371

Book R e v i e w J. Grayson, Freedom From Obsessive-CompuIsive Disorder: A PersonaIized Recovery Program for Living With Uncertainty
New York: ]eremy P. Tarcher/Penguin (2003) 302 pp.
R e v i e w e d by C. Alec Pollard, Saint Louis University a n d Saint Louis Behavioral Medicine Institute
N 1989,Judith Rapoport published The Boy Who Couldn't Stop Washing, the first book written for the general public on obsessive-compulsive disorder (OCD). Rapoport's b o o k was soon followed by the publication of four additional consumer-focused books (Baer, 1991; Foa & Wilson, 1991; Neziroglu & Yaryura-Tobias, 1991; Steketee & White, 1990), all o f which were written by p r o m i n e n t cognitive behavioral clinicians. Over the next decade, additional books emerged, covering m o r e specific OCDrelated topics such as scrupulosity, intrusive thoughts, childhood OCD, and family issues. To date, consumers seeking information on this disorder have at least 15 books from which to choose. So, with all these resources available, do we really n e e d another b o o k on OCD? After r e a d i n g J o n a t h a n Grayson's book, I believe the answer is yes. Several things distinguish Freedom From ObsessiveCompulsiveDisorderfrom prior books on OCD. One distinction is Grayson's extensive use o f scripts, self-statements OCD sufferers can use to motivate themselves to confront obsessional stimuli and resist engaging in compulsions. Scripts are tools to use when a therapist is n o t present. For Grayson, therapeutic scripts are not designed to comfort or p r o m o t e relaxation. O n the contrary, Grayson believes a false sense of reassurance interferes with the kind o f learning necessary to recover from OCD. The scripts Grayson prescribes do n o t dwell on the improbability of feared events, which would risk promoting the illusion that nothing bad can happen. His scripts attempt to motivate by reminding OCD sufferers of the devastating impact o f their disorder. If reassurance is provided, it is to confirm the OCD sufferer's ability to cope with negative events. A n o t h e r distinction o f this b o o k is the strength of the section on specific subtypes of OCD such as contamination obsessions, checking, symmetry obsessions, and pure

Cognitive and Behavioral Practice 12, 371-372, 2005 1077-7229/05/371-37251.00/0 Copyright 2005 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

obsessions. These chapters offer in-depth discussions of the issues and obstacles c o m m o n l y associated with each form of OCD. The content is accessible to consumers yet sophisticated e n o u g h to be instructive even to highly experienced clinicians. The most significant distinction o f Grayson's book, however, is its emphasis on the role of uncertainty, as suggested by the subtitle. Grayson believes difficulty with uncertainty is the "core of OCD." From his perspective, avoidant and compulsive behaviors are desperate attempts to obtain a state of absolute certainty that a feared event will n o t h a p p e n . For example, the compulsive checker thoroughly inspects his house before going to work in order to achieve a sense of complete certainty the house is safe from harm. Relative certainty is n o t sufficient for the OCD sufferer. It must be 100%. O f course, a state o f absolute certainty, if obtained at all, is an illusion that cannot be maintained. Some d o u b t eventually returns, leading to increased anxiety and additional compulsions. The average person can live comfortably with a reasonable a m o u n t of uncertainty, but the OCD sufferer cannot tolerate even m i n o r doses of doubt. The categorical imperative of cognitive behavior therapy, Grayson asserts, is to help OCD sufferers learn to live with doubt. Grayson's concepts have significant implications for treatment. He is critical of some cognitive behavioral practitioners who, from his perspective, reinforce the OCD sufferer's quest for certainty. He warns of the dangers o f conceptualizing exposure and response prevention (ERP) or behavioral experiments as methods to discover whether a feared o u t c o m e actually occurs. H e is equally wary of cognitive interventions that examine prior evidence or use logical analysis to determine the likelihood o f feared catastrophes. All of these approaches risk feeding the OCD sufferer's desire to be certain something bad will n o t happen. In contrast, Grayson encourages OCD sufferers to accept that bad things do happen and challenges them to learn to live with this fundamental fact of life. Grayson is not the first to recognize the association between OCD and intolerance of uncertainty. After all, the disorder has long been labeled the "doubting disease." Almost a decade ago, an international collaboration studying the relationship between cognition, obsessions, and compulsions identified intolerance o f uncertainty as one o f the key cognitive domains relevant to OCD (Obsessive Compulsive Cognitions Working Group, 1997). Nonetheless, no one has articulated the c o n c e p t and integrated it into treatment as thoroughly as Grayson. The effort to help OCD sufferers deal with uncertainty is evident at every stage of Grayson's approach, f r o m the design o f ERP to the scripts his patients use to motivate themselves during treatment. Like most books, Freedom From Obsessive-Compulsive Disorder has limitations.

372

Pollard

T h e t r e a t m e n t sections would be more useful for consumers in a workbook format, with more informative subheadings a n d more clearly labeled steps of treatment. I n addition, because of its emphasis o n intolerance of uncertainty, Grayson's book devotes comparatively little att e n t i o n to other cognitive d o m a i n s relevant to OCD, such as overassumption of responsibility a n d perfectionism. Finally, Grayson does n o t address the more sophisticated questions that naturally arise when considering his approach. Is intolerance of uncertainty a by-product or a cause of OCD? Is OCD the only disorder associated with i n t o l e r a n c e of uncertainty? If not, what is u n i q u e about the relationship between OCD a n d intolerance of uncertainty? In fairness, I do n o t expect a book written largely for consumers to answer questions of this nature. However, it would be interesting to know Grayson's perspective o n these issues. Freedom From Obsessive-Compulsive Disorder is a wellwritten a n d i n t e r e s t i n g b o o k that clinicians as well as consumers should find valuable. Both will appreciate the practical tools a n d s o u n d advice Grayson provides, and, if the a u t h o r achieves his objective, m a n y therapists will be r e c o n s i d e r i n g some of the ways in which they c o n d u c t treatment. Academics seeking a comprehensive discussion of the cognitive aspects of OCD should look elsewhere. Grayson's emphasis is squarely o n intolerance of

uncertainty. Any approach that emphasizes a particular cognitive d o m a i n is sure to draw criticism, b u t Grayson's arguments are c o m p e l l i n g a n d the u n i q u e features of his approach can be easily integrated with other methods commonly used by cognitive behavior therapists. With apologies to Grayson, one thing is certain. Some OCD sufferers will decline his invitation to a b a n d o n certainty. Those who persevere, however, are likely to benefit greatly from this important addition to the OCD literature.

References

Baer, L. (1991). Getting control." Overcoming your obsessions and compulsions. Boston: Litde, Brown, & Company. Foa, E. B., & Wilson, R. R. (1991). Stop obsvssing! New York: Bantam Books. Neziroglu, E, & Yaryura-Tobias,J. (1991). Over and over again: Understanding obsessive compulsive disord~ Lexington, MA: Lexington Books. Obsessive CompulsiveCognitions Working Group. (1997). Cognitive assessment of Obsessive-CompulsiveDisorder. Behaviour Research and Therapy, 35, 667-681. Rapoport, J. L. (1989). The boy who couldn't stop washing. NewYork: E.E Dutton. Steketee, G., & White, K. (1990). Whenonce is not enough: Help for obsessive compulsives. Oakland, CA: New Harbinger Press. Address correspondence to C. AlecPollard, Ph.D., St. Louis Behavioral Medicine Institute, Anxiety Disorders Clinic, 1129 Macklind Ave., St. Louis, MO 63110; e-mail:Pollarda@slu.edu.