Responsibility-focused CBT for OCD

Domain II · Behavioural & cognitive · Paul Salkovskis · 1999

What it is

An individual, formulation-driven CBT for OCD. It combines Beckian cognitive therapy with exposure and response prevention (ERP). Here ERP is delivered as a set of behavioural experiments that test the patient's beliefs.

Format

• Format. Individual outpatient sessions, which can be weekly or time-intensive. Sessions are "relatively long", and recordings of them are given to the patient as homework. Home visits are a useful addition. Within NICE stepped care:
• Mild impairment, or patient preference: low-intensity CBT including ERP, up to 10 therapist hours. This can be guided self-help, telephone or group.

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• How do you and the practitioner understand what is happening, in spiritual or cultural terms? Is that a source of comfort, worry, or both?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• Bring mood back up before the session ends.
• Set the review date in the calendar at the start.
• Keep a light, curious tone. Done mockingly, this can feel dismissive.
• Narratives that include reassuring endings or "undoing" lines. Take them out.
• Consider the ethics of seeing patients outside the office and record your rationale.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.