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Human Nature Review 2003 Volume 3: 252-253 ( 7 May )
URL of this document http://human-nature.com/nibbs/03/rachman.html
The Treatment of Obsessions
by Stanley Rachman.
Oxford University Press, 2003
Reviewed by Eduardo Keegan, Professor of Clinical Psychology and the Psychotherapies, University of Buenos Aires, Buenos Aires, Argentina.
This book is one of the Cognitive Behaviour Therapy: Science and Practice series, published by Oxford University Press. Edited by David M. Clark, Christopher Fairburn and Steven Hollon, the series intends to provide state-of-the-art cognitive behaviour therapy interventions for a number of common mental disorders. They typically include updated and precise descriptions of cognitive models for a given disorder, assessment tools, clear guidelines for treatment and a number of practical clinical tools.
The Treatment of Obsessions deals mainly, but not only, with a particular kind of obsessive-compulsive disorder: that characterised by the absence of compulsions. This is not a rarity: one in every three OCD patients will not show compulsive behaviour. Why is this a matter for concern rather than a blessing? Well, compulsive behaviour has been, for decades now, easier to treat psychologically than obsessions. Or, to put it the other way around, obsessions are very resistant to behavioural interventions such as exposure and response prevention.
Stanley Rachman reviews the standard behavioural interventions for OCD patients, and his presentation is authoritative, given that he has largely contributed to the development of these approaches. Rachman links the limitations of behavioural interventions to theoretical matters. Thus, the book begins by presenting a model of OCD that is more cognitive than behavioural, and that was generated mainly by Paul Salkovskis and what used to be known as the Oxford group of cognitive therapy.
The model contends that obsessions are not different to normal intrusive thoughts. This idea represents an important departure from a long tradition of research on the matter. Patients suffering from obsessions will normally have an altered sense of responsibility and dysfunctional ideas about intrusive thoughts of unacceptable content. The attribution they make about having these thoughts and the way they choose to cope with them turns these harmless intrusions into devastating and time-consuming obsessions. Thus, the model offers a number of ideas on how these obsessions could be managed, ideas that have proven quite effective in controlled trials.
The chapter on assessment -in which the evaluation of cognitive biases is central- includes a series of very practical toolkits for the clinician. It covers many different measures, such as the Maudsley Obsessional Compulsive Inventory, the Obsessive-Compulsive Inventory, the Personal Significance Scale and the Thought-Action Fusion Scale. Clinicians will also find a semi-structured interview for the assessment of obsessions.
The chapters on treatment describe interventions very clearly and will be especially helpful for the novice cognitive therapist. The book ends with six case illustrations, which provide a very clear picture of how the treatment strategies are implemented.
Stanley Rachman is a gifted speaker and writer, and The Treatment of Obsessions is a good proof of these qualities. He presents a clear and succinct account of the topic in his simple and elegant style. Having been an important figure in the development of these theories and treatments1, with so many things to say, it must have been difficult to come up with a relatively short and well-balanced book.
The graphic design is austere but nice. In my opinion, it would have been better to design the toolkits in a way that they could be easily turned into forms (I assume they are meant to be used by the therapists who purchase the book). Pull-out forms of a CD-ROM, quite common in CBT manuals, would have been of great help.
Other than this, the book is very good and a cost-effective inclusion for the armamentarium of the psychotherapist.
1. The interested reader may have a look at his contribution to Clark, D. M. and Fairburn, C. (1997) Science and Practice of Cognitive Behaviour Therapy, also by Oxford University Press.
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© Eduardo Keegan.
Keegan, E. (2003). Review of The Treatment of Obsessions by Stanley Rachman. Human Nature Review. 3: 252-253.
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