Why Doesn't Every Therapy Work for OCD?
Unfortunately not all therapy is created equal when it comes to OCD treatment. Some individuals spend years in therapy without meaningful improvement in OCD symptoms. This isn't due to a lack of effort or dedication from the individual or the therapist, it's because OCD responds to a particular kind of treatment: one that works to break the cycle of OCD as opposed to providing general emotional support around it.
Understanding What Keeps OCD Going
OCD operates in a cycle: we experience an intrusive thought, sensation, image, or urge (obsession), then we experience anxiety, discomfort, or uncertainty. We then feel compelled to engage in a behavior that neutralizes or alleviates this anxiety or discomfort (compulsion), which leads to a degree of relief. This relief reinforces the cycle of OCD, making us feel like we need to engage in the compulsive behavior every time we feel the anxiety or discomfort.
Seeking reassurance from others, avoiding certain people or situations, and attempting to achieve certainty are all examples of compulsive behaviors. By engaging in compulsions, and feeling a degree of relief as a result of engaging in these behaviors, we reinforce the cycle of OCD.
Effective treatment for OCD includes understanding this cycle, and interrupting it so it doesn't continue to play out and be reinforced. Instead of focusing on reducing anxiety, effective OCD treatment actually emphasizes increasing tolerance to anxiety, discomfort, and uncertainty.
Why Some Common Therapy Approaches May Be Less Effective
Here are some common treatment pitfalls:
Traditional talk therapy: Spending too much time analyzing intrusive thoughts without addressing compulsions and behavioral responses.
Reassurance: Accidentally reinforcing OCD by repeatedly answering questions or providing certainty.
Avoidance-based approaches: Encouraging clients to avoid distressing situations rather than learning to tolerate uncertainty.
General anxiety management: Focusing exclusively on relaxation and anxiety reduction without addressing compulsive behaviors.
Overemphasis on insight: Helping clients understand why they have OCD without teaching them how to respond differently to it.
Why ERP Isn't Always Effective When It's Not Implemented Correctly
Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. This is because ERP focuses on interrupting the OCD cycle.
In the past, ERP focused mostly on exposures, however, this alone didn’t produce better outcomes for people with OCD. It turns out that response prevention, combined with exposures, is where the magic happens. During response prevention we are retraining our brains to understand that we can respond to anxiety and discomfort in different ways, and that we don't have to engage in compulsions in order to be okay.
It's important for OCD therapists to be aware of sneaky compulsions, compulsions that are unseen or more easily fly under the radar. Mental compulsions are very common for people with OCD, and it's important to treat these as any other kind of compulsion. Another sneaky compulsion is safety behaviors: behaviors that we engage in to alleviate anxiety during an exposure. An example is confronting a fear of allergies by going outside, but keeping allergy medication on hand.
It’s important to create a consistent ERP practice outside of therapy sessions. Think of it like a muscle: the more you exercise, the stronger you become over time. ERP therapy for OCD works just like this. The more you practice facing your fears, the more your tolerance for anxiety, discomfort, and uncertainty increases, which also increases confidence.
The Importance of Recognizing Mental Compulsions
Mental compulsions are incredibly common, but can often fly under the radar because they're not visible to others.
Some examples of mental compulsions include rumination, repeating, counting, hypervigilance, mental reassurance, catastrophization, comparison, and mental self punishment.
It's important that OCD treatment addresses both physical and mental compulsions, as all compulsions serve the same function within the OCD cycle: to alleviate, suppress, or neutralize anxiety, discomfort, and uncertainty.
What Makes OCD Treatment More Effective?
It’s important that the following components are present in evidence-based OCD treatment:
Accurate assessment and understanding of the OCD cycle
Exposure and Response Prevention (ERP)
Addressing reassurance seeking and avoidance
Identifying overt and covert compulsions
Building tolerance for uncertainty and distress
Consistent practice and individualized treatment planning
Working with a therapist who has appropriate OCD-specific training
Does This Mean Other Therapy Approaches Have No Value?
While OCD responds best to treatments like Exposure and Response Prevention (ERP), there are other therapy approaches that can complement OCD treatment. Some complementary approaches include Internal Family Systems (IFS), Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and mindfulness.
In addition to OCD-specific treatment, these other approaches can offer the benefits of deepened self-understanding, self-compassion, and emotion regulation.
Conclusion: Effective OCD Treatment Requires More Than Reducing Anxiety
When it comes to OCD treatment, it's important to address the cycle of obsessions and compulsions. This begins with understanding the OCD cycle, and how it can be effectively interrupted.
If you have OCD that hasn't improved with traditional therapy, please consider whether you have received OCD-specific treatment. Not all therapy approaches are created equal when it comes to OCD, and it tends to respond best to certain kinds of treatment, like Exposure and Response Prevention (ERP) therapy.
Please know that OCD is very treatable, and with the right therapeutic approach, individuals can break free from the cycles that are holding them back and reclaim their lives.
The goal of OCD treatment isn't to eliminate every intrusive thought or uncomfortable feeling. It's to help individuals learn that they can experience uncertainty, tolerate distress, and live meaningful lives without allowing OCD to dictate their decisions and behaviors.
