Evidence-Based Treatments for OCD - And Why They Matter

Therapy is not “one size fits all.”

Just as doctors have specialties, so do therapists. You wouldn’t go to your dentist if you had a heart murmur, you’d seek out a cardiologist.

Different diagnoses have different treatments, and it’s important to find a specialist so you are ensured effective care that will not worsen your symptoms.

What are Evidence-Based Treatments?

Evidence-based treatments are therapeutic approaches that are supported by research and proven to be most helpful for that particular mental health condition.

According to the International OCD Foundation (IOCDF), current first-line, evidence-based treatments for OCD are (1):

» Exposure with Response Prevention (ERP)

» Medication (SSRIs)

Other treatments can be incorporated into therapy for better outcomes and to offer different approaches.

For OCD, these can include (1):

» Acceptance and Commitment Therapy (ACT)

» Inference-Based Cognitive Behavioral Therapy (I-CBT)

» Metacognitive Therapy

» Mindfulness-Based Therapy

» Second-line & augmenting medications (SNRIs, etc.)

Treatments to Avoid for OCD

Again, therapy is not a "one size fits all." Every clinician is trained differently, implements modalities differently, and likely has an area they are passionate about treating above all others. When a therapist finds their niche, they typically work to expand their knowledge and expertise on the topic, making them a true specialist who knows what is best for their clients.

Different treatments were created to fit different needs, and oftentimes they are not meant to be interchangeable with one another. What works for one diagnosis might not work for another based on how the diagnosis maintains itself and how it impacts a person's thinking, behaviors, quality of life, etc.

The following approaches and interventions are supported by research as being contraindicated for OCD specific treatment, meaning they offer techniques and perspectives that go against the gold-standard approach. This list is by no means exhaustive, but gives some insight into a few treatments to avoid for OCD specific care.

It's important to note that these modalities are not harmful in and of themselves, and can be great for certain diagnoses. However, in the context of OCD specifically, these approaches have been shown to actually worsen symptoms and keep a person stuck in the cycle.

Talk Therapy (2)

» There is no research that supports talk therapy as being effective for OCD.

» In talk therapy, it’s common to engage with the thought content (i.e., what the thought is about) and try to provide insight into the client’s concerns.

» However, in OCD, engaging with thought content adds fuel to the fire and gives the brain more to worry about, rule out, etc. It can feed into mental compulsions that keep the OCD cycle going (overthinking, ruminating, analyzing situations, playing out hypotheticals, etc.).

» It’s also common to provide clients with reassurance during talk therapy, which is another compulsion that further maintains the cycle (if this wasn't so bad, I wouldn't have to be getting reassurance for it).

» There’s a heavy focus on thoughts, so therapists may not focus on changing behaviors or stepping outside of one’s comfort zone, which is crucial in OCD.

Thought Stopping (2)

» Thought stopping is an intervention where a person applies a mild, unpleasant stimulus every time they experience an unwanted thought (think snapping a rubber band on your wrist, yelling “stop!”, etc.).

» Thought stopping reinforces the idea that these thoughts are bad and have to go away, which further fuels fight-or-flight. Think about it - why would we make something go away if it wasn't bad? When we do this, the brain registers that thing as a threat and keeps an eye out for it in the future so it can protect us from harm. However, the brain can't tell the difference between real danger and perceived danger, so it will respond the same way to a rabid animal as it would an intrusive thought.

» So every time you have an intrusive thought, fight-or-flight kicks in because the brain registers the thoughts as threats, keeping you anxious.

» Those with OCD often suppress their thoughts already, so if this was effective it would be working by now.

Cognitive Restructuring (2)

» This technique is wonderful in depression, anger, and anxiety, and there are even empirically supported cognitive therapies for OCD specifically (Wilhelm, Steketee, 2006; 3).

» Non-OCD specific approaches involve finding evidence to challenge one’s fears and thoughts - is this really true, how accurate is this, let's see how likely this is to happen, etc.

» In doing this, people get swept into the thought content and try to find absolute certainty that their thought is not true or accurate. Because OCD does everything in its power to feel certain, both of these mechanisms end up reinforcing OCD long-term and act as a form of reassurance.

» Those with OCD often already recognize that their thoughts may be unreasonable or exaggerated, so this approach can cause a lot of frustration and reinforce feelings of being misunderstood or unheard.

Psychodynamic / Psychoanalytic Therapy (2)

» This modality involves speculating possible connections between one’s symptoms and their personal history/experiences, or finding hidden meanings in one’s thought processes.

» Intrusive thoughts are egodystonic, meaning they’re the opposite of who someone is, their belief system, values, etc. That's part of what makes them so distressing. Intrusive thoughts are also involuntary, so a person does not choose to have these thoughts.

»  Intrusive thoughts are not a reflection of who we are as people. So to try and make personal connections between one’s thoughts and personal experiences can create a lot of shame and guilt, or create even more self-doubt regarding one’s “true intentions,” which is what we strive to undo in OCD therapy.

Relaxation (2)

»  Techniques like deep breathing, progressive muscle relaxation, etc. are great to help us regulate and ground ourselves.

»  However, these strategies only alleviate the anxiety caused by intrusive thoughts - they do not address the intrusive thoughts themselves.

»  These can become very compulsive very quickly when a person relies on them to feel better, make anxiety go away, "this is the only way I'll get through this," etc.

»  In this context, it further fuels the idea that intrusive thoughts and anxiety are bad and need to go away, strengthening fight-or-flight that turns on every time a thought or feeling is experienced.

»  Benzodiazepines can be placed under this category as well, as they serve a similar function to make anxiety go away quickly. While they are effective in achieving their purpose, it goes against what anxiety and OCD treatment tries to teach: anxiety is uncomfortable but not dangerous, it will go away on its own, and you are capable of feeling uncomfortable without needing to rely on compulsions.

»  By letting anxiety work its way out on its own, over time the brain begins to unlearn that anxiety is a threat, despite the discomfort, and fight-or-flight stops kicking in as frequently.

In Conclusion

We as therapists are not supposed to know how to treat everything - if we did, it would significantly dilute the quality of our care. Leaning into our niche is what allows us to make such great connections with our clients, as we can provide them with hope and make them feel understood and welcomed in our care.

If you don’t know how to treat something, refer out to specialists who do. It would be a disservice to prevent our clients from receiving the best care possible just because we ~think~ we know how to help them.

Different treatments exist for a reason - they all have potential to be incredibly helpful, but only in the right contexts. It's wise and ethical to do the research and ensure we are not causing our clients any harm or indirectly worsen their suffering.

OCD (and all other diagnoses) require evidence-based treatments for true, meaningful results.

Thank you :) and stay warm! ☃️

Julia

Sources

1. https://iocdf.org/ocd-treatment-guide/

2. https://iocdf.org/expert-opinions/ineffective-and-potentially-harmful-psychological-interventions-for-obsessive-compulsive-disorder/

3. Wilhelm, S., & Steketee, G. S. (2006). Cognitive therapy for obsessive compulsive disorder: A guide for professionals. New Harbinger Publications.