Downloaded by [New York University] at 04:59 12 August 2016 “I strongly recommend this expert clinical guide to the psychological treat- ment of obsessive compulsive disorders. The depth of Dr. Sookman’s clinical experience and her command of the literature are evident in the thorough coverage of assessment procedures, how to optimize the effects of therapy and deal with problems. The numerous case illustrations are well-chosen and clearly described.” —S. Rachman, Emeritus Professor, Institute of Psychiatry, London University, and University of British Columbia. “Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder: An Expert Clinician Guidebook by Dr. Debbie Sookman is an outstanding contribution to the science and clinical practice related to the full range of Obsessive Com- pulsive Disorder. This is an excellent book in every way imaginable. Clearly written and organized, Sookman provides a critical and scholarly review of the state of the art on OCD. Every researcher and clinician can benefit from this superb book. The reader benefits from the considerable clinical expe- rience and scholarship that Dr Sookman possesses, while learning specific and powerful tools in helping those who suffer from OCD. Case examples illustrate the importance of conceptualization and the value of empirically supported treatments. I am particularly impressed that Sookman was able to balance such sophistication in her critical and scientific understanding of OCD, while still writing a clear and concise book on the topic. This is a book I will recommend to both beginning clinicians in training and to seasoned researchers and practitioners.” —Robert L. Leahy, Ph.D., Director, American Institute for Cognitive Therapy “Dr. Sookman’s book is a remarkable compilation of the current literature on Obsessive-Compulsive Disorder (OCD). Dr. Sookman emphasizes the need Downloaded by [New York University] at 04:59 12 August 2016 for evidence based treatments and elaborates what these are, how specialty cognitive behavior therapy interventions are best applied, their efficacy rates and the reasons for failure. Case illustrations make this guidebook especially compelling. I strongly recommend this expert guidebook to everyone who is interested in OCD.” —Fugen Neziroglu, Ph.D., ABBP, ABPP, Director of the Bio-Behavioral Institute, Great Neck, NY and author of numerous books including, Overcoming Body Dysmorphic Disorder and Overcoming Compulsive Hoarding, both OCD Spectrum Disorders. This page intentionally left blank Downloaded by [New York University] at 04:59 12 August 2016 Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder is an expert clinician guide for administration of evidence-based specialized cognitive behavior therapy (CBT) for obsessive compulsive disorder and its subtypes. This book focuses on strategies to identify and resolve com- plex and varied reasons for resistance to CBT and to optimize symptom remission, generalize improvement, and forestall relapse during treat- ment for OCD. The interventions discussed build upon and elaborate the clinical and research work of other OCD experts, clinicians, and research- ers in the field of cognitive therapy, and are based on the author’s own research and clinical experience as an internationally known expert treat- ing thousands of OCD patients. Criteria are outlined for symptom recov- ery and for treatment resistance in the context of optimal evidence-based specialized CBT delivery. Featuring treatment models and illustrative case studies, this book is a necessary addition to the library of mental health professionals who work with patients suffering from OCD. Downloaded by [New York University] at 04:59 12 August 2016 Debbie Sookman, PhD, is Director of the Obsessive Compulsive Disor- der (OCD) Clinic, Department of Psychology, McGill University Health Centre, Associate Professor, Department of Psychiatry, McGill Univer- sity, Montreal, Canada, and President of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD, www.ciocd.ca). Dr. Sookman is an internationally known expert in specialty assessment and treatment for OCD and Related Disorders and is a Fellow and Certified Trainer/ Consultant of the Academy of Cognitive Therapy, USA. Practical Clinical Guidebooks Series Rosqvist Exposure Treatments for Anxiety Disorders: A