Behaz,. Res. Ther. Vol. 34, No. 5/6, pp.

433446, 1996
~ Pergamon Copyright © 1996 Elsevier Science Ltd
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CORRECTING FAULTY APPRAISALS OF OBSESSIONAL

THOUGHTS

MARK H. FREESTON*, JOStlE RHI~AUME and ROBERT LADOUCEUR

l~cole de psychologie, Universit6 Laval and Centre de Recherche, Universit6 Laval Robert-Giffard,
Quebec, Canada G1K 7P4

(Received 22 September 1995)

Summary--Cognitive techniques are becoming more widely established in the treatment of obses-
sive-compulsive disorder (OCD). This paper extends previous work by van Oppen and Arntz (1994,
Behaviour Research and Therapy, 33, 79-87) on overestimation of threat and excessive responsibility by
discussing other types of appraisals that may be involved in OCD, particularly when overt compulsions
are absent. Examples are given of types of intervention that may be useful to correct faulty appraisals
concerning the overestimation of the importance of thoughts such as thought-action fusion, excessive
responsibility, perfectionistic concerns such as the need for absolute certainty, and expectations about
anxiety and its consequences. Copyright © 1996 Elsevier Science Ltd.

INTRODUCTION
Exposure and response prevention is the treatment of choice for obsessive-compulsive disorder
(OCD) but cognitive therapy has been proposed as a complement to existing treatment methods
or as an alternative when patients refuse exposure (e.g. Salkovskis, 1989a; Salkovskis & Westbrook,
1987; Steketee, 1993). Although some cognitive strategies have been described (e.g. Salkovskis,
1985, 1989a; Salkovskis & Westbrook, 1987; van Oppen & Arntz, 1994; Riggs & Foa, 1993; Warren
& Zgourides, 1991), most of these interventions seem more appropriate for cases where overt
compulsions are present. There has been less discussion of strategies to be used with patients
reporting obsessive thoughts only. This paper describes a number of cognitive correction strategies
that have proved useful with patients consulting for obsessional thoughts. First, relevant cognitive
models will be reviewed, major types of faulty appraisal will then be identified and then specific
strategies will be suggested for each type of appraisal.

COGNITIVE MODELS OF OCD

Over the last 20 years various accounts of OCD have been proposed (van Oppen & Arntz, 1994).
In the most comprehensive cognitive account to date, Salkovskis (1985, 1989b) proposed that
perceived responsibility for harm to self or others is at the heart of OCD. More recently Rachman
(1993) provided anecdotal support for this position especially with checkers, and Lopatka and
Rachman (1995), and Shafran (1995) manipulated responsibility in clinical checkers leading to
temporary changes in symptom levels. Van Oppen and Arntz (1994) have provided treatment
recommendations based upon this model that once again seem most adapted to checkers. A recent
extension of the model (Salkovskis, Richards & Forrester, 1995) articulates how responsibility may
be linked to intrusive thoughts by arguing that among OCD patients: (1) thinking about a negative
outcome gives the patient a sense of agency; and (2) the lack of the normal omission bias (where
Ss feel less responsible when doing nothing than when actually doing something) leads patients
to assume that they are responsible for any possible outcome. Neutralizing then acts to reduce the
perceived responsibility (Salkovskis et al., 1995). In an attempted integration of evidence from the
thought suppression paradigm and Salkovskis' positions, Clark and Purdon (1993) propose that
beliefs about the need to control thoughts are critical in OCD. They suggest that the various

*Author for correspondence.

433
434 M a r k H . F r e e s t o n et al.

neutralization strategies are only symptomatic of underlying beliefs about control and have no
causal role. Finally, Freeston and Ladouceur (1996a) propose that a number of faulty appraisals
of intrusive thoughts may contribute to the maintenance of OCD. Not all of these appraisals may
be unique to the disorder but may still have an important role in maintaining the disorder. This
position is briefly developed below.
Based on experience with a large number of patients without overt compulsions, Freeston and
Ladouceur (1996a) propose that a wide variety of types of incorrect appraisal of intrusive thoughts
may be involved in the development and maintenance of OCD. What is common to all patients
is the high degree of importance that they attach to the presence or the content of their obsessive
thoughts. Although this may be an epiphenomenon or a consequence of suffering from OCD, a
recent treatment study showed that the appraisal of intrusive thoughts by 29 patients diagnosed
with OCD without overt compulsions changed during treatment (Ladouceur, Freeston, Rh6aume,
Letarte, Thibodeau, Gagnon & Bujold, 1994). Furthermore, changes in beliefs that were specifically
related to obsessions were correlated to changes in obsessive symptoms, whereas changes of equal
magnitude in general irrational beliefs were not (Freeston & Ladouceur, 1995a). This is consistent
with cognitive models of OCD.
The results reported above were obtained with standardized structured measures. We assessed
various types of interpretations that the patients made about their thoughts using a semi-structured
clinical checklist. Using a 17-item basic checklist of items drawn from previous experience with this
population, patients were questioned about the different ways that they 'attached importance' to
their thoughts. The patients reported a wide range of obsessions including aggressive, sexual,
somatic, contamination, and religious themes, as well as preoccupation with ambiguity and
doubting about past actions. They endorsed between 6 and 22 different interpretations (mean 12.1).
The standardized items are presented in Table 1 with the percentage endorsement listed in the right
hand column.
Several points deserve comment. The first 10 items were all endorsed by more than half of the
Ss and reflect expectations about having the thought, ideas about control, and also interpretations
about what having the thought means. The expectations are that anxiety will occur, the individual
will be unable to control the thought, and that the thought will cause interference. The majority
reported additional idiosyncratic interpretations indicating the need to identify the possible
personal meanings that the individual may attach to their thought. Since this checklist was
originally devised in 1991 the theoretical analysis of OCD has continued and instruments with
similar functions assessing interpretations of specific thoughts have been developed by a number
of teams (Salkovskis et al., 1995; Rachman, Shafran, Thordarson, Neufeld, Sawchuk, Mclver &
Fairbrother, 1995).
Our experience with the target population and the growing body of empirical support has led
us to propose five broad groupings of faulty beliefs and related appraisals that may be present among

