posted on Apr, 26 2010 @ 12:19 PM
This book is an excellent manual that describes a focused, specific treatment for obsessions. The book is well written, succinct and has a number
of very practical strategies to manage obsessions. The book is most appropriate for the treatment of older adolescents and adults.
The book is divided into ten chapters. The first few chapters discuss the nature of obsessions, the background and the rationale for this treatment.
The following three chapters focus on assessment procedures and stages one and two of treatment which are considered essential for therapists. The
subsequent chapters, that address techniques and tactics for coping with self-defeating safety behaviour and different forms of obsessions, are
non-essential and are utilized when appropriate. Therapists are provided information on how to assess progress and manage problems. The ninth chapter
is entitled “Therapist’s toolkit” and is a summary of all the key instruments described in the manual that the therapist can utilize in
treatment. The final chapter has a series of case illustrations, demonstrating the types of cases that can benefit from treatment. The author does
describe one case that did not improve with treatment.
Rachman emphasizes that this treatment is to be used for classical obsessions that have three main themes: aggression, sex, or blasphemy. This
treatment may be beneficial in a proportion of children and adolescents as a recent study found that the most common obsessions in a sample of
children with OCD were contamination and worries about harm and in adolescents, more religious
Rachman’s theory of obsessions draws on the work of Salkovski and Clark. Salkovski believed that it was not the content of the intrusions but rather
the meaning that the person attached to such intrusions that was important. Salkovski identified that individuals with obsessions have a sense of
inflated responsibility. Clark argued that panic is caused by a catastrophic misinterpretation of certain bodily sensations. Rachman’s cognitive
theory states that obsessions are caused by catastrophic misinterpretations of the significance of one’s unwanted intrusive thoughts. In the case of
obsessions, inflated responsibility is particularly noticeable when people are prone to the cognitive biases of thought-action fusion (TAF), a concept
coined by Rachman. TAF refers to the phenomenon in which people tend to regard their thoughts as being psychologically equivalent to the corresponding
action and/or believe that their thoughts of possible misfortunes actually increase the likelihood that the misfortune will occur. This concept has
been well studied in adults. There is only one study examining the cognitive processes proposed to be etiologically important in the conceptualization
of OCD in a sample of children between age 7 and 13 years. Children with OCD were found to have significantly higher ratings of responsibility,
severity, TAF, and less cognitive control than non-OCD children. There have been no such studies in
With respect to assessment, the Yale Brown Obsessive Compulsive Scale (Y-BOCS), the Obsessive-Compulsive Inventory (OCI) and the Beck Depression
Inventory (BDI) are recommended as part of the preliminary assessment. For the specific assessment of obsessions, a semi-structured interview that is
designed to collect information about the content and frequency of the obsessions, the triggers, safety behaviour, and maintaining conditions, as well
as the personal significance that the patient attributes to the obsessions, is conducted. The Personal Significance Scale helps in the assessment and
guides the course of therapy. The scale consists of 26 questions, all of which are rated on a 10 cm visual analogue scale, which would be useful for
adolescents. The scale is administered at the beginning of each session to measure the personal significance of the obsessions, the amount of
obsessional activity per week and the degree of distress it causes. A therapist version is completed at the end of each session. Patients can also
keep a simple daily record of their unwanted intrusive thoughts. As a guide to treatment, the 19- item self-report Thought Action Fusion (TAF) scale,
which provides a total score indicating the proneness to this cognitive bias, is utilized.
The treatment consists of 8–12 weekly sessions, starting with twice a week and gradually tapering to once every three weeks. A session-by-session
progress chart sets out the structure for each session. Rachman suggests that the sessions be taped and the patients review the tape before the next
session. The patient is given homework exercises and it is emphasized that the work between sessions is crucial. Booster sessions are planned as
necessary, and review and follow-up meetings are always arranged.
The primary aim of treatment is to assist the patient to make more realistic and accurate interpretations of the significance of their unwanted,
intrusive thoughts. The techniques are essentially cognitive and can be used to supplement the standard Obsessive Compulsive Disorder (OCD)
treatments. It is important for the therapists to use flexibility in administration of the treatment.
As the focus is on changing the patients’ misinterpretations of the significance of the intrusive thoughts, the first step in treatment is
education. Patients are informed that unwanted intrusive thoughts are nearly universal and they are given a printed list of common examples. The
second part of the educational component consists of a description of the treatment model, the rationale of the treatment plus references. The patient
is asked to explain the treatment model and their response is recorded.
The second treatment stage involves collecting a full account of the content of the obsessions. Encouraging the patient to describe and then record
the occurrence of the obsession, in a mechanical manner, changes their significance. The collection of this information is then used, in the usual way
of cognitive therapy as a basis for assessing the patient’s interpretation of the obsession. The patient is encouraged to construct alternative
interpretations of the intrusive thoughts and to match the available evidence for and against the original catastrophic significance and the
alternatives. This step may include behavioural experiments. The avoidance behaviour that results from the obsessions is tackled by encouraging the
patients to gradually and steadily expose themselves to the anxiety-evoking situations.
Other techniques to work with self-defeating safety behavior such as avoidance, concealment, thought suppression, neutralization, reassurance seeking,
and obsessions are outlined. For example, mini-experiments, in which the patient tests the validity of specific expectations, are outlined. The
purpose of the mini-experiments is to allow the patient to collect direct, personal information, pertaining to important OCD beliefs. These
behavioural experiments are in contrast to exposure exercises in which the primary aim is to reduce fear.
To monitor changes, the therapist can observe changes on the Personal Significance Scale at each session. At the end of treatment the pretreatment
measures, OCI, Y-BOCS, BDI, and the full structured interview are re-administered. Rachman stresses that an important index of change is the
Overall, this book is a very useful, practical manual for older adolescents and adults. It will be important to follow this treatment over time to
determine if it can be applied to children and younger adolescents.
There is help, but like all addictions and obsessions, one must first recognize that there is a problem first, and want help.
[edit on 4/26/2010 by whatukno]