Practitioner’s Guide to Concepts, Methods, and Evidence-Based Practice Marshall, Marshall, Serran, and Fernandez Treating Sexual Offenders: An Integrated Approach Emmelkamp and Vedel Evidence-Based Treatments for Alcohol and Drug Abuse: A Practition- er’s Guide to Theory, Methods, and Practice Dugas and Robichaud Cognitive-Behavioral Treatment for Generalized Anxiety Disorder: From Science to Practice Perkins, Conklin, and Levine Cognitive Behavior Therapy for Smoking Cessation: A Practical Guide- book to the Most Effective Treatments Ramsay and Rostain Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psycho- social and Medical Approach Hofmann and Otto Cognitive Behavioral Therapy for Social Anxiety Disorder: Evidence- Based and Disorder-Specific Treatment Techniques Downloaded by [New York University] at 04:59 12 August 2016 Muller and Mitchell Compulsive Buying: Clinical Foundations and Treatment Gardner and Moore Contextual Anger Regulation Therapy: A Mindfulness and Acceptance- Based Approach Sookman Specialized Cognitive Behavior Therapy for Obsessive Compulsive Dis- order: An Expert Clinician Guidebook Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder An Expert Clinician Guidebook Debbie Sookman Downloaded by [New York University] at 04:59 12 August 2016 First published 2016 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2016 Taylor & Francis The right of Debbie Sookman to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Sookman, Debbie, author. Specialized cognitive behavior therapy for obsessive compulsive disorder : an expert clinician guidebook / by Debbie Sookman. p. ; cm. — (Practical clinical guidebooks series) Includes bibliographical references and index. I. Title. II. Series: Practical clinical guidebooks series. [DNLM: 1. Obsessive-Compulsive Disorder—diagnosis—Case Reports. 2. Cognitive Therapy—methods—Case Reports. 3. Comorbidity—Case Reports. 4. Obsessive- Compulsive Disorder—therapy—Case Reports. 5. Treatment Refusal—Case Reports. WM 176] RC489.C63 616.89'1425—dc23 2015007996 ISBN: 978-0-415-89954-3 (hbk) ISBN: 978-0-415-89953-6 (pbk) ISBN: 978-1-315-68065-1 (ebk) Typeset in ITC Legacy Serif by Apex CoVantage, LLC Downloaded by [New York University] at 04:59 12 August 2016 IN LOVING MEMORY OF MY PARENTS BELLA AND LARRY SOOKMAN, TO MY PARTNER ARTHUR LANDA WITH DEEP APPRECIATION FOR YOUR LOVE AND INSPIRATION, TO THE MANY HELPFUL AND SUPPORTIVE COLLEAGUES FROM WHOM I HAVE LEARNED, AND TO THE THOUSANDS OF PERSONS SUFFERING FROM THIS DISABLING DISORDER WHO SOUGHT MY HELP Downloaded by [New York University] at 04:59 12 August 2016 This page intentionally left blank Downloaded by [New York University] at 04:59 12 August 2016 Contents CHAPTER 1 Introduction 1 About OCD 1 Clinical Symptoms of OCD 6 OCD Related Disorders 7 Summary of Central Theoretical and Treatment Issues in Assessment, Treatment, and Research of OCD 10 CHAPTER 2 OCD Subtypes and Comorbidity 19 CHAPTER 3 Downloaded by [New York University] at 04:59 12 August 2016 Theoretical and Treatment Literature 27 Theoretical Literature 27 Treatment Outcome Literature 32 Predictors of Outcome—Patient Characteristics 40 ix CONTENTS CHAPTER 4 “Resistance” to Specialized Cognitive Behavior Therapy for OCD 43 Outcome Literature Relevant to Treatment Resistance 44 Reasons for and Meanings of Resistance to Evidence-based CBT for OCD 47 CHAPTER 5 The Scientist–Practitioner Model 51 OCD Assessment Protocol 51 Process of Assessment 55 The Therapeutic Relationship 55 Treatment Phases and Components 57 Psychological Interventions 60 CHAPTER 6 Treatment of Obsessions 63 Case Illustration 67 CHAPTER 7 Treatment of Contamination 73 Further Clinical Characteristics of Contamination Types 75 Case Illustrations 78 Downloaded by [New York University] at 04:59 12 August 2016 CHAPTER 8 Treatment of Checking 99 Case Illustration 102 CHAPTER 9 Treatment of Symmetry, Ordering, Arranging 109 x CONTENTS CHAPTER 10 A Schema-based Model 113 The Model in Theory 118 The Model in Practice: Schema-based Assessment and Treatment Interventions 123 Outcome of This Approach 130 Case Illustrations 132 CHAPTER 11 Intervention Criteria for an Optimal Trial of Specialized CBT for OCD, Criteria for Recovery, Criteria for CBT Resistance 157 Criteria for an Optimal Trial of Specialty CBT for OCD 158 Indications for