A few years ago, I went to a homecoming football game at my alma mater Cornell University - and learned first-hand why OCD treatment fails as often as it does.
Before the game, my old department had a tent party with a
spread of food: one tray piled high with ribs, another with hamburgers, and a
third with "healthy vegetarian sandwiches."
Guess how that turned out? The ribs were gone in short
order, the hamburgers soon after. But even though many people were still
complaining about being hungry, the kale-and-tofu-sandwich pile sat there
completely untouched. (As for me? The ribs were delicious, and I was glad I
came early.)
I know what many public health experts would say: that these
people were making bad choices. That evidence shows they would be healthier and
live longer eating the tofu sandwiches. That we need to invest in more
education about better eating habits.
Here's what I would say: if we want people to eat healthier,
we need healthy food that more people actually eat.
As a trained OCD therapist who suffers from it personally, I
feel exactly the same way about OCD treatment. Exposure and response prevention
(ERP) is currently the gold standard for treatment, with a great deal of
literature behind it. It basically involves doing what makes you uncomfortable,
without doing any of the behaviors you normally do to soothe this discomfort,
until you get used to it. And even with newer models like ACT and inhibitory
learning, the focus is still on distress tolerance.
The problem is that many people - and for that matter, many
clinicians - like exposure therapy about as much as they like tofu. It often
(but not always) helps when people DO it, but the same literature will tell you
it fails about half the time because of factors such as treatment refusal,
dropout, treatment failure and relapse. Some people simply
won't do it - and more importantly, some people bravely do it and it simply doesn't
work, or kinda sorta works. Too often our treatment community has nothing to
say to this unlucky 50%, and promotes a message that recovery is only for the
special brave people.
In fact, current clinical research sometimes seems bent on
making treatment more uncomfortable with each passing year. For someone like me
in my sixties, I've watched the CBT field evolve from Barcaloungers and Valium
to a joyless focus on exposure and distress tolerance. As for research on how
to make treatment more palatable with fewer dropouts, I mostly hear crickets.
People should be eating their evidence-based tofu, and that's that.
I am not a Luddite about ERP. I practiced it and taught it.
I've seen it work firsthand. And I deeply respect the lived experience of
people who feel it has changed or even saved their lives. So I get their
fanaticism for it. But I'm also gently suggesting that some of you may be
handing many of your clients nothing but tofu sandwiches, and dismissing many
of them as treatment failures.
But in my humble opinion, perhaps we could reach more
sufferers - and more clinicians - without throwing the evidence-based baby out
with the bathwater. There is an approach that already works in fields like
addiction, tobacco cessation, and social services. It's called harm reduction.
Harm reduction is exactly what it sounds like. If you are an
alcoholic and can't quit, drink less this month. If you are hooked on
cigarettes (only 15% of whom ever quit, according to the literature), vape for
now. If your social services client is a hot mess, explore what strengths they
can build on to be a little less of a hot mess this week. In short, ease people
into long-term success by building short-term confidence, versus making them scale
what, for some, is an impossibly high wall.
What might harm reduction look like in OCD treatment? Instead
of promoting "torture therapy," think about evidence-based strategies
that help but are more palatable – like controlling rumination, very gradual
exposure, mastery instead of habituation, or the right kinds of cognitive
approaches. Think of an "ERP Lite" that most people won't fail or
drop out from, that we promote as the first line of treatment. Which can then,
of course, be titrated up to torture therapy for those who truly need it.
This was frankly my own approach when I was in practice, and
it actually worked quite well. Instead of asking people to make themselves
uncomfortable, I asked them to stay comfortable and gradually expand their
comfort zones - and had close to a 90% treatment response rate. But what one
obscure therapist in upstate New York thinks doesn’t matter: what matters is
what research shows to be effective. And we’ll never know unless more people DO
that research.
"But ERP is the only evidence-based approach for OCD!"
Umm … sort of. Just this month, a newly-published meta-analysis
of RCTs on ERP concluded that successful ERP studies basically correlate with researcher
bias. They also concluded that it is better than placebo but not significantly
better than other treatment approaches, gains from it are modest, and its
research outcomes aren’t duplicated in actual clinical practice.
So first of all, I think my evidence can beat up your
evidence. Either way, we still fail far too many people whose suffering
matters. And we desperately need to build an evidence base that looks beyond
painful treatment approaches that too many people “flunk” and too many non-OCD
therapists are reluctant to use. Which means doing better research that puts
treatment acceptance front and center.
So would a harm-reduction approach help more people, with
fewer dropouts and treatment failures? We won’t know until someone decides to make this a research
hypothesis. And we should. Oh and, by the way, I'm allergic to tofu.
(Photo credit: Ponyo Sakana from Pexels)
