Disgusting-ly good news about OCD treatment

Is there such as thing as good news about disgust? Yes! If you suffer from or treat contamination OCD based on disgust, I recently published a new proposed treatment protocol for it that could be useful information for you and your therapist - particularly if traditional exposure-based OCD treatment hasn't helped as much as you would like.

A growing body of research is now showing that contamination OCD based on disgust ("I can't stand feeling gross", "I'll never feel clean enough again") is processed in a different part of the brain than COCD based on fear ("I'll get sick from germs or poisons, or will get others sick"). More importantly, it doesn't respond to traditional exposure therapy the same way. I recently published a proposed treatment protocol for disgust-based OCD based on emerging literature, involving rapidly learning to practice functioning better, as a clinical article in the IOCDF Spring 2023 Newsletter (see page 13).

This article has already generated a great deal of positive feedback from OCD sufferers and clinicians alike, many of whom have shared that it has helped in cases where people previously felt stuck with existing treatment approaches. I have also recently discussed this on several major podcasts in the field, including Kevin Foss' FearCast Podcast, Stuart Ralph's The OCD Stories, and Kristina Orlov's The OCD Whisperer (coming July 2023).

More to come on this - stay tuned!

Theory X, Theory Y and Treatment Motivation

Psychotherapists and corporate executives often have little in common. Unless you’re someone like me, who has done both. 

Because of this, I have come to feel that a core concept of corporate leadership holds the key to effective therapy for anxiety disorders. This concept is known as Theory X versus Theory Y.

I became a psychotherapist later in life, in my mid-50s. Decades earlier, I was director of customer services for a California software startup that is now a major part of a nearly billion-dollar operation. Let's explore how this concept ties in with success in both of these fields. 

First, a little background

Theory X and Theory Y were the brainchild of 20th-century management professor Douglas McGregor – who, in turn, was a student of famed psychologist Abraham Maslow. His ideas have survived remarkably well into the 21st century.

Theory X holds that employees fundamentally lack ambition, avoid responsibility, and need to be pushed. Theory X managers feel unless you “motivate” employees with rules, boundaries and consequences, they will goof off. Theory Y, on the other hand, presumes that people have intrinsic motivation to do a good job when they are shown respect and given agency.

Theory Y management strategies have built some of the most successful businesses of all time, by fostering autonomy and initiative at all levels of the organization. Another surprising place you will find Theory Y is the military, who realized that you don’t want unmotivated slugs sharing a foxhole with you. Many books have documented this trend, from the 1980s classic In Search of Excellence to recent bestsellers like Brené Brown’s Dare to Lead.

My own corporate success was largely fueled by Theory Y principles - for example, team involvement in hiring and policy decisions, cross-functional responsibilities, and championing individual growth and achievement. Everyone felt heard, respected, and had a reason to feel important when they walked in the door each morning, and they in turn delivered. This helped our company grow rapidly and eventually go public. Later, I led another 24-hour call center operation to near-perfect customer satisfaction, near-zero turnover, and a 25% sales increase in the middle of a recession using a similar approach.

So, what does any of this have to do with psychotherapy?

I feel therapy for anxiety disorders has unwittingly made a hard turn towards Theory X over the past several years. Since the 1970s, it has moved from a focus on relaxation and desensitization to a focus on sucking it up and facing your fears. Have a phobia? Go at it head-on. OCD compulsions? Turn the Nike slogan on its head and "just don't do it." Your kid has anxiety? Suck it up, Junior.

As a result of this, too many therapists now see themselves as agents of confrontational change, whose job is to make clients face up to what their symptoms are costing them, and then push them to “do the work” of uncomfortable treatment strategies.

This is more than a change in clinical technique – it is a cultural shift. For the record, I support techniques that involve facing your fears, like exposure therapy, when they are paced appropriately and delivered humanely and collaboratively. But too often, these approaches entail a power dynamic that revolves around pushing the reluctant to do the uncomfortable.

