The findings of this thesis indicated a link between attachment representations, sensitive self structures, perceptions of others and the world, and OC phenomena. As suggested earlier (see figure 6), internal working models of attachment relationships may increase the likelihood of (and maintain) dysfunctional cognitive beliefs, enhance the propensity to scan for stimuli related to personal self sensitivities and boost negative perceptions of the environment. Further, a negative representation of attachment results in increased anxiety related to abandonment and fear of rejection. Treatment of individuals presenting with OCD should therefore address such anxieties and negative perceptions of self, others and the environment.
According to Bowlby (1988), the role of the therapist is primarily to serve as a secure-base for the client. Providing conditions of trust, empathy, support and unconditional positive regard enable clients to explore their working models of self and their attachment figures, leading to reappraisal and a restructuring of these models. An effective therapist should challenge a client's existing patterns of relating. For example, a client high in avoidance behaviors or deactivating strategies stemming from negative IWMs of others would find the intimate aspect of the therapeutic relationship difficult, and would try and use their habitual ways of interacting with people within the therapeutic context. An effective response by the therapist would be to challenge such patterns of relating with methods such as immediacy and interpersonal problem solving. This type of interaction would provide the client with the experiences of a new relationship where they can increase their sense of self-worth, self acceptance and perceptions of others.
The therapist may also explore past and current interpersonal behaviors and detect communalities between past and current feelings, thoughts and behaviors. The therapist can then encourage the client to examine how previous understandings of self and others affect their current functioning.
In the context of the therapeutic relationship, it is important to consider that the interaction between the clients' and therapists' attachment strategies was found to predict therapeutic process and outcomes (Dozier & Tyrrell, 1999). Thus, the nature of the negative internal representations in OCD clients found in this study suggests that therapists should focus particular attention on their own interaction style and its influence on the therapeutic alliance, particularly when engaging patients in treatment.
The findings from this thesis also suggest that attention to the individuals' perceptions of self is warranted when dealing with individuals suffering from OCD. Anxiety and preoccupation with particular intrusions may stem from sensitivity in particular self domains. It would be useful for the therapist to identify these sensitivities and probe into the reasons underlying them, for example, through the downward arrow technique (Salkovskis, 1999). This would help the therapist challenge the assumptions underlying perceptions of incompetence in such domains, the excessive importance attributed to them, and may help increase perceptions of competence or the number of valued domains (e.g., athletic or intellectual). Such probing will also allow the patient to recognize the relationship between their symptoms and their perceptions of self. Again, the therapist must be conscious of the patients' need for consistent, caring, non-judgmental interactions that will increase the flexibility of the clients' self structures and validate their valued aspects (Rogers, 1961; Safran & Segal, 1990).