OCD Treatment: When ERP Isn’t Working

 

“And when you're alone, there's a very good chance
you'll meet things that scare you right out of your pants.
There are some, down the road between hither and yon,
that can scare you so much you won't want to go on.”

― Dr. Seuss, Oh, the Places You'll Go!

OCD treatment tends to revolve around a simple hero story: learn to do things you’re afraid of, resist your compulsions, tolerate your anxiety, and eventually you'll get better.

Except when you don’t, as Dr. Seuss would say.

Exposure and response prevention, or ERP for short, is the current “gold standard” psychological treatment for OCD. Its name is also its strategy: you expose yourself to thoughts or actions that trigger you, and prevent yourself from responding with a compulsion. Eventually, you learn to get used to – or at least make peace with – whatever triggers you.

In an ideal world, ERP would always work. And according to behavioral research, it often does: depending on which studies you read, it helps around 60-80% of the people who do it. Unfortunately, when you count in factors like treatment refusal, treatment failure, dropout, and relapse, its actual effectiveness is closer to 50%. And even when it works, it isn’t a cure.

I am very familiar with this disorder, and with this treatment: I am a retired therapist who treated OCD for many years, trained over 100 clinicians on OCD diagnosis and treatment, and published refereed research on it. And I've also suffered from OCD for much of my adult life. So I’ve had the privilege of studying it from both sides of the couch.

I actually had very good outcomes overall treating it as a clinician. But here, I want to look at a topic our field rarely discusses: what to do when you’re one of the unlucky ones for whom ERP isn’t working. Let’s dive in.

Why does ERP fail?

There may be any of a number of reasons why ERP isn’t successful. Here are just a few:

You have other issues going on. We clinicians refer to these as “co-morbidities.” Trying to do exposure on top of, say, a severe depression or trauma may feel like trying to exercise with a 200-pound weight around your neck. Research has corroborated that issues like these can often interfere with successful ERP.

Your type of OCD doesn’t respond well to ERP. One such example is disgust-based contamination OCD, where you fear feeling unclean rather than being harmed – according to a recent research survey, “Many studies have found exposure to be ineffective, or less effective, in reducing disgust-related reactions … Moreover, if the effects are observed, [the] effects are not sustained in the long term.”

Your therapist didn’t click. Therapists are human like you, and no one strategy works for everyone. You might have felt rushed into exposures you weren’t ready for. Or you may have piddled around doing lame exposures while your core problems continued to get worse. Or there was a personality clash. Or you couldn’t build enough trust to engage in a difficult form of treatment. No one therapist has the right personality or treatment approach for everyone – even if they’re an OCD expert and you have OCD.

You aren’t ready yet. For some of you right now, ERP may be like how I feel at an amusement park: I don’t care how much you try to sell me on riding the Tower of Doom, I’m not going. Or there may be times when exposure would feel overwhelming on top of other major life stresses. However much OCD specialists might wish otherwise, dropout and treatment refusal rates for ERP remain stubbornly high according to the literature.

Perhaps the biggest reason that ERP fails is that, well, no treatment works 100% of the time. Even antibiotics fail at least 15% of the time, and facing your fears is generally a lot harder than gulping down a pill. Whatever the reasons are, you’ve got lots of company. It doesn’t mean that you are weird, defective, or have to give up on your OCD getting better.

Treatment strategies when ERP fails

Now, let’s look at some of the things you can do from here. Here are a few of my favorites:

Go slower. This was always my go-to strategy as a clinician, and it usually worked very well.

I often stood the logic of ERP on its head, for the express purpose of getting people to try it. Instead of focusing on bravery and tolerating anxiety, my instructions were to “start in your comfort zone, stay in your comfort zone, and see where you can take your comfort zone from week to week.” How well did this work? Actually, quite well – I even published an IOCDF poster paper about it a while back.

Dr. Allen Weg, a well-regarded OCD expert and author, has a great video that spells out this approach a little further. The bottom line is that ERP may still work for you, if you simply attack it in small enough steps – and focus on making gains instead of scaring yourself.

