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CBT for Mental Compulsions

Posted on Friday, August 08, 2008

Question: Does CBT work for mental compulsions, such as math or symmetrical games? If so, how do you start?

Richmond, VA

Answer: Cognitive Behavioral Therapy is a broadly efficacious treatment for obsessive-compulsive disorder (OCD). Specifically, a form of behavior therapy (Exposure and Response Prevention [ERP]) has been shown to produce superior treatment results to the most effective psychotropic medications in several large, multi-site National Institute of Health sponsored clinical trials (e.g., Foa et al., 2005). There are several good self-help books on ERP (e.g., Abramowitz, 2005).

For some time, clinicians and researchers have identified people with OCD who engage in mental compulsions. That is, rather than neutralize the distress experienced with obsessional intrusion by using overt compulsive rituals (e.g., washing one’s hands in response to feelings of contamination; checking repetitively in reaction to obsessional doubts), these individuals use covert rituals (e.g., neutralizing a “bad” thought with a “good” thought). Research on OCD symptom heterogeneity has consistently identified a large subgroup of individuals often referred to as “pure obsessionals” (e.g., Calamari et al., 2004), individuals who have no overt compulsions but who consistently neutralize obsessions with covert mental behavior (e.g., praying; mental checking involving repetitively reviewing events in one’s mind, etc.). In other words, pure obsessionals are not so “pure”, and rather than not engaging in compulsive behavior, these individuals do all their compulsions covertly. Although a different symptom variation of OCD, ERP can be applied effectively (Salkovskis & Westbrook, 1987), and treatment outcome is very good (Freeston et al., 1997). See Purdon and Clark’s (2005) self-help book for examples of treating mental rituals.

In applying ERP to mental rituals, the task is the same-having the patient become willing to experience the obsessional concern and related distress, but refrain from using their compulsions to reduce distress. This allows the individual to discover repetitively that their distress diminishes nonetheless, and allows them to become less reactive to obsessional intrusions. The task is more difficult, though. The individual with washing compulsions can often more easily refrain from getting up and going to the sink to decontaminate, while the individual with well-practiced mental rituals may be able to converse with others at work while simultaneously completing several, covert mental rituals. Mental rituals are clearly more portable, and can be done in social settings covertly, settings where many people with OCD attempt to minimize ritualizing.

Clinically I have found that although many patients indicate they have no control over their mental rituals, a careful look suggests otherwise. Often, people with extensive mental rituals stay in a setting free from distractions so they can focus on “getting things right” in their mind. ERP is supported by graduated, but progressively more active engagement in life. Going out to dinner with friends, engaging in conversation, and focusing on hopefully an interesting topic make the prevention of mental ritualizing more likely. Staying at home to think, to get it right, leads to more mental ritualizing. 

The critical issue for effective treatment of mental ritualizing is good assessment. The clinician and patient must work together to identify all the obsessional intrusions and all the related compulsions (neutralizing behaviors including avoidance behavior) to set the stage for effective treatment and good outcomes.