Table 1. Endorsement of typical interpretations of thoughts by patients with obsessional ruminations

Interpretation Endorsement
(%)
If I think about it l will become very anxious 92
Thinking about it increases the chances that it will happen 88
One should always have control of one's thoughts 72
Having the thought means that I am not like other people 72
If I start to think about it, I have to keep on thinking about it until 1 have dealt with it 68
If I start to think about it, I will be unable to stop 68
Thinking about it a lot means that it is really important otherwise I wouldn't think about it 68
Thinking about it means that I am going crazy 64
Having this type of thought is dangerous for myself and for others 56
if I think about it now I will be unable to do things that I have to do 52
Having this type of thought means that I will lose control and become violent 48
Thinking about it means that I will never get better 48
Thinking about it means that I am a bad person 40
If I think about it while 1 am doing something, it completely ruins whatever it is I am doing 40
Having a violent thought means that I will really do it 32
At least one additional interpretation 72
At least two additional interpretations 32
At least three additional interpretations 24
Note: N = 29.
 Obsessional thoughts 435

OCD patients. These beliefs and appraisals may apply either to the thought's occurrence, or to its
presence, or to both.

(1) Overestimating the importance of the thoughts and its derivatives such as distorted Cartesian
thinking, fusion of thought and action, and magical thinking (Freeston, Ladouceur, Gagnon
& Thibodeau, 1993; Freeston, Ladouceur, Rh6aume & Letarte, 1994; McFall & Woller-
sheim, 1979; Rachman, 1993; Rachman et al., 1995; Salkovskis, 1985, 1989a, b).
(2) Exaggerated responsibility for events beyond the control of the individual and the conse-
quences of being responsible for harmful events (Freeston et al., 1993; Ladouceur, Rh6aume,
Freeston, Aublet, Jean, Lachance, Langlois & De Pokomandy-Morin, 1995; Ladouceur,
L~ger & Rh6aume, 1995; McFall & Wollersheim, 1979; Rachman, 1993; Rh~aume,
Ladouceur, Freeston & Letarte, 1995; Salkovskis, 1985, 1989a, b; Salkovskis et al., 1995; van
Oppen & Arntz, 1994).
(3) Need to seek a perfect state such as the absolute certainty or completeness or perfect control
over thoughts and actions (Baer, 1994; Clark & Purdon, 1993; Ladouceur, Freeston,
Gagnon, Thibodeau & Dumont, 1994; Liebowitz & Hollander, 1991; McFall & Wollersheim,
1979; Rachman & Hodgson, 1980; Rasmussen & Eisen, 1991; Rh6aume, Freeston, Dugas,
Letarte & Ladouceur, 1995; Steketee, 1993).
(4) Overestimation of the probability and the severity of the consequences of negative events
(Carr, 1974; van Oppen & Arntz, 1994; Ladouceur et al., 1995; Rh6aume, Ladouceur,
Freeston & Letarte, 1994, 1995; Salkovskis & Westbrook, 1987; Steketee, 1993; Warren &
Zgourides, 1991).
(5) Beliefs that anxiety caused by the thoughts is unacceptable and/or dangerous (Steketee &
Foa, 1985; McFall & Wollersheim, 1979; Riggs & Foa, 1993; Warren & Zgourides, 1991).
These dimensions are not necessarily orthogonal: harming obsessions may involve some degree
of faulty appraisals of the importance of thoughts such as thought-action fusion and the
consequences of anxiety in increasing this likelihood, whereas doubts about possible mistakes may
involve overestimating the probability and severity of danger, magical thinking, as well as
exaggerated responsibility. The five groupings represent a broader analysis and may be less
parsimonious at a theoretical level than some other accounts but reflect our clinical experience with
these patients. We are continuing to study these types of interpretations among OCD patients using
appropriate control groups of clinically anxious patients. A series of clinical studies are also
underway with the goal of documenting clinical change during treatment (Freeston & Ladouceur,
1995b)

COGNITIVE TECHNIQUES FOR OBSESSIVE T H O U G H T S

Cognitive techniques may target any one of a number of different themes that are commonly
observed in patients with obsessional thoughts. We have used cognitive techniques in three ways
with patients without overt compulsions. In the first way they may be used as a means of facilitating
exposure by first addressing patients' concerns such as the power of thoughts to cause actions, the
nature of responsibility, and the consequences of anxiety. They are a prerequisite or corequisite
for effective exposure.
In the second way they may be used as a supplement to exposure in order to fully integrate the
new information generated by exposure, encourage generalization, and create conditions that will
minimize the chances of relapse. Thus for some patients, selected targets may be addressed very
early in therapy whereas for others, cognitive targets will be addressed once the patient has
mastered the basics of exposure. Finally, we have had results which encourage the hope that
cognitive therapy without exposure and response prevention is possible for some patients with
obsessive thoughts (Freeston & Ladouceur, 1996a). For the time being, however, we recommend
a combination of exposure and response prevention and cognitive therapy.
Providing a cognitive-behavioral account of obsessions is the initial cognitive intervention. We
provide patients with basic data on: (1) the prevalence of OCD; (2) an extensive list of intrusive
thoughts from community samples who do not consult for their thoughts; (3) the prevalence of
436 Mark H. Freeston et al.

