Monthly Archives: October 2009

The Right Treatment for OCD

OCD is both a learned and biological disorder.  Medication may help with biology, but it doesn’t change learning. This is why meds alone usually result only in a 30-50% reduction in symptoms.  For some people, even if meds are working biologically, the learned part of OCD can mask the effects of medication.  The treatment for the learned part of OCD is a cognitive behavioral technique called Exposure and Response Prevention (ERP).  I’ll briefly describe what this entails, but first I wanted to emphasize why this is the first line treatment for OCD:

  1. The research data supporting ERP have been available since 1984 (really research began appearing as early as 1976, but by 1984, ERP has been established as the main treatment for OCD).
  2. The American Psychological Association has a short list of treatments designated as empirically supported treatments, that is, treatment for which there is good evidence they work.  It is unfortunately a short list.  ERP for OCD is on that list.
  3. In 1997, The Journal of Clinical Psychiatry printed, “The Expert Consensus Guidelines for the Treatment of OCD.”  This journal tends to specialize in medication studies.  The guidelines conclude that ERP is the first line treatment for OCD and that SSRI medications are also important.
  4. The 2007 Practice Guidelines printed by the American Psychiatric Association conclude that ERP is the main psychological treatment for OCD.  They report some evidence for other CBT techniques, but emphasize that ERP is the main psychotherapy treatment.  They also say that SSRI’s are important.
  5. Almost all OCD experts, whether behavioral or medical in their backgrounds, agree that ERP is critical for treating OCD.  Such agreement is very unusual in the mental health field.
  6. This is the consistent message that the national OC Foundation tries to spread (their website: www.ocfoundation.org )

So it is tragic to admit that it is easier to help OCD sufferers than it is to change the behavior of mental health professionals.  A treatment that works, is expounded by experts and professional organizations and has been around for over a quarter of a century, should be easy to find.  But it isn’t.

If you are looking for treatment, your therapist should say that ERP is a part of treatment.  Saying CBT isn’t enough, since there are many CBT techniques, and you want the right one.  There are a number of good books about OCD and treatment, obviously including my favorite (my book).  The one popular one most experts disagree with is Brainlock, so pick one of the others.

So what is ERP.  It is simple; however, simple is not easy.  You can try the self-help approach, but this is very hard.  If there are no OCD specialists in your area (the OC Foundation may be helpful in helping you locate one), you may be able to find a therapist who would be willing to be supervised by an experienced OCD clinician.  Many of my colleagues and I do this.  I’m going to over-simplify treatment for now, since the alternative is to write another book.  Treatment has basically 3 parts:

  1. Helping you accept the goal of treatment.  At the core of most OCD symptoms is the desire to be 100% certain about your issue — that you are absolutely clean, that you won’t hurt someone, that you did or didn’t see ‘x.’  This isn’t reasonable as there is no way to be certain about anything.  So the goal of treatment is deciding that you want to live with uncertainty.  Note that I said learn to live with.  If it was a simple decision, you would be better now.  Once you’ve decided this, EPR is a major part of the path.  However, I am not saying ERP instead of meds.  Most of my patients do both.
  2. Exposure, helping you to directly confront your fears.  It is scary, but so is your life at this moment.  Again, because it isn’t easy, you may find a self-help program too hard.
  3. Response prevention.  Helping you to stop the rituals.  Exposure without this is pointless.  If you think about it, many of your worst occasions were marked by the endless ritualizing.  For those with primarily mental obsessions, you also have rituals, mental ones in the form of trying to figure something out or trying to convince yourself that everything is okay.

I know this is short, but ERP and usually and SSRI medication are the treatments for OCD.  If your therapist doesn’t know the above, then you need to educate them or move on.