Journal of Cognitive Psychotherapy: An International Quarterly, Volume 13, Number 4,1999
A Cognitive Approach to
the Treatment of
Primary Inferences in
Obsessive-Compulsive Disorder
Kieron O'Connor
Sophie Robillard
Centre de recherche Fernand-Sequin, Canada
In this article, it is argued that obsessive-compulsive disorder (OCD) with
overt compulsions, where there is overvalued ideation, is primarily a disorder
of the imagination and hence, by implication, psychological therapy should
principally ress the client's imagination, rather than other cognitive
processes. According to this model, the OCD client imagines a state of affairs
which is then taken 'as if it were a reality and does so because of the
persuasive influence of an imaginary narrative fiction. This narrative is
replayed, often in condensed form, in the OCD context and leads the client
into a chain of maladaptive inferences about a possible state of affairs. The
client then acts in accordance with what might be present rather than what is
actually present.
An inference-based approach (IBA) which directly addresses and challenges the imaginary narrative of the client is outlined, with clinical illustrations. The IBA approach complements other cognitive-behavioral therapy
(CBT) and can be used in conjunction with existing CBT methods which
focus more on modifying the interpretations and secondary appraisals subsequent to primary inferences.
Cognitive approaches to understanding obsessive-compulsive disorder (OCD)
with overt compulsions have focused largely on the storing or processing of
perceived information. Early theories focused directly on potential perceptual
deficits, such as problems in selecting relevant and suppressing irrelevant information (Enright & Beech, 1993) in storage and recall of perceived information (Sher,
Mann, & Frost, 1984) or incongruence in the way perception and action are
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facilitated or inhibited under complex or novel task demands (Otto, 1992; Reed,
1991). Recent cognitive theories of OCD have referred to the role of attentional bias
interfering with perception, and leading to a heightened vigilance for and encoding
of danger or threat (e.g., Tata, Leibowitz, Prunty, Cameron, & Pickering, 1996;
Wilhelm, McNally, Baer, & Florin, 1996). Other authors have suggested that it is
faulty appraisals following initial intrusive thoughts and perceptions which maintain them as problematic (Freeston, Rheaume, & Ladouceur, 1996).
However, phenomenologically speaking, the OCD client is not anxious about
what is but what might be; hence, the standard epithet attached to OCD is the
pathology of doubt.' It is almost exclusively what is not physically apparent which
is feared, and this fear is not simply in anticipation of what might happen but of what
might be there now and cannot be seen or detected in the normal way. This point is
doubly substantiated, first, by evidence that OCD clients have no problems
perceiving reality (Brown, Kosslyn, Breiter, Baer, & Jenike, 1994) (although they
may be less confident about what is seen), and second, since, in any case, it is not
just perceived attributes that trigger OCD behavior. Although, at first glance, it may
appear that the OCD client fears dirt, disorder, and so forth. It is clear that the fear
is largely of what this state symbolizes, either overtly as in the case of mental
pollution (Rachman, 1994) where moral or other symbolism is clear (e.g., cleanliness is next to godliness) or more subtly, where the aversive state of affairs is
conditional on situational idiosyncrasies over and above shared physical qualities
(e.g., the person fears disorder or microbes associated with one group of people or
situations but not another).
OCD can be reconceptualized as a disorder of the imagination rather than
perception in the sense that the client imagines a state of affairs which is then taken
'as if it were a reality. The person then acts in accordance with the dictates of the
imagination rather than the perceived demands of the real world. The OCD person
is perfectly able to perceive reality and to distinguish between what is or is not real.
But imagination imposes on this reality a preoccupation with what might also be
there, or with what this reality might signify.
Whatever the adequacy of this conceptualization of OCD as a disorder of the
'imagination,' it clearly has some heuristic value in accounting for the 'may be'
quality of OCD doubt. The OCD 'belief is usually always about a possibility, not
a certainty. In this sense, as the Obsessive Compulsive Cognitions Working Group
(1997) has noted, the word belief may be a misnomer, since beliefs are usually
always certain. In fact, the OCD person infers a state of affairs rather than believes
in it.
Perception deals with what is there, imagination with what could be there. The
OCD client could have no problems perceiving reality and yet 'know' at the same
time that something other than the evidence of his other senses might be present.
Equally, the model would predict that in carrying out the ritual, the client would not
be attentive to reality but to the imagined reality, and that performing the ritual
would be antagonistic to taking in more perceptual information. The OCD client
Treatment of Obsessive-Compulsive Disorder
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should not confuse a perceived event per se with an imagined event, since as noted
the OCD client has no difficulty in perceiving what is there or is not there, but with
imagining what might be there as well. So how does the client with OCD come to
infer an imaginary state of affairs?