such thoughts; and (4) the similarities and differences between community samples and patients
who consult (i.e. it is not the presence of the thoughts but the degree of distress, effort, frequency
and duration that differs). It should be noted that when we use exposure and response prevention
it is presented within the context of a cognitive account of obsessional thoughts. The individualized
model presented to the patient provides an alternative non-pathological explanation of their
obsessive symptoms. This model is presented in some detail and is referred to throughout treatment
to explain why some things worked such as successful exposure tasks, why others did not, and why
symptoms are decreasing or temporarily flaring up. In this sense we use an explicitly cognitive
approach with the aim of changing not only symptom levels but the patients' implicit account of
their difficulties (see also Salkovskis, 1991). For example, we would help a patient with aggressive
thoughts to change a working model from "I have crazy thoughts that mean that I am very
dangerous" to "I have thoughts that seem crazy and that I interpret in a way that makes me
anxious". Exposure may result in habituation to the anxiety response but it may also be
conceptualized as a behavioral experiment that will test predictions based on dysfunctional
appraisals of the obsession such as anxiety never decreasing, that thinking something means that
it will happen, etc.
Consistent with this overall approach, we target specific examples of faulty appraisals that lead
to neutralizing activity and distress. Once target appraisals have been identified, a variety of
techniques may be used, limited only by the therapist's creativity and the patient's ability to actively
participate. One of the best ways of identifying underlying assumptions is to use the 'downward
arrow' (Burns, 1980) also known as the 'so what happens next?' technique where the original
thought is examined sequentially for proximal and distal consequences. It is not uncommon in the
course of this technique to find several types of underlying assumptions: for example, appraisals
of excessive harm are often based on faulty appraisals of the severity and probability of
consequences as well as exaggerated responsibility. The appraisals and underlying beliefs can be
challenged by any appropriate technique. The second part of this paper will present a number of
examples of interventions that have proven useful with patients. However, we will first make a few
general comments about the use of cognitive techniques with obsessive thoughts.
The importance of continued behavioral analysis cannot be overemphasized. For example, if
behavioral experiments are avoided, it is important to identify what is driving the avoidance
behavior: an experiment to test feelings of responsibility may be refused if the person still believes
that the likelihood of danger is too high. Conversely, if the consequences of being responsible are
too awful, the task will be avoided even if the probability is minimal. Likewise, deeper levels of
meaning may not be easily identified at the first attempt with the downward arrow because patients
have often been avoiding thinking or talking about these possibilities for many years. In many cases
this may reflect the patient's fears of being hospitalized, losing their children, or some other
consquence. For example, in many cases the idea "I must control my thoughts" is accompanied
by an implicit "or e l s e . . . " , even though the consequence (e.g. "or else I will lose control of my
actions and will become crazy") may not be immediately accessible, or if accessible not revealed.
The therapist can address these concerns directly by distinguishing between wanting to do things
and being afraid of doing things. Thus we sometimes observe a process that may be compared to
peeling an onion where the patient comes back with "what we were talking about last week doesn't
bother me anymore, what really bothers me is . . . " until the ultimate consequence is reached.
Finally, if seemingly new obsessional thoughts or target situations emerge it is likely that a common
underlying interpretation has been missed (Riggs & Foa, 1993). In all these cases we refer back
to the original model and add the newly acquired information about the underlying beliefs.
It is important to keep in mind that arguing about minor probabilities or subtle details has long
been recognized as a pitfall with OCD patients and is likely to waste time without convincing the
patient (Rachman & Hodgson, 1980). It may indeed be counter-productive for the therapist to
provide information in the realm of general everyday living because this may provide a source of
reassurance allowing the transfer of responsibility to the therapist. Aiding the patient to generate
the new information is more helpful, for example, by asking how a respected colleague, family
member, or neighbor would think or act in the situation. Discussions about small details are often
aimed at the probability or causality of feared consequences which, although they provide the
content of the threat, can distract from responsibility, overimportance of thoughts, or the need for
 Obsessional thoughts 437

certainty which may be more important in OCD. Thus, the emphasis should always be on designing
appropriate behavioral experiments that will allow the patient to test alternative hypotheses
developed with the therapist.
Another potential problem is the propensity of some patients to incorporate cognitive techniques
into their repertoire of neutralizing strategies. We have developed a number of guidelines to help
patients resolve their occasional confusion between neutralizing and adequate appraisal. First,
adequate appraisal is always to allow the patient to act in an appropriate non-neutralizing manner;
this normally means confronting the situation or thought. Second, adequate appraisal does not
need to be repeated each time the person is confronted with the thought or situation; if the person
finds herself repeating the same cognitive analysis, this is a sign that neutralization is probably
taking place. Third, new information is useful in adequately appraising new situations; excessive
information seeking, or checking on previously obtained information is also a sign that neutraliz-
ation is probably taking place. Finally, if the person is not sure, the optimal strategy is to confront
the situation or thought. We then suggest a response delay for the cognitive analysis: it can always
be conducted at some other point in time when the person is not just trying to remove feelings
of discomfort, responsibility, etc.
It is important to remember that at the start of treatment, the patient does not believe that there
is an alternative way to appraise the thoughts or situations related to the obsession. Patients may
agree that the alternative is logical and can accept the possibility intellectually but that they have
always believed that their way of looking at things was the only correct way and do not expect
to change (Teasdale, 1993). It is best not to force the issue immediately and to accept the two points
of view and agree to review the evidence on a regular basis as the therapy proceeds. To open up
the possibility that beliefs can change, the therapist can look for other beliefs that have been
modified because they have proven to be no longer useful, or to be untrue, or even harmful. For
example the belief "smoking doesn't harm me" or "I could stop when I wanted to" is a good
example for ex-smokers. Other beliefs that have been changed over time may be found with dietary
habits, seatbelt use, bicycle helmets, religious practice, etc. The idea is to show that beliefs may
be changed voluntarily when they are no longer true or when they are harmful.
Finally, some patients are reluctant to admit that they are improving because to do so would
superstitiously (by magical thinking) cause a relapse. Alternatively they "couldn't stand the
disappointment" if the symptoms returned. In the first case the thought-action fusion present
should be challenged (see examples below). In the second case emphasis should be placed on a
coping model of knowing what to do when symptoms occur in the context of relapse prevention.
In both cases the beliefs should be challenged so that the patient adequately attributes improvement
to his or her own behavior in challenging faulty appraisals and acting consequently.

