Q: As a therapist trained in traditional talk therapy, I find work with OCD clients difficult and frustrating. Can you offer guidelines about the principles of effective treatment?
A: The past 3 decades have seen a revolution in the understanding and treatment of obsessive compulsive disorder (OCD). In the early 1980s, OCD was thought to be rare, and there were no established best methods for treatment; however, we now understand OCD to be quite common, and a clearer understanding of its nature has led to the development of effective treatments, especially exposure and response prevention (ERP), sometimes called exposure and ritual prevention. Additionally, the introduction of effective psychopharmacology has broadened the range of people with this disorder who can be helped.
Understanding OCD begins with grasping the similarities and differences among the phenomena that comprise it. Obsessions are repetitive thoughts or images that feel uncontrollable, threatening, repulsive, or shocking. They arrive in a whoosh, accompanied by an urge to avoid or remove them. Compulsions are actions or thoughts that function temporarily to lower anxiety. It’s easy to recognize behavioral compulsions like cleaning and checking, but purely mental compulsions are far more common and important than previously understood. Mental compulsions include counting rituals, memory checking, distractions, ritualized prayer, and self-reassurances. Clients will often refer to their mental compulsions as rationalizing or analyzing or even problem-solving. Since mental compulsions often go unnoticed, you’re probably seeing more people with OCD than you think.
Many people with OCD aren’t easy to diagnose. People with unwanted intrusive thoughts of causing harm, violence, or suicide invariably engage in internal attempts to suppress, avoid, or counteract these thoughts. They describe themselves as having these thoughts stuck in their mind, and they worry what the thoughts mean about their character and whether they might act on any of them. People with the form of OCD called scrupulosity, or overblown-conscience OCD, engage in mental rituals consisting of internal conversations about responsibility, good and evil, and right and wrong. And those who suffer from pathological-doubt OCD pose themselves unanswerable questions---such as “How can I know my reality is the same as yours?” or “What happens after death?” or “How can I be sure my loved ones are safe?”---and then engage in tortuous attempts to find certainty where it can’t exist.
The diagnostic key for OCD is to locate the obsessive thought that initially raises anxiety distress and the compulsive thought (it’s usually a thought, but not always) that provides the temporary relief. This pattern of anxious arousal followed by temporary relief creates an ongoing, self-reinforcing cycle. It exists independently of any past or present conflict or unresolved issue. That’s why traditional talk-therapy approaches to OCD provide such limited help. Instead, effective help for OCD must target the factors that maintain the symptoms, not discussions of their origins or analysis of their content.
Clients with OCD can present as panicky, depressed, and agoraphobic, as well as with a wide range of personality problems and relationship issues. The obsessive and compulsive elements of OCD can have almost any content, since it’s this functional relationship---that obsessions raise anxieties, while compulsions lower them---that defines the disorder. If the obsession has depressive content, the client can be incorrectly diagnosed as depressed. Thus, OCD can masquerade as a wide variety of issues or problems.
Regardless of the presenting issues in OCD clients, nearly all involve the need for certainty in a world that provides little. In fact, intolerance of uncertainty is a central feature of OCD. As with all anxiety disorders, avoidance of anxiety is both what maintains and strengthens it, and overcoming the disorder means counterintuitively moving clients toward experiences that increase their distress. In other words, exposure---if done the right way---is the active therapeutic ingredient.
The understanding that compulsions are the engines that drive obsessions has led to the development of ERP as a special type of exposure work for OCD. Simply put, clients are deliberately exposed to triggers that set off obsessive thoughts---along with the strong urge to avoid and the increase in anxiety---while refraining from engaging in any compulsions (behavioral or mental) used for dealing with those thoughts. During this time, the clients are helped in coping with their anxiety by focusing on the following five steps.
1. Expect to feel triggered because of prior sensitization.
2. Label the thought and anxious arousal as OCD, since labeling is the first step toward disabling.
3. Surrender the struggle and allow the distress to remain without trying to push it away through compulsions, since that which we resist tends to persist.
4. Actively allow the thoughts and feelings to remain. This is more than “putting up with” them: it’s welcoming them with open arms.
5. Tolerate the uncertainty that you might be wrong in each of the previous steps.
Going through these steps stops the reinforcing cycle and leads to extinction (either inhibitory learning or habituation), allowing new neurological pathways to form so that distressing thoughts---unreinforced by the effort to defeat or respond to them---begin to feel less important. Over time, the obsessional thoughts decrease in frequency and intensity. Thoughts not dreaded, avoided, or resisted lose their power to demand the compulsive response that maintains and reinforces them.
This blog is excerpted from “The Many Guises of OCD” The full version is available in the Nov/Dec 2014 issue. To subscribe, click here. >>
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