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.

3 Comments

  • My daughter A., who is 19 y.o., has been suffering with OCD and its spectrum disorders since the third grade. I am suffering because of witnessing it for so many years. It is so difficult to watch and to be verbally abused. She is in crisis now and scared to death as most of the ornaments are glittery. Before that, it was lint on her clothes and sheets, doorknobs because they are metal. She has been living in PA and going to college, but she is living alone in her Grandfather’s house and functioning what she says just fine until I moved in with her a mo. ago. I got a job transfer with the same co. I have been working with in VA to PA. Since then, she says I have ruined her life, that I have taken over, etc. etc. I helped her hang her posters, get her bedroom decorated, the same thing a Mom would do if her child were going to move into the dorm.
    This past Sun., I put up a little 4 ft. Xmas tree with glittery ornaments on it. I specifically put it away from her into an entirely different room. In fact, she has nothing in her living room and bedroom in the way of Xmas anything… However, her perception is that the whole house is contaminated and she needs to leave. So, she drove herself to VA yesterday with me following. She has been completely hysterical, to the point she cannot finish this semester and take her finals. How sad is that? We drove back to VA since she has lived here all of her life and the Psychiatrist here knows her hx. OMG, we saw the Psychiatrist last night after driving down here from PA. She has been going to Univ. of Pgh. I have not gone to work since Wed.. I cannot afford to lose my job. BTW, she was able to drive herself. She is vehement about never going back to the house she has been living in since August. It is contaminated and everything in it is contaminated. It is so sad. She cannot even go back to take her finals because she doesn’t want to come back to the house. She took everything out in plastic bags; put it into her truck and I followed her here to VA. She would not ride with me. I am also contaminated in her eyes and so is my car. I cannot hug her, comfort her, she tells me to stay back. To make a long story even longer…the Psych. we saw last evening, said she needs inpatient trt. He did not feel that outpt. Would work for her at this point. I agree. HOWEVER, she said she doesn’t want to get better, she doesn’t want to go. What recourse do we have? I have been trying to get her to go to inpatient trt for years. Now that it has gotten to this point, she gets hysterical, over the top, screaming, irrational…It is hard on her but it is equally unbearable for me. What can I do? Where would you recommend we go and how can we go anywhere without her consent to go get help?
    This is so all consuming. I cannot even begin to tell you how guilty I feel. I moved in with her and all of these sxs became exacerbated. She has become paralyzed, I feel it would have happened sooner of later that I was the catalyst for it to happen. She has been this way since third grade.
    I would appreciate if you could give us some recourse to consider for inpatient trt for my daughter Alexa. It is just heartbreaking. She is only 19. She has her whole life ahead of her. I would love to see her enjoying some of it and to become a fully functioning adult.
    Thank you in advance for your help.
    Best regards,
    Diana

    • Diana, you are writing about a very difficult problem and if I could solve this in a short paragraph, I would be a genius. There are a couple of steps you need to take, but to take them you need help. You will need help to disentangle your life from hers — I know you want to take care of your daughter, but you are also enabling her. I am not suggesting tough love — that is something easy to suggest, but very hard to do. Again, I’m suggesting ways of protecting your life, because it doesn’t help either of you to go down with her. As you know, she will not listen to reason, so your attempts to convince her will fail. Reasoning with her at this time is something you need to give up on. There is an approach that we call strategic pressure to try to help a sufferer who refuses treatment. It is difficult and unfortunately hard to find therapists with the experience to do this. If you had her consent there are 3 inpatient programs I would recommend, the Houston OCD Program, Rogers Memorial Hospital in Wisconsin, and the OCD Institute in Boston. Without her consent, you can’t force hospitalization unless she is suicidal or violent. Again your options are strategic pressure or at least working with a therapist to help you not enable her. For example, when she went to VA there was no need to follow her or help her get there. If she was capable of going, your assistance simply made it easier. And if she isn’t capable, then you enabled her. In terms of your concern for her, if her driving there was a danger, then the fact you followed her was not helpful — being present when she crashes her car wouldn’t raise the odds of saving her life. I know this is hard and this is not an answer you want. There is some hope, there are some ways you may be able to help, but you are right it is very sade to know that someone could get better if they would do treatment and then be helpless because they won’t.

  • I have the same problem and didn’t know it had a name until a few years ago. Now I’m finding out that it is treatable, that’s wonderful.

Leave a Reply

Your email address will not be published.