It takes a lot of guts for patients to make the decision to break up with obsessive-compulsive disorder. They have been living many years with tormenting thoughts and fears, dictating how they go about their days.

When your patient is on board with breaking up with their OCD, you want to encourage them not to DRIFT away from OCD, but rather to look forward to how they want to live in the future, and to break up with OCD.

Exposure and response prevention (ERP) is the gold standard for treating OCD. [1] The procedure is simple, but the task of breaking up is always emotionally difficult. Let’s examine the DRIFT treatment barriers (my made-up acronym) so we can support our patients in officially kissing OCD goodbye.

OCD is a complicated disorder that includes intrusive thoughts, images, and urges that cause people to feel extreme distress, anxiety, disgust, and/or fear. [2] Many recognize that these thoughts are illogical. In order to cope with the distress, people generally use compulsions to reduce the experienced distress.

These take the form of rituals, reassurance questions, neutralization, and avoidance behaviors. [2] Over time, compulsions become tightly linked to the initial fear, and behaviors are performed nearly instantaneously. Colloquially, some patients have described this to me as a “habit” or “quirk.”

During their intakes, patients often present as self-conscious about their thoughts and are worried that they might be judged for having thoughts about sexuality, violence, scrupulosity, contamination, and symmetry. Frequently, they identify these irrational thoughts and do not know how to deal with these fears. Wouldn’t you be scared, too?

These thoughts are normal, and everyone has scary thoughts. Yet the difference is the terrible consequence that may occur as a result of these frightening thoughts. Let’s applaud the courage it takes to discuss these fearful thoughts.

During the process of exposure therapy, treatment barriers can arise in a similar manner to late-night ex-texts: stealthily and uninvited. Let’s take a closer look at navigating these roadblocks, using DRIFT as a guide.

D: Difficulty Understanding Treatment Rationale

Exposure and response prevention (ERP) is a demanding treatment, encouraging a lifestyle change encompassing uncertainty. Asking patients to face their biggest fears directly – and then some – is quite the challenge!

Sometimes patients do not understand why exposures are important, which makes it difficult to believe in the treatment. Dedicating time in session to discuss the treatment theory and examples of how treatment works can help patients overcome the first obstacle of ending their relationship with OCD.

Throughout the psychoeducation component, checking for understanding can be done in multiple ways. Patients often feel relief when they explain their own OCD cycle, and when they can identify how their exposure items can help them live life more fully, their motivation for treatment often increases.

When patients understand how OCD can be like a sneaky ex, finding ways to cause subtle avoidance behaviors in daily life, they are more likely to catch themselves in the moment and develop a further understanding of how OCD functions for them.

R: Readiness

We try to meet patients where they are and help them to overcome their struggles. With OCD, people often believe a terrible outcome could occur if they disobey OCD. Evaluating treatment readiness is helpful to determine when the patient wants to get better.

For instance, you can ask patients how willing they are to do an exposure and how much they believe the exposure will help them break up with OCD. As with break-ups, it can be easy to fluctuate between willing to fully let go and running back into their ex’s open arms.

Motivational interviewing helps patients overcome ambivalence about readiness to engage in treatment. [3] Consider asking questions to highlight what OCD has stolen from the joys of living. Emphasizing the patient’s desire and need for change is crucial for resolving the fluctuating willingness needed to create sustained behavior change. When patients articulate their personal motivation, values, and life goals, they are ready to break up with OCD.

I: Insight

Another element of behavior change for OCD is assessing the patient’s level of insight. At times, patients may believe their OCD fears are logical and their reasons for engaging in compulsions throughout the day are necessary to keep themselves and their loved ones safe.

When this occurs, patients are fused with their thoughts, and it can be more difficult to break this pattern. It can be helpful to consider thought experiments: for instance, for someone who fears committing a hit-and-run, you can ask them to use Jedi mind tricks to crash cars on the highway, and to ask God to strike lightning in the therapy office. These types of experiences can help the patient develop the view that their fears may not be as accurate as they predicted.

Level of insight can also fluctuate as to whether or not intrusive fears are ego-syntonic or ego-dystonic. Ego-syntonic fears are behaviors and values that align with obsessions and personal beliefs, and ego-dystonic fears differ from one’s personal beliefs. Generally, patients with good insight have ego-dystonic thoughts, in which they know their thoughts are irrational.

