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Treatment options for OCD: A psychotherapist’s perspective By: Kristy Cobillas, M.Ed, LPC

Considered the “gold standard” treatment for Obsessive Compulsive Disorder when combined with psychopharmaceuticals, ERP provides relief of symptoms in 80% of OCD sufferers undergoing treatment. Not unlike exposure to phobias, ERP will reduce and possibly extinguish OCD symptoms by systematic and repetitive exposure to triggers.   While this outcome is good news, ERP has its downside, as this treatment modality provokes anxiety and can feel physically and emotionally intolerable. 

OCD triggers are often framed through the question of “what if?”: “What if I have cancer? What if I am damned to hell? What if I am a sexual deviant? What if my husband is cheating on me?” 

ERP will reduce and possibly extinguish OCD symptoms by systematic and repetitive exposure to triggers. 

With OCD, there is no real evidence in the here and now that any of these ideas are true. In fact, the client knows these thoughts are irrational. Regardless of the lack of logical thinking, the client engages in compulsions to make sure that the feared “what if” won’t happen.  For instance, someone with the thought, “What if I have cancer?” might spend hours researching symptoms, go to multiple doctors, and/or repeatedly check their body for signs of cancer.  

ERP begins by creating a hierarchy of these anxiety-provoking triggers. Then, through imaginal or in vivo exposure, the client immerses themself in the feared idea or behavior and resists the urge to compulse.

After repeated and consistent resistance to compulsion, the client finds that habituation takes place, and anxiety reduces; the client learns to live with the “same uncertainty” that non-OCD people live with, and hyper-alertness fades.  

Thanks to the hard work of Frederick Ardema, Ph.D., and Kieron O’Connor, Ph.D., an alternative treatment for OCD has been formulated. As an accepted evidence-based practice for the past 20 years, I-CBT has overcome some of the limitations of standard treatment and provides a viable alternative/addition to ERP.  

Ardema, et al, developed an inference-based conceptualization for the treatment of OCD. An inference is a conclusion that is made based on logic and reasoning.  Those who have OCD suffer because their reasoning process has been hijacked, and they become “inferentially confused.”  

For instance, one might think, “I forgot about the time I got stung by a bee at the zoo.  My sister reminded me of the story and I still can’t remember it.  So, since I can’t remember that incident, it is also possible that I molested a child and don’t remember that, either.”

I-CBT focuses on the client’s feared self, inferential confusion, and overvalued ideation to address such false reasoning. 

I-CBT could be considered, in part, a type of narrative therapy. Through I-CBT, the client slows down the thinking process, dissects the sequence of their thoughts, explores their logic and reasoning, and identifies inferential confusion, in order to reveal what the OCD is saying. Through this process, the hijacked thinking becomes blatantly obvious.  

The client then uses sense data (data that is achieved through the five senses, common sense, memory bank, what others have said about them, etc.) to create a portrait of their real self.  Armed with this data-rich self-portrait, the client then creates an alternative narrative to what the OCD is screaming at them.  

This process creates a side-by-side comparison, which can be thought of as two separate worlds.  When triggered, the client can choose either to return to their sense-based schema or travel over the bridge to the land of endless imagined possibilities.  

When triggered, the client can choose either to return to their sense-based schema or travel over the bridge to the land of endless imagined possibilities.

Bottom-Up Vs Top-Down

ERP is considered a “bottom-up” technique, which means it is not cognitive but is based on emotional and physiological information.  By repeated exposure to the feared situation, the brain forms new neural pathways, and the original stimulus no longer sets off emotional and bodily alarms.   

With ERP, the client is repeatedly exposed to the distressing stimulus and habituates to it until it has little to no effect on them.  While exposure is taking place, the body and brain are setting off alarms that need to be ignored, and the sufferer learns to  “accept the uncertainty” of the “feared doubt.” The process can be compared to desensitizing someone to their fear of heights. 

In contrast, I-CBT is considered a “top-down” technique.  Through systematic exploration, OCD’s thinking errors are exposed. With I-CBT, the client then makes a choice between staying in what is true according to sense information (see, touch, taste, hear, and smell) and  “crossing over” into the land of endless imagined possibilities (where OCD likes to take you).

Both techniques are acceptable options for the treatment of OCD; however, if they are used together, the therapist has to make sure that the client doesn’t compulsively create OCD and alternative narratives.  

When the mind is quiet, they can use I-CBT to see where their thinking went awry.

In other words, if a client is in the middle of an OCD onslaught, they must first use ERP to slow the cycle, and then, when the mind is quiet, they can use I-CBT to see where their thinking went awry.  The therapist must carefully help the client manage the process because if I-CBT is used to make the uncomfortable feeling from the OCD flare go away, the technique would be a compulsion and actually reinforce the OCD loop. The complementary therapies, therefore, must be employed with skill and sensitivity to the client’s processes.

As a lived-experience therapist, I can definitely see the value in both of these evidence-based practices as each offers benefits for the OCD sufferer.  It has been my experience that the practice of ERP prevents the client from diving deep down the rabbit hole into the land of “what if” and that I-CBT reshapes the thinking processes, resulting in the client trusting what they know to be true about themselves and their circumstances.  

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