ARTICLE IN PRESS

Behaviour Research and Therapy xxx (2009) 1–9

Contents lists available at ScienceDirect

Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

Treatment of obsessions: A randomized controlled trial

Maureen L. Whittal a, b, *, Sheila R. Woody b, Peter D. McLean b, S.J. Rachman b, Melisa Robichaud a, b
a
University of British Columbia Hospital, Vancouver, BC, Canada V6T 2A1
b
Department of Psychiatry, University of British Columbia and the Vancouver CBT Centre, Canada

a r t i c l e i n f o a b s t r a c t

Article history: This study tested Rachman’s cognitive behavioral method for treating obsessions not accompanied by
Received 8 July 2009 prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and
Received in revised form an active and credible comparison of stress management training (SMT). Of the 73 adults who were
16 November 2009
randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treat-
Accepted 17 November 2009
ments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and
depression as well as improved social functioning. Overall, CBT and SMT showed large and similar
Keywords:
reductions in symptoms. Pre–post effect sizes on YBOCS Obsessions for CBT and SMT completers was
Obsessions
Cognitive therapy d ¼ 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom
Stress management measures immediately after treatment, these differences were no longer apparent in the follow-up
period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive
changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The
robust and enduring effects of both treatments contradict the long-standing belief that obsessions are
resistant to treatment.
Ó 2009 Elsevier Ltd. All rights reserved.

To meet diagnostic criteria for obsessive–compulsive disorder
(OCD), an individual must experience recurrent, egodystonic,
anxiety-producing obsessions or excessive, ritualistic compulsive
behaviors (APA, 1994). Early OCD studies focused on people with
observable compulsive behaviors (e.g., checkers and washers), as
the overt nature of the compulsions was more easily adapted to the
behavioral treatment methods of the time. Covert compulsions and
obsessions were more difficult to address. Behavioral strategies of
imaginal or in vivo exposure to obsessions typically produce high
levels of anxiety and can be difficult to tolerate.
Occasional intrusive thoughts are common. Rachman and de
Silva (1978) and Salkovskis and Harrison (1984) indicated that at
least 90% of community and analogue samples report experiencing
unwanted intrusive thoughts, the content of which can be similar to
those reported by people with OCD. However, the meaning given to
these intrusions is believed to differentiate clinical from nonclinical
samples. Whereas the latter group tends to appraise intrusions as
relatively benign, individuals with OCD appraise the occurrence of
such thoughts as personally significant (i.e., having the thought
means I am ‘‘mad, bad, or dangerous’’).
* Corresponding author at: University of British Columbia, Vancouver, BC, Canada
V6T 2A1. Tel.: þ1 604 822 1789; fax: þ1 604 822 7452.
E-mail address: whittal@interchange.ubc.ca (M.L. Whittal).
Because these appraisals raise anxiety about the self and the
future, they also motivate efforts to neutralize the thought or
decrease the perceived probability of the feared event (e.g., acting
on the content of the thought) by avoidance or compulsive
behavior. For example, egodystonic intrusions of intentionally
harming children may be interpreted as signaling that the person is
evil and potentially dangerous and hence should avoid being alone
with children. Consistent with other cognitive theories, Rachman
(1997, 1998, 2003) emphasized that the appraisal of personal
significance, not the content of the thought, is pivotal in generating
the distress, frequency and behavioral disturbance associated with
obsessions. Cognitive–behavioral treatment derived from this
theory is designed to reduce or eliminate the person’s maladaptive
appraisals of the personal significance of the intrusive thoughts.
Just two randomized trials have examined the treatment of
obsessions without prominent overt compulsions. In one of these
trials, Freeston et al. (1997) used a combined treatment with
imaginal exposure (i.e., loop tape exposure to the obsession) as the
core of the treatment package but also included other cognitive
strategies. At post-test, 67% of the participants showed significant
change, declining to 53% at follow-up. These gains were produced
with considerable treatment effort (approximately 40 h/partici-
pant). Freeston, Leger, and Ladouceur (2001) subsequently pub-
lished a promising case series using cognitive therapy without
exposure. O’Connor et al. (2005) conducted a small randomized
controlled study with obsessionals who were treated with

