OCD Therapy’s PR Problem – and How to Solve It

An old joke from my Irish Catholic upbringing goes like this: A group of priests asked their superior if they could smoke while they prayed, and were told, “Absolutely not!” Later, they tried another tactic with a new superior: they asked if they could pray while they smoked, and got an enthusiastic “yes.”

What does this have to do with treating anxiety disorders like OCD with exposure therapy? A great deal. Because I believe that if you change the language you use with your clients about it, you can get much better outcomes.

You see, exposure therapy has a PR problem. It is effective: according to research, if you face your fears, stick with them long enough, and keep at it, many of them will go away. But if you read most books or articles on OCD treatment, they emphasize how much you have to suffer. How brave you have to be. How you need to suck it up and eventually face even your very worst fears. In essence, how treatment consists of torture, torture, and more torture.

Unfortunately, for many clients, this is like asking them if we can smoke while we pray – because for too many, the answer to doing this kind of exposure therapy is “no thanks.” The dirty secret of exposure therapy is that while it often works, according to the literature it only helps about 50% of sufferers once you count in treatment refusal, dropout, treatment failure, and relapse. We now help a lot more people than we did in the days before exposure therapy, but still leave way too many sufferers with no answers.

The reason for this, in my view, isn’t just exposure therapy itself. I feel it is also due to an almost gleeful focus within our profession on strong exposures and scaring the bejeebers out of our clients – at conferences, on social media, in articles and awareness campaigns. We’re combining some good science with a serious PR problem that in my view – as an OCD clinician – is unnecessarily keeping some people away from treatment.

For example, for this week’s OCD Awareness Week, people were encouraged to post videos of facing scary situations with the hashtag #FaceYourFears. Some OCD sufferers may be inspired watching people do things like swallow cockroaches or drive along steep cliffs in South America (both actual videos posted this week) – and I salute their courage! But others may see videos like these and say, “Um, if that’s how brave *I* have to be to get well, I think I’ll just keep checking my locks 20 times a day.”

Which leads to one of the most common questions I hear from my clinical colleagues: “How do I get my clients to do their exposures?” The answer, in my humble opinion, is to use a similar strategy that you probably used to get your children to eat their vegetables: go a little more slowly, and use the right language to make it more palatable.

Changing the outcomes by changing the language

When I was trained in exposure and response prevention (ERP) therapy at the IOCDF’s Behavior Therapy Training Institute (BTTI) in 2014, I had lots of questions about it – for example:

· How do you get clients to buy in to making themselves really uncomfortable?
· What are the potential ethical and liability implications of egging on a client to do something that might, in fact, traumatize them?
· How does it affect the therapy relationship when you are constantly pushing your clients out of their comfort zone?
·How do you deal with gender and power dynamics? I’ve had female clients openly tell me that, as trauma survivors, it’s triggering for some male therapist to push them to do exposure.
· Perhaps most importantly, is there a better and less painful way to do ERP, so that more people actually DO it?

So I resolved to try a kinder, gentler approach to ERP in my own private practice. After educating clients on how ERP worked, I gave them one simple instruction – choose whatever level of ERP felt comfortable to them that week, practice it every day, see where they could take their comfort zone from week to week, and report back to me. Totally their choice. And I made it clear that I would rather see them experience success than get freaked out, and would never judge them.

Listen carefully: I still instructed them to do ERP. I taught them all about sitting with their anxiety and reaching an “extinction burst” where the fear started to go away. All I did was change my language to make ERP sound easy, do-able, and effective. My approach was based around the idea that we all have a level of anxiety we are willing to tolerate and practice every day, as long as we willingly choose it.

This approach also informed how I coached people from week to week. If they bravely tried a big exposure, I congratulated them. If they tried a very small exposure, I congratulated them. And if they couldn’t bring themselves to do ANY exposure at all? I congratulated them for respecting their own judgment, and then broke things into even smaller steps like imagery desensitization, mindfulness, or simply slowing down, delaying or reducing their rituals – which, by the way, often gave them more traction to eventually start doing live exposure.

So how did it turn out?

