Outpatient Behavior Therapy
Even when symptoms are quite severe, outpatient therapy is usually sufficient for significant symptom relief. Sometimes people have been so demoralized by years of unrelenting OCD symptoms that they think they need to be hospitalized. Hospitalization or a stay at a residential facility may or may not be a good choice. A course of outpatient therapy may be just as effective at significantly less cost.
I refer to outpatient treatment as "standard" or "regular" or "weekly" therapy when it involves meeting once or twice a week, typically for 45 to 50 minutes each session. A course of this therapy typically runs from several weeks to a few months. This is usually sufficient for most cases of OCD. In some cases, significant progress can be made in only 2-3 sessions. If you live a considerable distance from Austin, or if OCD symptoms have not responded to weekly therapy, more frequent therapy involving more hours per day or more days per week, may be more practical or more effective.
We will work together to come up with a plan and methods to help you achieve your goals. In some ways it's similar to having a personal trainer help you tone up your physical body; but here we're helping you tone up your "mental muscles" to deal with OCD. In both cases, more "face time" is usually needed at the beginning. As time goes by, we might decide to switch to having sessions every other week or less frequently; or by having shorter (25-minute) sessions.
Treatment of Choice for OCD
Experts have agreed for some time now (Expert Consensus Guidelines for the Treatment of OCD, Journal of Clinical Psychiatry, vol 58, supplement 4, 1997) that the best treatment for OCD is Cognitive-Behavioral Therapy (CBT) or Behavioral Therapy (BT). These evidence-based (supported by empirical research) approaches are the cornerstone of treatment at AustinOCD, whether therapy is weekly, intensive, or in-home, and whether or not medication is also prescribed.
CBT and BT are very similar and are treated here as synonymous. CBT includes cognitive therapy techniques, which can be very helpful when combined with BT. The specific behavioral technique most commonly used in treating OCD is called E&RP or E/RP or simply ERP, which stands for Exposure and Ritual Prevention or Exposure and Response Prevention. They mean the same thing. Exposure and Response Prevention is the original term, but since we want to prevent only compulsive responses (i.e., rituals) to obsessional thoughts, not all responses, many therapists now prefer the term Exposure and Ritual Prevention.
ERP involves two steps, exposure (to obsessional thoughts) and, not surprisingly, ritual prevention. Exposure means allowing yourself to be in situations that trigger your obsessions. Depending on your specific OCD symptoms, examples might be getting your hands slightly dirty, locking the front door, driving down a bumpy street, or being in the kitchen with a sharp knife and your child. If this is done correctly, this "exposure" would trigger obsessions about dirt or germs, whether you really locked the door or not, whether or not you hit a pedestrian, or whether you might harm your child.
Ritual prevention, in these examples, would consist of NOT washing your hands, NOT checking the lock, NOT looking in the rear-view mirror, and NOT putting the knife away or telling your child to leave the kitchen. Just as performing your compulsive rituals would reassure you and thus lower your anxiety, refraining from these behaviors will result in your anxiety going up. This can be quite unpleasant, but it is not harmful. A good therapist will work closely with you to come up with specific exposures that will make you anxious but not too anxious, so that you will be successful at resisting your compulsions. After your anxiety level goes up, it will level off, and then (this is the therapeutic part) drop. It typically goes up quickly and comes down slowly. It is important not to perform the ritual behavior to reduce your anxiety. The therapy will work if you let it.
As ERP treatment continues, you can expect your obsessive thoughts to become less frequent, less intense, and briefer. If this does not happen, you and your therapist need to do something differently. Often the problem is that your exposures are too mild or that you are not doing them often enough. Another problem is that you might be performing some other anxiety-reducing ritual behavior.
People often ask "If OCD is a biological disorder, then shouldn't it be treated with drugs?" Not necessarily. Someone who can't sleep because of psychological reasons (e.g., stress, anger, or worry) can be helped by medication, and someone who can't sleep for "biochemical" reasons (e.g., too much coffee) can be helped by psychological techniques. Interestingly, PET (positron emission tomography) scan research has shown that successful behavioral treatment of OCD results in the same kinds of changes in brain biochemistry that medication causes. (See also the section on Medication.)
Motivation to actually do the ERP is an issue that nearly everyone with OCD struggles with. It can be terrifying, or at least uncomfortable, to face the fears (or disgust, or doubts) that trigger your compulsions. It can also be quite comforting, even if the relief only lasts a moment or two, to continuing performing the compulsions -- even when you know that performing them only fuels more obsessions and leads to even more compulsions, even when performing them interferes terribly with your quality of life, and even when you have already experienced the benefits of refraining from doing compulsions. I focus on helping you stay motivated, using techniques called "Motivational Interviewing" or "Motivational Enhancement," essentially ways to keep the "pros and cons" of continuing to work on your treatment in the front of your mind.
I also often integrate an approach known as "Acceptance and Commitment Therapy" (ACT), which has much in common with ERP, in which you accept your obsessions but at the same time commit to refraining from performing compulsions, which, over time, has the effect of reducing the frequency and intensity of your obsessions and the urges to perform the your compulsions.