Do you struggle with obsessive-compulsive disorder (OCD)? Have you seen multiple therapists with minimal lasting changes? Do you think this means that you’re beyond help and there’s no hope for you to stop living under the thumb of your OCD? These are questions I am frequently asked. When people call to inquire about services, they often ask if treatment will help for their OCD. In general, a number of people are skeptical of therapy. Some are discouraged because the therapy they’ve had in the past has not been helpful for them. When they start talking about their treatment history and how many providers they have seen, this makes sense! Let’s discuss the difference between what people think treatment for OCD will look like and what it should look like.
What is Therapy?
What do you think about when you hear the word therapy? Many people often assume a therapist sits in a chair with their notepad and asks, “How do you feel?” They may also visualize someone lying on a couch talking about whatever is on their mind, receiving an occasional nod or “mm hmm” from the therapist. Here, the person often feels validated, heard, and just allowed to let out whatever they’re feeling within a safe space. This is a form of therapy often referred to as talk therapy. While it is useful for treating certain presenting problems or concerns, it is not recommended for OCD. The leading practice for treating OCD is a specific type of cognitive-behavioral therapy (CBT) called exposures with response prevention (ERP). Keep reading to learn more about why talk therapy is not recommended for OCD and why you should seek a therapist who specializes in CBT and ERP if you want to conquer your OCD.
Research Suggests CBT
Throughout the years, research has shown many times over that cognitive-behavioral therapy (CBT), specifically exposures with response prevention (ERP) is the first-line treatment for OCD. Numerous studies have displayed that this type of therapy is absolutely the most effective for producing both short- and long-term gains in people suffering from OCD. In fact, approximately 80% of people who participate in ERP treatment for OCD respond well to the therapy and are able to make significant gains. Once they terminate their treatment, they often maintain these gains independently. Booster or maintenance sessions are offered as needed to help with long-term management of OCD and to help generalize the skills learned to any new OCD symptoms.
Exposure with Response Prevention (ERP)
Now that we know research suggests ERP, let’s quickly take a closer look at what it is and how it works. ERP is a specific technique used under the cognitive-behavioral therapy umbrella. It is focused on thoughts, feelings, and behaviors and how these can trick us into maladaptive patterns of OCD. By learning about this cycle, we are much better equipped to break it!
For OCD, treatment will focus on identifying the triggering thoughts. Once these thoughts have been identified, we can understand the distress (feelings) they cause. These feelings then lead one to behave in a way that is compulsive, ritualistic, and/or avoidant. The distress often decreases after this behavior or avoidance is completed. This might not sound like a terrible idea, because no one wants to feel distress! However, the problem comes from the idea that this behavior or avoidance actually increases the likelihood that we will experience those thoughts in the future. By escaping the feeling and engaging in a behavior that “supports” the thoughts, we are actually strengthening those intrusive thoughts and encouraging them to continue. Therefore, we are more likely to experience the thoughts and engage in the exact same cycle numerous times over.
Once this cycle is identified, the goal of therapy is to slowly begin approaching these triggers (exposure), while decreasing the compulsive behaviors (response prevention). Now, this may sound like an impossible feat. Rest assured, a well-trained therapist will be able to help find an appropriate starting place so that there can be success in the process. They often set up a hierarchy, or exposure-to-do list, of the compulsive behaviors that are interfering in the person’s life. Likely, the sufferer would not start with the most difficult exposure practices. Instead, they’d probably start with an easier task so they can learn about the process and feel a sense of accomplishment before moving on to harder exposures. Although individual goals will be set with the individual, the general goals of this type of treatment are:
- Learn how to tolerate distress caused by the trigger
- Intrusive thoughts are just that…thoughts not facts
- One can tolerate not knowing for sure
- One can start to live with OCD instead of in reaction to OCD
When this exposure process is experienced, these goals are met. Intrusive thoughts actually get challenged and changes (learning) happen within the brain. As more exposures occur, more learning happens and anxiety and distress decrease. As the anxiety and distress decrease, the intrusive thoughts decrease in frequency and intensity. Once this technique is learned and practiced, the OCD becomes much more manageable. Then, the strategy can continue to be implemented in the future if OCD changes content or themes. This may sound well out of reach and far too hard. It is hard and I am not going to say it isn’t. But, if one is willing to endure the distress and anxiety in the short-term to complete the exposures, there is an opportunity for huge long-term benefits and relief from symptoms. Because what we know for sure, is the current cycle of doing what OCD wants, is not working!
Why Traditional Talk Therapy Isn’t As Effective
As mentioned, people have usually been to a few different therapists before finding my clinic. This is usually the result of a therapist not adequately trained in CBT/ERP, or to them engaging in the less effective therapies for their OCD, i.e., talk therapy. Talk therapy can actually be counterproductive to the individual with OCD, as it often focuses heavily on the thoughts and feelings and less on the responses to them. What this may do is stress the importance of the thought instead of learning that we can have and tolerate distressing thoughts without needing to react to them. Another thing that may happen is they might try to come up with strategies on how to avoid potential triggers with the goal of decreasing anxiety and distress, which actually strengthens the OCD. Another common thing I’ve heard regarding previous therapies is that they try to rationalize their way through the thoughts. On the surface, this doesn’t sound like a bad idea. However, with OCD, this can become a sneaky reassuring compulsive behavior, as it provides a sense of certainty. Since we’re talking about OCD here, that reassurance and certainty only lasts for a short period of time before one has another intrusive thought and feels like they need that reassurance and certainty again so they can feel better. Hence, we’re back to that vicious cycle.
The Good News
Once the correct type of treatment with the right provider has been found, one can progress leaps and bounds when it comes to management of their OCD. Although it is a chronic disorder, it is absolutely something that can be managed and kept at bay. It will ebb and flow over the course of a person’s lifespan, but the strategies learned in CBT/ERP are most often able to be adjusted and applied to the various presentations. Once an individual is able to shift the power dynamic from living under OCD’s thumb to being able to effectively cope with intrusive thoughts and urges, they are able to regain so much emotional freedom from their OCD that it truly can be life changing. Now, this doesn’t mean that they may not need a booster or maintenance session for refreshers to continue honing their skills. But ultimately, they can lead happy, healthy, productive lives and that, in itself, is success!
This post is not to say that traditional therapies do not have their time and place where they shine and are extremely beneficial. Instead, the focus is that OCD is not one of the disorders best suited for that type of treatment. In short, if you are looking to experience freedom from intrusive thoughts and in search of therapy, please ask specifically about cognitive-behavioral therapy and exposures with response prevention. It will be hard work, but the things we work the hardest for are often the things we want the most; in this case…freedom and relief. The way I answer the question at the beginning of the post about if treatment will help is, “Yes, but it’s going to take time and hard work for both of us, but if you’re in, I’m in.”
