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Therapy for Obsessive Compulsive Disorder

Updated: Mar 3, 2023

Overcoming Obsessive Compulsive Disorder (OCD) is a challenging task for many sufferers. Individuals diagnosed with OCD struggle with obsessions, compulsions or both. Obsessions are characterized by intrusive unwanted thoughts, images or urges which causes the sufferer anxiety while compulsions involve behaviours or mental acts that a sufferer feels compelled to do in order to neutralize an obsession. Often, the time that a sufferer spends on the obsessions or compulsions is significant and may begin to interfere with other areas of functioning like school, work, leisure or important relationships.

Sufferers may seek out therapy before or after a diagnosis has been made. The key feature that drives OCD sufferers into therapy is the degree to which their symptoms begin interfering with an activity or goal they would like to achieve, but feel may be impossible.

Often, sufferers experience a large gap between their private and public lives. This disparity is emotionally taxing and can further contribute to feelings of anxiety that can make every day tasks a challenge. Sometimes, the connection between an obsession and a compulsion may appear reasonable. For instance, if I leave home for the weekend, I may check that I locked my door before leaving. An individual with OCD will struggle to limit their checking behaviour to occasional circumstances and they may have other compulsions they employ which take up a lot of time and energy. Alternatively, there may be no apparent connection between an obsession and a compulsion. For example, a sufferer may try to neutralize anxiety that arises from an obsessive image of a billboard by turning in a circle three times. The connection between the obsession and the compulsion in this example is less obvious and certainly appears less reasonable. Whether the compulsion appears reasonable or not, the sufferer spends significant time each day engaged in their OCD behaviour. In severe cases a sufferer will stop functioning at school, work or in their personal relationships.

Approximately 2-3 percent of the population has OCD. However, based on my experience it is likely that this number is under-reported since many OCD sufferers don’t seek treatment or have been misdiagnosed. The most common OCD categories include (1) contamination, (2) checking, (3) order, symmetry, counting and movement, and (4) primary mental obsessions. Although these issues are most common, the specific obsessions and compulsions within each category are limitless which is why it is important to begin with a thorough assessment. This also means that each treatment plan is unique.

Education itself does not help sufferers resolve this problem. In fact, most sufferers report that their obsessions are irrational. That does not change the intensity of those obsessions or the compulsions that temporarily reduce their anxiety. OCD arises from a combination of neurobiology and learning. A common approach to treatment involves medical intervention to address neurobiological factors and therapy to address the learned component of OCD. Your therapist can discuss treatment options with you and, with your consent, communicate with your doctor if necessary.

Loved ones often become affected by the sufferers’ OCD. Family and friends play an important role in convincing a sufferer to seek out treatment because they are in a position to observe the negative impact of OCD symptoms. For instance, if a sufferer does not let their parent leave home without checking to ensure that all of the taps in the home are shut off, the fridge is closed and the oven knobs are off then family visits may become fraught with tension.

At first glance, many obsessions and compulsions seem reasonable. If I happen to drive too quickly over a speed bump, I may think “what did I hit?!” and it would be reasonable to even check my car to see if I damaged my tires or undercarriage. A specific type of OCD involves “hit-and-run” scenarios where a sufferer is obsessed about the possibility of hitting, or having hit, a pedestrian and they engage in multiple checking behaviours (compulsions) to reduce the anxiety related to those obsessions. For instance, a hit-and-run sufferer might always drive during the day and avoid night-time driving. They may avoid driving down a busy road, or avoid rush hour, to reduce the likelihood that they will hit someone. They may drive around the block multiple times just to make sure that they didn’t hit a person. Even after they arrive home, they may check their vehicle again and again to make sure there are no dents, or blood, on the vehicle that would indicate they hit someone. They may take the compulsion further by turning on the news to determine if there have been any hit-and-run reports in their community that might tell them that they are the responsible party. No degree of compulsive checking will ever satisfy an obsession completely. It is the uncertainty that cannot be accepted and accepting uncertainty is a normal part of life. The difference between a sufferer and non-sufferer is that a non-sufferer may have one of the thoughts listed above but be able to dismiss it and move on. Sufferers cannot. If this sounds like torture, it is. However, sufferers can break free from the constant strain of obsessions and compulsions with effective treatment.

Therapy for OCD involves a specific evidence-based treatment called Exposure Plus Response Prevention (ERP); my work is guided by the ERP model outlined by Jonathon Grayson (2008). There is no other type of therapy that has been proven to be as effective at overcoming OCD. Currently, there is only one way and therapy is not easy. However, most sufferers are living a life that is already challenging. Since the fears associated with obsessions are often catastrophic it may seem counter-intuitive to face them directly through ERP. That is why therapy requires a commitment to one important goal before proceeding. That goal is to answer the following treatment question with a “yes”: are you ready to live a life of uncertainty? If the answer is yes, then you have accepted the challenge of ERP therapy and you may begin your progress toward recovery. If the answer is “no” then you are not yet ready to proceed and your therapist will work with you on comparing your current life to the future life you want, and that you deserve, to help you develop motivation to answer the question with a “yes”. Therapy for OCD requires courage. Courage is not an emotion. Courage is what you do when you are afraid.

In general, ERP therapy for OCD involves the following steps:

1. Education about OCD

2. Completion of a detailed OCD assessment

3. Development of personal recovery goals

4. Creation of your ERP program

5. Implementation of, and adherence to, your ERP program

6. Monitoring progress and challenges

7. Re-assessment and development of a relapse prevention plan

Since evidence is required to determine the effectiveness of your ERP plan, your therapist may give you a duo-tang to monitor each step along the way. You should have a clear understanding of each structured step in order to proceed with the necessary ERP at home between sessions. It may feel overwhelming to seek therapy for OCD. However, the time that sufferers devote to treatment is often much less time than they already devote to their symptoms. If you have any questions about OCD treatment, please contact me for more information. You are also welcome to set up an initial consultation to discuss therapeutic options and your own individualized treatment plan.

David Small

R. Psych.


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