Daniel Carlat, MD. Vice Chair, Community and Public Sector Psychiatry, Tufts University School of Medicine. Publisher, Carlat Publishing.
Dr. Carlat has no financial relationships with companies related to this material.
After reading this article, you should be able to:
1. Understand the recommended first-line treatment approach for adults with OCD.
2. Recognize the fundamental elements of ERP for OCD and distinguish them from alternative therapeutic approaches.
3. Identify the most suitable type of exposure therapy for clients with obsessive thoughts without rituals, considering factors that may limit the use of in vivo exposure.
Although obsessive-compulsive disorder (OCD) was once considered highly treatment-resistant, randomized controlled trial findings now support the efficacy of several treatments, including cognitive behavioral therapy (CBT), pharmacotherapy with serotonin reuptake inhibitors (SRIs), and combined treatment. According to the National Institute for Health and Care Excellence (NICE) guidelines (last updated in 2019, see https://www.nice.org.uk/guidance/cg31) CBT that includes exposure and response prevention (ERP) is considered the psychological treatment of choice for OCD.
The Basics of Exposure and Response Prevention
So, what is ERP? It's a type of CBT that gradually exposes clients to situations or objects that trigger obsessional fears and urges to ritualize, followed by instructions to abstain from compulsive behaviors. The primary components of ERP include in vivo exposure, imaginal exposure, ritual prevention, processing, and, when feasible, home visits. Through this approach, clients learn several important points, including:
To effectively implement ERP, I'd recommend the following seven steps:
During exposures, make sure to steer the client away from safety behaviors or subtle avoidance techniques, like thinking about something else, chatting with someone, or only touching the toilet seat with one finger. These behaviors can prevent them from fully experiencing distress and make it harder to conquer fears in the long run. Also, teach family members not to enable “OCD by proxy” by answering questions about contamination or washing the client’s clothes for them, as this could reinforce OCD-related distress.
The specific form of exposure therapy can vary depending on the symptom and triggering situations. For clients with intrusive thoughts triggered by certain events or objects, in vivo exposure usually works well. However, some people may have obsessive thoughts without rituals, and the target behaviors are the thoughts themselves. In these cases, consider using imaginal exposure, audio loop recordings of the bad thought, or videos with triggering themes. These techniques can be helpful when it's difficult or impossible to use in vivo exposure (e.g., worrying about harming others or satanic possession).
Further Training in ERP
Some therapists may be able to use some of the tips in this article to begin to integrate ERP principles into their therapy sessions. However, in order to become truly proficient in the technique, you will need more training. Here are some good resources that you should find helpful.
CBT, particularly when it includes ERP, offers an easy-to-understand approach for clients. It's a versatile method that can be applied to a wide range of OCD symptoms.
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