0005-7967/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2009.11.010

Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
 ARTICLE IN PRESS
2 M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
individual versus group therapy using a combination of contem-
porary cognitive methods and ERP (loop tape or in vivo exposure to
obsessions). Both formats resulted in a significant decline in YBOCS
total scores from pre to post-treatment. Not surprisingly, individual
treatment produced a greater decline than group treatment.
To date there are no randomized trials examining the efficacy of
contemporary cognitive treatments in the absence of prolonged
and explicit imaginal or in vivo exposure for obsessions with few to
no overt compulsions. The current study sought to compare
Rachman’s (2003) cognitive behavior therapy for obsessionals with
few or no overt compulsions to a credible and active comparison
treatment of stress management training (SMT) as well as to
a waitlist control. This CBT does not use repetitive imaginal or
explicit in vivo exposure for the purpose of habituation. In a small
study (n ¼ 18), Lindsay, Crino, and Andrews (1997) compared the
efficacy of an SMT protocol to exposure treatment for broad-based
OCD. YBOCS scores were unchanged over the course of treatment
with SMT (mean YBOCS at pre ¼ 24.4 and post ¼ 25.9). As expected,
the exposure group showed significant decreases in YBOCS scores
at post-treatment.
Turning to the present study, in comparison to both the waitlist
control and SMT, CBT treatment was expected to produce
substantial reductions in OCD symptom severity; the YBOCS
Obsessions subscale was the primary outcome measure for the
study. Additional secondary outcomes (accompanying anxiety,
depression, and social functioning) were also expected to change
significantly with CBT. Importantly, CBT was expected to produce
a significant reduction in maladaptive appraisals of the personal
meanings of the thoughts as well as other OCD-related cognitions.
These changes were expected to be stable through a one-year
follow-up.
Method
Design
Participants were randomized to type of treatment (CBT or SMT)
and to a start time (immediate or 3-month delay). Treatment
consisted of 12 h-long individual sessions plus an information
gathering session following the diagnostic interview. Assessments
were completed at intake, following 12 weeks of waitlist for those
randomized to receive delayed treatment, and post-treatment, as
well as six and 12 months follow-up.
Based on previous research (Freeston et al., 1997; Lindsay et al.,
1997), the study was powered to test for large effect sizes in the
comparison of cognitive therapy with either stress management
training or waitlist control. These previous results led us to antic-
ipate large effect sizes for CBT and near-zero effect sizes for both
SMT and the waitlist control. Using the smallest effect size observed
in Freeston et al., 30 participants per condition would provide
statistical power greater than 0.80.
Participants
Participants were recruited between November 2002 and July
2006. Several methods were used to draw attention to the study
including television and print media, letters to local psychiatrists
and other mental health providers, a study website and physician
referral to our hospital-based anxiety disorders specialty treatment
clinic, where all treatment was subsequently conducted. Diagnoses
were based on the Structured Clinical Interview for DSM-IV (SCID;
First, Spitzer, Givvon, & Williams, 1996), and OCD severity was
assessed with the Yale-Brown Obsessive Compulsive Scale (YBOCS;
Goodman et al., 1989). Participants were provided a written
description of the study if they met the following inclusion criteria:
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
(a) primary diagnosis of OCD, (b) few or no overt compulsions, (c)
functional impairment from OCD for a minimum of one year, (d)
18–65 years of age, (e) fluency in written and spoken English, (f)
willingness to be randomized to type of treatment and start time,
(g) either free of psychoactive medications or on a stable medica-
tion regimen for three months prior to intake assessment and
willingness to refrain from making any medication changes
throughout treatment. Exclusion criteria included: (a) severe
depression with accompanying suicidal intent precluding ethical
randomization to delayed treatment, (b) organic mental disorder,
thought disorder, current alcohol or drug dependence, (c) concur-
rent psychological treatment for any Axis I or II disorder, aside from
marital therapy or supportive therapy for depression, (d) prior
adequate trial of CBT for OCD.
One hundred sixty-two individuals were judged appropriate for
clinical interview based on an initial telephone screening. Of these,
80 were excluded because they did not meet inclusion criteria; nine
individuals declined to participate in the study. Seventy-three
participants completed the initial evaluation, consented to partic-
ipate, and were randomized.
Treatments
CBT for obsessions was completed as described in the manual
published by Rachman (2003). Although treatments were individ-
ually tailored to the presenting obsession and the associated
appraisals and beliefs, treatment began by normalizing the pres-
ence of unwanted thoughts as indicated by previous analogue and
community studies (Rachman & de Silva, 1978; Salkovskis & Har-
rison, 1984) and illustrating the importance of the appraisal process
(e.g., ‘‘This is an odd thought but meaningless’’ versus ‘‘This thought
means I can’t be trusted around children’’). Participants received
a list of intrusions that have been reported by individuals who do
not have OCD (see Rachman, 2003) and were encouraged to talk
with others regarding unwanted thoughts. Participants were also
encouraged to use the list to identify additional unwanted thoughts
that are not upsetting and to examine the non-threatening
appraisals of those thoughts.
The CBT model for maintenance of obsessions was illustrated
within the context of normalizing intrusions. Specifically, the
presence of an unwanted intrusive thought is not problematic per
se, but the associated interpretation can give rise to emotional
distress, avoidance, and the urge to neutralize the intrusion. The
target of treatment is the maladaptive interpretation of unwanted
ideation. Unwanted thoughts are part of the human experience
but they do not persist or provoke upset if they are interpreted as
having no personal significance. Specific treatment tactics
depended upon the details of the intrusion and the appraisal.
Some of these strategies include a demonstration of the paradox
of thought control (e.g., try to not think of a pink elephant),
thought action fusion experiments, ‘on duty’ versus ‘off duty’
exercises, decreasing concealment of obsessions from significant
others, focus of attention experiments and the relationship
between values and obsessions (i.e., the intrusion is upsetting
and recurrent because it clashes with important values). For
additional details see Rachman (2003) and Whittal, Robichaud,
and Woody (in press).
The treatment manual for the SMT was prepared internally
(Woody, O’Neill, Fairbrother, & McLean, 2003) drawing from sour-
ces that included Öst (1987), Paterson (2000), and Clark et al.
(1998). (The full manual is available upon request from the
authors.) The rationale for SMT was discussed at length in the first
one or two sessions and was tailored to the participant’s particular
concerns. The positive correlation between stress and obsessions
was emphasized as the foundation of the SMT rationale. The
 ARTICLE IN PRESS
M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
bidirectional nature of this relationship, which quickly results in
a vicious circle was also emphasized: life stress, be it from positive
or negative events, can increase obsessions, which in turn further
increase stress. Accordingly, gaining skills to more effectively cope
with and reduce the impact of stressful life events is expected to
positively influence obsessions. The goal of SMT is to help partici-
pants recognize and manage both the external sources of stress in
their life and their reactions to it. The skills of stress management
require practice and effort to maintain, and patients were informed
that if they applied the skills on a regular basis, they would likely
observe a reduction in stress levels that would naturally reduce the
frequency of obsessions.
After identifying stressful areas of the patient’s life, skills
training followed a modular approach, individualized to the
participant. Typically treatment began with applied relaxation (Öst,
1987). By reducing the frequency and intensity of the physiological
signs of stress, applied relaxation can allow the patient to feel more
confident about staying in control when obsessional thoughts
become more intense. A second module was designed to boost
skills relevant for coping with interpersonal stress, such as dealing
with criticism, providing negative feedback when necessary,
resolving conflicts and assertiveness. The focus of the interpersonal
effectiveness module is to promote interacting with others based
on genuineness rather than fear of their opinions or attitudes. The
third module of the SMT package is organizational skills. Partici-
pants learn to identify areas of disorganization and procrastination
that increase personal stress and learn more effective time
management and problem-solving strategies. As with the CBT, the
therapist determined the order and emphasis of various prescribed
elements of SMT.
Measures
Diagnosis
The Structured Clinical Interview for DSM-IV (SCID; First et al.,
1996) was used to diagnosis Axis I disorders at intake. The inter-
viewers, all having prior training and experience with the SCID,
were doctoral level psychologists or postdoctoral fellows super-
vised by the investigators. In cases of diagnostic uncertainty, the
final decision was made by investigators after review and
consensus discussion of all case material. Post-treatment and
follow-up SCIDs were completed by an interviewer who was
uninformed about group assignment or outcome.
Obsessions and compulsions
The Yale-Brown Obsessive Compulsive Scale (YBOCS; Goodman
et al., 1989) is a clinician-administered and rated scale that was
used to assess symptom severity and to identify the type of
obsessions present. The YBOCS has five items each on the obses-
sions and compulsions subscales; the total score (possible range
0–40) is the sum of the subscales scores. The YBOCS displays
excellent inter-rater and test–retest reliability over one week
(Goodman et al., 1989; Kim, Dysken, & Kuskowski, 1990), although
internal consistency findings for the measure are somewhat mixed,
with acceptable alpha for the total scale (a ¼ 0.69–0.91; Goodman
et al., 1989; Woody, Steketee, & Chambless, 1995) and variable
alphas for the briefer subscales (a ¼ 0.77 and 0.51 for the Obses-
sions and Compulsions scale, respectively; Woody et al., 1995).
Discriminant validity is weak for this instrument (Taylor, 1998);
nevertheless, the YBOCS was used to facilitate comparison with
other studies. Inter-rater reliability in this study for the YBOCS was