SPECIFIC INTERVENTIONS
Over-estimation of the importance of thoughts
This occurs in several forms and subsumes what we have referred to as distorted Cartesian
reasoning (Freeston et al., 1994), two forms of thought-action fusion that Rachman and colleagues
(1995) have labelled Likelihood and Moral Thought Action Fusion, and in its most extreme form
we find superstitious or magical thinking. The Oxford group led by Paul Salkovskis would probably
include most of what we have labelled as the overimportance of thoughts under responsibility based
on the basis that thinking about something makes the person implicity responsible (Salkovkis et al.,
1995). Although their analysis neatly links intrusive thoughts to responsibility, we have found it
useful with patients to address overimportance of thoughts and responsibility separately as two
types of faulty appraisal which may often be related. As Rachman (1993) states: "Given that
affected people attach undue significance to their intrusive thoughts, this over-interpretation can
become entangled with their exaggerated sense of responsibility" (p. 151).
Distorted cartesian reasoning. This error is based on the simple idea that the mere presence of
the thought gives it some status: "It must be important because I think about it and I think about
it because it is important". We explain the circularity of this reasoning using a local sausage
advertisement explaining that people buy more of this brand of sausages because they are fresh
438 Mark H. Freeston et al.

and they are fresh because people buy more! Other variants include " I f I think about it that means
that I secretly want to" or "it reflects my true nature". In fact one patient with harming obsessions
believed that her thought reflected "a seed of evil within her".
The cognitive model is used to explain how thought suppression can explain the occurrence of
unwanted thoughts. Behavioral experiments can be conducted using the suppression paradigm, not
only for short term enhancement or rebound effects, but also over the following days (by
self-monitoring). Here an unimportant thought is targeted and subjected to the suppression task
("For the next five minutes do not think about . . . " ) . To challenge the belief "it is important
because I think about it", thought sampling or thought recording methods can be used to show
that many unimportant thoughts occur. Finally, we have used attentionai experiments to show that
deciding something is arbitrarily important can increase its salience and the degree of preoccupa-
tion. With somatic obsessions we asked the patient to focus intensely on a part of the body not
previously associated with any obsessions (e.g. the tip of the nose) and monitoring subsequent
preoccupation. Alternatively the patient can be asked to notice all the occurrences of an everyday
object.
Likelihood thought-action fusion. A married woman had horrific images of her husband in a car
accident and used a prayer to counter the image each time. Here is the downward arrow associated
with this thought.
If I keep on thinking about my husband having an accident
and don't pray each time, he will have an accident
l
It will be my fault
l
I could never forgive myself

I would become depressed and commit suicide.

The key assumption here is that thoughts can increase the probability of an event or can even
cause events. Note that in this form of thought-action fusion, responsibility is quite evident and
makes the consequence even more awful. One way that we have successfully challenged the belief
about increased likelihood is with behavioral experiments. For example, the patient buys a lottery
ticket on Monday and thinks repetitively about winning the jackpot for half an hour a day all week
(chances are 1 in 14,000,000 for the most popular lottery in Quebec). Alternatively, a minor
household appliance is identified that is known to be in good working order (e.g. a toaster). The
patient thinks 100 times a day that the appliance will break down within the next week. The
outcome is then compared to the prediction. Another suggestion that has been used is to try to
kill a goldfish by thought action. Although as yet no patient has actually taken up the task,
proposing the idea has proved useful in challenging beliefs about thought-action fusion.
Moral thought-action fusion. A second example is based on the idea that thinking is as bad as
doing. In this example, a young woman patient reported personally unacceptable sexual images
since early adolescence. The downward arrow identified the following sequence
Sexual image
l
These thoughts are unacceptable
l
I should not have these thoughts and should control them