Anxiety therapists who privately treat squeamish clients like disobedient schoolchildren and debate how to “motivate” the non-compliant sound exactly like Theory X managers who try to push their lazy employees to get back to work. And unfortunately, outcome studies show that these clinicians often get similar results as these workplaces do – far from perfect. This is why I feel strongly that the next frontier in anxiety treatment needs to also be a culture change. Now, let’s explore this.

Bringing Theory Y into the therapy room

I hear the same thing over and over again from clients and clinicians alike with lived experience with anxiety disorders. Clinical strategy of course matters – and often matters a lot – but one of the biggest factors in our recovery is often how much a therapist listens to us and collaborates with us. Here are some of the things I’ve heard people describe about their real experiences behind closed doors in treatment:

·        Therapists try to “motivate” people to keep doing things that ultimately aren’t working for them.

·        A manualized treatment protocol takes precedence over the whole person sitting in front of them, including factors such as trauma, life change, health status, neurodiversity, and more.

·        Dr. Wonderful decides how well the client is progressing, what their goals should be, and how hard they should be working.

·        Stuck points in treatment are presumed to be the fault of the client, and they are branded as treatment failures or told to come back when they are “ready.”

All of these spring from the same kind of Theory X "get back to work" mentality I experienced back when I was a bored grocery store clerk in high school. Had these therapists adopted a Theory Y mindset, regardless of the approach they used, I am convinced that they would have had much better outcomes.

Here is how I would compare these mindsets:

Theory X anxiety treatment	Theory Y anxiety treatment
Have clients confront themselves with what their symptoms are costing them.	Explore what a client’s own goals and motivations are.
Enforce accountability for treatment compliance.	Check in with them and help them strategize next steps.
Push them to challenge themselves.	Help them self-motivate by building on achievable victories.
Help clients face their fears.	Help clients function better and expand their boundaries.
Focus on bravery.	Focus on strategy.
Assume that treatment failures are the fault of the client.	Assume that treatment failures are the fault of the approach.
If they remain stuck, dismiss them as a treatment failure	If they are stuck, meet them where they are at. Be patient, flexible, and open to modifying your approach.
Think like a tough-love coach.	Think like a helpful consultant.
Confront clients who aren’t working hard enough to recover.	NEVER EVER shame a client – listen and troubleshoot.

 

In a very real sense, a Theory Y approach could help self-regulate what clinical approaches work best, by giving clients a voice in what is or isn’t working for them – and in the process, build the kind of clinical relationships that give these approaches their very best chance of success. Unfortunately, this subtle but important attitude rarely finds its way into either graduate school training or research studies.

How evidence-based is Theory Y?

Given the amount of confounding factors in most organizations, much of the literature on Theory Y’s effectiveness has taken the form of management case studies. However, an ambitious multi-level analysis performed in 2015 showed that Theory Y did, in fact, have a major impact on organizational performance. McGregor himself saw the need for some of both approaches, but clearly proposed his theory based on the importance of motivation.

As for its impact on psychotherapy, for now you’ll have to trust the observations of one humble executive-turned-therapist in remote upstate New York: in my own experience, clinical and personal, as well as those of my colleagues, it is a huge and often game-changing factor in treatment motivation and therapy outcomes. To be frank, I almost never hear people complain about treatment itself – they complain about clinicians who judge them, shame them, push them, and pigheadedly insist there is only one way – theirs, of course – to get well.

So my advice? Get out of expert mode. Listen to your clients, be open to hearing and trying new ideas, and don’t give up on people. Then watch what happens. Personally, I firmly believe this will be the next frontier in effective anxiety treatment.

(Postscript: I received a very thoughtful comment on this blog, to the effect of "is there no place for urging bravery, or letting people know they aren't helping themselves get well?" And I agree 100%! (I also happen to believe this person is a very wise and humane therapist.)

