One of our core values at Anxiety Specialists of St. Louis is to use therapies that are evidence based. This means that we use treatments that have strong research showing that they are effective for a particular symptom or disorder. This doesn’t necessarily mean that other therapies don’t work, it just means that other therapies don’t have the research base that evidence based therapies do. The therapies that have research support for Obsessive Compulsive Disorder (OCD) are Exposure and Response Prevention (ERP) and Cognitive Behavioral Therapy (CBT).
If you are interested in learning more about the research support for different symptoms and diagnoses, you can look through the information here from the Society of Clinical Psychology.
What is exposure and response prevention therapy?
Exposure and response prevention has two parts.
The first part is exposure. Exposure sounds scary but it just means facing your fears. We do this little by little. We start by making a list of things you’d like to do that you don’t feel able to do now because of anxiety. We also think about things you may be avoiding because of anxiety or feeling uncomfortable and add those to the list. Then we put those things in order from easiest to hardest and we start with the easiest. This list is called an exposure hierarchy.
We believe in doing exposures that you can be successful with and we never, ever force you to do something you’re not willing to do. Our job is to support you and encourage you in tackling these fears, not bullying you into doing something you’re not ready for.
Exposures can be done in a few different ways. The first is “in vivo” exposures, which are the most common. In vivo means “in the living body,” and in exposure terms it means something that you practice in your real life. Another way exposure can be done is in the imagination through “imaginal” exposure. This might be used if it’s important to practice facing fears that can’t be faced in real life (for example, someone being upset with you or failing an important exam). Imaginal exposures are sometimes practiced by writing scripts or stories.
The second part of the therapy is learning to prevent the response to discomfort (also sometimes known as a ritual or a compulsion). What are these responses? They can be anything, really. Some common examples include checking that your doors are locked, mentally reviewing your activities for mistakes, or searching the internet for symptoms.What makes a compulsion a compulsion (or a ritual a ritual) is how it functions or what it does. If it reduces the anxiety or distress, it’s probably a ritual. Reducing ritualizing is just as important as the exposure part of therapy.
The goal of therapy is to help you learn to sit with distress without relying on these rituals to escape. The pattern that keeps people stuck is having an intrusive thought, feeling distress, and doing a ritual to escape. The problem is that the rituals are never enough. The relief they provide is temporary, meaning that they have to be repeated or expanded or intensified. Giving up rituals or compulsions is the way to get out of these never ending loops.
What does OCD therapy look like? What are some ERP examples?
(Content warning: discussion of medical- and health-related triggers in this section)
ERP therapy will look different based on your specific triggers. The exposure component will involve facing things that make you uncomfortable. This is the part of therapy that people are often the most nervous about. It’s important to remember that we work together on this. You’ll decide what your exposure tasks will be and you’ll decide when you’re ready to tackle them. The job of the therapist is to coach you and support you and yes, sometimes nudge you a bit, but never to force you. We start exposures whenever clients are ready to start and then we approach more difficult things when willingness to do them increases.
Let me give you some specific examples. For someone who has a health related fear, we might start with words related to the fear. For example, words like blood clot, attack, diagnosis, test, scan, terminal, cancerous, etc. etc. We might start by reading or writing the words or saying them out loud. We continue to repeat this exercise until you are ready to move on to something more challenging.
Next we might move on to images that are triggering. These could be images of a procedure, a cancerous mole, or other representations of fears, for example losing the ability to see or the ability to walk. Again, we repeat this until you’re ready to move on. The next step might be reading blog posts or articles about a particular medical condition, followed by listening to podcasts or interviews about health concerns. From there we might watch videos about health conditions or death.
Another and related element to this part of exposure treatment is helping you to live your life. For example, if a fear of cancer has prevented you from calling or visiting a relative who is going through chemotherapy, working toward making contact with that loved one will likely be an important part of treatment.
Which therapy is best for OCD? Does exposure therapy for OCD work?
The question of which therapy is best is a tricky one. Of course, everyone is different and there is no way to predict what type of response you’ll get from treatment. What research can tell us is what works for most people and what effect we might expect from treatment on average. From that perspective, the research is pretty clear that CBT and ERP are very helpful for OCD symptoms.