If I cannot control them I am not like everybody else

l
If they excite me it means that I must really want to do that
l
I am a perverted, morally bad person.
The key assumption here is that some thoughts are unacceptable and are morally equivalent to
the action. In this case occasional arousal in response to the thoughts was highly distressing for
the patient. We have successfully challenged this type of belief by: (1) introducing new information;
 Obsessional thoughts 439

and (2) distingushing between thoughts and action. Three types of information were pertinent here.
First, the patient was informed that a wide range of novel erotic stimuli, especially taboo subjects,
unrelated to preferred sexual behavior, can lead to arousal. Second, the relationship between
anxiety and sexual arousal was discussed (Warwick & Salkovskis, 1990). Third, readings such as
My secret garden by Nancy Friday, a compendium of women's sexual fantasies, established that
women can think about a lot of different sexual thoughts and thus enlarge a sense of normality.
Two interventions were used to distinguish between thoughts and action. First, the patient
identified personally acceptable sexual thoughts that she had not wanted to act on and had not
acted on. Second, morality was defined as actively choosing to act or not to act upon a number
of different possibilities according to values and principles. Thus, the occurrence of thoughts is not
related to morality; choosing to act on thoughts or not is a function of morality.
One particularly effective way of normalizing thoughts is to ask the patient to talk to people in
whom they have confidence about the types of strange thoughts that they experience. Although
effective, patients are often reluctant as they are secretive about their obsessions. In one case, a
patient used a questionnaire measure (the Obsessive Intrusive Thoughts Inventory, Purdon &
Clark, 1993) which is a list of highly-egodystonic thoughts to conduct her own survey among 10
of her peers.
Superstitious or magical thinking. In this form we find a particularly strong form of
thought-action fusion where, for example, numbers become associated with safety or danger. This
then leads to repetition of neutralizing actions a safe number of times or avoiding objects, actions
or events that contain a dangerous number. Letters and colors may also be involved. We have
found this type of appraisal particularly difficult to modify for a number of reasons. First, in our
experience the level of conviction is often very high and in some cases would fall within the 'poor
insight' sub-type proposed by DSM-IV (American Psychiatric Association (APA), 1994). Second
the feared catastrophes normally involve family members and the consequences are subjectively too
awful for the patient to risk any change. Third, in most other cases of thought-action fusion there
is a mixture of possible causality by normal real world mechanisms where the likelihood of an
already possible negative outcome is increased by thought-action fusion. However, in this extreme
form there is either absolutely no causal mechanism other than thought-action fusion and from
the patients' standpoint they are totally responsible, or that even in the presence of other
contributing factors they retain the pivotal responsibility as if they are "the straw that broke the
camel's back". The fact that the possible danger may not be imminent but at some undetermined
point in the distant future only complicated matters. Thus it is hard to design behavioral
experiments that are either acceptable to the patient or that if acceptable, are considered to be a
reasonable test of the underlying beliefs by the patient. These patients are also likely to refuse
exposure for the same reasons. One possible avenue that has proved useful in some cases is to
concentrate on the arbitrary nature of some of the associations between the number (or letter, or
color, etc.) and safety or danger. Alternatively, giving the patient a brief holiday from responsibility
(Rachman, 1983) may enable the magical thinking to be addressed.

Responsibility
As van Oppen and Arntz (1994) have provided an in-depth discussion of targeting responsibility,
we will not provide a detailed example but will comment on a number of issues. We have found
that the key to challenging responsibility appraisals is to first establish an awareness (e.g. by self
monitoring) of situations where the patient takes excessive responsibility. Emotional cues such as
feeling guilty or uncomfortable about something are often the best way of detecting excessive
responsibility. When patients take excessive responsibility for specific events, one way of demon-
strating the excessive nature is to transfer responsibility (on a temporary basis) to the therapist
through a contract for any harm that will occur during a specified period (Rachman, 1993).
Thoughts, behavior and reactions are then monitored and compared to a similar period when the
responsibility is re-transferred to the patient. A less formal demonstration that has proved useful
is by the patient predicting his or her reactions (cognitive, emotional, or behavioral) when
responsibility is transferred to someone else, for example, if someone is paid a large sum to take
care of the situation. The patient is asked, "would you still neutralize if you had paid $30,000 to
440 Mark H. Freeston et al.

Table 2. Example of correction of the need for certainty

Advantages Disadvantages

Knowing that 1 know Self-doubt and frustration when I

Certainty aboul a few things
don't succeed (most of the time)
Reading less
Loss of pleasure in reading
Preoccupation and distraction,
fatigue

a person for driving behind you to make sure that you had not hit someone?" Lopatka and
Rachman (1995) provide a list of additional ways that responsibility may be challenged.
An additional way to challenge appraisals of responsibility is for the patient to act as prosecuting
attorney and/or defense attorney to argue the case. It is often more difficult for the patient to be
the prosecuting attorney because usually the only evidence of guilt (i.e. responsibility) is, by
emotional reasoning, their subjective feeling of guilt. The patient must instead prove his 'guilt' by
finding solid arguments with real empirical proof ("What are the facts?"). When the patient plays
both roles, he can consider and compare two opposing points of view, thus highlighting the
modifiable nature of the appraisal. The role of the therapist is to play the judge and 'strike from
the record' inadmissible evidence such as hearsay ("I once heard t h a t . . . " ) or irrational arguments.

Perfectionism
Perfectionistic appraisals exist in a number of forms and seem to be based on the idea that a
perfect state can exist. Although obsessions of symmetry, completeness and 'just right' phenomena
in compulsive behavior are well known forms of perfectionism (Rasmusen & Eisen, 1991), other
forms observed with patients without overt compulsions include the need for certainty or the need
to know, and, in some cases, the need for control.
Need for certainty. A young male graduate student with a range of obsessions related to different
ambiguities had repeated obsessions that he had not perfectly understood things he had read. His
reading slowed, he took less pleasure in reading, and would become distracted in other tasks by
trying to see whether he had understood what he had read by explaining the text to himself.
What if I didn't understand everything I read

