PSYCHOLOGICAL THERAPIES FOR OBSESSIVE COMPULSIVE DISORDER
To read up on the psychological therapies for obsessive compulsive disorder, refer to pages 539–548 of
Eysenck’s A2 Level Psychology.
Ask yourself
 How can the psychodynamic approach be applied to the treatment of
obsessive compulsive disorder (OCD)?
 How can the behavioural approach be applied to the treatment of OCD?
 How can the cognitive approach be applied to the treatment of OCD?
What you need to know
PSYCHODYNAMIC
THERAPY
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Effectiveness
Appropriateness
BEHAVIOURAL
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Effectiveness
Appropriateness
COGNITIVE
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Effectiveness
Appropriateness
Psychodynamic therapy
The key goal of psychodynamic therapy is to enable patients to recover their repressed memories and
provide them with insight into their disorders.
Freud used free association to gain access to the unconscious. This involves the client saying whatever
comes into his or her mind. The client might be reluctant to say what he or she is really thinking. However,
according to Freud, long pauses in what the client says indicate that he or she is moving close to an
important repressed idea. Skilled therapists regard the presence of long pauses as an indication that
additional questioning and discussion are required.
A second method Freud used to access the unconscious was dream analysis. He claimed we are much more
likely to gain access to repressed material while dreaming than when we are awake because the censor in
our minds that keeps the repressed material in the unconscious does not work as well during sleep. The
repressed material is included in our dreams in a disguised or symbolic form because of its unacceptable
nature. Freud called the dream as we remember it the manifest content and the true or underlying meaning
the latent content. Dream analysis involves interpretation of the symbols in the manifest content and
questioning clients about their dreams to work out the latent content.
Progress in therapy depends partly on transference. This involves the client transferring onto the therapist
the powerful emotional reactions previously directed at his/her own parents or other highly significant
others. These intense feelings can be negative or positive and the client is usually unaware of what is
happening. Transference often provides a direct link back to the client’s childhood by providing a recreation of dramatic conflicts that were experienced at that time. As a result, transference can facilitate the
uncovering of repressed memories.
The psychodynamic approach to therapy is difficult to use with patients suffering from OCD because
patients often tend to be suspicious of therapists, whom they suspect of invading their private thoughts and
threatening their security by questioning them.
EVALUATION OF PSYCHODYNAMIC THERAPY
Effectiveness
 Modest effectiveness. There is general agreement that Freud’s original
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psychoanalytic treatment has only modest effectiveness in the treatment of
OCD.
Not a valid basis for therapy. It is questionable whether the psychodynamic
approach, with its emphasis on the anal stage of development, provides a
valid basis for therapy.
Ineffective with severe mental disorders. It can be argued that
psychodynamic therapy is only effective with minor disorders because of the
common effects of therapy e.g. therapist warmth and therapeutic alliance
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between therapist and client. The treatment does not offer anything specific
to help patients with severe problems such as OCD.
Encourages obsessive thinking. The “talking cure” may actually be
counterproductive because the analytical nature of it may encourage patients
to think excessively about the details of their problems, and of course
obsessive thinking is part of the problem!
Appropriateness
 Focus on undoing. Freud’s focus on undoing to cancel out clients’ urges and
reduce their anxiety does offer insight into compulsive behaviour. Therefore
it is appropriate for psychodynamic therapy to focus on undoing in
treatment.
 Overemphasis on childhood factors. It seems inappropriate for therapy to
focus on patients’ early childhoods, given that there is practically no evidence
that early childhood is of any real relevance in producing the disorder.
 Ignores behaviour and cognition. Psychodynamic therapy does not
directly focus on changing behaviour or cognition, yet, as we will see in the
next two therapies, focusing on these aspects has more success than focusing
on repressed childhood memories.
Behavioural therapy
Exposure and response prevention therapy is a behavioural therapy. Exposure involves exposing patients to
situations that trigger their obsessions and compulsions. Response prevention involves not allowing the
patients to perform the rituals they would typically use to reduce anxiety. The combination of these two
strategies leads to extinction of the fear response.
Behavioural therapy begins with an assessment of the patient’s obsessional thoughts and impulses and the
stimuli that trigger them. The patient is also asked to consider the negative consequences they imagine will
occur if they confront the feared stimuli and do not perform their compulsive actions. Exposure starts with
only moderately distressing stimuli and only when the patient seems to be coping successfully is he or she
exposed to more distressing situations. The patient is expected to practise exposure for several hours alone
before the next treatment session.
EVALUATION OF BEHAVIOURAL THERAPY
Effectiveness
 Strong evidence for effectiveness. There is strong evidence that therapy
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based on exposure and response prevention is effective. Eddy et al.’s (2004,
see A2 Level Psychology page 542) meta-analyses found behaviour therapy
(exposure + response prevention), to be slightly more effective than
cognitive or cognitive-behavioural therapy. According to most behaviour
therapists, it is successful because it provides an opportunity for conditioned
fear responses to extinguish.
