Dawn: We recently discussed OCD and its symptoms. Now let’s talk about treating it. Dean, when someone comes to you for therapy and clearly describes symptoms of OCD, how do you begin treating them? What is the first thing someone can expect to happen when they walk into a therapist’s office?
Dean: This is a good starting point for the discussion. Clients should expect the first session to involve an assessment of their symptoms and to understand how the symptoms are experienced in everyday life. At the end of that initial session, the therapist should also begin a process formally referred to as psychoeducation. This is when the therapist guides the client in understanding the specific and unique nature of their OCD, and how the treatment they expect to provide will alleviate those symptoms.
Dawn: So, if I understand this correctly, during the first session, the therapist will assess the client’s symptoms and then discuss a treatment plan that will ultimately help them go away?
Dean: Yes, and the client can ask questions.
Dawn: What is the most successful treatment for OCD, and the one clients are most likely to encounter?
Dean: The treatment with the greatest research support is called exposure with response prevention (ERP). This treatment involves specifically confronting situations that might provoke intrusive thoughts, followed by the client refraining from the rituals that alleviate those thoughts. This could be through imagining the situation or confronting it in real life. The therapist reviews the symptoms, and the client picks the symptom for the ERP exercise.
Dawn: In our last piece, you gave an example of someone being fearful of using a steak knife because they have intrusive thoughts of using it to harm a fellow diner. Their ritual involved checking to make sure no one at the table is bleeding. How would you use ERP to treat this client?
Dean: Using this example, a starting point for a client might be holding a dull butter knife while in the office. Assuming that goes well, the next step might be for the client to hold an ordinary serrated kitchen knife. For each of these increasingly challenging steps, the client feels less anxiety about holding the knife. The response prevention part would involve the avoidance of checking for blood anywhere each time they hold knives.
Dawn: How would you treat someone whose primary symptoms involve contamination fears and washing rituals, which is another symptom type you described last time?
Dean: For this symptom type, let’s assume the main contaminant is household solvents, like paint thinner. In that case, a starting point might be for the client to handle the bottle of paint thinner and then refrain from using soap and water to wash their hands. A next step might be to again handle the paint thinner bottle and then touch their face. Again, the pace is set by the client.
Dawn: And finally, you discussed orderliness and symmetry, and a specific symptom someone might have that involves arranging and rearranging the same items to get them just in the right order. How would you treat that person?
Dean: This is generally considered the easiest of all OCD symptom types to treat. It would start with the client selecting something they would view as simple to leave out of order. So, let's use the example of a client who is focused on the orderliness of a bookshelf in their home. They might start by simply taking one book and swapping its position on the shelf with one other book. The next step might involve moving two books out of order, and so on. For each step, the client would need to leave the books out of order.
Dawn: If I’m understanding this all correctly, what you are doing through the treatment for all these different symptoms is getting the client to be comfortable with the things that make them uncomfortable?
Dean: Yes, precisely.
Dawn: Thank you for explaining what ERP is. Perhaps in the future we can go over some other treatments.
Dean: My pleasure! Yes, there are a lot of other treatments out there that we should cover.
What are your thoughts about the I-CBT approach that many clinicians are now incorporating or focusing on solely as an approach to treating OCD?