Treatment for OCD
Whether you’ve researched therapy OCD, or this is all new information, I’m hoping to break down the two treatments I offer for OCD: Exposure and Response Prevention (ERP) and Inference Based Cognitive Behavioral Therapy (I-CBT).
Getting Started
Prior to jumping into treatment, I’ll first complete a general assessment. You can expect to answer questions like: what is bringing you to counseling, how long you’ve been feeling this way, what your health history looks like, and your goals for therapy. If OCD comes up, then I’ll complete an assessment that more specifically looks at just your OCD symptoms, triggers, compulsions and distress level.
After I have assessed for OCD and we have a good idea of what is bothering you, I then like to explain the various treatments for OCD and give clients the opportunity to ask questions and discuss which one might be their preferred treatment, unless it is clear that one will likely work better than the other for your specific type of OCD.
Exposure and Response Prevention (ERP)
Exposure and response prevention (ERP) is the treatment that most clients have heard about. It has been around longer, researched more and is the more common treatment for OCD. ERP involves being exposed to the things that make you anxious without completing the compulsion (the behavior that tends to reduce or neutralize the anxiety). The basic steps of ERP are as follows:
Identify all obsessions and compulsions together
Identify how distressing they are
Create a hierarchy, or list from least to most distressing
In session practice being exposed to a trigger without completing the compulsion
Practice this at home throughout the week
Gradually we move on to harder and harder compulsions
I know this can sound scary for a lot of people. It can even sound impossible. You might be thinking if it were that easy you would have done it by now. And you might be wondering why you would need to do this. Which are both common, and excellent, questions. And, at the same time, ERP has been an incredibly effective treatment for so many people!
How hard is ERP?
I get that ERP sounds incredibly difficult to do, and can be, but we will break things down to more manageable steps to make it less overwhelming. While I occasionally get clients who want to jump to some of the hardest items in their hierarchy, most clients prefer to start more slowly and with some that are less distressing. We will pick something that makes you mild-moderately anxious. We practice it in session (when possible), to give you the opportunity to try it with my support. We can even break things down into smaller steps, instead of just removing a compulsion, if that feels more appropriate.
Let’s take, for example, a common example of hand washing (excessive washing, repeatedly washing, and/or using very hot water). One way to approach this compulsion would be to touch something anxiety provoking without washing hands. Or delaying hand washing longer than usual. Another might be to work on gradually decreasing the water temperature over time. We can get creative and work with your comfort level - wherever that may be - to gradually work to a place that feels better for you and less driven by the anxiety.
There is homework involved with ERP, averaging 20-30 minutes per day ideally. The goal is to have you practice the exposures at home, in the moment when you’re being triggered. The more you do it, the more likely you are to experience habituation and the quicker treatment will go.
What’s the point of ERP?
Ultimately, we hope that you’ll feel less distress and that compulsions take over less time in your day so you get that time back to do the things that matter. I think what most clients and therapists hope this will be achieved through something called habituation. Habituation is essentially the more you do something the less anxious you feel to do it. So the more you are triggered and don’t do the compulsion, ideally over time you feel less and less anxious when you come across that trigger, and the less likely you will feel the need to do the compulsion.
Unfortunately, habituation doesn’t happen for everyone, for various reasons. But even without habituation I see two things often happen. One is that people learn that they can tolerate that level of anxiety and are more willing to tolerate that feeling when it really matters, which results in not doing a compulsion even though the anxiety is still present. Second, which stems from the first, people often feel more confident after tackling these difficult triggers. And these two are, in my opinion, the greatest benefits of ERP.
Inference Based Cognitive Behavioral Therapy (I-CBT)
ERP isn’t the only treatment out there now. More recently, I-CBT has been making it’s way to US clinicians., and these two treatments couldn’t be more different.
I-CBT is NOT exposure based. If you’ve watched The Wizard of Oz, you may remember the line “pay no attention to the man behind the curtain”. I like to tell clients that we’re pulling back the curtain to reveal what’s really behind the OCD, to hopefully make it less scary. Kind of like when you’re watching a scary movie, if you pause to think about how the actors are all on a set, saying their lines, and there are people who will come and edit the scene later to enhance it and put it all together - your heart may start to pound a little less even though the movie is still playing out.
So with I-CBT we will look at the things driving the OCD including the “logic” (or what seems like logic) that OCD uses, the way OCD pulls you into your imagination and into a story (similar to a movie) to increase anxiety, and the vulnerabilities or fears within yourself that OCD sometimes taps into. We work on mindfulness, imagery, exploring your true identify and values, as well as fun little homework assignments along the way.
How hard is I-CBT?
I-CBT consists of numerous modules that do involve homework. Without the homework assignments, little to no progress will be made. It’s really important to take what we’re working on in session out into your everyday where OCD is! However, the homework assignments are generally pretty brief, averaging about 15 minutes per day. Clients may feel some distress at the beginning of treatment, because we’re starting to talk about your OCD more than you are used to. There can be a lot of shame for some people with OCD and some of the themes of OCD they have, or they may just not like talking about it. But overall, it causes less distress (from what I’ve seen) after the first few sessions and less than ERP.
What’s the point of I-CBT?
The goal of I-CBT is to gain a better understanding of how OCD lies, tricks, cheats and convinces you that you should be anxious and that compulsions are necessary. This understanding is meant to help you fear OCD less, reduce how much you’re caught up in it, and instead be more present in your body, your senses and your values.
Well, there it is. The two treatment options I offer for OCD! If you have questions, or want to schedule a consultation to see if I’m a good fit, feel free to reach out!