Here's the difference in my mind, using the framework of Theory X versus Theory Y. Taking a Theory Y approach to leadership doesn't mean you can't ever fire or discipline employees. I've done both in my management career, when it was needed. Likewise, there are many testimonials (look, for example, at many IOCDF conference keynotes from recovered sufferers) where the right kind of tough love was life changing, and perhaps even life saving.

However, there is a big difference between firing an employee who is stealing the toilet paper or creating drama every day, versus a workplace full of rules and punishments where people are terminated constantly. Likewise, in the clinical realm, there is a huge difference between the using right kind of aikido in the treatment room when it is appropriate, versus a toxic and unhealthy power dynamic that doesn't listen to clients and regularly uses shame and confrontation as a treatment tool. I am fine with the former but not the latter.)

The Gallagher Clinical Dogma Test

Most therapists have been trained in a particular approach to treatment for anxiety disorders: CBT, ERP, ACT, third-wave, psychoanalysis, or whatever. And if there is reasonable evidence for what you are doing, that’s great. 

But are you TOO wedded to your way of doing things, to the point where it may actually be harming your clients? 

Here is a simple test: Let’s say that you tried your usual treatment approach with your client. They gave it a fair shot. The client reported that it didn’t help or made things worse. Check the boxes below if you did any of the following:

⎕ Implied they were doing your approach wrong, or haven’t practiced it enough.

⎕ Stated that they weren’t working hard enough at it.

⎕ Tried to “motivate” them to recommit to your form of treatment.

⎕ Described them – in your notes, or worse, to them – as a “treatment failure.”

⎕ Did not suggest – or refused to try – any approaches besides yours.

⎕ Used the terms “evidence based” or “gold standard” at any time AFTER the client disclosed your approach wasn’t helping.

⎕ Said something to the effect of “Almost all my clients succeed with my approach, but if you are an exception, I can refer you out.”

⎕ Suggested that they should come back when they are ready to work on their problems.

Scoring: Give yourself one point for every box you check. If your score is anywhere between 1 and 8, you are putting your dogma ahead of your clients' interests, and the problem is you.

So what is the theoretical basis behind this highly accurate clinical assessment? Simple. In my nearly 70 years on this planet, and my own lived experience with anxiety disorders, I have been told every single one of these things myself in treatment. And I have extensive outcomes data as well: every single one of them turned out to be wrong, and a different approach eventually worked much better for me.

Moreover, this assessment has been validated across every major treatment strategy of the last half century: I have heard these things from people practicing psychoanalysis, CBT, ERP, third-wave approaches and even finding my inner child (seriously). 

Finally, this has been cross-validated by years of seeing clients myself as a psychotherapist, as well as my connections with other therapists dealing with their own anxiety disorders. These results are consistent as well: collectively we are all TIRED of having treatment providers blame us for the failures of their approaches – and worse, having the burden always be on US to navigate among clinicians who see just one way to do things, as we seek proper treatment.

Joking aside, evidence-based treatment strategies do matter. You just can’t use them as a blunt instrument for everyone, while ignoring how well they actually work for each client. 

I actually keep up with the literature on anxiety treatment, and actual research to date on it is still nuanced, incomplete, and continuing to evolve. And it feels clear to me that, ever since the days of Freud, the single biggest cause of treatment failure in our profession lies not in our methods, but our tribalism about these methods. And the EBT specialist who presses on when their approach isn't helping is just as guilty as, say, the Gestalt psychoanalyst who won't mention evidence-based approaches.

Personally, I am a hardcore cognitive-behavioral therapist who practices ERP, ACT, IBT, mindfulness, and other evidence-based strategies. I am also an engineer by training who believes in science. But I never shamed clients, gave up on them when something wasn’t working (although I did sometimes collaboratively refer them to other experts), or put my training ahead of the person in front of me – and perhaps more important, never stopped learning.

So, did you discover that your own dogma may be getting in the way of your effectiveness as a therapist? There is a proven approach for dealing with this, popularized a few years ago by Bob Newhart’s fictional psychologist Dr. Switzer: Stop it!