The Most Effective Treatment for OCD
Written by Steff Brand, M.S., LPC, NCC
San Antonio Clinical Director
“Everything in my home has its place. It’s my OCD.”
“I wash my hands a lot more than most people. I’m so OCD.”
“All my spreadsheets are color coded and organized alphabetically. I’m super OCD about them.”
“I like to get things done in a specific order. I’m OCD about it.”
At some point in time, just about everyone has heard an inaccurate use of the term OCD. Many people use it interchangeably with words like organized, clean, structured, or particular. While I AM so glad that our society has normalized this phrase (I mean, all press is good press, right?), I think it is imperative to distinguish the very important differences between the aforementioned adjectives and Obsessive Compulsive Disorder (OCD). Some of these examples COULD be indicators that someone has OCD, but the habits alone are certainly not enough to qualify someone for a formal diagnosis. The habits would need to be due to obsessions. Obsessions are recurrent thoughts, images, or urges that are unwanted and cause significant distress. Even if someone states that they commonly have obsessive, intrusive thoughts, that still is not enough to meet criteria for OCD. In a recent workshop I attended, the instructor made a joke that 90% of people report having obsessive thoughts and 10% of people are liars. This is because it is totally natural to obsess over things sometimes; passion does not equate to disorder.
To qualify for an OCD diagnosis, the obsessions will ALWAYS also come with the need to perform compulsions. Compulsions are rituals that provide a sense of relief from the anxiety associated with the obsessive thoughts. If someone obsesses over whether they turned off the stove, the ritual might be to go check and ensure all the burners are completely off and there are no red lights indicating heat. If someone has obsessive fears about getting very sick or contracting an infection, the ritual might be to excessively clean their house or take a full-blown shower as soon as they get home from being anywhere in public. If someone has perfectionism obsessions, the ritual might be to completely proofread an email ten times before sending it off to their boss. For an individual with OCD, it is believed that if they perform these repetitive physical or mental acts then they can prevent the catastrophe that their anxious brain so desperately fears.
Finally, to meet a formal OCD diagnosis, the symptoms need to meet a particular level of severity and are not better explained by something else. This is where it is necessary to obtain a clinical assessment from a therapist or a psychiatrist. A trained clinician will help you talk through the impact that the obsessions and compulsions are having on your overall functioning. Generally, if symptoms are causing distress and are consuming an hour or more of your day, it is likely that you will meet criteria for OCD. Your clinician will make sure the symptoms are not due to physiological effects of alcohol, drugs, or medication. They will also rule out any other disorders that might better explain what is happening.
What if It IS Clinical OCD?
First, take a deep breath because you are finally about to have some answers as to why life feels so hard. For most of my clients with OCD, it becomes really freeing to safely talk about their obsessions and compulsions and learn that there is an effective treatment option for them. OCD is sometimes misdiagnosed as generalized anxiety, social anxiety, or an eating disorder. It can also occur as a comorbidity with these other diagnoses and just be missed due to the emphasis of treatment being on these other concerns. The major problem with that is that the treatment for these other concerns, usually some method of cognitive restructuring, does not help OCD. In certain cases, it can actually strengthen obsessive narratives and make the OCD worse. Exposure and Response Prevention (ERP) is considered the gold standard treatment for Obsessive Compulsive Disorder because it minimizes or eliminates the need to engage in the disruptive, time-consuming, ritualistic behaviors. It has a 75% response rate, compared to a 40% response rate with medication. Also, many people that take the medication route, still decide to do ERP so that habits stick after medication is discontinued.
What to Expect with ERP Treatment
Let me start by saying that ERP is often not enjoyable. For this reason, I always provide my clients with lots of psychoeducation before starting treatment and really make sure to paint a picture of what they can expect. In the first session, we will utilize an assessment called the YBOCS (Yale- Brown Obsessive Compulsive Scale) to confirm the OCD diagnosis and understand the severity of symptoms to create an appropriate treatment plan.
During the second session, we will confirm if ERP treatment is appropriate. If fitting, we will make a plan that works with your schedule. It is recommended to facilitate ERP sessions once or twice a week for 50 or 80 minutes for an average of 17-25 sessions after the intake. Depending on the severity of the OCD, progress could take more or less time. In this session, we will discuss how ERP breaks you out of your unhealthy process by avoiding compulsions. The idea is that once you disconfirm your fears, anxiety will run its course without your intervention, and you will be able to tolerate the uncertainty of not knowing for sure if you are safe.
In the third session, we will use the SUDS anxiety scale to rank your different triggering items and build a hierarchy for exposure preparation. We will talk about the different types of exposures, in vivo and imaginal, and possibly even do our first exposure in session. When you leave, you will be asked to completely avoid compulsions at home. If you give in, you will be instructed to spoil the ritual. For example, if your compulsion is to excessively wash your hands and you give in, you might be asked to go touch something you consider dirty and avoid the hand washing after that. If we do an exposure in this session, you will be asked to practice the exposure every day for homework and fill out a form that monitors your anxiety while you are away. At all following sessions, we will always start by reviewing your homework experience.
Around the middle of treatment, we might re-do the YBOCS assessment and redefine your hierarchy of triggers to get a pulse on treatment progress. Research shows that if we can get your YBOCS scores to a 12 or lower, you are unlikely to relapse after terminating sessions. Before we agree to terminate, we will talk about why your scores are lower and make a plan for if relapse does occur in the future. We will also be sure to have already reintroduced behaviors that were removed but are healthy and important for you in the future. For example, if your compulsions were excessive exercising or hand washing, we will monitor the reintroduction of these habits and ensure that OCD behavior is not again triggered.
As I mentioned earlier, this treatment is anything but fun. I will ask you to do things in and out of session that intentionally trigger your anxiety and then ask you to sit in the discomfort. ERP requires immense bravery, but you are not alone in the process. I will be checking on you in and out of session and making sure that we are moving at a gradual pace to avoid any type of flooding. It is also important to remember that this process is temporary and data shows that it is possible to eliminate the frustrating urges that have been getting in the way of your work, your positive self-image, your relationships, and your mental clarity. Please reach out to our office if ERP sounds like the next step for you.
Resources to Normalize and Support OCD
Movies
Unstuck: An OCD Kids Movie
Turtles All the Way Down
Podcasts
The OCD Stories hosted by Stuart Ralph
Purely OCD hosted by Lauren Rosen, LMFT, and Kelley Franke, LMFT
Books
Getting Control: Overcoming Your Obsessions and Compulsions by Lee Baer, PhD
Loving Someone with OCD: Help for You and Your Family by Karen J. Landsman, PhD, Kathleen M. Rupertus, M.A., M.S., & Cherry Pedrick, RN
Workbooks
Getting Over OCD, Second Edition: A 10-Step Workbook for Taking Back Your Life by Jonathan Abramowitz, PhD
The OCD Workbook: Your Guide to Breaking Free from Obsessive-Compulsive Disorder 3rd Edition by Bruce Hyman, PhD & Cherlene Pedrick, RN