Treatment of Obsessions, The

Canadian Psychology, May 2004 by Stewart, Sherry H

STANLEY RACHMAN The Treatment of Obsessions New York: Oxford University Press, 2003, 160 pages (ISBN 0-19-851537-5, US$36.95 Paperback)

Reviewed by SHERRYH. STEWART

This treatment manual is part of Oxford's Cognitive Behavior Therapy: Science and Practice series edited by David Clark, Christopher Fairburn, and Steven Holion. The goals of the book are to provide background theory and research, and to describe treatment techniques for a new cognitive-behavioural treatment for patients whose major or sole problem is obsessions (i.e., recurrent, unwanted thoughts, impulses, or images that the person finds unacceptable or disgusting).

As Rachman describes at the outset, until recently, progress in treating obsessions in obsessive-compulsive disorder (OCD) lagged far behind the progress made by cognitive-behavioural therapists in treating compulsions (i.e., repetitive, Stereotypie behaviour). We have known since the early 1980s that we can successfully treat compulsive behaviors like compulsive checking and cleaning - through exposure and response prevention (ERP). However, ERP was not designed to treat the cognitive symptom of obsessions, even though obsessions are the primary problem for nearly one-third of OCD patients. Rachman reviews the prior lack of success of procedures intended to treat obsessions (e.g., "thoughtstopping"). Given the frequency of obsessions as the primary or only problem in OCD patients and the absence of effective prior treatments for obsessions, this manual is a welcome addition to the literature.

In the first two chapters, Rachman describes the nature of obsessions and background cognitive theory and rationale for his novel treatment. He acknowledges that he draws heavily on the work of David Clark (cognitive theory and therapy for panic disorder) and Paul Salkovskis (cognitive theory of obsessions). Rachman clearly describes the three types of classical obsessions - (a) Aggressive/harm obsessions, such as thoughts of harming children or elderly people; (b) Sexual obsessions, such as fears of sexually molesting a child; and (c) Blasphemous obsessions, such as fears of making sacrilegious gestures in a church. he reviews considerable data that indicate intrusive thoughts are a common and normal experience. he then clearly presents the cognitive theory of obsessions, which asserts that catastrophic misinterpretation of the meaning and significance of unwanted thoughts is the factor responsible for turning a nonclinical intrusive thought into a recurrent and troubling obsession. For example, a woman who has an intrusive thought of harming her child develops a harm obsession when she misinterprets her original unwanted thought as evidence that she is a dangerous and evil person. Rachman reviews the accumulating clinical and psychometric evidence for this cognitive theory gathered by his own team and by research groups worldwide. I found this section of the book to be clear, comprehensive, and current, while still managing to remain appropriately brief.

In the third chapter, Rachman reviews the importance of proper assessment of the obsessional problem for use in treatment planning, tracking progress (also covered in Chapter 8), and evaluating outcome. he recommends a specific set of tools (structured interviews, questionnaires, behavioral tests, and clinician ratings) for conducting a thorough assessment and suggests when they should be employed at various points in the therapy process. The specific set of tools allows the clinician to gather information about the frequency and specific content of the obsessions, the antecedents, safety behaviours (e.g., avoidance, neutralizing, concealing the thoughts from others), and maintaining factors, as well as associated emotional states (e.g., depression). Since this is a cognitive treatment, Rachman places particular emphasis on evaluating the personal significance or meaning the patient is attaching to obsessive thoughts via tools developed by his research team. A very helpful aspect of this section is that the relevant tools developed by his own research group are actually contained within the manual in Chapter 9 ("Therapist's Toolkit"). A limitation is that very little information is provided on the psychometric properties of the recommended tools.

The fourth through seventh chapters describe the content of the treatment and specific therapeutic strategies. The treatment is divided into two stages. Chapter 4 presents the first stage, which is psychoeducational (e.g., providing the patient with information on the high frequency of unwanted, intrusive thoughts in the general population; educating the patient about similarity in content and form between clinical and nonclinical intrusive thoughts; introducing the patient to the rationale for treatment). One of the strengths of this section is that useful tools for accomplishing these goals are provided in the Therapist's Toolkit. Specifically, Rachman has included a list of common intrusive thoughts gathered from nonclinical and clinical (obsessional) samples, which can be used to illustrate the similarities in form and content to the patient. Also, he has included a written description of the treatment rationale. This can be used to supplement the therapist's verbal explanation and to stimulate discussion about the therapy rationale to ensure patient understanding. I also appreciated suggestions for analogies that can be used (e.g., comparing the patient's true values and beliefs vs. obsessions to signal vs. noise, respectively, in a radio signal).