excellent (r ¼ 0.87 for Obsessions subscale and 0.97 for Compul-
sions subscale), as assessed by independent ratings of a randomly
selected 33% of audiotapes of the intake YBOCS interviews.
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
3
As is indicated by the high inter-rater reliability, the way in
which the YBOCS was used was very consistent within this study.
However, given that there may be differences in the use of the
YBOCS and what is considered a covert compulsion, the following
discussion may be helpful in accounting for variance between
research groups. In comparison to other researchers (e.g., Freeston
et al., 1997) who used a broad definition, we considered compul-
sions to be rule-governed overt or covert actions that were
completed in a rigid and stereotypic way. Examples include
repeating a prayer following a blasphemous intrusion, altering an
aggressive image from stabbing to hugging a beloved pet, or
repeating an action such as crossing a threshold free of an intrusion.
Other forms of neutralization including distraction, thought
suppression and internally debating the veracity of the intrusion
were not considered compulsions as they were not completed in
stereotypic ways or according to rigid rules.
Cognitions
The revised 44-item version of the Obsessive Belief Question-
naire (OBQ; Obsessive–Compulsive Cognitions Working Group,
2005) was used to measure the strength of beliefs related to
obsessions. Items are rated on a 1–7 scale with higher scores
reflecting a stronger belief. The revised OBQ has excellent internal
consistency (a ranging from 0.89 to 0.95 for all 3 subscales), as well
as demonstrated convergent and discriminant validity (OCCWG,
2005). The OBQ-44 has three empirically-derived subscales:
Responsibility/Harm, Perfectionism/Certainty, and Importance/
Control of Thoughts. The 31 items on the revised Interpretation of
Intrusions Inventory (III; OCCWG, 2005) are designed to measure
appraisals associated with idiographic intrusions. Items are rated
on a 0–100 scale and averaged for a total score. Although originally
developed with subscales, the III appears to be unifactorial
(OCCWG, 2005). The III has acceptable psychometrics.
As the aim of the CBT was to reduce or eliminate the person’s
maladaptive appraisals of their intrusive thoughts, it was essential
to measure these appraisals before and after treatment. Hence, the
Personal Significance Scale (PSS; Rachman, 2003), a 17-item ques-
tionnaire that assesses such appraisals, was used. Participants are
instructed to respond to the items with reference to the primary
obsession for which they were seeking treatment. Items assess the
degree to which respondents believe the occurrence of the obses-
sion indicates they are untrustworthy, mentally unstable,
dangerous, weird or a bad person. Other items assess the degree to
which the individual believes it is important to conceal or control
the thoughts. in the present study, the PSS displayed excellent
internal consistency (a ¼ 0.90) and was strongly correlated with
the III (r ¼ 0.71). The correlation between the PSS and the OBQ total
score was r ¼ 0.62, which is due to a rather strong association with
the Importance and Control of Thoughts subscale of the OBQ
(r ¼ 0.78). Correlations with the Responsibility/Threat Estimation
(r ¼ 0.40) and Perfectionism/Certainty (r ¼ 0.34) subscales were
lower. As might be expected, there is a moderate relationship
between PSS scores and depression as measured by the Beck
Depression Inventory – II (r ¼ 0.35). The PSS, however, is not
significantly related to general anxiety as measured by the Beck
Anxiety Inventory (r ¼ 0.12), nor does it simply reflect obsession
severity, showing a low correlation with the YBOCS Obsession scale
(r ¼ 0.13).
Depressed mood and general anxiety
The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown,
1996) is a widely used 21-item measure of depression with strong
psychometric properties. The Beck Anxiety Inventory (BAI; Beck &
Steer, 1993) is a 21-item measure of state anxiety with excellent
psychometric properties (Beck, Epstein, Brown, & Steer, 1988).
 ARTICLE IN PRESS
4 M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
Functional impairment
The Self-Report Social Adjustment Scale (SAS-SR; Weissman &
Bothwell, 1976) was used to measure overall social functioning.
Each of its 42 items is rated on a 5-point scale with higher numbers
reflecting greater impairment. The SAS-SR has good internal
consistency and test–retest reliability (Edwards, Yarvis, Mueller,
Zingale, & Wagman, 1978). The self-report scale shows good
agreement with interviewer assessment of functioning, good
criterion-related validity, and sensitivity to treatment change
(Weissman & Bothwell, 1976).
Treatment expectancy
The Credibility/Expectancy Questionnaire (Borkovec & Nau,
1972) was used to assess credibility of each treatment as well as
patient expectations of successful outcome. This scale is commonly
used in treatment outcome studies and has acceptable psycho-
metrics (Devilly & Borkovec, 2000).
Homework compliance (Primakoff, Epstein, & Covi, 1986)
Therapists rated homework compliance using a scale from 0 (did
not attempt the assigned homework) to 5 (attempted more than
was requested). This scale has not been subjected to psychometric
evaluation.
Treatment integrity
Postdoctoral fellows with experience in the treatment of anxiety
and OCD treated 87% of the participants. MW, SW, SR, and PM
treated the remaining 9 people. PM and SR respectively supervised
the SMT and CBT. Training consisted of reading the treatment
manuals, listening to tapes of the therapies being conducted,
participating in case conferences and treating practice cases that
were not part of the study. Both supervisors met regularly with the
postdoctoral fellows for case review and to plan future sessions.
The investigators rated therapist competence and protocol
adherence without knowledge of the outcome of treatment (i.e.,
supervisors, therapists, and independent evaluators involved in
a specific case were excluded from rating tapes of that case). All
sessions were audiotaped, and 20% of these tapes were randomly
selected for ratings of competence and integrity, independent of
the supervision process. Tapes were rated blindly, without knowl-
edge of treatment condition or symptom status. Tapes from eight
patients (four in each condition) were not available for rating.
The raters correctly classified 100% of the tapes in terms of the
type of therapy being delivered. Of 141 sessions rated, only one
instance of protocol failure was noted. This involved a tape of a CBT
session; the other rated session for that patient showed adequate
adherence to the CBT protocol. Although overall ratings indicated
no gross violations of protocol, there were examples of less serious
cross-contamination of intervention strategies, particularly for the
SMT condition. Of those tapes involving SMT, 23% were rated as
using some procedures consistent with the CBT protocol; of the
tapes involving CBT, just 5% were rated as using some procedures
consistent with the SMT protocol. Of the 15 SMT patients for whom
some CBT procedures were noted during integrity ratings, all
patients but one had other tapes rated as fully adherent (i.e., no
protocol contamination) to the SMT protocol. All of the three CBT
patients with some SMT procedures had other tapes rated as fully
adherent to the CBT protocol.
Raters also judged the overall quality of the therapy, taking into
account the apparent difficulty level of the patient as well as
nonspecific therapy skills and specific protocol skills. Respectively,
95% and 97% of the SMT and CBT sessions were rated as satisfactory
or better in terms of overall quality, which did not differ by treat-
ment condition, t (138) ¼ 1.50, p ¼ 0.14.
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
Therapists also rated homework compliance on a weekly basis.
There were no significant differences between CBT and SMT on any
session (ts < 1.0). Mean homework compliance for the CBT group
was 3.50 (SD ¼ 0.95) and 3.58 (SD ¼ 1.09) for the SMT group,
indicating that both groups did most of their assigned tasks each
week.
Results
Data analytic strategy
Analysis of covariance (ANCOVA) was first used to compare
outcome variables following the waitlist with participants who
received immediate treatment with CBT or SMT, controlling for
initial status. To compare CBT and SMT with more power, we next
repeated ANCOVA analyses comparing all patients who received
CBT or SMT, regardless of whether treatment was immediate or
delayed. Several multivariate outliers were detected in initial
examination of the data. In most cases, results did not differ when
these observations were excluded, so the full sample results are
reported. In one case, noted below, the results changed slightly
with exclusion of an observation with a very large residual and high
leverage statistics.
Patient characteristics
The average age of participants at intake was 31.5 years
(SD ¼ 9.7). Of the 73 participants, 34 were female (46.6%). Most
participants reported a European ethnic background (84.9%); the
remaining reported Asian (10.9%) or other backgrounds. Partici-
pants reported an average of 14.7 (SD ¼ 2.5) years of education.
About half of the participants were single, 42.5% were living in
a marital relationship, and 6.9% were divorced. Although only 52.0%
of participants were employed full-time, 31.5% were unemployed
by choice (e.g., student, parent of young children). There were no
significant differences between treatment groups on any of these
demographic variables.
Regarding psychiatric status, 75.3% of patients had at least one
additional Axis I diagnosis; 39.7% had at least two additional
diagnoses, the most common being major depression (34%), dys-
thymia (16%), or generalized anxiety disorder (16%). Global
Assessment of Functioning (Axis V) scores ranged from 45 to 80,
with a mean of 59.5 (SD ¼ 6.3). Half of participants (52.0%) were
taking stable doses of medication prior to intake.
Participants recalled the onset of their OCD as occurring, on
average, at age 17.5 (SD ¼ 8.6). Content of participants’ predomi-
nant obsessions were primarily aggressive (53.2%) or sexual (41.6%),
although some religious obsessions were also evident (5.2%). About
a third of participants (32.5%) reported obsessions that fell into
more than one content domain. There were no significant differ-
ences between treatment groups on any of these indicators of
psychiatric status or on any measure of OCD symptoms.
Patients in the SMT condition showed greater variability in their
ratings of treatment expectancy than did patients in the CBT
condition, F (31, 37) ¼ 3.21, p < 0.001, but a t-test comparing means
with unequal variances did not show differences in level of
expectancy ratings between the treatments, t (46.7) ¼ 1.05,
p > 0.30.
Treatment completers versus dropouts
Patients were considered to have completed treatment if they
received at least eight of the 12 sessions and provided post-treat-
ment data. One participant assigned to SMT was withdrawn from
the study due to worsening depression and a consequent
 ARTICLE IN PRESS