Before I went to BTTI training, I attended a workshop from one of the giants of OCD treatment, and asked him point blank what he thought about a gradual approach to exposure. His thoughtful response was, “I’m in favor of anything that works, but I’m concerned people will just get stuck doing a bunch of wimpy exposures.”

He had a good point. But at least in my practice, I actually saw the opposite: when I put clients completely in charge of their exposures, and didn’t shame or push them, they got hooked. Often they went further and faster than I would have ever imagined. More important, they came back week after week and looked forward to our sessions.

Perhaps most importantly, this approach seemed to work at an epidemiological level. In a retrospective study of my OCD cases that I published as a research poster at last year’s IOCDF conference, here were my outcomes:

· Everyone improved
· No one dropped out or terminated prematurely
· Average reductions in YBOCS OCD scores were nearly 40%
· 90% were treatment responders, and 70% were full treatment responders

(My criteria for inclusion in the study were (a) dx of OCD, (b) at least 4 sessions of treatment, and (c) assessment via YBOCS. So I did exclude things like "one and done" sessions, people who had to relocate in the middle of tx, or people referred out due to serious co-morbidities.)

These outcomes are comparable with other studies I've seen in the literature for standard ERP. With perhaps one main exception - a longer course of treatment, averaging a little over 22 weeks. And it WAS standard ERP - just not presented as "torture therapy."

What are the implications for practice?

First of all, I am just one obscure therapist in the middle of upstate New York who had a part-time private practice and a fairly small sample size, and is now retired from practice. So the short answer is “I don’t know yet.”

That said, our knowledge base for treating OCD and anxiety disorders is still young and evolving. So in my view, it’s time we devoted more research to the question of whether we can make ERP more tolerable AND more effective for clients. Because I truly believe that if we can do more to solve the basic PR problem of exposure therapy, we can help a lot more people. And who knows, perhaps next year's hashtag might even be #FaceYourFearsGradually.

Does Gratitude Make You Happier?

Many people talk about practicing gratitude as a path to happiness. Does it work?

The answer is “often but not always.” Imagining what you should be grateful for and focusing on it can, indeed, help you feel happier. But this technique works best if you understand the science behind it.

To me, experiencing gratitude is just one example of what we therapists call cognitive restructuring: a lofty term for changing the way you feel by changing your self-talk. Here are some examples of it:

• When you change “my life sucks” to “I have a lot to be thankful for.”
• Same with changing “I can’t deal with my control-freak boss” to “My boss is detail-oriented, and here is how I should manage my relationship with her.”
• Ditto with changing “I hate those Republicans/Democrats/Millennials/whatever” to “I don’t see the world the same way as them, but I try to understand why they feel that way.”

In each of these cases, simply changing your internal language helps you feel better and more in control.

What happens clinically when you practice gratitude is that you are performing a form of cognitive restructuring known as scaling: in other words, you compare your life favorably to your own previous perceptions or other people’s lives. When I was growing up, for example, a popular slogan was, “I cried because I had no shoes – and then I met a man who had no feet.”

However, for gratitude to really make you happier, you have to believe both sides of this equation: first, that you are better off than you thought, and second and more importantly, that you can make peace with the state you are actually in. In other words, you honestly perceive that your life is better than you were seeing it before.

Unfortunately, some people find it very hard to do this. Take a trauma survivor, for example: her emotional pain and sensitivity may loom very large for her, and realizing that she has things to be thankful for – like food, a roof over her head, or even a partner – may not change the how bad her current reality feels.

This is where the deeper principles of cognitive restructuring come in. A trauma survivor may not be able to feel gratitude, but she probably can change her narrative from “I suffer from trauma and life is terrible” to “I suffer from trauma, so here are tools that I could use to feel at least a little better in this moment, and here are goals I could strive towards in small steps.” This kind of narrative-changing uses exactly the same clinical principle as gratitude, but often works much more powerfully. Especially when you keep practicing it over time.

So should you try to practice gratitude in daily life? Absolutely! I personally do it every day: often I will reflect on how in this moment I am warm, safe, dry, well-fed (admittedly too well-fed sometimes), and wake up every morning with someone I love. But a good therapist would never shame someone when gratitude doesn’t help. More important, its underlying principles truly can help anyone feel much better.