It's as if I understood nothing

I won't know what I need to know

|'11 end up knowing nothing

I'll fail
This was challenged in three ways. First, the dichotomous thinking (If I didn't understand
everything then it is as if I understood nothing) was identified and challenged. Second, the
advantages and disadvantages of trying to understand everything perfectly were exposed (Table 2).
Once the advantages and disadvantages were established, the validity of the advantages was
challenged. In this case the patient had to identify the number of times he was certain of what he
had read. In fact (as may be predicted) he admitted this happened extremely infrequently if at all.
Thus, not only was he: (1) engaged in the fruitless pursuit of so-called advantages that almost never
happened; but (2) he also suffered all the disadvantages of seeking perfect understanding. This
opened the door to modify the underlying beliefs by a change in behavior.
To challenge the prediction ("If I don't understand everything that I read, I won't know what
I need to know"), a behavioral experiment was devised. He first divided things into three categories.
(1) Things that only have to be read in summary fashion (publicity, brochures, junk mail,
newspapers etc.)
 Obsessional thoughts 441

(2) Things that have to be read and understood in general terms (background reading, reading
for pleasure)
(3) Things that have to be read and well understood (exam material, job applications, etc.).
In the first category things were to be read as fast as possible. In the second category, the first page
was read at his normal speed, subsequent pages were to be read ~ faster. The third category
remained unchanged for the time being. Not only was the prediction not true, but the patient found
that his pleasure increased, his speed increased, distraction decreased and he ended up knowing
more because he read more and worried less. He was eventually able to take a third category (i.e.
important) text and read some parts faster than others, according to their relative importance.
Need to know. The perfectionistic desire for complete certainty or the 'need to know' may take
other forms. The following example shows how two or more appraisals may be simultaneously
involved. A 38 yr old teacher had a wide range of obsessions about harm occurring to people in
improbable situations such as a child falling into an empty grave and then being buried alive, a
baby being left in a freezer in the supermarket, or an old person lying in a ditch at the side of the
road. These obsessions were triggered when he was not sure whether he had seen something that
may have been someone in danger. He was originally bewildered by the unremitting stream of
apparently unrelated sources of potential disaster, all of which he might be able to prevent.
Neutralization consisted of 'running the film', transferring responsibility to others, finding reasons
why he could not go and check, and occasional checking behavior. Initial interventions targeted
two aspects.
First, the wide ranging obsessions were analyzed for their common themes. The obsessions were
always about statistically improbable events happening to the very young, the very old or the sick
i.e. helpless people: the patient did not have obsessions about healthy people aged 15-50. The
obsessions were redefined as a single general obsession where the patient would 'fill in the blanks'
according to the situation: "I think I have seen something white move near an open grave that might
possibly be a small child who may f a l l in and be buried alive and I might be held responsible for
not saving him/her, I would feel guilty all my life". This intervention helped the patient gain some
sense of control. Next, excessive responsibility taking was identified distinguishing between being
a 'good citizen' and 'everybody's guardian angel' where the former means responding appropriately
when, for example, actually seeing someone who is really hurt, and the latter means trying to make
sure that no one is in danger of any type of improbable harm when there is no evidence that it
is in fact true. Using the 'pie technique' on a series of such obsessions, the patient was able to
attribute responsibility more appropriately.
These two interventions had some effect and enable the patient to stop transferring responsibility
to others, normally his wife, or cognitively neutralizing by trying to remember what he had seen,
or giving himself 'valid' reasons why he could not go and check thereby decreasing his responsibility
(e.g. "I have to go and pick up my children"). Despite adequate appraisals of responsibility and
acceptance that these were extremely unlikely events, he remained upset by the fact that he would
never know for sure: "I know that it's highly unlikely that it will occur and that even if it did my
responsibility is minimal, but I will never know for sure if there really was someone there". In fact,
in several cases he was more concerned about not knowing for certain, than whether the supposed
victim was dead or alive.
The most intense obsessions were normally associated with moments where he would no longer
be able to go and check, for example, when the hole was filled or when he returned home after
holidays, even though he may have first observed something indicating that someone was possibly
in danger several days previously. It was more important to know whether or not he had really
seen something: the person would be long dead if the scenario were true. If responsibility was the
main concern here, checking would probably have taken place.
The most effective technique to challenge the belief that certainty was necessary was reframing
response prevention as a behavioral experiment where the patient observed his 'need to know for
sure'. When an obsession occurred, he was to take the risk of not acting on it (i.e. no mental or
physical strategies to check out the truth or divest himself of responsibility) and to watch how his
'need to know' responded. On each occasion where he resisted neutralizing, his need to know about
the particular event quickly faded and did not come back despite fears that he would become 'stuck'
 442 Mark H. Freeston et al.

