4404995-496570 00 4862195-60261500School of Public Health Post-Graduate Program in Counselling and Psychotherapy 88265203835Date Submitted

4404995-496570
00
4862195-60261500School of Public Health
Post-Graduate Program in Counselling and Psychotherapy
88265203835Date Submitted: 1st October 2018
00Date Submitted: 1st October 2018

POSTGRADUATE STUDENT ASSIGNMENT SHEET
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Name Aashna Narang
Student ID A1752627
Course PUB HLTH 7003 – Cognitive Behaviour Therapy
Course Co-ordinator Dr Alexandra Bloch-AtefiStudent email address [email protected]
Assignment Number: 2
Assignment Title: Critical review of a chosen CBT application
Wordcount: 1441

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Abstract
The aim of this assignment was to prove the efficacy of cognitive behaviour therapy (CBT) in treating adults with Obsessive compulsive disorder (OCD). As part of this assignment the researcher analysed several articles as well as peer reviewed journals to prove CBT to be an effective therapeutic tool in reducing the symptoms of OCD. One of the major CBT tools used is the exposure and response prevention (ERP) which has been found to be the primary tool in treating OCD, reducing symptoms of depression and improving client’s wellbeing (Shinmei et al., 2017). It was found to be effective in treating adolescents, adults as well as children. ERP was also found to be effective in other settings such as family and group therapy. However, ERP was found to have certain shortcomings. It was found to be challenging for clinicians and clients and some of its components were found to be ineffective in outcome prediction (Craske et al., 2008; McKay et al., 2015). It was also found to be unresponsive to certain OCD symptoms (Walsh ; McDougle, 2011). Despite these limitations however, CBT along with ERP were found to be extremely effective in treating OCD.
Introduction
In this assignment, the researcher would be talking about the effectiveness of cognitive behaviour therapy in treating OCD in conjuncture with exposure and response prevention. The researcher would also be talking about the relation between CBT and ERP and the use of ERP in treating OCD. The prevalence of OCD and the suitability of ERP with the adult population would also be discussed. Additionally, the context in which ERP would be used in psychotherapy and other health settings would be talked about along with the limitations of this tool.
According to Slade et al., (2009) OCD was found to be prevalent in 1.9% of the Australian adult population in a 12-month period. OCD has been categorised as one of the 10 most debilitating diseases in terms of loss of income and quality of life, by the world health organization (National Institute for Health and Clinical Excellence, 2011).
Cognitive behaviour therapy has been found to bring efficacious results in treating OCD. The main focus of cognitive behaviour therapy (CBT) is the study of the relationship between thoughts, emotions and behaviour (Beck, 1976). According to the ABC model by Albert Ellis (1957), the antecedent events (A) influence or cause the formation of negative automatic thoughts or beliefs (B) which in turn lead to certain consequences (C). Similarly, according to Oltean et al., (2017) our behaviours and emotions (consequences) are directly influenced by our cognitive processing (beliefs) of the life events rather than the life events (Antecedent events) themselves.
Thus, according to CBT, Obsessive compulsive disorder can be understood as the recurrence of certain automatic thoughts or formation of beliefs which can be obsessive (e.g., if I don’t wash my hands thrice after using the toilet I will die of germ contamination) which causes the individual to perform compulsive behaviours (e.g., washing hands up to 10 times) to decrease the anxiety caused by such thoughts/beliefs.

CBT was discovered to be successful in reducing OCD symptoms, moreover, these results were found to be enduring (Olatunji et al., 2013).