For example, in a 2007 peer-reviewed paper called “Psychological treatments versus treatment as usual for obsessive compulsive disorder” a group of researchers combed through the literature to find studies of OCD treatment. They found eight high quality studies that compared cognitive behavioral therapy to treatment as usual. In these studies, the treatment as usual groups included people who actually received no treatment, were on a waiting list for treatment, or received usual care. Taken together, results showed that cognitive behavioral treatments were better than treatment as usual at reducing OCD symptoms.
Another paper from 2005 found Cognitive-behavioral therapy, which encompasses exposure with response prevention and cognitive therapy, has demonstrated efficacy in the treatment of obsessive-compulsive disorder. This review also looked at long-term outcomes associated with ERP and cognitive therapy. The authors found that cognitive therapy added to ERP improves the ability to sit with distress, changes negative beliefs, and improves client’s ability to complete therapy assignments and stick with therapy over time.
What are the disadvantages of exposure therapy?
I love working with exposure therapy. It’s the reason I specialize in anxiety and OCD symptoms. But I don’t believe this therapy is the best fit for everyone.
To get the most out of this approach, clients have to be willing to do things that are difficult. This therapy is challenging. When people want to get better but aren’t quite ready to take the leap and try something new, they tend to stay stuck. You can learn more about readiness to change and take a quiz here.
ERP for OCD also requires clients to be active. The biggest results come from consistent practice outside of the therapy sessions. People who are able to make their therapy work a priority and to make changes every day usually see the results they’re hoping for. To get different results, things have to change. Our job is to help and support people who are ready to make some changes.
How does exposure therapy work?
There are a few theories about how exposure therapy works. Ultimately, there is probably some truth to each of these theories.
For many years, we thought that exposure therapy worked because it helps people get used to things that are uncomfortable or scary. By repeating something frightening over and over and over and over and over, we eventually learn that the thing is not so bad. In learning terminology this is called “habituation.” You might think about how uncomfortable it is to jump into a cold pool or lake early in the summer before it’s warmed up. At first all you can focus on is how cold it is, but if you’re able to stay in for a while, eventually you get used to it. Or maybe when you first started driving a car you had a lot of anxiety but after driving to school and then work day after day after day after day, you also got comfortable with that.
After many years of research, the data showed an interesting pattern that suggested that maybe habituation wasn’t important for overall symptom improvement. What researchers found is that the amount of habituation, or how much anxiety decreased during an exposure, wasn’t related to overall treatment outcome. Researchers also found that the decrease in anxiety between therapy sessions also wasn’t related to treatment outcome. So what does this mean? Basically, it seems to mean that how quickly a person gets used to something that makes them uncomfortable doesn’t really matter. So if you’re around something that scares you but you feel like you’re still anxious, that’s okay. Why then do people still get better?
This led to the development of a different theory, called Inhibitory Learning. The idea behind inhibitory learning is that we actually can’t “unlearn” anything. So if we have associations between a certain thing and fear, we can’t unlearn that. How then does exposure work? The idea is that through exposure we are creating new learning. In this case, the new learning would be between a certain thing and safety (or toleration). This new learning inhibits the old learning. This means that the new learning is stronger or more likely to be activated than the old learning.
Other recent ideas about how exposure therapy works focus on willingness and practicing living your life, even though you might feel uncomfortable. This theory puts more emphasis on connecting with your values and engaging with behaviors that matter to you, like being a more present parent or getting out of the house to spend time with friends. This approach is less focused on the idea of repeating exposures over and over to achieve habituation and more focused on accepting unwanted thoughts and feelings without letting them stop you.
What kind of therapist do I need for OCD therapy?
Mental health professionals come from a variety of training backgrounds. It can be confusing!
A psychiatrist is a medical doctor who has completed additional training in psychiatry and can prescribe medication. A psychiatric or mental health nurse practitioner is a nurse who specializes in mental health and might also provide therapy or prescribe medications.
A psychologist or a masters level therapist may be able to provide therapy for OCD, depending on their training. A psychologist has a PhD in clinical, counseling, or education psychology and can provide therapy but not prescribe medication. Masters level counselors, clinicians, and therapists may include licensed professional counselors, licensed marriage and family therapists, or licensed social workers. It’s important to find out about the training and experience a therapist has with OCD before beginning treatment with them.
If you have additional questions about ERP or are ready to tackle your OCD head on, please contact our care coordinator today for your free 15 minute consultation!