At times, however, obsessions can become ego-syntonic, in which someone emotionally connects with their thoughts and believes OCD thoughts can be good or protective. For instance, think of a patient with “just right” OCD who feels strong urges to straighten and tidy their environment.

This person may also hold a strong personal value of organization and neatness and prefer to live in this manner. It can be difficult to practice “being messy” exposures when someone does not believe in the benefit of tolerating the discomfort caused by messiness. Helping patients recognize the value of their exposure and identifying how OCD has stolen precious time can increase motivation for treatment.

Ego-syntonic fears have also been observed in patients with scrupulosity. For instance, someone’s faith may be a core value, and they pray in a certain way as prescribed by their religious leader. OCD causes people to fear the unlikeliest of scenarios. As a result, values such as prayer can become a fearful experience due to the anticipated consequences of not living according to stringent rules set by OCD. Collaborating with religious leaders can be helpful to obtain permission to practice exposures to intrusive thoughts when someone has a lower level of insight.

F: Family Accommodation

Treating OCD and working within the family system is one of the most challenging aspects of recovery. Loving parents and partners of those with OCD often are sucked into the OCD cycle. When OCD is triggered, people are often in a significant state of distress, where a seemingly small act of reassurance, checking behavior, or avoidance can make all of the discomfort disappear. Families can develop patterns, which begin subtly, to accommodate OCD. Over time, these patterns evolve into rituals where families are supporting OCD rather than their loved ones.

After providing psychoeducation to family members about OCD, families are often on board to help their loved ones break up with OCD. Creating family contracts is a useful tool to set boundaries and to set the stage for empathic ways to kiss OCD goodbye. [4] Family contracts can be made in session with a therapist or at home.

These work by asking families to generate predictable situations that they have accommodated in the past and to look at alternative solutions. An open and honest discussion can help the patient and family identify both individual and family goals in the moment. This can include the family agreeing to response prevention (e.g., the family not engaging in rituals) and the patient redirecting their attention to the immediate goal at hand.

T: Therapist Beliefs

Before any major life decision — like a break-up — it is especially important to do a reality check. As psychologists, we occasionally get in our own ways. Research suggests that therapists underuse and misuse exposure due to concerns about “the treatment’s safety, tolerability, and ethicality prior to conducting an exposure session.” [5]

Therapists who hold negative beliefs about exposures, or who do not fully believe in the benefits of this treatment, can unintentionally send subtle messages that exposure is unhelpful to their patients. This can, unfortunately, lead to less effective treatment. [5]

In clinical practice, these messages can be sent by developing a hierarchy when encouraging patients to start at the easiest level, when the patient is motivated to start higher on their list. In fact, using a SUDs (subjective units of distress) scale can dissuade patients from trying the most challenging exposure, teaching patients that they cannot handle their fears.

It is best to use your clinical judgment to determine the helpfulness of using a SUDs scale, depending on factors such as the patient’s ability to communicate distress and their understanding of treatment. It is especially important to begin exposures at the most challenging levels that a patient is willing to try.  

In reality, approaching the most challenging fears increases patients’ beliefs of self-efficacy. As a therapist, please check yourself to make sure you are sending “you can do this” vibes to your patient and to ensure you are using exposure in the most effective manner possible.

In the end, once your client is ready to for OCD treatment, make sure you encourage a clean break-up rather than a slow DRIFT away from OCD.

References

[1] How is OCD Treated? (n.d.). Retrieved from https://iocdf.org/about-ocd/ocd-treatment/

[2] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

[3] Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford press.

[4] Landsman, K. J., Rupertus, K. M., & Pedrick, C. (2006). Loving someone with OCD: help for you and your family. Oakland, CA: New Harbinger Publications.

[5] Farrell, N. R., Deacon, B. J., Kemp, J. J., Dixon, L. J., & Sy, J. T. (2013). Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation. Journal of Anxiety Disorders27(8), 763-771.

Melissa Fasteau, PsyD

Melissa Fasteau, PsyD, is a clinical psychologist at the Houston OCD Program. She specializes in treating OCD and anxiety disorders at residential, intensive outpatient, and outpatient levels of care. Dr. Fasteau is also a certified Bergen 4-Day Treatment therapist. B4DT is an OCD treatment protocol from Norway which is being studied in the USA for the first time. Dr. Fasteau is the secretary of OCD Texas and is passionate about making evidence-based treatment and education available for all.
Melissa Fasteau, PsyD

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