What’s the deal with therapy?
Therapy is one of those things that are really hard to understand until you’ve tried it. Some people swear by it, others have sworn it off. It’s impossible to say everyone should try therapy because in most cases it gets very expensive, but if it’s accessible to you and you think you might benefit from it, therapy is worth a try. Especially if you have OCD.
There are many types of therapy, but the stuff that works for OCD is pretty specific, and not every therapist knows how to do it. Traditional counseling–the kind you see on television where the therapist works with the patient to figure out why they’re feeling bad and what might be causing it–can be very helpful for improving other aspects of your mental health, but usually won’t help with OCD symptoms. If the therapist doesn’t recognize the OCD symptoms for what they are, they can make things worse, as patient and therapist may enter a cycle of compulsions and reassurance.
Let’s use a quick example. A patient comes in and says “Every single time I’m in a doctor’s office I’m struck by all these thoughts about how I’ve definitely just caught a deadly illness but won’t know until I’m dying from it.”
The therapist says, “Let’s challenge those thoughts and see if they stand to reason. What makes you think you’ve caught a deadly illness? Are there deadly illnesses in the doctor’s office? How might you know they’re there?” Now the therapist is asking the patient to engage in the same behavior that has become problematic: trying to figure out whether or not they might’ve contracted a deadly illness.
Alternatively, the therapist might say: “People are in doctor’s offices all the time and they don’t get sick. I think you’ll be just fine.” In this case, the therapist has filled the patient’s compulsive need for reassurance.
In either case, the OCD symptoms are not going to improve. A better response to this OCD patient, even though it might sound brutal at first, is something like: “You’re absolutely right. You might have caught a deadly illness while you were in the doctor’s office.” Of course, this is fundamentally true, and it’s this kind of uncertainty in our lives that people with OCD find it so hard to tolerate.
This acknowledgement of uncertainty is central to a treatment process called Exposure and Response Prevention (ERP). ERP is a specific form of Cognitive Behavioral Therapy (CBT) that has two components: exposure and response prevention.
The basic idea of ERP is this: you expose yourself to anxiety, obsessions, and distress; then you prevent the compulsions you’d normally perform in response. Over time, you habituate to the difficult thoughts and sensations– meaning they don’t bother you anymore. You have to prevent your compulsions or this habituation cannot occur.
The exposure part means you work with your therapist to put yourself, little by little, into situations that bring on your obsessions. Whatever you’ve been avoiding because of your obsessions and the distress they cause, your therapist will help you work toward not avoiding it. This has to be carefully planned to ensure it’s effective, and so that you’re gradually building toward your goal rather than moving too quickly and getting completely overwhelmed.
Exposure can be really uncomfortable, but it’s worth it if you’re tired of feeling so anxious and afraid. Sometimes exposures are just about imagining yourself doing something, and other times they involve actually going out and putting yourself in the stressful situation.
The response prevention part is probably even more important. The repetitive responses, or compulsions, that you’ve been performing have to stop in order for you to spend less time and energy on your OCD symptoms.
A lot of people will say that it’s about learning to “just sit with your anxiety,” but this is kind of unclear. Are you really supposed to just sit there resisting your compulsions until you feel less anxious? In some cases, yes. In other cases, response prevention has to be done on the fly. For instance, if you’re exposing yourself to anxiety at work or around friends, you usually aren’t able to just quietly sit there doing nothing for an extended period of time.
Sometimes doing response prevention means finding other ways to cope with the distress, besides performing your compulsions. But you don’t want to be doing anything that decreases your anxiety, or it won’t have the opportunity to come down on its own. So you’ll have to work closely with your therapist to make a plan. The first step is to become aware of what you normally do, because sometimes we do compulsions without even knowing it. Then you can try to do something else. But response prevention, like exposure, is highly individualized– it has to be done on a case-by-case basis.
Without the response prevention part, doing exposures is just unnecessary pain and won’t help you get any better. In order to give yourself a chance to habituate to the distress– that’s when the horrible feelings you’ve been dealing with finally grow weaker– you have to avoid doing anything to get rid of that distress.
A quick example: a therapist gets a new patient who’s so afraid of hitting someone while driving that she finds herself looping back whenever she goes over any kind of bump. The therapist might decide that, for an exposure, the patient will repeat out loud while driving, “I just hit someone, I seriously hurt someone back there.” As response prevention, the patient agrees not to loop back and check at any point during her drive. If this is too much right away, she’ll agree not to loop back for five minutes, then ten minutes, then thirty minutes, and finally the whole drive.
It’s important to be honest when starting response prevention about whether or not you might be able to fully resist your compulsions. Sometimes you’ll need to start with a smaller goal, like delaying them for a minute. Then you build up to five minutes, ten minutes, and so on. If you’ve been doing a compulsion very frequently for a long time, it’s unrealistic to expect that you can suddenly stop.
While it can be exhausting and difficult, ERP is currently the most effective form of therapy for people with OCD. With a good ERP plan and a bit of motivation to stick with it, people can see drastic improvement in the amount of time they spend each day on compulsions and the way they feel about their life.
Lastly, there’s another form of therapy that can be helpful when combined with CBT and ERP. It’s called Acceptance and Commitment Therapy, or ACT, because it teaches people how to accept the way things are and the way they feel while also identifying their values and acting in line with them. Together, these two things give a person psychological flexibility, or the ability to enter a situation completely open to whatever it will bring and change your behavior as needed in response to what’s happening.
ACT can be helpful for people with OCD in a number of ways. First of all, knowing your values is very important when ERP treatment gets tough. You might ask yourself, “What in the world am I going through all this pain for?” If you know what you want in life, you know what you’re working hard for. The mindfulness techniques taught in ACT are also helpful during exposures, so you can try noticing things around you and accepting whatever feelings arise in you. Lastly, psychological flexibility can vanish when obsessive-compulsive symptoms begin: you’re not capable of openness to thoughts and feelings because there’s so much fear and anxiety built up around them.
There isn’t a single form of therapy that works for everyone, but there’s a good chance one of these might help you. It’s impossible to say everyone should try therapy, because in many cases it’s really expensive, but if it’s accessible to you and you think you might benefit from it, therapy is worth a try.