Treat the co-morbidities first. Perhaps you have things that are weighing you down and get in the way of doing ERP – like depression, trauma, substance abuse, grief, or major life changes. Sometimes it makes sense to treat these things first, so that you get the most benefit from your OCD treatment. And in my view, the best therapists for OCD are those who treat you as a whole person, and not just as someone who is or isn’t doing their exposures.

Focus on acceptance rather than exposure. Guess what – if you have OCD, you’re already doing exposure constantly. Unless you are stupendously talented at avoiding everything, you probably get triggered by your OCD each and every day – you have intrusive thoughts, feel contaminated, worry that you turned off the stove, or whatever. These daily triggers can become an opportunity to learn from exposure, without necessarily choosing more of it.

One growing strategy for managing these daily exposures is a full-blown, evidence based alternative to ERP known as Acceptance and Commitment Therapy, or ACT (pronounced “act” and not its initials). Like ERP, it involves tolerating distress and avoiding compulsions – but instead of exposure, the focus is on moving towards a life you value. A couple of recent self-help books (here and here) give a good overview of it, and studies have shown comparable effectiveness to ERP.

Develop emotional regulation skills. Are you highly sensitive and triggered by everything? There’s an app for that. Or more accurately, a treatment strategy. It’s known as Dialectical Behavior Therapy, or DBT for short.

DBT isn’t a cure for OCD. Rather, it focuses on skills like emotional regulation and distress tolerance. Developing these skills may, in turn, make it easier to engage in ERP or other evidence-based treatments for OCD. DBT is widely taught in groups or online in many communities, and good self-help books and, yes, apps exist as well.

Know when you need a coaching change. You may have found that working with Dr. Suck-It-Up was too much to handle. Or that your therapist didn’t know how to “titrate” exposure so that you were successful at it. Or at the other end of the spectrum, perhaps you really could benefit from more intensive care because of how you are functioning, and are spinning your wheels with your current therapist.

No one therapist is right for everyone, including me. And while there is sadly a shortage of trained OCD specialists nowadays, that doesn’t mean the first one you find with OCD treatment credentials is always the right one. This leads me to what I feel is an important and often under-utilized tool for getting the right kind of care for yourself: your gut.

There is no harm in getting second opinions and shopping around if therapy isn’t helping you. In fact, I would run, not walk, from any therapist who discourages this. And personally, I am biased toward therapists who help make treatment do-able and successful for you, and don’t just preach tough love. Remember, we’re really just plumbers, in the sense of being hired professionals who work for you – you’re the boss, and you get to call the shots.

Other evidence-based strategies. The research literature – or for the layperson, a good online search – will reveal many approaches for treating OCD beyond ERP. Some areas you’ll find include cognitive approaches (where the emphasis is on changing your thoughts or addressing compulsive rumination), meta-cognition (e.g. awareness of how you think), inference-based therapy, counter-conditioning, and more.

Note carefully that I’m not suggesting approaches that are considered to be pseudoscience or have been shown to have limited effectiveness. Rather, these are approaches that are currently under investigation for treating OCD. Are they as widely used as ERP? In general, no. But if ERP isn’t working for you, why not look at other approaches that might?

Finally, don’t shame yourself

I’m putting this point last for a reason. I feel one of the single biggest factors in getting well from OCD is HOPE, and blaming and shaming yourself for struggling with treatment just pushes you further from your goals.

Sadly, sometimes people in our profession don’t help. Not all of us, and hopefully not most of us. But some may subtly dismiss ERP dropouts as “treatment failures” or people who “won’t do the work” – when perhaps, for you, it was more like pulling on a door marked “PUSH.” Either way, I want you to focus on what you CAN do from here, and feel OK about it.

(For whatever it’s worth, when my clients would sheepishly tell me that they didn’t do any exposure, I’d congratulate them on using their good judgment – and then get to work with them on next steps.)

