrative examples for each assessment tool. The book concludes with several clinical examples that highlight different presentations of obsessions. Also of note, complications in the treatment of obsessions are highlighted. Since the writing of The Treatment of Obsessions, there have been additional developments in the conceptualization of OCD that should be noted. Research on subtypes of the disorder suggests that, as Dr. Rachman implies, obsessions without accompanying compulsions are distinct from other symptom presentations of the disorder.5 However, treatments for the different subtypes (with the exception of hoarding) all generally respond to ERP, including obsessions without overt compulsions. Dr. Rachman presents procedures consistent with ERP, couched in cognitive therapy terms, in the form of behavioral experiments. These experiments are effectively exposure exercises (i.e., coming in contact with items that might provoke obsessions, such as knives for individuals with harming obsessions), but with the goal of provoking typical cognitive biases rather than focusing on producing habituation. It has been suggested recently that, of all the major components of treatment for obsessions, behavioral experiments produce the greatest therapeutic effect.6 Rachman lays out the approach with clarity, and users of this manual should be able to realize positive results with their obsessional clients. Overall, The Treatment of Obsessions provides an excellent resource for clinicians by describing, succinctly, the model of obsessions and the methods for most effective intervention. While the focus is on obsessions without compulsions, the book will not be useful for clients presenting with pure obsessions not associated with perceived negative outcomes, such as intrusive and repetitive melodies. Some clients may also not necessarily identify with the cognitive biases described in the book, in light of research since the publication of this volume showing that there is a subtype of individuals with obsessions who do not endorse cognitive biases associated with the disorder. This last finding was in secondary analyses of data from the Obsessive-Compulsive Cognitions Workgroup7 that Rachman cites in this volume. Since Dr. Rachman has been at the leading edge of research in this area, a revised edition would no doubt take up this important issue. I would highly recommend this volume for clinicians and general practitioners who need a succinct volume to aid in developing effective interventions for pure obsessions.