with the uncertainty. Each of these events was then added to a mental pile of "things that I do
not need to know for sure".
This example raises the question about which is more fundamental here. Was responsibility more
or less fundamental than the need for perfect certainty? Did the patient need to know because of
the inflated responsibility? We have seen cases of responsibility without the need for perfect
certainty: " I f I am not responsible then it doesn't matter, I don't need to know". We have also
seen a case where ambiguity itself was aversive, where no consequences were foreseen: "Ambiguity
just makes me uncomfortable, I just don't feel right until I have resolved it or until something else
distracts me". Both were present in the current example and needed to be addressed. With both
exaggerated responsibility and perfectionistic attitudes behavioral experiments are useful such as
deliberately making a small error, changing a rigid habit, or provoking ambiguous situations and
then predicting the specific negative consequences and comparing them to the real outcome. When
appropriately reframed, these experiments enable more accurate predictions to be made and will
change more general beliefs.
Need for control. Generally the need for control, especially the need to control thoughts, is found
at an intermediate level in the downward arrow and further questioning will reveal ideas about
thought-action fusion, responsibility, or predictions of catastrophe. However in rare cases the need
for control is an end in itself. One patient avoided a range of pleasurable activities because unrelated
thoughts (notnecessarily objectively unpleasant) might intrude thereby spoiling the experience.
This idea was challenged by first examining the feasibility of thought control by behavioral
experiments on concentration and suppression (trying to think exclusively about something and
then trying not to think about something). Second, the advantages and disadvantages of holding
this belief were examined. Third, the patient was instructed to predict his level of enjoyment before
an activity, then complete the activity regardless of thoughts that may arise and rate his actual level
of enjoyment.
One final comment on working with patients with perfectionistic attitudes. It may be important
for the therapist to have a more flexible attitude to homework assignments. One patient even
reported that she did not 'deserve' to get better because she was not as compliant as she felt she
should have been. It is hard to model that seeking perfection is a pointless and counterproductive
exercise if insisting on very high performance standards. The importance of a coping model rather
than a mastery model is very important here: to avoid self criticism, demoralization, and
abandoning assignments, success must be defined as a good effort resulting in a passing grade.
Using a metaphor appropriate in Quebec and the prevalence of winter sports: therapeutic
assignments are not figure skating, there are no points for artistic merit, only for getting across
the ice in one piece. Negotiating the fine line between flexible attitudes to performance and implicit
tolerance of avoidance behavior can be tricky and should be addressed explicitly. Finally, some
patients set increasingly (and impossibly) high treatment outcome goals such as the absence and
continuing absence of any obsessive thought. Once again it is important to review the model and
show the impossibility of such a goal and to reframe the increasing expectations within the context
of dysfunctional perfectionism.

Overinterpretation of threat
This has been dealt with in some length by van Oppen and Arntz (1994) so will only be
commented on briefly here. At a theoretical level, overestimating the probability and severity of
negative outcomes is generally not specific to OCD, it is a general characteristic of anxiety disorders
(Mathews, 1990; Salkovskis, 1991). In OCD these faulty appraisals provide negative outcomes for
which the individual will assume responsibility. The overinterpretation of threat thus provides the
substrate for subsequent appraisals of responsibility (Ladouceur et al., 1995; Rh~aume et al., 1994,
1995). It can be useful to address the overinterpretation of threat and predict more realistic
consequences to facilitate exposure, behavioral experiments etc. However, adequate appraisals of
severity and probability of outcome are unlikely to be sufficient or produce lasting therapeutic gains
if beliefs about responsibility, the need for certainty, or the overimportance of thoughts remain
unchallenged. Some scenarios are so catastrophic that even a minute possibility of being responsible
for the outcome is unacceptable. It is crucial to address the appraisals that are putatively more
 Obsessional thoughts 443

specific to OCD such as the overimportance of thoughts, excessive responsibility, and the forms
of perfectionism such as the need for certainty described above.

Consequences of anxiety
At a theoretical level, beliefs about the consequences of anxiety and discomfort are not thought
to be central to the development of OCD but may play an important maintaining role. Such beliefs
can drive some forms of neutralizing and avoidance behavior and will thus prevent discomfirmation
of more central faulty beliefs and appraisals. It is also one of the most important obstacles to
successful exposure. These beliefs occur in two main forms: "anxiety is dangerous"; and "anxiety
stops me from functioning". Note that in both cases the concern may be about the immediate
consequences of anxiety or can apply to some future moment when anxiety may return.
Anxiety is dangerous. We have often observed the first type of belief about anxiety among people
with aggressive and motor urges. In this case, a 33 yr old woman had obsessional thoughts about
calling out insults and swear words. The worst place that these thoughts could occur was on the
bus.
What if I cry out 'You bastard!'
l
If I have this thought on the bus I might become very anxious
l
If I become very anxious I will lose control
l
If I lose control I may actually cry out 'You bastard!' when I'm on the bus
l
Everyone will look at me
l
I will be so out of control that I will go completely crazy
l
They will call the psychiatric hospital
1
They will come and get me in an ambulance
l
They will lock me up
1
I will never see my family again
l
I would die of shame.
Notice how anxiety provides a link in a thought-action fusion chain: thought~anxiety--*action.
In the absence of anxiety the patient did not believe that the thought would lead to action. In fact
feeling anxious for any reason led to avoidance behavior and the patient could only take the bus
on 'good days' when she felt calm. This type of thought usually lends itself very well to exposure.
The normal procedure would be record the scenario on a looped tape (where the scenario goes right
through to the ultimate consequence, dying of shame), listening to the tape repeatedly while not
neutralizing, and then listening to the tape and/or forming the obsessional thought in the target
situation.
However, the patient's fears about anxiety prevented successful exposure. These were addressed
by a variety of means. First, more detailed information was given on anxiety and on its
consequences. Second, all previous occasions where she was anxious and had 'lost control' were
analyzed. For example, when she 'lost control' in the bank: "So what did you do? Scream at the
top of your voice? Fall down? Attack someone?" It was thus established that she had never actually
lost control but was afraid of losing control. Third, anxiety induction techniques similar to
strategies used in the treatment of panic can be used as a behavioral experiment to show that
symptoms of anxiety such as depersonalization, distorted visual perceptions etc. are typical
symptoms of acute anxiety. Once anxious, patients can be asked to 'lose control' which inevitably
leads patients to the conclusion that they are unable, even in this state. These types of intervention
444 Mark H. Freeston et al.

