Introduction to OCD
Despite having doubt and fear as their nearly constant companions, roughly half of all individuals with obsessive compulsive disorder (OCD) are not getting the help they need (National Institute of Mental Health). They aren’t getting diagnosed early enough, they’re paying for years of therapy that isn’t helping, or they’re avoiding treatment entirely because they see it as too frightening. This dismal reality began to matter to me personally when my eight-year-old daughter suddenly became one of those people—and my five years of graduate school and 15 years of licensed clinical experience had not equipped me with the tools to help her. Unfortunately, the same was true for many of the therapists with whom she and I would meet in our search for help.
Obsessive compulsive disorder can be incredibly difficult to treat. Part of the challenge is that it is complex and multifaceted. Frequently it shows up in ways that don’t look familiar to clinicians unless they specialize in treating OCD, and the symptoms often shift and change, making a clear understanding of it even harder. In addition, even with the best intentions, clinicians can easily fall into specific OCD-related traps that may reinforce symptoms, making OCD worse over time instead of better. Further, research and experience show that OCD does not respond well to talk therapy, which is a predominant modality for many clinicians.
The frontline treatment for OCD and related anxiety disorders is exposure therapy with response prevention (ERP). Based in the tenets of cognitive behavioral therapy (CBT), ERP prioritizes the development of a witnessing capacity to observe thoughts and feelings realistically, and it is highly effective. Unfortunately, not everyone who seeks therapy has access to clinicians trained in ERP. And, despite well-documented research providing evidence of its efficacy (American Psychiatric Association), ERP has some limitations and drawbacks; it is sometimes not enough for reasons ranging from limited treatment compliance to other diagnostic issues, including trauma.
Many therapists who are not trained in CBT or ERP may be skeptical about providing it—and with some reason; indeed, some research suggests a fairly limited response to these frontline treatments. In addition, having heard horror stories about clients being told, for example, to lick toilet seats or eat food off the floor they may carry concerns that exposure therapy can be unpleasant, even traumatizing. (Exposure to compulsion triggers is challenging—it’s designed to be, even though it’s voluntary.) They may also have the perception that ERP doesn’t work at all because some people do not habituate to the anxiety and many of those who do experience relief find that symptoms recur or surface later in another domain.
Even for clients participating fully in ERP with a trained therapist, other factors may impede progress. Co-occuring disorders such as substance abuse or eating disorders may be implicated in the OCD and further complicate a client’s ability to address OCD symptoms in therapy. Complex and developmental trauma can pose many problems in treatment of OCD when even low levels of exposure may overwhelm a client’s ability to cope.
And treatment is further complicated by the fact that many people with OCD have also been traumatized by the very experience of having OCD. Individuals with OCD often spent their childhoods thinking they are horrible people because of the gruesome, disturbing, or fearful thoughts or images that incessantly pop into their heads. These internal critical voices may sabotage treatment by reinforcing obsessions and compulsions and even creating an additional layer of depression and feelings of worthlessness, causing people to avoid therapy altogether because they don’t feel they are worth saving. Finally, the ensuing real-life results of having OCD can further complicate people’s lives—and therefore treatment—resulting in the loss of jobs and relationships, homelessness, hospitalizations, suicide attempts, and complete disability.
Still, cognitive behavioral therapy with exposure and response prevention (CBT with ERP) tends to provide about 35% symptom relief in about 90% of the people who receive it, and about 75% symptom reduction in roughly 40% of clients who participate (Kozak and Coles, 2005). But what can we offer to those who need more? This is the question I asked ten years ago following my daughter’s sudden onset of a severe form of OCD. And it has sparked more than a decade of research, training, and experience.