Best practices for CBT treatment of taboo and unacceptable thoughts in OCD

Abstract

Although general cognitive behavioural therapy (CBT) can help alleviate distress associated with obsessive-compulsive disorder (OCD), strategies tailored to targeting specific cognitions, feelings, and behaviours associated with OCD such as exposure and ritual prevention (Ex/RP) and cognitive therapy (CT) have been shown to be a significantly more effective form of treatment. Treatment of individuals with unacceptable/taboo obsessions requires its own specific guidelines due to the stigmatizing and often misunderstood nature of accompanying thoughts and behaviours. In this article, OCD expert practitioners describe best practices surrounding two of the longest standing evidence-based treatment paradigms for OCD, CT and Ex/RP, tailored specifically to unacceptable and taboo obsessions, so that clients may experience the best possible outcomes that are sustained once treatment ends. In addition, CT specifically targets obsessions while Ex/RP addresses compulsions, allowing the two to be highly effective when combined together. A wide range of clinical recommendations on clinical competencies is offered, including essential knowledge, psychoeducation, designing fear hierarchies and exposures, instructing the client through behavioural experiments, and relapse prevention skills. Key learning aims (1) To learn about the theoretical underpinnings of specialized approaches to treating taboo/unacceptable thoughts subtype of OCD with gold-standard CBT treatments, cognitive therapy (CT) and exposure and ritual prevention (Ex/RP). (2) To learn about recognizing and identifying commonly missed covert cognitive symptoms in OCD such as rumination and mental compulsions. (3) To learn how to assess commonly unrecognized behavioural symptoms in OCD such as concealment, reassurance seeking, searching on online forums, etc. (4) To gain a nuanced understanding of the phenomenology of the taboo/unacceptable thoughts OCD subtype and the cycles that maintain symptoms and impairment. (5) To learn about in-session techniques such as thought experiments, worksheets, fear hierarchies, and different types of exposures.