M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9 5

Table 1 standard deviations, and effect sizes for the waitlist group are
Means (and standard deviations) for participants on waitlist (n ¼ 28). presented in Table 1.
Time 1 Time 2 d 90% CI for d
YBOCS obsessions 10.93 (2.16) 10.54 (2.74) 0.13 0.18 to 0.44 Secondary outcomes
YBOCS total 17.54 (5.94) 16.50 (6.33) 0.18 0.14 to 0.49 The same results were observed for YBOCS Total scores, F (3, 69) ¼
Beck depression inventory 19.32 (13.24) 18.32 (12.05) 0.14 0.17 to 0.45 14.43, p < 0.001, h2p ¼ 0.29, with lower scores following treatment
Beck anxiety inventory 18.96 (9.90) 17.79 (10.43) 0.18 0.14 to 0.49
than following the waitlist. The treatments likewise produced
Overall social adjustment 2.21 (0.44) 2.19 (0.46) 0.04 0.27 to 0.35
OBQ-responsibility/harm 4.40 (1.30) 4.34 (1.36) 0.08 0.23 to 0.39 significantly lower BDI scores than did the waitlist, F (3, 67) ¼ 3.97,
OBQ-perfectionism/certainty 4.19 (1.17) 4.00 (1.30) 0.14 0.17 to 0.45 p ¼ 0.02, h2p ¼ 0.11, and lower BAI scores, F (3, 67) ¼ 6.16, p ¼ 0.003,
OBQ-importance/control 4.39 (1.28) 4.19 (1.28) 0.34 0.02 to 0.66 h2p ¼ 0.16, as well as better social adjustment, F (3, 67) ¼ 7.80,
Interpretation of intrusions 60.70 (20.74) 58.35 (21.20) 0.17 0.14 to 0.48 p < 0.001, h2p ¼ 0.19.
Personal significance scale 80.58 (27.37) 80.92 (28.73) 0.02 0.34 to 0.29

Note: YBOCS ¼ Yale-Brown Obsessive Compulsive Scale, OBQ ¼ Obsessional Beliefs
Questionnaire (44-item version).
medication change. Two SMT participants left the study before
completing eight sessions, as did three participants in the CBT
condition. Patients who completed treatment and those who
terminated prematurely were not significantly different with
regard to any demographic variable, treatment expectancy, or any
indicator of severity of OCD or psychiatric status.
Cognitions
Participants in treatment had lower scores on the PSS than did
participants on the waitlist, F (3, 66) ¼ 24.42, p < 0.001, h2p ¼ 0.43.
Participants also had lower scores on measures of OC cognitions
following treatment than was evident following waitlist, 6.64  F
(3, 66)  17.68, p < 0.002, 0.17  h2p  0.35 for the III and three
subscales of the OBQ-44.
Comparing SMT and CBT

To maximize power for the comparison between CBT and SMT,

Comparing treatments to waitlist
Primary outcome
A one-way ANCOVA was used to compare post-treatment scores
on YBOCS Obsessions after controlling for scores on this variable at
intake. Intent-to treat analyses using multiple imputation for
missing observations yielded the same results as those for treat-
ment completers, so only the completer analyses are reported here.
The independent variable had three levels: waitlist, CBT, and SMT.
For this analysis, however, post-hoc tests were examined only for
the comparisons involving waitlist, as the two treatments were
compared in analyses presented below. This analysis showed
a strong treatment effect, F (3, 69) ¼ 19.44, p < 0.001, h2p ¼ 0.36.
Planned post-hoc comparison showed YBOCS Obsessions scores
were lower following treatment than following the waitlist. Means,
patients who received immediate and delayed treatment were
included in the same dataset. Table 2 shows the means, standard
deviations, and within-group effect sizes for these groups. For
patients who participated in the waitlist conditions, pretreatment
score in these analyses corresponds to the assessment immediately
prior to treatment (i.e., following the waiting period).
Primary outcome
A one-way ANCOVA compared post-treatment scores on YBOCS
Obsessions controlling for pretreatment scores using a two-level
independent variable: CBT versus SMT. Analysis of patients who
completed treatment showed CBT produced significantly lower
YBOCS Obsessions scores than did SMT, F (2, 64) ¼ 4.38, p ¼ 0.04,
h2p ¼ 0.06. The difference between treatments remained true in the
analysis of intent-to-treat data with multiple imputation for

Table 2
Means (and standard deviations) for all treatment completers – immediate and delayed.

Pre-treatment Post-treatment Pre–post Pre–post 6 Months follow-up 12 Months follow-up Pre-12 mo. Pre-12 mo.

Mean (SD) Mean (SD) d 90% CI Mean (SD) Mean (SD) d 90% CI
Cognitive therapy (n ¼ 37) (n ¼ 37) (n ¼ 34) (n ¼ 34)
YBOCS obsessions 11.27 (2.78) 4.62 (2.88) 2.34 1.80–2.86 4.85 (3.32) 5.21 (3.90) 1.52 1.09–1.93
YBOCS total 18.03 (6.29) 6.43 (4.77) 1.76 1.32–2.19 8.68 (6.83) 8.00 (6.54) 1.23 0.85–1.60
BDI 18.62 (9.63) 10.89 (8.99) 0.81 0.49–1.11 9.87 (7.33) 11.06 (7.25) 0.93 0.59–1.27
BAI 18.03 (9.72) 9.22 (7.04) 0.97 0.63–1.29 11.06 (9.35) 11.50 (8.39) 0.67 0.35–0.98
Social adjustment 2.15 (0.41) 1.88 (0.31) 1.07 0.72–1.40 1.98 (0.43) 2.00 (0.46) 0.53 0.22–0.83
OBQ-response/harm 4.47 (1.39) 2.75 (1.23) 1.29 0.91–1.65 2.66 (1.48) 2.79 (1.51) 1.39 0.97–1.79
OBQ-perfect/certain 4.16 (1.50) 2.89 (1.36) 0.99 0.65–1.33 2.81 (1.43) 2.99 (1.42) 1.05 0.69–1.41
OBQ-import/control 4.34 (1.30) 1.84 (1.02) 1.84 1.38–2.28 1.84 (1.06) 2.03 (1.11) 1.50 1.06–1.92
III 60.28 (20.56) 19.63 (23.11) 1.50 1.09–1.89 16.47 (20.44) 18.43 (20.91) 1.58 1.14–2.00
PSS 82.28 (27.20) 22.10 (25.16) 1.86 1.39–2.30 19.38 (24.14) 27.88 (24.31) 1.78 1.31–2.23