A paramount goal of CBT and ERP is to augment the tolerance of unpleasant experiences. The goal is to help the clients tolerate anxiety caused by obsessive thoughts as well as reduce the use of avoidance or safety behaviour(s). Thus, breaking the vicious cycle of obsessive thoughts and compulsive behaviours (Abramowitz & Arch, 2014).
Research conducted on CBT since the 1960’s has shown ERP to be an efficacious and a chief tool in treating individuals with OCD symptoms (Morgan et al., 2013; Strauss et al., 2015). ERP involves a continuing and a persistent exposure to a situation or a stimulus that elicits fear. This is combined with instructions to refrain from indulging in compulsive behaviour. ERP combined with cognitive therapy, which focuses on altering dysfunctional beliefs has also shown to bring positive results (Olatunji, Davis, Powers, ; Smits, 2013).
According to Himle and Franklin, (2009) the chief component in ERP is extinction, which is caused by the systematic exposure to fear or anxiety inducing stimuli as well as deterrence of escape behaviours.
The main focus of ERP is to ebb obsessional anxiety by systematically subjecting the client to those events which incite distress, then the clients are asked to deliberately avoid the compulsive behaviours until they are habituated or adapted to the situation. Eventually, the clients are able to identify faulty beliefs and evaluate the probable effects of abstaining from or engaging in compulsive behaviours. Thus, they learn to subsequently eliminate those compulsions (Foa, 2010).
ERP has proven to be efficient not just with adults who have OCD (Strauss et al., 2015) but with children and adolescents as long as the treatment is modified according to their needs (Herren et al., 2016).

Since the employment of ERP was first described by Meyer (1966), CBT has become so advanced for OCD that it is considered the most efficient psychotherapeutic method for treating OCD (McKay,2015).
It has also been discovered by Gillihan, Williams, Malcoun, Yadin ; Foa, (2012) that ERP enables clients to reduce compulsive behaviour as they abstain from ritual behaviour, which in turn weakens the urge to ritualize. Additionally, by recurrently facing the anxiety invoking stimuli (e.g., touching dirty clothes), they discover that the dreaded consequence (e.g., contracting infection) does not occur. Even if, the exposure sessions are unable to help reduce the distress, clients experientially learn to endure the anxiety caused by the distressing stimuli (Craske et al., 2008).

According to Walsh ; McDougle (2011) for clients with milder OCD symptoms and negligible comorbidity, ERP has been a desirable form of psychotherapy. It was also discovered in the same study that 55% of the clients who completed 10-20 ERP therapy sessions experienced considerable improvement.
Group ERP therapy was also discovered to be very effective, especially for socially alienated clients and it was less expensive (Jaurrieta et al., 2008). 70% of the families reported family ERP therapy to be effective as it aimed at family accommodation of the OCD symptoms (Merlo, Lehmkuhl, Geffken, ; Storch, 2009).

While introducing CBT as well as ERP to the client, the researcher would first explain how CBT focuses on an individual’s cognitions or automatic thoughts formed by the faulty perceptions of certain experiences that lead to distressing emotions which eventually result in unwanted behaviours. Thus, to help them overcome the distress caused by the obsessive thoughts, the researcher would talk about the process of gradually exposing them to an anxiety provoking situation either by actually exposing them (in vivo) or having them imagine it (imaginal exposure) and instruct them to refrain from using ritualized behaviour.

Eventually, the repeated exposure would help them get habituated to the distressing situation without getting disturbed and thus would aid an alteration in their cognitions, emotions and behaviours.
An anticipated outcome could be that clients who have comorbid depression or anxiety may find ERP therapy sessions to be difficult and distressing (Walsh & McDougle, 2011).
A potential contraindication can be the use of reassurance. A lot of people have experienced the need to feel reassured in relation to their obsessions (Williams et al., 2011). Reassurance however, can cause delays in the ERP progress as it inhibits direct exposure to the feared situation. (Gillihan, Williams, Malcoun, Yadin & Foa 2012). Another contraindication could be the inability to identify and address mental compulsions. Mental compulsions are the behaviours which are used to reduce anxiety, they reinforce obsessions, thus may result in the harmful outcome of maintaining OCD (Pence et al., 2010).

A shortcoming of ERP could be, the habituation that occurs within the exposure therapy session can be helpful but is not a robust prognosticator of treatment outcome (Craske et al., 2008). Secondly, Williams et al (2011) found ERP to be ineffective in treating all types of OCD symptoms. ERP was also found to be less responsive to sexual and religious obsessions (Walsh & McDougle, 2011). Lastly, clinicians experienced ERP to be challenging and clients experienced it to be confronting, especially the ones who had severe symptoms (McKay et al., 2015).

Conclusion
In conclusion, cognitive behaviour therapy has proven to be effective in treating obsessive compulsive disorder with the help of exposure and response prevention. There have been several studies that have proven the success rate of using ERP in treating OCD and ERP being the primary tool used. Certain limitations of ERP were observed which proved that it can be challenging for the clients and the therapist as well. However, it still proved to be an effective tool resulting in positive outcomes.