Individual differences. Does not work for all patients. About 25–30% of
patients who start exposure and response prevention therapy drop out,
mostly because of the high levels of anxiety that are created in the
therapeutic situation. Among those patients who remain in treatment, 20%
or more fail to derive much benefit from it. Thus, the therapy does not work
for up to 50% of patients.
A multi-dimensional approach. A combined approach to treatment seems
more effective because research shows that adding drug therapy to exposure
and response prevention can persuade more patients to persevere with
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behavioural therapy because the drugs help reduce the anxiety caused by the
technique (Hill & Beamish, 2007, see A2 Level Psychology page 543).
Artificiality. The nature of exposure and response prevention can be
artificial because the patient is not experiencing the feared stimulus in a
natural way. Seligman (1995, see A2 Level Psychology page 543) used the
term efficacy studies to describe this approach and contrasted such studies
with effectiveness studies, which involve the messy and much more complex
situation often found in clinical practice, when patients have other mental
disorders besides OCD (comorbidity). Comorbidity is common in
effectiveness studies but typically missing from efficacy studies. This means
the research lacks generalisability to real-life clinical practice.
Well controlled and scientific. The controlled nature of efficacy studies has
allowed research to be carried out in which we have confidence in the
interpretations of the findings, and so these studies have informed our
understanding.
Cognitive factors are ignored. The behavioural approach does not consider
cognition because this is neither observable nor measurable. This is a
weakness because cognitive therapists suggest the reason exposure and
response prevention therapy is effective is because it helps patients to
change their dysfunctional beliefs about the threats posed by situations they
find distressing. Thus, effectiveness may be due to cognitive factors more
than behavioural ones.
Appropriateness
 Valid basis for therapy. Patients with OCD have maladaptive ritualised
behaviours and so the focus on preventing these, and at the same time
extinguishing the fear response, is appropriate. Exposure and response
prevention therapy demonstrate to patients that it is possible to control and
to reduce the anxiety they experience when confronting distressing
situations.
 Ethical issues. Exposure therapy with prevention is anxiety-provoking and
can be distressing for patients. This can lead to a high drop-out rate and
questions the appropriateness of the therapy because some would argue it is
unethical for therapists to create such high levels of anxiety in vulnerable
patients. Informed consent can be an issue as patients may not fully grasp
just how demanding the treatment is going to be.
 Individual differences. The therapy isn’t suitable for all patients with OCD
because it can be dangerous if used with patients suffering from substance
abuse, active psychosis, or who have thoughts of committing suicide.
 Doesn’t treat the obsessions. Exposure and response prevention therapy
focus more on compulsions than on obsessions, suggesting that this form of
therapy may be less appropriate for patients whose symptoms consist
mainly of obsessions.
Cognitive therapy
Attempts have been made to combine cognitive therapy with exposure and response prevention to produce
cognitive behavioural therapy. However, this has not been found to be very effective (Hill & Beamish,
2007, A2 Level Psychology page 544). The main goal of cognitive therapy is to change patients’ faulty
cognitions and thereby challenge their obsessional thinking. One approach within cognitive therapy is the
pie technique. With this technique, the patient indicates their degree of responsibility for a negative
outcome linked to their obsessional thinking. The percentage of responsibility is very high and so the
therapist supports the patient in exploring other source of responsibility until their own percentage is
lowered to a more realistic amount.
Another technique is called the “double standard” technique. This also seeks to lower the patient’s
perceived sense of responsibility by asking them first to imagine their own level of responsibility for a
negative outcome. They are then asked whether they would find someone else responsible and guilty if the
same threatening event happened to this person. There is usually a high discrepancy between their own
level of responsibility and that which they attribute to others and can therefore result in the patient feeling
less responsible than before for unfortunate outcomes.
Freeston, Rheaume, and Ladouceur (1996, A2 Level Psychology page 545) developed several ways of
challenging the dysfunctional beliefs of obsessive compulsive patients. Patients often overestimate the
importance of their obsessional thoughts, based on the illogical belief: “It must be important because I think
about it, and I think about it because it is important” (Freeston et al., 1996, p. 437). This belief can be
challenged by asking patients to record their thoughts to show that many unimportant thoughts occur every
day. Another method is to ask patients to attend closely to something obviously unimportant (e.g. the tip of
their nose). This shows that it is entirely possible to spend much time thinking about matters that have very
little importance.