Stress management (n ¼ 30) (n ¼ 30) (n ¼ 27) (n ¼ 24)

YBOCS obsessions 11.03 (3.31) 5.77 (3.07) 1.90 1.38–2.39 5.59 (3.48) 5.59 (3.37) 1.41 0.96–1.86
YBOCS total 17.73 (7.73) 9.10 (6.48) 1.49 1.05–1.93 8.93 (7.78) 9.33 (7.76) 1.09 0.68–1.48
BDI 17.90 (11.10) 10.17 (9.43) 0.82 0.46–1.16 10.33 (8.32) 8.29 (8.15) 0.75 0.36–1.12
BAI 14.48 (8.90) 9.13 (7.32) 0.59 0.25–0.92 9.15 (6.46) 7.88 (7.58) 0.98 0.56–1.38
Social adjustment 2.30 (0.46) 1.94 (0.44) 1.07 0.67–1.44 1.99 (0.52) 1.97 (0.55) 0.90 0.49–1.29
OBQ-response/harm 4.17 (1.31) 3.17 (1.40) 0.97 0.57–1.34 3.13 (1.33) 2.92 (1.30) 1.16 0.69–1.61
OBQ-perfect/certain 4.29 (1.06) 3.14 (1.31) 1.25 0.81–1.66 3.20 (1.44) 3.06 (1.41) 1.22 0.74–1.68
OBQ-import/control 4.39 (1.22) 2.90 (1.39) 1.20 0.78–1.61 2.73 (1.33) 2.56 (1.34) 1.32 0.82–1.79
III 60.15 (18.85) 31.43 (20.47) 1.30 0.88–1.71 30.84 (21.17) 26.49 (21.82) 1.36 0.88–1.81
PSS 86.02 (23.97) 46.41 (27.71) 1.35 0.92–1.77 46.07 (28.39) 40.46 (26.35) 1.35 0.87–1.80

Note: YBOCS ¼ Yale-Brown Obsessive Compulsive Scale, BDI ¼ Beck Depression Inventory, BAI ¼ Beck Anxiety Inventory, OBQ ¼ Obsessional Beliefs Questionnaire 44-item
version, III ¼ Interpretations of Intrusions Inventory, PSS ¼ Personal Significance Scale.

Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
 ARTICLE IN PRESS
6 M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
incomplete cases, t (63.41) ¼ 2.12, p ¼ 0.04. After removing one
multivariate outlier, the effect was slightly smaller and the p value
slightly larger, F (2, 63) ¼ 3.57, p ¼ 0.06, h2p ¼ 0.05. The intent-to-
treat analysis showed the same result without the multivariate
outlier case, t (65.12) ¼ 1.96, p ¼ 0.06. Fig. 1 demonstrates the
YBOCS Obsessions raw scores over time between groups.
Secondary outcomes
Among patients who completed treatment, CBT resulted in
significantly lower YBOCS Total scores than did SMT, F (2,
64) ¼ 5.60, p ¼ 0.02, h2p ¼ 0.08, an effect that was also observed in
the intent-to-treat analysis, t (65.21) ¼ 2.37, p ¼ 0.02. Analysis of
neither treatment completers nor intent-to-treat datasets showed
differences between the treatments on BDI scores, F (2, 69) ¼ 0.02,
p ¼ 0.88, h2p < 0.01, BAI scores, F (3, 69) ¼ 0.62, p ¼ 0.43, h2p < 0.01, or
overall social adjustment, F (2, 69) ¼ 0.04, p ¼ 0.85, h2p < 0.01
(completer statistics presented).
Cognitions
As expected, patients who completed CBT also endorsed fewer
appraisals of personal significance of their obsessive thoughts on the
PSS than did SMT patients, F (2, 62) ¼ 13.97, p ¼ 0.0004, h2p ¼ 0.18 (see
Fig. 2). Patients who completed CBT showed less endorsement of
OC-related cognitions on the III than did those who completed
SMT, F (2, 63) ¼ 4.54, p ¼ 0.04, h2p ¼ 0.07. This difference was also
observed for two subscales of the OBQ-44: Responsibility/Harm,
F (2, 62) ¼ 5.09, p ¼ 0.03, h2p ¼ 0.08, and Importance/Control of
Thoughts, F (2, 62) ¼ 16.91, p ¼ 0.0001, h2p ¼ 0.21. The post-treatment
score on the Perfectionism/Certainty subscale of the OBQ-44 did not
differ between treatments, F (2, 62) ¼ 0.92, p ¼ 0.34, h2p ¼ 0.01. Intent-
to-treat results show a similar pattern: OBQ-Resp/Harm t
(56.60) ¼ 2.18, p ¼ 0.03; OBQ-Perf/Cert t (65.00) ¼ 0.60, p ¼ 0.55;
OBQ-Import/Control t (52.44) ¼ 3.90, p < 0.001; III t (62.73) ¼ 2.22,
p ¼ 0.03; PSS t (58.11) ¼ 3.84, p < 0.001.
Clinical significance
Based on the recommendations outlined by Jacobson and Truax
(1991), we defined clinically significant change as comprised of two
20
CBT
15
SMT
Waitlist
10
5 elements of CBT in them (although blinded coders accurately
0
Intake Post-treatment 6 months 12 months
Assessment Time
Fig. 1. YBOCS Obsessions Subscale by group across assessment occasions. Notes:
Membership in the waitlist group is not independent of the two treatment groups.
These participants were randomized to a treatment that followed the waitlist. Thus,
the ‘‘post-treatment’’ assessment time for the waitlist participants is more accurately
considered as ‘‘post-waitlist’’. The standard deviation bars are not given for all groups
in order to improve readability of the figure, but they are similar in size to those
represented in the graph.
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
120
CBT
100 SMT
Waitlist
80
60
40
20
0
Intake Post-treatment 6 months 12 months
Assessment Time
Fig. 2. PSS scores by group across assessment occasions. Notes: Membership in the
waitlist group is not independent of the two treatment groups. These participants were
randomized to a treatment that followed the waitlist. Thus, the ‘‘post-treatment’’
assessment time for the waitlist participants is more accurately considered as ‘‘post-
waitlist’’. The standard deviation bars are not given for all groups in order to improve
readability of the figure, but they are similar in size to those represented in the graph.
elements: reliable change score of at least 1.96 and a post-treat-
ment YBOCS score that meets criterion a (i.e., post-test YBOCS
Obsessions score below 5.79). Of those receiving CBT, 27 of 37
patients met criterion a, and 30 showed reliable change, so that 59%
achieved clinically significant change on the YBOCS Obsessions
subscale. Among patients receiving SMT, 17 of 30 met criterion a,
and 18 showed reliable change, with 43% achieving clinically
significant change. These proportions were not significantly
different with this sample size, c2(1, N ¼ 67) ¼ 1.73, p ¼ 0.19. When
examining the YBOCS Total scores, 20 of 37 (54%) receiving CBT
and 7 of 30 (23%) receiving SMT achieved clinically significant
change, resulting in proportions that were significantly different,
c2(1, N ¼ 67) ¼ 6.50, p ¼ 0.01.
Moderators
We examined numerous variables, including dichotomous
indicators of medication use, comorbid depression, referral source,
and psychosocial stressors as well as years of education, therapist,
and homework compliance. Proposed moderator variables were
entered into the model as a main effect and in interaction with
treatment type. There was no evidence that the effect of treatment
varied significantly according to patient status on any of these
variables, 0.18  t  1.07, 0.29  p  0.86.
Treatment integrity
As described above, some SMT sessions were coded as having
classified all sessions). To test whether this cross-contamination
was responsible for the strong effect of SMT on outcome, we
examined residual gains scores of the primary and secondary
outcome variables. One-tailed (directional) t-tests were conducted
to ascertain whether outcomes of SMT patients with cross-
contamination were better than those who received SMT with no
evidence of CBT procedures. Results consistently showed SMT
patients with evidence of cross-contamination had similar or
worse outcomes than did those with no evidence of cross-
contamination. This pattern is contrary to the expected result if
elements of CBT observed in the SMT tapes were responsible for
the strong effects of SMT.
 ARTICLE IN PRESS
M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
Maintenance of treatment gains
Six-month follow-up
An ANCOVA, using pretest status as a covariate, showed no
differences between treatment conditions on any measure of
symptoms (ps > 0.28). In contrast, all measures of cognition
showed lower scores for patients who had participated in CBT than
for those who had participated in SMT, Fs (2, 56)  6.11, ps < 0.02,
h2p > 0.10, with the exception of the Perfectionism/Certainty
subscale of the OBQ-44, which continued to be similar between
treatments, F (2, 56) ¼ 1.94, p ¼ 0.17, h2p ¼ 0.03. See Table 1.
12-Month follow-up
As was observed at the six months point, there were no differ-
ences between treatment conditions on any measure of symptoms
(p > 0.26). Differences on the cognitive measures remained low and
by 12 months were not significantly different. Two measures, the
PSS and the Importance/Control of Thoughts subscales of the OBQ-
44, showed statistical trends for the CBT patients to have lower
scores, F (2, 53) ¼ 3.74, p ¼ 0.06, h2p ¼ 0.06 and F (2, 53) ¼ 3.14,
p ¼ 0.08, h2p ¼ 0.06, respectively.
Discussion
According to the cognitive theory, obsessions are caused by
serious misinterpretations of the personal significance of intru-
sions. It follows that if these maladaptive interpretations are
reduced or eliminated by formal therapy, or by any other means,
then the frequency and the distress of the obsessions will steeply
decline. CBT and SMT for primary obsessions resulted in a strong
and broad treatment effect when compared to waitlist. Large effect
sizes emerged for both treatments on the YBOCS obsessions
subscale at post-treatment as well as the YBOCS total score (ds
ranging from 1.49 to 2.34). Large treatment effects were also found
for the personal significance measure and the OCD cognition
measures (ds ranging 1.27–1.86). More modest treatment effects
were observed on measures of general anxiety, depression and
social functioning (ds from 0.59 to 1.07). Two thirds to three
quarters of participants in both treatments achieved clinically
significant change that was still evident at a 12-month follow-up.
Mediators of treatment outcome will be examined in a subsequent
paper. Consistent with cognitive theory, both groups of partici-
pants’ PSS scores were near the top of the scale prior to treatment
and after the waitlist period; that is, the intrusions were being
seriously misinterpreted.
The present findings compare favorably to effect sizes obtained
in general OCD controlled trials as well as OCD with primarily
obsessional content. Two recent meta-analyses reported pre–post
effect sizes of d ¼ 1.48 and d ¼ 1.50 (Abramowitz, Franklin, & Foa,
2002; Eddy, Dutra, Bradley, & Westen, 2004). In comparison to the
two published randomized controlled trials on treatment of
primary obsessions (Freeston et al., 1997 and O’Connor et al., 2005),
the mean post-treatment YBOCS total score for CBT completers
(6.4) in the current study is slightly lower. Freeston reported a post-
treatment mean YBOCS total score of 7.2 (SD ¼ 5.2) for completers
and 9.8 (SD ¼ 8.2) for the total sample including the 17% who
dropped out of treatment. O’Connor et al. (2005) reported a post-
treatment YBOCS total score of 8.0 (2.8) for the 17 participants who
completed individual treatment. As neither treatment study
reported separate scores for obsessions and compulsions,
a comparison of subscales is not possible.
The current study is the first randomized trial of an intervention
based on Rachman’s (1997, 1998) cognitive theory of obsessions
using patients with few or no overt compulsions. CBT for obses-
sions overlaps somewhat with contemporary CBT treatments for
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
7
general OCD but also has unique features. Using this specialized
CBT protocol, YBOCS totals at post-treatment were similar to scores
reported by a college student sample (Frost & Steketee, 2002).
Appraisals of personal significance declined appreciably with
treatment. Two of the three OBQ subscales and the III score also