Previous work in OCD (O'Connor & Robillard, 1995,1996) noted how overvalued ideas can be embedded in a running narrative that is, from beginning to end,
grounded in an imaginary story of what is present and what will be the ensuing
consequences. Clients with OCD seem more easily persuaded by arbitrary narratives than controls or clients with other anxiety disorders (O'Connor & Pelissier,
1998). We hypothesize that a self-generated narrative produces the obsessional
inference by persuading the client that an imagined state of affairs is a reality.
Therapy focused on this initial obsessional inference (e.g., perhaps I left my
cooker on . . . ) is termed an inference-based approach (IBA) and addresses
principally the narrative context or internal monologue in which the primary
inference is embedded and seeks to unravel its imaginary character. Clients may
readily concur that part of their OCD fears are imaginary, but typically they feel that
they 'cannot take the risk' of not performing the neutralizing action because of the
small chance that they may be right. This 'yes but what if component frequently
leaves the client with an investment in the logic of the compulsive action. The IBA
premise is that the narrative is not 80%, 90%, or 99% improbable, but 100%
imaginary. Hence conventional cognitive methods, which aim to demonstrate the
low probability that the primary inference will occur, are not appropriate here, since
the problem lies not with perceiving probability, but in imagining it.
Current popular cognitive conceptualizations (Freeston et al., 1996; Rachman,
1997; Salkovskis, 1989; Van Oppen & Arntz, 1994) draw a sharp distinction
between 'negative intrusions' and appraisal processes. In current cognitive therapy,
emphasis is placed on confronting the client's appraisals that, for example, the
initial intrusive thoughts are important, that they will lead to drastic consequences,
or exaggerated blame for the person. The primary 'negative intrusions' themselves
are generally considered normal (except when evidently bizarre), and Salkovskis
(1989), for example, terms them 'mental flotsam.' The 'secondary inferences' or
appraisals are considered the more generic and self-referential whereas the primary
inferences are seen as more transitory and situation-specific. The IBA has been
developed exclusively in the context of OCD with overt compulsions, but it
conceptualizes initial negative intrusions as 'primary inferences' made about a state
of affairs. These primary inferences are considered embedded in an imaginary
narrative, and it is this narrative, not the subsequent appraisals, which forms the
focus of IBA.
Treating the narrative context as a unit is essential to unraveling the imaginary
associations because the primary inferences, taken in isolation by themselves, may
seem plausible. A cooker can be left on; door locks can come lose. But in the context
of the client's narrative surrounding, leading up to, and justifying this event, the
primary inference is completely imaginary. In our clinical experience to date, the
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narrative event forming the basis for the obsession has never occurred in the form
imagined. Conversely, real negative events which have occurred (although they
may be tied to the onset of OCD) do not enter into the content of the OCD narrative
structure. In the case of OCD with overvalued or delusional-like ideas, the bizarre
content of the primary inferences is evidently imaginary. Although our initial
observations of the importance of the OCD narrative derived from studying this
delusional-like subgroup, we now consider that even nonbizarre inferences can
conform to the imaginary prototype.
A client would be considered to suffer from the type of problematic primary
inference addressed by the IBA program if she/he met all of the three following
criteria:
1. (a) Client has a conviction that an event has happened or can happen
without any objective proof and in the absence of any objective indication
that it is likely to happen; or (b) client has a conviction that some object or
person possesses a property that is undetectable by normal senses or means.
2. (a) The conviction of criterion 1 (above) is defended solely with
reference to information gained from sources distant from and irrelevant to current reality (irrelevant being no objectively demonstrable
relation between the sources of information and the present reality); or
(b) the conviction of criterion 1 (above) is defended solely with
reference to a purely subjective source (e.g., subjective feeling or sense
of correctness) that has no demonstrable relation to objective criteria
of correctness.
3. The person who is convinced that an imagined or hypothetical reality
is a real probability will also lack insight about this confusion between
reality and imagination.
The clinical validity of this conceptualization of OCD is considered in the
following account of an IBA treatment program.
