“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!