differentiated the SMT and CBT groups at post-treatment, although
Perfectionism/Certainty was not significantly different between
CBT and SMT. As discussed earlier, Rachman’s treatment is focused
on the meaning of the intrusions – that they are not important or
revealing in any way, and as such, they are not threatening. Given
the focus of the treatment used in the current study, the observed
pattern of OBQ results and other cognitive measures is consistent
with Rachman’s theory.
Contrary to expectations, SMT produced results that were nearly
as strong and well maintained as CBT. Although not unwelcome,
the finding that SMT produced robust and positive changes that
were maintained over a year was a surprising one. The SMT manual
was developed specifically for this study, but a similar protocol
used in a small study by Lindsay et al. (1997) resulted in no change
in YBOCS scores. One relevant difference may have been that the
Lindsay et al. protocol did not include skills for interpersonal
effectiveness (e.g., dealing with criticism, being assertive). The
Lindsay et al. protocol consisted of breathing retraining, progressive
muscle relaxation and structured problem solving of non-OCD
concerns. Perhaps a more important difference was the duration of
treatment. Participants in the Lindsay et al. study received 15 h of
therapy massed over three weeks compared to the current study
that provided 12 h in once-weekly sessions over three months. The
relatively compressed treatment schedule in the Lindsay study may
have provided insufficient time to alter response to life stressors
and therefore failed to produce a change in OCD severity. It is also
unclear whether participants in the Lindsay et al. study saw SMT as
a credible treatment, as treatment expectancy was not reported.
Simpson et al. (2008) also used the Lindsay version of SMT as an
active comparator. In this study, pharmacotherapy was augmented
with either SMT or ERP fpr 108 patients with OCD who had failed to
respond satisfactorily to the medication. The patients received 17
sessions over eight weeks of ERP or SMT while continuing on the
medication. The ERP augmentation produced large and significant
reductions in YBOCS total scores (25.4 at pre-treatment to 14.2 at
post-treatment), but the SMT augmentation produced minimal
change (YBOCS total 26.2–22.6). However, it should be noted that
the homework compliance for the SMT group was only fair (mean
of 2.6/5) whereas the compliance for the ERP group was 3.1/5.
Given the previous literature and cognitive theories of obses-
sions, our SMT results appear to be exceptional, leaving the
pressing question of why the our SMt protocol worked so well.
Differential treatment credibility is not likely to be responsible, as
both CBT and SMT were rated as credible. Treatment expectancy did
vary more within the SMT group, but there were no group differ-
ences in mean expectancy ratings. There were instances of cross-
contamination within the SMT group but this is also unlikely to be
responsible for the robust SMT findings. As described earlier, cross-
contamination appears to have been minimal and thus seems an
outside possibility to account for the strength of the SMT. Moreover,
SMT patients who had some cross-contamination of CBT proce-
dures did not show better outcomes than did SMT patients with
uncontaminated treatments. As such, the CBT procedures received
by a small portion of the SMT patients appear not to be responsible
for the robust SMT treatment result.
Cognitive theories of obsessions would suggest that CBT, which
directly focuses on normalizing and reappraising intrusive thoughts,
should be a substantially more powerful intervention than SMT,
given that the latter is devoid of intervention focused on the obses-
sions. Nevertheless, the observed findings may be interpretable from
 ARTICLE IN PRESS
8 M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
the perspective of cognitive theory. Patients in both treatments
showed large changes in OCD-related cognitions and threat
appraisals, indicating that cognitive change did occur during SMT
even though it was not specifically addressed in treatment.
How might this cognitive change have occurred? Therapists
providing SMT did not react negatively upon hearing the content of
the obsessions and in fact encouraged increased social contact and the
eventual application of relaxation skills to anxiety provoking situa-
tions such as interpersonal conflict or stressful life circumstances. A
focus on enhanced social contact likely provided the implicit message
that the therapist regards the patient’s thoughts as non-significant
and does not fear for the safety of others when the patient is nearby.
Another possibility is the relaxation component of SMT, implemented
under cue control and applied in daily situations was sufficiently
distracting and may have averted efforts at thought control and
permitted a natural decay in the frequency of the unwanted thoughts.
It is also possible that a measurement effect influenced the
results. Prior to each treatment session, all participants completed
the Personal Significance Scale in addition to ratings of the severity
of their obsessions during the previous week. By repeatedly elic-
iting patients’ appraisals of their intrusions on the PSS, we may
have implicitly conveyed our view of the importance of these
appraisals. Even the participants in the SMT condition had to pay
attention to their personal interpretations by monitoring and
reporting them before every session, although the SMT therapists
did not discuss the PSS ratings during sessions. As patients do not
typically notice their appraisals of obsessions without direct
questioning, those in the SMT condition likely became aware of
their appraisals in a way that would not have occurred without the
measurement undertaken for the study.
Prior studies have observed cognitive changes in the context of
behavioral activation (Jacobson et al., 1996) or behavioral stress
management (Clark et al., 1998). In a similar vein, the SMT in the
current study may have shifted patients’ energies from attempting
to understand and control their thoughts to becoming more
engaged and effective in their lives, which, although unmeasured,
may have reduced severity and distress of obsessions. In this way,
SMT may have served as a healthy and constructive diversion from
obsessions, as therapists helped patients to focus attention on
identifying and achieving important short-term life goals. This
implicit behavioral activation may have reduced obsessions via
improvement in depression. Although speculative, it is also
possible that disconfirmation of feared consequences may have
occurred as patients reduced general avoidance; homework
assignments may have inadvertently involved people or situations
the patient had avoided in part due to obsessions (e.g., visiting
friends who happen to have children).
The robust treatment outcome with both protocols contradicts
the long-standing belief that obsessions are particularly resistant to
treatment (e.g., Jenike, 1993; Rachman, 1983). These results are
particularly encouraging in light of the relatively low dropout rates
(6.8%) and amount of therapist time (12 treatment hours and 3–4
assessment hours). Although the treatment time in the current
study is consistent with recent treatment trials of general OCD (e.g.,
van Oppen et al., 1995; Whittal, Thordarson, & McLeanWhittal,
2005), previous trials with obsessionals utilized protocols of longer
duration. Freeston et al. (1997) reported the average duration of
treatment involved 40 therapist hours, whereas O’Connor et al.
(2005) reported 20 h.
Dropout rates were also higher in the Freeston et al. (17.2%
dropout) and O’Connor et al. (10.5%) studies than in the current one.
One methodological difference that might account for the differ-
ential dropout rates is the use of loop tapes. CBT participants in our
study were encouraged to decrease efforts to block or suppress the
intrusions and instead regard them as mental noise and dismiss
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
them accordingly. There was no repetitive, prolonged or intentional
exposure to obsessions via loop tapes or any other planned expo-
sures. Incidental, occasional unplanned exposures of unknown
duration may have occurred, but exposure and response prevention
as properly defined and employed was not included in either
treatment protocol.
Study limitations
The primary dependent measure, the YBOCS, has limitations for
this OCD subtype. It was developed to test the effect of medication
on OCD and contains no items that address metacognitions. There
is also confusion in the scoring of items related to resistance and
control of obsessions and compulsions. We did, however, train
assessors in the use of these items to maintain reliable and
consistent assessments throughout the study. Another limitation is
that avoidance behavior is measured with only one item on the
YBOCS that is not included in the total score. The difficulties with
the use of the YBOCS as a primary outcome measure are aggravated
with select OCD subtypes. For example, Frost, Steketee, and Gri-
sham (2004) developed a distinct measure of hoarding, as the
existing YBOCS was inadequate to properly assess the nature and
severity of this subtype.
The initial YBOCS Total scores for our sample were also mark-
edly lower than those observed in the Freeston et al. (1997) study,
despite the fact that the samples were otherwise apparently
similar. These differences may be due to the samples, to variation in
how the YBOCS is used in different research groups, or to some
other factor. Notably, the O’Connor et al. (2005) study reported
