Directions in Specialized Cognitive Behavior Therapy for Resistant Obsessive-Compulsive Disorder: Theory and Practice of Two Approaches

This paper discusses specialized approaches developed for patients with obsessive-compulsive disorder (OCD) who are resistant to cognitive behavior therapy (CBT). Following a review of theoretical and outcome research, two approaches developed to resolve persistent OCD are described and illustrated. Cognitive therapy (CT) designed to address characteristic dysfunctional beliefs has shown promising results (Wilhelm et al., 2005; Wilhelm & Steketee, 2006). CT modules focus on understanding and correcting OCD-related beliefs (e.g., inflated responsibility, need for certainty, perfectionism) pertinent to each patient’s symptoms, using specialized strategies and behavioral experiments to test and modify maladaptive hypotheses and related negative emotions. CT appears to be acceptable to many patients and may reduce refusal rates and improve collaboration during exposure and response prevention (ERP). It is not yet clear whether this method improves outcomes for patients who have not responded to previous ERP. A schema-based CBT approach developed by Sookman and Pinard (1999, 2007) for resistant OCD of different subtypes aims to broaden the scope of CT, to improve patients’ capacity to fully engage in ERP, and to reduce susceptibility to relapse. Available results with previously CBT-resistant patients suggest this approach may improve learning during CT and collaboration in ERP, resulting in recovery for some patients. Criteria are outlined for defining CBT resistance and assessing treatment response using various outcome measures and stringent criteria. The ultimate goal of expert intervention for OCD is remission. The authors propose theory, practice, and research directions to help ameliorate symptoms and related difficulties in resistant OCD.