EVALUATION
We initially construct a hierarchy of compulsions based on the self-efficacy
principle and measuring confidence in resisting the rituals (Condiotte & Lichtenstein,
1981). Since we are focusing specifically on primary inferences about reality, we
need also to distinguish primary inferences from inferred secondary consequences
of the primary inference. Although primary and secondary inferences are chained
together, secondary consequences tend to be more accessible and vivid to the person
(e.g., if I do not check, then the house will burn down). Both primary and secondary
inferences are distinct from interpretations and appraisals about what it means to
have the obsession or compulsion. We use rating scales which measure the
confidence (0-100%) in resisting the ritual, the probability (0-8) of the primary
inference, and the realism (0-8) of the secondary consequences.
Treatment of Obsessive-Compulsive Disorder
363
Primary and Secondary Inferences
A convenient format to separate primary and secondary inference is to use a logical
template of the form: 'if... then.' For example: If my hat blows off in the wind, then
I will be exposed to ridicule. Here, in logic, the first clause after if is the primary
inference [or premise], the causes after then are the secondary inferences [or
corollary]. If the primary inference is not clear, it is possible to work back from the
consequences and ask: "... and that will happen if what state of affairs [is true], or
[happens]... ?" So, in the following example, the client spontaneously volunteers
a consequence to the therapist. C: "If I don't check the cooker, the house will burn
down." T: "And the house will burn down if what state of affairs is true." C: "Well,
if the cooker is left on and catches alight." The inference can be subsequently refined
by asking: T. "So, you are checking the cooker to check for what?" C: "Well, to
make sure the plates are not left on. Of course, I know they aren't really, but I just
want to be sure." T: "So, when you go to check, precisely what thought comes in
into your head?" C: "That the plates may be still on." Primary inference: The plates
may still be on. Secondary inference: (Then) the cooker will catch alight and burn
the house.
Problems With Eliciting Primary Inferences
The person may initially reply: "I don't know why I do it (the ritual) but I feel bad
if I don't." The motivation can be explored by detailing the exact nature of the
compulsion (e.g., smoothing out the creases in a pillow) and asking why this and
why not another action. The person may report only vague consequences to not
doing the ritual (e.g., I'll feel ill at ease). This reaction can be refined by exploring
'family resemblances,' for example, what other sort of events make the client feel
ill at ease in the same way.
In order to check if the correct inference has been targeted, 'counterfactual'
techniques can be used to create a hypothetical situation where the 'inferred doubt'
is completely eliminated. Example of counterfactual technique: The client avoids
any contact when using a public toilet. There are two possible primary inferences:
'other people have used the toilet and it may be contaminated,' 'because it's a toilet,
it may be contaminated.' Hypothetical counterfactual: "OK, imagine you have to
use a brand new toilet, you are 100% sure no one else has used it, do you feel the
need to avoid contamination?" If the person replies "no," the first inference is
satisfactory.
The primary inference is assessed on the basis of probability (0 = improbable8 = extremely probable), since the certainty/probability of the initial state of affairs
is a key element of the 'perhaps' quality of the inference. The secondary inferences
are assessed according to how realistic (0 = realistic-8 = unrealistic) the consequences are [if the primary inferences are certain]. It should be added that the
consequences, although often exaggerated, may in fact be realistic if the primary
inference is certain. Overall conviction measures how convinced the person is of the
Table 1. Examples of the Distinction Between Primary and Secondary Inferences and the Narratives Justifying
the Primary Inferences
Narrative
Primary inference
Secondary inference
Although I turned off the oven ring,
it might not have dosed properly.
I know of a kitchen which caught fire
because the child played with the stove.
The oven ring may be still on.
If the oven ring is on, then the kitchen will
catch fire and the house will burn down.
All the people who use the bus are
poor and dirty, they are uneducated
and don't wash properly.
The hand rail on the bus might be dirty.
If the hand rail is dirty, then if I touch it,
I will be contaminated and spread germs,
There should be no errors in any aspect
of a well written letter, and spaces,
margins, and the size of each letter
should all be absolutely equal.
There may be errors in the letter
I have written.
