Top 5 Mistakes Made by Therapists Treating Obsessive-Compulsive Disorder

Common causes for OCD treatment failure

Monnica Williams, Ph.D., ABPP

Most people seeking mental health treatment are unaware of the wide variety of perspectives and theoretical orientations that factor into the treatment process. Not every therapist who claims to treat OCD actually knows how to do it. OCD treatment is a type of cognitive behavioral therapy (CBT) that requires a specialized protocol called Exposure and Ritual Prevention (ERP or EX/RP) or Cognitive Therapy. For example, although any medical doctor can take your blood pressure, only a few can do heart surgery. Likewise, just about any therapist can help someone who is feeling a little blue, but only a few can effectively treat OCD.

• Providing Too Much Reassurance
• Failing to Identify the Core Fear
• Exploring the Roots of the OCD
• Indulging Over-explaining
• Missing Covert Rituals

How can you tell the good therapists from the bad ones? The following guidelines are the most common mistakes made by therapists in the treatment of OCD. If your therapist is making any of these mistakes, you may consider finding someone with more experience and better training.

Providing Too Much Reassurance

People with OCD often feel the need to be constantly reassured in regards to things that make them anxious. Most therapists have been trained to provide reassurance to clients as needed, and certainly a small amount of reassurance is appropriate at times. However, compulsive demands for reassurance are an OCD ritual that must be stopped if the client is to make progress. The therapist should explain to the client that requests for reassurance will not be heeded. Furthermore, friends and family should not be used as a source of reassurance by the client. Inexperienced therapists may unwittingly spend whole sessions providing reassurance to their OCD clients. Therapists must teach their clients that reassurance-seeking should be avoided at all costs.

Failing to Identify the Core Fear

Most people with OCD have many different compulsions, and for treatment to be effective, the person with OCD must learn how to stop their compulsions. Each compulsion can be individually addressed in the treatment process. However, it is very important to determine what the person with OCD is most afraid of, because chances are all of the compulsions spring out of a single core fear. If a therapist addresses the compulsion without getting to the core fear, it is just like cutting the top off of a weed. A new compulsion wiil spring up, leaving the core fear (and the OCD) intact.

Exploring the Roots of the OCD

Searching for the core fear should not be confused with digging for the "root" of the problem. People with OCD often believe that their disorder was triggered by a particular event. They may believe if they can just figure out what caused it, then maybe they can fix it. However, OCD is caused by a combination of genetics, environment, and stressors. So there is no cure to be found be ruminating about the origins of the disorder. Unfortunately these types of musings fall very neatly in line with a type of therapy called psychoanalysis or psychodynamic therapy, also called "talk therapy." This treatment includes understanding a person's childhood as a way to indirectly cure emotional problems. This approach simply does not work for OCD. CBT is the only proven treatment, and there are over 100 research studies that bear this out.

Indulging Over-explaining

People with OCD often believe that the therapist must understand every facet of their experience in order to properly diagnose and treat the OCD. As a result the person with OCD may spend much time talking about childhood issues, experiences during adolescence, observations about their own thoughts processes and the world, and theories about how their OCD might be overcome. It is quite easy for a lazy therapist to sit back and let the OCD patient ramble, and then take their money at the end of the session. However, this tendency to over-explain is actually a compulsion that should not be entertained by the therapist. A good OCD therapist will help the client understand this and gently interrupt as needed in order to move the therapy forward.

Missing Covert Rituals

Compulsions can be overt rituals, like washing over and over, or they can be covert, such as repetition of silent prayers. Mental rituals are a type of covert compulsion that takes place completely in a person's mind. Mental rituals include things like mentally reviewing events, self-reassurance, mental undoing, silent counting, etc. These can also be somatic compulsions, like mentally monitoring vital signs or checking for signs of arousal. Sometimes people with only covert compulsions believe they do not have any rituals (sometimes called "pure obsessionals" or "pure-o"). Therapists must address these covert compulsions in treatment because covert rituals maintain the disorder in just the same way as overt compulsions. Failure to address mental compulsions will result in treatment failure.

Source

Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Ritual Prevention (Ex/RP) for OCD. Journal of Obsessive-Compulsive & Related Disorders, 1(4), 251-257. doi: 10.1016/j.jocrd.2012.05.002