(Note: This is an article I published privately for my peers in the OCD treatment community a while back, after attending the 2015 OCD conference in Boston. It received a good response, including positive comments from the director of the International OCD Foundation. While this article is aimed at fellow therapists, I am posting it here for interested lay people and OCD sufferers as well.
As a postscript: in 2018, I published a research poster paper at the 2018 IOCDF conference in Washington, DC about this approach, showing a 90% treatment response rate across my own cases. A link to this paper is here.)
As a postscript: in 2018, I published a research poster paper at the 2018 IOCDF conference in Washington, DC about this approach, showing a 90% treatment response rate across my own cases. A link to this paper is here.)
What do people who suffer from obsessive-compulsive disorder
– one of the most maddening neurological mental illnesses – have in common with
tightrope walker Nik Wallenda? Perhaps more than we give them credit for.
OCD treatment has come a long way. Just over twenty years
ago there were no conferences, few proven treatment options, and a lot of
really ill people out there. Today there is much more hope, much better
treatment, and a very active and engaged research community. Particularly in
the area of exposure and response therapy (ERP), now viewed as the gold
standard for OCD psychotherapy.
However, I feel ERP still suffers from a PR problem - one that could be fixed with better linguistics. According to current literature, treatment refusal and dropout rates for ERP can total 30% or more. Add those who relapse, or get “stuck” beyond a certain point of treatment, and you have a lot of people suffering – often after working hard and going through a lot of discomfort. Some of my own clients frankly disclose that when they first read about OCD treatment, they walked away feeling dejected and hopeless, because they felt they lacked the bravery to pursue it.
However, I feel ERP still suffers from a PR problem - one that could be fixed with better linguistics. According to current literature, treatment refusal and dropout rates for ERP can total 30% or more. Add those who relapse, or get “stuck” beyond a certain point of treatment, and you have a lot of people suffering – often after working hard and going through a lot of discomfort. Some of my own clients frankly disclose that when they first read about OCD treatment, they walked away feeling dejected and hopeless, because they felt they lacked the bravery to pursue it.
This is where Nik Wallenda comes in. He is famous for
high-wire feats such as crossing the Grand Canyon or Niagara Falls. But he prepares
for these events by practicing for hundreds of hours on a wire that is just a
few feet off the ground, safe and supported at all times. In other words, he loses his fears by making himself comfortable enough
to do a lot of practice, and gradually but continually improve.
I use a Wallenda strategy with many of my OCD clients. I don't
talk about bravely facing their fears. I don't focus on habituation or
extinction bursts. Instead, after we do some cognitive work and create an
exposure hierarchy, I give them the following instructions for daily practice:
Start in your comfort
zone, stay in your comfort zone, and
see where you can take your comfort zone
from week to week.
This puts clients completely in charge of whatever they feel
ready for – but it also gives them an incentive to track their progress and
continually improve. Wherever they feel safe is where we start, whether it is gradual
exposure and response prevention, imagery or mindfulness practice. Then I give
them plenty of support and encouragement.
Sometimes clients surprise me with their rapid gains, which
I cheer enthusiastically. Other times it is a game of small steps or setbacks,
which I normalize and empathize with. Sometimes they feel stuck and we explore
new strategies, such as imagery desensitization. Either way, I stay unfailingly
positive as I encourage them to keep practicing
and turn their battle with OCD into lots and lots of easy.
And you know what? It seems to work. I am just one small
sample – a private practice in the middle of upstate New York. But on
standardized assessment measures of OCD, I generally get very good clinical
outcomes with my clients compared with what I see in the literature. With two key
differences: (a) it some cases, it may take us longer to get there and (b) they
almost never drop out.
I realize this approach isn't for everyone. For example, serious
cases such as inpatient clients may need stronger exposures to get better
quickly. For others, doing what they never thought they could do might be an
important teachable moment. And I realize that some people could technically
skate along with minimal exposure and make no progress - although I find that
time and patience actually lead most of my clients to improve. But I have come
to feel that most people do their very best with OCD treatment when we make
getting well seem easier than staying ill.
I suspect that behind closed doors, this is how many of us
actually treat OCD anyway, if we don't want our clients to run for the hills. So
here is my challenge: stop glorifying strong exposures. Too many people
associate ERP with standing in filthy dumpsters or confronting intrusive
thoughts head-on. Let's change our language, and see if a kinder, gentler
approach to ERP - like Nik Wallenda uses - might reach more people and give us
better long-term outcomes.