If there are errors, then I will feel
bad about myself,
Table 2. Profiles of Two Clients Diagnosed With OCD, With Overvalued Ideation, Who Completed a 20-Week
Cognitive-Behavioral Treatment Protocol Which Included IBA
Client 1
Client 2
Post
Pre
Post
Pre
Ritual Situation
Eff
Pri
Sec
Eff
Pri
Sec
Eff
Pri
Sec
Eff
Pri
Sec
1
2
3
4
5
6
7
8
9
10
0
0
0
20
20
0
0
0
0
10
0
8
8
8
8
6
6
6
8
8
8
7
7
7
7
7
7
7
7
8
80
80
90
90
95
90
95
95
98
95
0
0
0
0
0
0
0
0
2
2
8
8
8
8
8
8
8
8
8
7
60
50
50
40
40
30
30
0
0
0
4
4
4
5
3
6
5
8
8
8
3
6
4
4
5
2
3
0
0
1
90
100
80
70
100
75
80
50
50
75
4
0
0
1
0
0
0
3
3
1
5
8
8
7
8
7
8
5
6
7
5.0
(8.5)
6.6
(2.5)
7.2
(0.42)
90.5
(5.98)
0.4
(0.84)
7.9
(0.32)
30.0
(22.61)
5.5
(1.90)
2.8
(2.04)
77.0
(17.51)
1.2
6.9
(1.20)
(1.5)
Column 1: percentage efficacy, ordered hierarchically, in resisting rituals over 10 situations; Column 2: strength of primary
inference (0 = improbable-8 = very probable); and Column 3: secondary inference (0 = realistic-8 = unrealistic). The profiles are
given pre- and post-treatment. Eff = efficacy; Pri = primary inference; Sec = secondary inference.
X
SD(n- 1)
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necessity of performing the ritual. In other words, to what degree (0 = no
conviction-8 = extreme conviction) is the person convinced that doing the ritual is
necessary to accomplish or prevent the consequences. Our previous work shows
that all three scales can vary independently during therapy, although less so where
there is overvalued ideation, as in the two case examples. The data in Table 2
illustrate how each scale may show a distinct profile for each client over a hierarchy
of 10 distinct compulsive rituals per client.
TREATMENT
Step 1. Discover Elements of the Imaginary Narrative
The first major step is to explore the internal monologue which is behind the primary
inference. Sometimes the story comes spontaneously. Example: T: "So you don't
handle your mail when it arrives." C: "I saw the postman dragging his bag on the
ground and when I look at the people delivering circulars, I can see they are not
clean. The person who sorts the letters doesn't wash—why would he—they don't
get a chance— I was at a sorting office once and it had no facilities—there was paint
peeling off the walls; I mean touching all those sorts of objects, one after another,
then the letter gets put through the same letter box as the circulars and I've seen the
person who delivers circulars, scruffy dirty, and it drops on the mat." T: "Do you
check to see if it's dirty?" C: "Well, no, it's obvious it's dirty. I just know it is."
The narrative intertwines irrelevant associations with hearsay, out-of-context
facts, and provisional hypotheses. The person knows the mail is dirty, by her/
his'intelligence' not through her/his senses. Although in most cases the story leads
to imaginary inferences on an external state of affairs, in other circumstances the
narrative may refer to the type of person the client feels she/he is or should be. The
person may claim no perceivable repercussions if, for example, an act is not
performed in the correct way. But there may be repercussions to her/his self-image
and the narrative could relate to how people like her/him should behave. Example:
A person is overconcerned with the way a letter should be written, the spaces
between letters must be equal, the forming of the letters and the margins must be
precise, and any mistakes mean the letter must be redone. At first there seem no
secondary consequences if the letter is not written properly, except a feeling of
being ill at ease. The client does not report any reason why the letter would be better
or worse if written another way nor any story surrounding the letter writing itself.
But he does tell us that he is the sort of person who does things correctly to the finest
point. C: "I am a tidy person, tidy people should be preoccupied about the way they
work, you must have rules and guidelines, you can't have everything let loose. It
may be excessive but I only feel happy if everything is ordered as well as possible.
That's the person I am, I do things right to the finest point." This story can be
elaborated, as we explain later, by examining exactly what the person means by
'tidy' and 'well done.' Sometimes, then, if there appears at first to be no story
Treatment of Obsessive-Compulsive Disorder
367
supporting the primary inference, this may be due to circumscribing the narrative
around the incorrect object, event, or relationship.
The narrative containing the obsessional inference may be so well rehearsed that
it is automatic and reported initially in shorthand form, or simply submerged in an
intense emotional reaction. Example: A client being asked why she cannot touch the
handrail in a metro simply makes a sickly grimace and a heaving sound. Even as the
person attempts to narrate the story, the extreme emotional reaction makes words
difficult and shows she is living the story rather than describing it. The thought of
the ritual becomes charged with the emotional impact of the narrative, and the
narrative is forgotten.