initial YBOCS Total scores similar to the Freeston study for patients
randomized to individual therapy and scores similar to the present
study for patients randomized to group therapy. As this subtype of
OCD has not been well studied, the sources of these differences are
not yet clear. Abramowitz et al. (in press) recently developed and
tested an alternate dimensional version of the YBOCS that focuses
on four dimensional empirically-supported OCD presentations
(contamination, responsibility for harm, unacceptable thoughts
and symmetry/completeness/‘just right’). The initial promise of this
measure awaits use in research and clinical settings to determine
its ultimate utility, but it may solve some of the problems inherent
with the YBOCS.
In retrospect, the failure to include process measures relevant to
understanding the effects of SMT was a clear omission. Given the
unexpected finding of an exceptionally strong SMT treatment
effect, a better understanding of the components associated with
this finding is necessary. Also, because the rating of homework
compliance is completed by the therapist, it is subject to bias and
should be considered a limitation.
In summary it appears that an OCD subtype once thought to be
difficult to treat is amenable to relatively brief contemporary
cognitive behavioral treatment and may also prove to be treatable
with stress management strategies. In view of the inconsistency
between our results with SMT and those reported with other
studies (Lindsay et al., 1997; Simpson et al., 2008), this result is
plainly in need of independent replication. The strong and broad
effects of CBT are encouraging but also need independent replica-
tion before the approach can be recommended. However, if our
SMT results are replicated by other centers, the clinical implications
are promising, as SMT is a relatively straightforward treatment to
disseminate – albeit theoretically threadbare.
Author note
The authors would like to thank Melanie O’Neill and David
Jacobi, who served as postdoctoral fellows on the study.
 ARTICLE IN PRESS
M.L. Whittal et al. / Behaviour Research and Therapy xxx (2009) 1–9
Additionally, we appreciate the contributions of Sarah Newth and
Nichole Fairbrother. David A. Clark and Arnoud Arntz kindly read an
earlier version of the manuscript and provided helpful feedback.
This research was funded by the Canadian Institutes of Health
Research.
References
Abramowitz, J. S., Deacon, B. J., Loatunji, B. O., Wheaton, M. G., Berman, N., Losardo, D.,
Timpano, K., McGrath, P., Riemann, B., Adams, T., Bjorgvinsson, T., Storch, E. A., &
Hale, L. Assessment of obsessive–compulsive symptoms dimensions: develop-
ment and evaluation of the dimensional obsessive–compulsive scale. Psycho-
logical Assessment, in press.
Abramowitz, J. S., Franklin, M. E., & Foa, E. B. (2002). Empirical status of cognitive–
behavioral therapy for obsessive–compulsive disorder: a meta-analytic review.
Romanian Journal of Cognitive and Behavioral Psychotherapies, 2, 89–104.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (DSM-IV) (4th ed.). Washington, DC: Author.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring
clinical anxiety: psychometric properties. Journal of Consulting and Clinical
Psychology, 56, 893–897.
Beck, A. T., & Steer, R. A. (1993). Manual for the beck anxiety inventory. San Antonio,
TX: Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory manual (2nd
ed.). San Antonio, TX: Psychological Corporation.
Borkovec, T. D., & Nau, S. D. (1972). Credibility of analogue therapy rationales.
Journal of Behavior Therapy and Experimental Psychiatry, 3, 257–260.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Fennell, M., Ludgate, J., et al.
(1998). Two psychological treatments for hypochondriasis: a randomized
controlled trial. British Journal of Psychiatry, 173, 218–225.
Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/
expectancy questionnaire. Journal of Behavior Therapy and Experimental
Psychiatry, 31, 73–86.
Eddy, K. T., Dutra, L., Bradley, R., & Westen, D. (2004). A multidimensional meta-
analysis of psychotherapy and pharmacotherapy for obsessive-compulsive
disorder. Clinical Psychology Review, 24, 1011–1030.
Edwards, D., Yarvis, R., Mueller, D., Zingale, H., & Wagman, W. (1978). Test-taking
and the stability of adjustment scales: can we assess patient deterioration?
Evaluation Quarterly, 2, 275–291.
First, M. B., Spitzer, R. L., Givvon, M., & Williams, J. B. (1996). Structured clinical
interview for DSM-IV axis I disorders – patient edition (SCIS-I/P, version 2.0 4/97
revision). Unpublished manual: Biometrics Research Department, New York
State Psychiatric Institute, New York, NY.
Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau, N., Rheaume, J., Letarte, H., et
al. (1997). Cognitive–behavioral treatment of obsessive thoughts: a controlled
study. Journal of Consulting and Clinical Psychology, 65, 405–413.
Freeston, M. H., Leger, E., & Ladouceur, R. (2001). Cognitive therapy of obsessive
thoughts. Cognitive and Behavioral Practice, 8, 61–78.
Frost, R. O., & Steketee, G. (2002). Cognitive approaches to obsessions and compul-
sions: Theory, assessment and treatment. Amsterdam: Pergamon.
Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive
hoarding: saving inventory – revised. Behaviour Research and Therapy, 42,
1163–1182.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L.,
Hill, C. L., et al. (1989). The yale-brown obsessive–compulsive scale, I: devel-
opment, use and reliability. Archives of General Psychiatry, 40, 1006–1011.
Please cite this article in press as: Whittal, M.L., et al., Treatment of obsessions: A randomized controlled trial, Behaviour Research and Therapy
(2009), doi:10.1016/j.brat.2009.11.010
9
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al.
(1996). A component analysis of cognitive–behavioral treatment for depression.
Journal of Consulting and Clinical Psychology, 64, 295–304.
Jacobson, N. S., & Truax, P. A. (1991). Clinical significance: a statistical approach to
defining meaningful change in psychotherapy research. Journal of Consulting
and Clinical Psychology, 59, 12–19.
Jenike, M. A. (1993). Obsessive-compulsive disorder: efficacy of specific treatments
as assessed by controlled trials. Psychopharmacology Bulletin, 29, 487–499.
Kim, S., Dysken, M., & Kuskowski, M. (1990). The yale-brown obsessive compulsive
scale: a reliability and validity study. Psychiatry Research, 41, 37–44.
Lindsay, M., Crino, R., & Andrews, G. (1997). Controlled trial of exposure and
response prevention in obsessive–compulsive disorder. British Journal of
Psychiatry, 171, 135–139.
O’Connor, K., Freeston, M. H., Gareau, D., Careau, Y., Dufour, M. J., Aardema, R., et al.
(2005). Group versus individual treatment in obsessions without compulsions.
Clinical Psychology & Psychotherapy, 12, 87–96.
Obsessive–Compulsive Cognitions Working Group. (2005). Psychometric validation
of the obsessive belief questionnaire and interpretation of intrusion inventory –
part 2: factor analyses and testing of a brief version. Behaviour Research and
Therapy, 43, 1527–1542.
van Oppen, P., de Haan, E., van Balkom, A., Spinhoven, P., Hoogduin, K., & van
Dyck, R. (1995). Cognitive therapy and exposure in vivo in the treatment of
obsessive compulsive disorder. Behaviour Research and Therapy, 33, 379–390.
Öst, L. G. (1987). Applied relaxation: description of a coping technique and review
of controlled studies. Behaviour Research and Therapy, 25, 397–409.
Paterson, R. J. (2000). The assertiveness workbook. Oakland, CA: New Harbinger Press.
Primakoff, L., Epstein, N., & Covi, L. (1986). Homework compliance: an uncontrolled
variable in cognitive therapy outcome research. Behavior Therapy, 17, 433–446.
Rachman, S. (1983). Obstacles to the successful treatment of obsessions. In E. B. Foa,
& P. Emmelkamp (Eds.) (pp. 38–57). New York: Wiley.
Rachman, S. J. (1997). A cognitive theory of obsessions. Behaviour Research and
Therapy, 35, 793–802.
Rachman, S. (1998). A cognitive theory of obsessions: elaborations. Behaviour
Research and Therapy, 36, 385–402.
Rachman, S. (2003). The treatment of obsessions. Oxford: Oxford University Press.
Rachman, S. J., & de Silva, P. (1978). Normal and abnormal obsessions. Behaviour
Research and Therapy, 16, 232–248.
Salkovskis, P. M., & Harrison, J. (1984). Abnormal and normal obsessions: a repli-
cation. Behaviour Research and Therapy, 22, 549–552, 549–552.
Simpson, H. B., Foa, E. B., Liebowitz, M. R., Ledley, D. R., Huppert, J. D., Cahill, S., et al.
(2008). A randomized, controlled trial of cognitive-behavioral therapy for
augmenting pharmacotherapy in obsessive–compulsive disorder. American
Journal of Psychiatry, 165, 621–630.
Taylor, S. (1998). Assessment of OCD. In R. P. Swinson, M. M. Antony, S. Rachman, &
M. A. Richter (Eds.), Obsessive–compulsive disorder: Theory, research and treat-
ment. New York: Guildford Press.
Weissman, M. M., & Bothwell, S. (1976). Assessment of social adjustment by patient
self-report. Archives of General Psychiatry, 33, 1111–1115.
Whittal, M.L., Robichaud, M. & Woody, S.R. Treatment of obsessions:enhancing
dissemination with videos. Cognitive and Behavioral Practice, in press, doi:10.
1016/j.cbpra.2009.07.001.
Whittal, M. L., Thordarson, D. S., & McLean, P. D. (2005). Treatment of obsessive-
compulsive disorder: cognitive behavior therapy vs exposure and response
prevention. Behaviour Research and Therapy, 43, 1559–1576.
Woody, S. R., O’Neill, M., Fairbrother, N., & McLean, P. D. (2003). Stress management
training for obsessions: treatment manual. Unpublished.
Woody, S. R., Steketee, G., & Chambless, D. L. (1995). Reliability and validity of the
yale-brown obsessive–compulsive scale. Behaviour Research and Therapy, 33,
597–605.