Ocd Behavior Therapy

Behavior therapy is not always effective. Some of the factors that have been reported to be associated with treatment failure include personality disorders (AuBuchon & Malatesta, 1994; Fals-Stewart & Lucente, 1993), especially schizotypal personality disorder, severe depression, overvalued ideas, consisting of strong convictions that the obsessive fears are real or symptoms in general, higher avoidance frequency, status at the end of treatment (O'Sullivan & Marks, 1991), use of depressants such as alcohol, barbiturates, carbomates and benzodiazepine anxiolytics (Greist, 1994), dissatisfaction with the therapeutic relationship, low levels of motivation, longer duration of complaints and noncompliance. 

The relationship between personality disorders and relapse is significant, especially since the occurrence of personality disorders in OCD patients is somewhere between 50-80% (Mavissakalian et al., 1990). However, the most important determinant of treatment failure appears to be noncompliance with the treatment program. At least 25% of those who begin a behavior therapy treatment program will end up not complying.

Aside from the more obvious ways in which patients fail to comply with therapy, Dar and Greist (1992) have pointed out that covert mental rituals can play a role in noncompliance. For example, patients who are about to face one of their fears during an exposure session may tell themselves that it is really safe because the therapist would not allow them to do anything that was really dangerous.

For years it was also believed that having obsessive thoughts without overt compulsions leads to treatment failure (Baer & Minichiello, 1990), but the work of Salkovskis and colleagues has shown this to be false. Salkovskis and Westbrook (1989) distinguished between two forms of ruminations: obsessions and `neutralizing' thoughts. Obsessions are the intrusive, involuntary thoughts patients have and neutralizing thoughts are covert behaviors that function to reduce the distress brought on by the obsessive thoughts.

The authors argued that failure of exposure and response prevention to work with ruminations has been due to overlooking this distinction and the fact that neutralizing thoughts are the responses that need to be prevented. Treatment consists of intense exposure to the obsessive thoughts, accompanied by techniques that prevent the covert neutralizing rituals. The procedure is discussed more fully in the section on treatment guidelines.