If the narrative is given in shorthand it can be helpfully elaborated with the
therapist by asking, for example, "what makes the handrail dirty?" "What makes
you sure you have forgotten to lock the door?" The person frequently volunteers the
narrative as if it were supporting evidence. If, however, the narrative is still difficult
to elicit, a further strategy is to examine the incoherences in the person's OCD
problem. Some 'dirty' things are considered dirty but others are not. In some
circumstances the person shakes hands and in others circumstances she/he does
not—why? Sometimes the checking is not necessary, sometimes it is—why? The
important point here is to look for variation in the circumstances of the OCD. This
information can be sought through a situational profile of when the compulsion does
or does not occur, or through recording variations in its nature and intensity over
time. Exposing the discrepancies in the initial labeling of the problem forces the
client to qualify and justify the conditional nature of the problem, so bringing into
consciousness the persuasive aspects of the narrative and its theme.
The narrative theme may include general statements which if taken at face value
appeal to a legitimate consensual attitude but may in fact mask idiosyncratic
features. For example, a person may say "a thing done should be well done." The
key phrase here is 'well done." Everyone likes things 'well done,' of course. But
what exactly does the person understand by 'well done' and does the client's
meaning have a lot or little in common with what would be understood by others as
'well done'? In fact, the client may invoke a criteria of 'well done' which exactly
impedes a job being 'well done' in the usual sense of the word. For example, 'well
done' may entail working at something until completely worn out. Any operational
words that appeal to a conventional understanding should be suspect. Example: A
client reported that she only felt comfortable when she felt 'in control.' But what did
'in control' mean to her? In this case it did not mean controlling all technical aspects
of the task but simply feeling reassured that nothing untoward will happen, a
reassurance that had little to do with actually controlling details of the task.
The specific meaning of phrases such as 'well done' or 'in control' is determined
by grouping together instances illustrating or not illustrating the concept. This
analysis reduces the taken-for-granted use of the concept down to the actual and
essential criteria used by the person to decide its meaning in practice. Analyzing key
terms involved in the primary obsessional inference reveals the inconsistencies in
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the way the client categorizes the primary object of anxiety and opens the way to
explore, in more detail, the symbolic and hence imaginary aspect of the obsessional
theme. Example: A client will not touch certain objects she categorizes as 'dirty.'
She considers poles, hands, and floors 'dirty,' but considers mud, chocolate, stains,
or excrement as 'not dirty.' We pose the question: What is similar within the 'dirty'
and 'nondirty' group which is dissimilar between the two category groupings? In
this case, a discriminating theme is that the former but not the latter are associated
with human contact. Example: A client says he checks his coat for insects and that
insects are to him phobic objects. The aversive insects are: ants, moths, bugs; the
nonaversive insects are mosquitos, spiders, cockroaches. The principal ordering
theme here is whether the insect is likely to eat/ruin clothes and whether it is small
and difficult to detect.
Exposing the symbolic nature of the category strengthens the argument that the
narrative-based inference is indeed imaginary, not empirical. At the same time, it
undercuts a large element supporting the emotionally persuasive power of the
narrative. Since if real dirt or real insects are not the issue, then an emotional reaction
of disgust associated with real dirt is no longer warranted in the OCD situation.
Step 2. Establish With the Client That the Narrative Is Fictional
The second step in the program is to establish with the clients that the basis for their
narrative is fictional. This is difficult, since one of the main points convincing the
person that she/he should act on the narrative is not that it is certain but the doubt
that at least a part of it may be right. As one client put it: "I can't take the risk of not
doing the ritual." The client might volunteer quite readily in the therapy context that
the ritual is stupid and tiring, but nonetheless remain convinced particularly at the
time of performing the ritual, that there is a small probability that the inference is
correct. This 'yes but what if logic drives the person to prepare for the feared event
because the consequences if it occurs are so grave. It is not the small probability of
the event which needs illustrating with the client, but the imaginary nature of the
event. If, for example, I estimated that there was a small probability each day that
a gunman would shoot at me, then, given the drastic consequences, I would be better
off, on a simple cost-benefit ratio, to prepare for the event each day even though the
probability itself was low. The OCD inference concerns not the misperception of a
low for a high probability event but the misconstrual of the reality of the event.
Whatever the truth of the event is in other contexts, the particular inferences drawn
in the person's particular narrative are purely fictional.
Example: Microbes do exist. The existence of microbes is often cited by OCD
clients who fear contamination as justification for a specific narrative recounting
how imaginary (invisible) dirt could be found on, say, a door handle or other objects.