The late bluesman B.B. King once did a public service announcement for the US government about the importance of having a good breakfast. Here’s what he said: “Don’t like breakfast food? Have a sandwich. Or some leftovers. Just as long as you start the day with something g-o-o-o-d in your stomach.”

I feel much the same way about OCD treatment. Not succeeding with exposure therapy? Try some ACT. Or a little cognitive therapy. Or go slowly. Just as long as you start each day with something g-o-o-o-d for your recovery. Just don’t give up. Best of success!

What can I *do* about grief?

 Image by Ryan McGuire from Pixabay

Grief affects all of us, throughout the course of our lives. From the unimaginable pain of a tragic death, to life changes like illness, career setbacks, retirement or an empty nest, we all experience losses that need healing. Even outwardly happy events like marriage or graduation can leave people feeling lost and struggling with life change. And in the throes of a global pandemic, grief is more rampant than ever nowadays.

Over the past decade, I’ve worked with many grieving people as a marriage and family therapist, and recently completed certification training as a grief counselor. And the biggest question people ask me about their own grief is always: what can I DO about it?

This past year, this issue became personal as well as clinical for me. I found myself suddenly and unexpectedly retired from a very successful speaking and writing career, following a pileup of life stresses and health issues. It shattered my sense of identity and purpose, and I was in a very dark place for several months. During this time, I learned first-hand how much confusing, contradictory and just plain bad advice is out there as you battle your own grief.

But I as move forward with my own recovery – and continue to help others – I would like to put my clinical hat back on and talk about the things you CAN do when you are coping with loss. Let’s take a look at what I and others have found helpful.

The problem with “support”

Client: "I feel overwhelmed with grief. What should I do?"
Therapist: "Sit with your feelings and be present with them."
Client: "And then what?"
Therapist: "What do you mean, 'And then what?'"

This is a common view of grief counseling: provide support and empathy for a natural-if-painful healing process, without giving advice, strategy, or trying to “fix” anything.

Do I agree with this model? Sort of, but not completely. Yes, grief is a natural healing process that takes time. Yes, it’s important to feel your feelings and process them. And absolutely, I’m not in favor of pushing your grief away with things like drinking, drugs or distraction.

But sometimes “support” isn’t enough. Think about it – if you had a broken arm or a splitting headache, would you rather have listening and empathy, or do something about the pain? Too often, we leave people who are hurting very badly with little guidance except to sit there and suffer.

You may not be ready to socialize, engage people, or laugh again, and simply need a good ear. That’s perfectly OK. As for me, however, the kind of “support” described above feels like sitting under a wet blanket. The single biggest thing I personally needed to start recovering was HOPE. That something wasn’t terribly wrong with me. That I wasn’t going to feel this way forever. Perhaps most importantly, what I could do to cope and start feeling better. And this is exactly what many of my own psychotherapy clients sought from me.

So now, let’s look at some of the tools that I feel helped me and others.

Some practical tools for grief

Normalizing. This is a mathematical term that, in counseling, means letting someone know their feelings are normal. Because in addition to sadness and loss, one of the biggest things most people are feeling is “what’s wrong with me?”

In grief, it isn’t at all unusual to experience symptoms like poor appetite, weight loss, insomnia, tearfulness, anxiety, unexpected waves of sadness, and many others. You may feel like every ounce of pleasure has drained out of your life, and wonder if it will ever come back. One survey showed that most widows felt they were going crazy the first year after their loss. So first and foremost, people need to know that in most cases, what they are experiencing is normal and they are going to be OK.

In my first session with a grieving client, I would often say, “If I told you that you may need to spend the next six months to a year of your life taking very good care of yourself, while you heal from this loss, would you find that thought comforting or disturbing?” Most people found it comforting, because it gave them perspective and showed them a light at the end of the tunnel.

I am aware that I’m breaking a cardinal rule of grief counseling here by even suggesting a time frame. It might take one person three months to start healing and another three years, and I tell them that too. But experience has taught me that people feel much more hope when you give them some semblance of a map.