References
Abramowitz, J. S., & Arch, J. J. (2014). Strategies for improving long-term outcomes in cognitive behavioral therapy for obsessive-compulsive disorder: insights from learning theory. Cognitive and Behavioral Practice, 21(1), 20-31.

Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. New York, NY: Penguin.
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour research and therapy, 46(1), 5-27.

Ellis, A. (1957). Rational psychotherapy and individual psychology. Journal of Individual Psychology, 13(1), 38-44.

Foa, E. B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2), 199.

Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common pitfalls in exposure and response prevention (EX/RP) for OCD. Journal of obsessive-compulsive and related disorders, 1(4), 251-257.

Herren, J., Freeman, J., & Garcia, A. (2016). Using Family?Based Exposure With Response Prevention to Treat Obsessive?Compulsive Disorder in Young Children: A Case Study. Journal of clinical psychology, 72(11), 1152-1161.

Himle, M. B., & Franklin, M. E. (2009). The more you do it, the easier it gets: Exposure and response prevention for OCD. Cognitive and Behavioral Practice, 16(1), 29-39.

Jaurrieta, N., Jiménez?Murcia, S., Alonso, P., Granero, R., Segalàs, C., Labad, J., & Menchón, J. M. (2008). Individual versus group cognitive behavioral treatment for obsessive–compulsive disorder: follow up. Psychiatry and clinical neurosciences, 62(6), 697-704.

McKay, D., Sookman, D., Neziroglu, F., Wilhelm, S., Stein, D. J., Kyrios, M., … & Veale, D. (2015). Efficacy of cognitive-behavioral therapy for obsessive–compulsive disorder. Psychiatry research, 225(3), 236-246.

Merlo, L. J., Lehmkuhl, H. D., Geffken, G. R., & Storch, E. A. (2009). Decreased family accommodation associated with improved therapy outcome in pediatric obsessive–compulsive disorder. Journal of consulting and clinical psychology, 77(2), 355.

Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour research and therapy, 4(4), 273-280.

Morgan, J., Caporino, N. E., De Nadai, A. S., Truax, T., Lewin, A. B., Jung, L., … & Storch, E. A. (2013). Preliminary predictors of within-session adherence to exposure and response prevention in pediatric obsessive–compulsive disorder. In Child & Youth Care Forum (Vol. 42, No. 3, pp. 181-191). Springer US.

National Collaborating Centre for Mental Health. (2011). Common mental health disorders: identification and pathways to care (No. 123). London, England: Author.

Olatunji, B.O., Davis, M.L., Powers, M.B., & Smits, J. A.J. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33-41.
Oltean, H.R., Hyland, P., Vallieres, F., & David, D.O. (2017). An Empirical Assessment of REBT Models of Psychopathology and Psychological Health in the Prediction of Anxiety and Depression Symptoms. Behavioural and Cognitive Psychotherapy, 45(6), 600-615.
Pence Jr, S. L., Sulkowski, M. L., Jordan, C., & Storch, E. A. (2010). When exposures go wrong: Trouble-shooting guidelines for managing difficult scenarios that arise in exposure-based treatment for obsessive-compulsive disorder. American Journal of Psychotherapy, 64(1), 39-53.

Shinmei, I., Kanie, A., Kobayashi, Y., Nakayama, N., Takagishi, Y., Iijima, S., Takebayashi, Y., Horikoshi, M. (2017). Pilot study of exposure and response prevention for Japanese patients with obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 15, 19-26.
Slade, J., Teesson, W., & Burgess, P. (2009). The mental health of Australians 2: report on the 2007 National Survey of Mental Health and Wellbeing.

Strauss, C., Rosten, C., Hayward, M., Lea, L., Forrester, E., & Jones, A. M. (2015). Mindfulness-based exposure and response prevention for obsessive compulsive disorder: study protocol for a pilot randomised controlled trial. Trials, 16(1), 167.

Walsh, K. H., & McDougle, C. J. (2011). Psychotherapy and medication management strategies for obsessive-compulsive disorder. Neuropsychiatric disease and treatment, 7, 485.

Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., … & Foa, E. B. (2011). Myth of the pure obsessional type in obsessive–compulsive disorder. Depression and anxiety, 28(6), 495-500.