Here a scientific 'fact' is being transplanted inappropriately to support a narrative
in which the possibility of contamination in this particular instance has been created
purely by the imagination (e.g., "well, imagine all the people using that doorknob
throughout the day, they probably don't wash their hands, some may even have been
Treatment of Obsessive-Compulsive Disorder
369
to the toilet, they will be sweaty .. .")• The OCD argument is rather like justifying
the conviction that an invisible dog exists in a particular room by appealing to the
fact that dogs, as a species, exist.
The IB A aim at this stage is not to dispute facts or probabilities but their relevance
to the OCD context. Yes, dirty doorknobs exist. Yes, microbes exist. But what is it
about the present context that justifies these 'facts' being wheeled in? What is the
direct evidence or experience in the here-and-now that these events will occur?
As noted previously, OCD preoccupations, in our experience, do not generally
concern immediate actual danger or danger previously experienced, only imaginary
danger. In this light, it is helpful to establish with the client that the fictional narrative
actually impedes empirical observation rather than follows from actual observation
of the task. Has the client made attempts to empirically verify the primary inference?
Would such information in any case change the inference? In our clinical experience, the answer to these questions is either no or barely, because the obsessional
conviction stems from the imaginary not the perceptual realm. The contextual
specificity in the selective use of 'facts' can also be highlighted by asking why the
person is afraid, for example, of touching microbes but not afraid of breathing them
in, when microbes exist also in the air. At the end of the second stage, the aim is that
the person is intellectually convinced that the narrative is 100% fiction, even if it is
still compelling nonetheless.
Step 3. Highlight the Difference Between a Genuine
Probability and a Hypothesis
After establishing that the primary obsessional inference is drawn from the
imagination, not the current environment, the third step is to highlight with the client
the distinction between a probability and a hypothesis, and so between reality and
the imagination by the use of exercises and metaphors. It is, of course, not always
easy for the person to distinguish between the real and the hypothetical in everyday
circumstances and we find a 'realism rule' helpful: (1) can I sense it, (2) has it
happened (now or before), (3) are there other valid possibilities apart from what I
am inferring about reality.
An initial strategy is to reintroduce the person to the way she/he relies, in nonOCD circumstances, on her/his normal senses for verification of what is (or is not)
there. A simple exercise done in the therapy session is to show the person a pencil
and ask if it is or if it is not there, and then ask (1) whether she/he is certain, (2) how
she/he is certain. Usually, the person has no problem with this exercise, and is
certain whether the pencil is there, because she/he can or cannot see it. In another
words, she/he is content to rely on her/his senses. A list of other situations where the
person relies entirely on her/his normal five senses can be drawn up with the person
covering all areas of life, such as crossing the road or meeting people at work. Often
these situations involve a far more immediate danger than the OCD situation, and
yet the client has no obsessional doubts. One can then transplant the OCD logic into
these non-OCD situations to highlight the contrary and literally nonsensical (i.e.,
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not using the senses) approach the person adopts to information gathering. The
person may not, for example, rest transfixed on the side of the road before crossing,
wondering if a car is there or not, even though she/he can't see it, or whether unseen
cars may be speeding along undetected. Highlighting discrepancies in mode of
inference has other therapeutic spin-offs, since it underlines for clients that in much
of their life they use normal inferences.
Step 4. Exposing How the Client Inverses Normal Inference
At the fourth step the difference between a rare probability and a hypothesis and an
imaginary story is underscored in order to reveal how the person inverses normal
inference processes by mistaking an imaginary hypothesis for a reality. A useful
illustration is the case of a comet, which if it did land, would be a rare event but,
nonetheless, an event different people could see, and agree on, using their senses.
On the other hand, proposing that there might be a comet as one possibility before
arriving on the scene is a hypothesis and saying there was a comet and acting 'as if
there were' when none is there, means using pure imagination. As a final exercise,
the person is asked to classify the obsessional narratives as a product of her/his
imagination, a hypothesis, or as a genuine probability.
Step 5. Construction of Alternative Narratives
The power of the narrative in guiding behavior can be demonstrated in the fifth step
by rehearsing an alternative monologue which recounts a version of the state of
affairs opposite to the original narrative supporting the primary obsessional inference. In constructing an alternative story during the fifth step, it is crucial that all
elements of the structure of the first monologue are respected, and the alternative
is as detailed as the first. Russell and van den Broek (1992) have noted that the
structure of narratives requires the key persuasive elements of events, relations,
transitions, contingencies, simply in order to make a convincing story.
Example: Obsessional narrative: The floor is dirty, even though I see no dirt,
because this is a busy building, there must be lots of people coming in off the street
with their muddy boots, not wiping their feet, walking through all day long, and
nobody cleaning up. Alternative narrative: The floor is clean because, although this
is a busy building, not many people come into this room, everyone who does wipes
their feet and in any case a cleaner mops the floor with disinfectant regularly.