Freeston et al. (1996, A2 Level Psychology page 545) have developed a number of ways of challenging
patients’ beliefs that thoughts can increase the probability of an event. For example, they challenge the
importance the patient attaches to their obsessions by asking them to think a about something meaningless
to show that thinking about something a lot does not make it important. They also challenge their faulty
belief that their thoughts can influence their environment by asking them to test this out, e.g. they could
think a household appliance will break down within the next week. Hopefully it will not! Thus, the faulty
cognition would be challenged.
EVALUATION OF COGNITIVE THERAPY
Effectiveness
 Effectiveness. Cognitive therapy has been found to be nearly as effective as
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behavioural therapy, which has high effectiveness (Eddy et al., 2004, A2 Level
Psychology page 546). Effectiveness does depend on the symptoms because,
unsurprisingly, cognitive therapy is better at treating the cognitive
obsessions than in treating the behavioural compulsions. Nevertheless,
cognition does influence behaviour, so in treating the cognition it is quite
possible that this could indirectly treat behaviour.
Less effective than behavioural in the long term. Cottraux et al. (2001, A2
Level Psychology page 546) found that the 1-year post-treatment patients
treated with exposure and response prevention showed further
improvement, whereas those treated with cognitive therapy did not. Initially
both therapies had appeared equally effective but in the longer term
behavioural therapy was more effective.
Drop-out rate. One of the advantages of cognitive therapy over exposure
and response prevention is that the drop-out rate is typically lower as the
technique does not involve the same anxiety.
A multi-dimensional approach. A combined approach may be more
effective because adding some elements of cognitive therapy to exposure and
response prevention can help to reduce drop-out rates and benefit treatment
(Abramowitz, 2006, A2 Level Psychology page 546). For example, focusing on
patients’ tendency to overestimate danger makes them more responsive to
behavioural therapy.
Appropriateness
Valid basis for therapy. OCD patients do have dysfunctional beliefs and
obsessions and so challenging these, as the cognitive approach does, is
appropriate. In particular, many techniques focus on patients’ exaggerated
sense of responsibility, which is also highly appropriate as this drives much
of their compulsive behaviour.
 Low drop-out rate. The fact that cognitive therapy is acceptable to the great
majority of obsessive compulsive patients, as is shown by the relatively low
drop-out rates usually found with it, justifies its appropriateness.
 Doesn’t treat behavioural symptoms. Cognitive therapists often focus on
the cognitive problems rather than the behavioural ones.
 Doesn’t address the underlying causes. Cognitive therapists focus on
changing faulty beliefs but do not consider why patients developed these
beliefs. This means the therapy may just be treating symptoms rather than
the underlying causes of behaviour. A therapy based on a clearer
understanding of the origins of these dysfunctional beliefs would be more
appropriate. For example, patients’ exaggerated concerns about personal
responsibility involve negative not positive outcomes. Maybe thus is due to
low self-esteem or a pessimistic personality type and so focusing on these
factors would be more appropriate and potentially effective in terms of
curing OCD.
So what does this mean?
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Any comparisons of the effectiveness of different treatments should be regarded with caution as it is
difficult to know if differences are due to the actual therapy or the individual differences of the patient or
therapist.
Therapy depends in part on the skills of the therapist, so differences in improvement may be due to such
differences rather than the treatment itself. The fact that patients usually choose their own treatment and are
therefore a self-selected sample also complicates a comparison of treatments. Moreover, recovery may not
be due to the specific nature of the treatment but due to general factors that underpin all treatments, such as
the effect of having someone sensitive to talk to and being able to express all worries and fears (known as
the “general therapy effect”).
Assessing the effectiveness of treatments is further complicated by the “hello-goodbye effect” whereby
patients overestimate their symptoms at the start of treatment and underestimate their symptoms at the end.
Another issue is publication bias whereby significant findings are published more than non-significant
ones. These biases may make therapies appear more effective than they really are. Imagine if all the
findings that a therapy doesn’t work are suppressed, then of course it’s going to appear effective!
Ethical issues raise further concerns as it is necessary to consider whether the patient can give fully
informed consent. A number of things can limit this: for example, the patient may not be provided with
enough information about the treatment, they may not remember the information accurately, and they may
agree just because they respect the therapist rather than understand the treatment.
However, in spite of all of these issues, it is important to understand as best we can the effectiveness and
appropriateness of therapies. This is because treatment is usually better than no treatment, even if part of
the improvement is a placebo effect.
The biological approach is moderately effective for OCD, but tends to have high relapse rates, so the
optimal approach to treatment is multi-dimensional because research suggests that patients will persist with
behavioural therapy if it is combined with drug therapy as the latter is needed to help them deal with the
anxiety produced by exposure and response prevention. However, these two techniques do not address the
faulty thinking that dominates OCD, so some element of cognitive therapy is also desirable.
Over to you
(a) Outline one or more psychological therapy(ies) for one anxiety disorder. (9 marks)
(b) Evaluate the therapy(ies) described in (a). (16 marks)