centered on the role of anxiety rather than on the thought as such will then allow functional
exposure to the thought with its dramatic consequences. We have seen this type of thinking with
other harming obsessions where the patient is not afraid of actually harming the person, but fears
becoming anxious to the point where they will 'go crazy' because of the anxiety.
The second type of interpretation, the idea that anxiety prevents the person from functioning,
can also be an obstacle to effective exposure, particularly when generalizing exposure and response
prevention to naturally occurring thoughts. This can be addressed by both retrospective and
prospective methods. As many of our clients were still employed and were anxious much of the
time, retrospective evidence was collected that despite anxiety, they continued to perform, even if
not at maximum performance (it is useful to address the perfectionistic idea about needing to
perform at a maximum level all the time, comparison with peers etc.). Patients in fact often report
that although obsessions may be very intense before or after an important event, they are absent
during the event itself. However this has not previously modified the prediction that obsessions will
occur during the event and that they will be unable to cope. Prospective predictions about
performance on specific simpler tasks are made, the patient is then instructed to expose to target
thoughts and observe real performance while anxious. Real performance is then compared to
predicted performance. The idea is both to correct the patient's expectations and to establish that
even when obsessions occur, the patient has the ability to function regardless. One instruction that
has been useful is to "notice the thought's presence but don't react to it, don't block it out, watch
it come and then watch it slowly go".
Finally, we have seen cases where as patients lose the conviction that their thought is actually
true (i.e. threat exists) they may still be tempted to neutralize so that they will not be 'stuck with
the obsession' and become anxious at some later date: "I can deal with it now, but what happens
if I panic tomorrow". Here it is the belief that future anxiety should be avoided which leads to
proactive neutralizing such as reassurance seeking or avoidance. Two interventions are indicated
here. First, it is important to return to the original model that states: (1) neutralizing guarantees
that the thought will return (the 'white bear' or 'camel' effect); and (2) not neutralizing leads to
the thought's disappearance. Explicitly reviewing of what happened on previous occasions and
identifying the pros and cons of neutralizing are usually sufficient for the patient to convince himself
to stay on the right track.

CONCLUDING REMARKS
The cognitive therapy of OCD is still in its infancy. Despite earlier work by Emmelkamp and
colleagues (Emmelkamp, van der Helm, van Zanten & Plochg, 1980; Emmelkamp, Visser &
Hoekstra, 1988; Emmelkamp & Beens, 1991), it is only recently that specific cognitive strategies
have been developed for OCD based on detailed analysis of the clinical features of OCD patients
(e.g. Freeston & Ladouceur, 1996b; Ladouceur et al., 1994; Ladouceur, Freeston, Gagnon,
Thibodeau & Dumont, 1994, 1995; Ladouceur, L+ger & Rh6aume, 1995; van Oppen, de Haan, van
Balkom, Spinhoven, Hoogduin & van Dyck, 1995). Two recent studies support the efficacy of
specific cognitive therapies with compulsive patients (van Oppen et al., 1995; Ladouceur, L~ger &
Rh+aume, 1995) and we have preliminary evidence that the efficacy of purely cognitive techniques
(no exposure and response prevention) can extend to obsessional ruminators. Although some
specific types of beliefs are likely to vary according to the sub-type of obsessive-compulsive
symptoms (e.g. washer vs checker vs ruminator) they may also vary within a given sub-type (see
Rachman, 1994, for a detailed analysis of three distinct profiles of washing and cleaning
compulsions). Thus, there is every reason to believe that individual analysis is the key to effective
treatment. Determining the optimal order of treatment for the cognitive targets described here is
a problem that can be addressed clinically. A case formulation approach (e.g. Persons, 1989)
requires formulating clinical hypotheses about the relative importance and interactions between the
different types of beliefs and appraisals based on an idiographic analysis. We are currently piloting
this type of approach using an independent evaluator who has access to standardized information
(structured interview and questionnaires) and a therapist who uses information from focused
clinical interviews. These two viewpoints are then used for a joint case formulation that will
determine the targets and the order in which they will initially be targeted.
 Obsessional thoughts 445

There are a number of important issues to be addressed. For example, DSM-IV (APA, 1994)
includes a sub-type of OCD with poor insight supported by field trials that identified 8% of 431
patients who were rated as currently lacking insight (Foa & Kozak, 1995). Further, 30% of 250
patients who feared that harmful consequences would occur were mostly or completely certain that
the consequence would in fact occur (Foa & Kozak, 1995). The question can be raised as to whether
beliefs that are strongly held, and that can lead some obsessions to be perceived as more
egosyntonic, are as amenable to cognitive interventions. Likewise, the optimal conditions for
working on irrational beliefs and faulty appraisals may well depend on mood-state (see Persons
& Miranda, 1991, for a discussion) given that the strength of beliefs and appraisals covaries with
mood state (Freeston & Ladouceur, 1995b). The presence of comorbid disorders may have an
impact on the ease of belief change, where, for example panic attacks may contribute to an ongoing
sense of loss of control, or excessive worry may help maintain beliefs about the importance and
possible benefits of some types of cognitive activity. We strongly believe that cognitive therapy
techniques will have an impact on the treatment of obsessional thoughts both by complementing
and potentiating existing exposure and response prevention packages and even by eliminating the
need for massed exposure in some cases, but also by extending the benefit of treatments aimed at
rapid and lasting symptom reduction to those Ss who refuse exposure and response prevention.

Acknowledgements--The manuscript was completed while the first author was supported by a fellowship from le Centre
de recherche, Universit+ Laval Robert-Giffard. This work was supported in part by le Fonds de la Recherche en Sant6 du
Quebec (FRSQ), and by the Medical Research Council of Canada.

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