Of course, it is not necessary that either monologue be true, simply that both
monologues within the therapy session be accepted as equally meaningful and
equally possible or equally fanciful to the person.
The point of the alternative narrative exercise in the IB A context is to: (1) show
the person how she/he uses the imaginary monologue as support for the obsessional
behavior; (2) demonstrate its power as an influence on affect and aversion;
(3) demonstrate that it is the monologue alone, and not the facts and other external
reassurances that dictate the obsessional inference. Hence, ipso facto, in order
Treatment of Obsessive-Compulsive Disorder
371
to change the strength of the obsession, this persuasive power of the narrative is
the principal target, rather than any resort to external facts and reassurance.
The immediate effect of the narrative exercise is most usually to decrease, a little,
the strength of the primary inference engendered by the initial obsessional narrative.
This immediate effect can be highlighted with the client, since it illustrates also how
introducing even a slight flexibility into the primary inference reduces the persuasive power of the obsessional narrative. Example: The lady who could not touch the
handrail of a train or bus because she was convinced it was touched by 'undesirables,' was asked to recount an alternative monologue in which only professors
touched the pole. Q: How did she feel after recounting the monologue? A: She was
now content to touch the pole. But what had changed? The pole itself? Or her story
about the pole? Clearly it was the latter. In this case, the ability of the monologue
to produce and effect an albeit slight and temporary improvement within the session
was useful in underlining the imaginary aspect of the obsession.
Step 6. Constructing Alternative Narratives Between Sessions
In the sixth step, the person constructs suitable alternative narratives around each
obsessional inference. The alternative narratives are empirically based on observation or experience and are designed to convincingly dislodge the possibility of the
original narrative. In order to be effective, the narratives do not have to be certain
in an opposite sense, but they do have to inject a convincing element of empirically
justified doubt into the OCD narrative. By doubting the doubt, the imaginary
conviction is weakened. The person is instructed to repeat the alternative narrative
as a challenge to the original narrative and consider what action should or should
not follow logically from the modified primary inference.
Clients encounter a number of operational problems in recounting the narratives.
The first tendency is to abbreviate or truncate the alternative narrative to save time,
particularly if the challenge occurs at a busy period in the day. This shorthand
version may be a compacted version of the narrative or a simply unrelated pejorative
such as 'it's all right, there's nothing there.' Neither, of course, are convincing since
they lack the structure and detail necessary to rival the initial hypothesis. A second
problem is that the person repeats the narrative, robot like, without thinking or
dwelling upon the significance of the account. The account must be related
consciously to be integrated in the way of thinking.
Step 7. Replacing Imaginary Criteria by Objective Criteria
The final, seventh step of the program concentrates on establishing objective
criteria—free from unjustified inferential associations—to judge whether a task is
done/clean/correct or not. What are the essential and sufficient criteria for determining, for example, if a door is closed? Establishing this rule is important for counteracting the subjective (nonempirical) criteria often used by OCD clients such as 'I've
done it five times' or 'it feels right' attested to by other authors (Richards, 1995).
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The antagonism between rehearsing the obsession and actually registering
empirical information is highlighted. The OCD narrative actively prevents the
seeking out of real information. But relying just on normal senses is often difficult
for the person since she/he finds this unsatisfying and 'too easy,' feeling they should
apply more effort than necessary. The end point as with other CBT techniques of
exposure and response prevention and reality testing is that the person now does
nothing (of an OCD nature) in OCD situations.
CONCLUSION
The IBA sees the original obsessional inference as significant and dysfunctional,
and views this as being maintained by a persuasive but erroneous imaginary
narrative. The key point in the IBA therapy is to help clients to gain insight into the
confusion between reality and imagination, and so to realize that they are imposing
an imaginary situation on reality, attempting to transform reality in accordance with
this image, and so by performing the ritual trying to achieve an impossible task. At
present, we find a period of 5 months is optimal to implement the IBA program.
Initially, the person may not be willing to accept that her/his problem is simply in
the imagination and that she/he is 'so stupid as to live in a dream world,' as one client
put it. Failures in therapy are generally due to incomplete acceptance of the
imaginary nature of the obsession and a reversion to according a plausibility and a
probability to the obsessional inference. In those clients for whom the IBA model
has credibility, success in reducing both conviction and ritual can be 100% (see
client 1, Table 2). IBA is presented here as one cognitive approach which may be
of use alongside others already shown to be effective. However, the IBA rationale
is not that anxiety will reduce with exposure or that the expected consequences of
not neutralizing are unrealistic, but that confidence in what is perceived is sufficient.