Cognitive restructuring. This is a lofty term for changing the stories you constantly tell your brain. It often works best when you do it in writing: listing your negative thoughts, looking for common errors in thinking, and then re-writing new and more rational thoughts.

This is a core tenet of what we call cognitive-behavioral therapy, or CBT. CBT doesn’t pretend to magically wipe away the pain of grief and loss. But it can make it feel more rational and tolerable. Here are some examples:

· “I’ll never feel better again” turns into “I’m going through a normal healing process.”

· “I could have done more to save my daughter” becomes “I used my best judgment at the time” (or perhaps “I am going to compassionately accept what actually happened.”)

· “Look at all the things I can’t do right now” turns into “This is a time to be kind to myself and adjust my expectations”

· “I am weak and defective” becomes “Here are the strengths I still have”

Behavioral activation. Much advice about grief revolves around how you should BE rather than what you should DO. To paraphrase Frank Sinatra, behavioral activation is more like “do-be-do-be-do.” A powerful evidence-based approach for treating depression, behavioral activation involves choosing activities – even if you don’t feel like doing them – and then seeing if they help or not.

So instead of sitting around the house, you go for a walk, meet the guys or the gals for lunch, take in a ballgame, or learn to play bridge. At first, it may feel like faking it until you make it. But in time, this leads to a roadmap of what daily activities work best for you.

Social support. When you are grieving, it’s OK to let people know you aren’t OK – and perhaps more importantly, let them know what you need from them.

If you aren’t in a place where you want to engage with people, that’s OK too. And not every human being who shows up in your life is nourishing or helpful – so it’s OK to take a pass on your opinionated Uncle Ernie, or that sibling who always pelts you with useless tips and platitudes. But often, the way out of grief is paved with connection with other people.

Self-care. Our minds and bodies have ways to feel better in the moment, if we learn to tap into them and use them. Techniques like diaphragmatic breathing, progressive muscle relaxation and body scanning aren’t cures for grief – and aren’t meant to be – but they are well worth learning and practicing to increase your coping skills and resilience. Same with doing things to be kind to yourself, whether it’s a favorite meal, binge-watching a favorite show, treating yourself to something special – or whatever works best for you.

Spirituality. God may seem mute sometimes when you feel trapped in the throes of grief. But this is a time of healing and reflection, and exploring and connecting with your faith is often part of that journey. For many people healing involves becoming part of something greater than ourselves, often in communion with others, and grief can be a sacred space from which deeper beliefs emerge.

Practical strategies. Finally, I feel the most important role of all for a grief counselor is to help people come up with strategies for getting through the next hour, day or week. Some of the most powerful and effective counseling I’ve done for grieving people has involved encouraging them to get out of Dodge before a painful holiday or anniversary, discussing what to say to people in their lives, strategizing how to get through a tough weekend, and more. I honestly believe that having a sounding board for navigating daily life is the single biggest purpose for seeing a counselor when you are grieving.

In addition, grief counselors often use tools to help people actively process their loss and start to move forward – these can include drawing exercises, structured journaling, rituals of connection, and more. If you are interested in exploring what you can do as self-help, a good place to start is the Grief Recovery Handbook by John James and Russell Friedman, available on Amazon.

Changing the way we look at grief

There is a common narrative about grief nowadays: It takes time. Don’t try to “fix” it. Accept painful feelings and sit with them. And if someone you know is grieving, just be present and listen to them.

Many of these concepts come from old-school psychodynamic therapy, with some trendy mindfulness sprinkled in. For some people, they suffice. For others, they don’t. Personally, I felt this worldview left me mired in goosh at a time when I was desperately seeking answers. So if what you’re hearing from Google or TED Talks isn’t really helping your own grief, you aren’t alone.

This is why I favor a more active approach – one that honors the natural healing process of grieving, and doesn’t promise a magic bullet to take it away, but gives people hope and a game plan for coping and feeling better. With the right support system – and more importantly, the right strategy – I truly believe it is possible to make these very painful transitions more bearable.