We are currently comparing the clinical efficacy of IBA and other CBT approaches.
In practice primary inferences could still be modified by both exposure and CBT.
A more realistic appraisal of the consequences of the primary inference may
indirectly modify the imaginary narrative behind the doubt. Although perception
and imagination are distinct, they are both modifiable by exposure to new perspectives (Bichsel & Roskas-Ewoldsen, 1997). Accurate perception of a physical
presence is the necessary catalyst for further work by the imagination and imaginal
re-interpretations are more likely to occur with 'good' rather than perceptually
'poor' figures (Peterson, Kihlstrom, Rose, & Glisky, 1992).
IBA, however, directly addresses the imagination, and in practice we have found
it particularly helpful in the presence of delusional-like or overvalued ideationallike primary inferences where there is an absence of insight (see DSM-IV field trial,
Foa & Kozak, 1995).
People with OCD whose convictions entail strong overvalued ideas are often
treatment-resistant to traditional cognitive-behavioral approaches (Foe, Steketee,
Gray son, &Doppelt, 1983; Steketee, 1994). Such cases would include, for example,
Treatment of Obsessive-Compulsive Disorder
373
persons who wash, believing they can be contaminated by the thoughts of others,
or a person who checks constantly for ants, convinced that ants are ready to eat his
clothes. Here the strong delusional-like ideation limits insight into the irrational
nature of the compulsion and into the link between the obsessions and subsequent
anxiety. Such people will generally not tolerate exposure. Also cognitive models
(e.g., Van Oppen & Arntz, 1994), which view the interpretations made about
otherwise normal intrusions as the factors responsible for maintaining the obsession, are nonapplicable, since the primary inference here is not normal, and hence
the exaggerated secondary interpretations may not be exaggerated.
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Case Examples
Table 2 shows the profiles of two clients diagnosed with OCD who completed
a 20-week cognitive-behavioral treatment protocol which included IB A. The table
shows: mean percentage efficacy (0-100) in not performing the ritual over the first
10 compulsive domains (which were arranged hierarchically during evaluation);
mean strength of primary inference over the same 10 situations (0 = improbable8 = very probable); and mean strength of secondary inference (0 = realistic-8 =
unrealistic). Diagnosis and administration of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was carried out in both cases by clinicians independent of the
study.
The first client, a lady, 50 years old, had been excessively washing her hands
since age 8 to 10 years. At the time of consultation she was washing her hands
30-50 times a day, after contact with humans or objects, with these rituals occupying
approximately 3 hours daily. The primary inference was that it was possible to catch
Treatment of Obsessive-Compulsive Disorder
375
microbes from contact or even passing close by animate and inanimate objects. The
supporting narrative related how microbes lived in sweaty hands, jumping from
hand to object or object to hand and survived invisibly in handmarks on door knobs,
ornaments, food, people, office papers, books, floors. If she touched these objects,
she feared catching microbes, becoming ill and dying. Interestingly in this client,
even in pretreatment the more extreme secondary inferences were rated as unrealistic (Y-BOCS, pretreatment = 34, posttreatment = 10).
The second client, a male aged 42 years, had washed his hands excessively from
the age of 13 years. He felt compelled to wash his hands after touching any object
in his own house, in particular, if he had seen members of his own family touch the
objects, for example, doorknobs, surfaces, electric plugs, televisionituals
occurred 15-20 times daily and occupied 1-2 hours per day. The primary inference
was that the objects might be dirty, and the supporting narrative recounted how his
family must be dirtier than himself because of their lifestyle and irregular routines
and lack of appropriate hygiene rituals. The consequences, if he touched the objects,
were that he would be dirty, make everything else in the house dirty and then be
obliged to organize a general time-consuming house cleaning. (Y-BOCS, pretreatment = 32, posttreatment = 15.)
The variability in the strength of primary and secondary convictions is evident
both within and between subjects. In client 1, there is a nonsignificant positive
relationship between the strength of primary and secondary inference pretreatment
(the more improbable primary inferences are associated with the more unrealistic
secondary inferences) (rJlO] = 0.55; p < 0.10), and in client 2, there is again a
significant pretreatment positive relationship indicating that the strength of secondary inference varied inversely with strength of primary inference (rJlO] = 0.91;
p< 0.001).
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