There you are, finding your feet in early OCD recovery or bobbing along pretty nicely for some considerable time, when all of a sudden, this thought: “But what if you relapse and go back to square one?”.
Hang on, is this an OCD thought or a real possibility? And the answer is, it's both! OCD is after all, episodic, stress-induced and very, very creative! Somewhat comfortingly, the chance of relapse is reduced with effective coping skills, used consistently. Seriously, skills are where it’s at! One study identified a much higher relapse rate in medication-only treatment (90% once medication is discontinued) versus a relapse rate of 20% for clients undergoing CBT-based treatment (1).
So, after observing that this is an OCD thought (skills practice!), what information can people with OCD keep in reserve to dramatically reduce the chances? In our experience, there are some risk factors that can be clearly identified, thereby enabling people to prepare or respond to some inevitabilities that may be hurled at them by life and everything in between. In our professional experience, we list these risk factors as follows:
Coming off medication too quickly: for our clients who are on medication, the urge to reduce their medication quickly follows a successful therapy experience. This fighting talk is all very well, but depending upon the timeframe involved, can seriously derail recovery if it’s premature. The drivers to become medication-free are varied but include, ‘I don’t want to rely on medication in the long term!’ and ‘I’m doing so well I can cope without medication.’ Naturally there is a conversation to be had with their prescribing physician but, from a psychotherapy point of view, keeping medication stable for at least 6 months to practice and reinforce new skills is advised. On the whole, people with OCD in the UK tend to be more medication averse, so early reduction and associated withdrawal can be a backwards move. As therapists, we often emphasize that medication isn’t failure, it’s a means of additional support (look out for our 'coming off meds too early' blog soon). With commitment & work, a medication-free life with OCD may well be possible. We are also keeping an eye on developments regarding the link between microbiome and OCD (more on that later).
Major life events: there’s no pause button on life, sadly, even when you are recovering from OCD. From small inconveniences to huge shockers, major change or life events can surprise any of us. Sometimes there is advance warning and the chance of proaction and sometimes there just isn't, and you have no choice but to react. As therapists, being proactive can involve forewarning clients and so we list the likely culprits which include events such as a new relationship or break up, a bereavement, financial difficulties, illness, a new baby, retirement or redundancy, starting university/college or moving house, etc. If these happen, with or without warning, there are steps to take which include our solution-focused support groups or scheduling some sessions.
Hormonal shifts: the link between post and pre-partum OCD isn’t clearly defined as yet but there is no doubt that pregnancy can trigger OCD or exacerbate existing symptoms. Some clients are more vulnerable to this than others and we have no idea of the risk factors since there is little to no research. Oh wait..there are some case studies circa 1999…I rest my case! For our female clients, their OCD can vary with their menstrual cycle and hence, a regular pattern may exist. With the latter, there is an opportunity to be proactive, but in the case of pregnancy, there can be almost zero indication regarding onset or exacerbation. They almost certainly won’t have been warned by their doctor, maternity unit or midwife about pre or post OCD symptoms and if they do present, OCD can be misdiagnosed as depression. The same may be said for female clients going through menopause although this is discussed/studied even less than pregnancy-related OCD. For our male clients (and some female), 11 years continues to be a seminal age with regard to initial OCD onset and it is thought that hormonal changes occurring in young teenagers play a role. Again, there is little to no research to shed any light.
Not focusing upon ERP (Exposure Response Prevention): the dreaded ERP! Behaviour work or ERP is the most feared yet often the fastest route to getting back on track if you have OCD. It has mythical status, given its power to kickstart recovery but also being super uncomfortable at the same time. Having experienced ERP from both sides, I’ve felt that pain! Interestingly, it can be the most difficult part of our role as OCD therapists and it takes experience and tenacity to do ERP, day in and day out with clients. I say to clients that there is good and bad news about ERP. The good news: it is powerful and fast (in psychotherapy terms). The bad news: it is uncomfortable and with good reason. So it’s no surprise that clients can drop ERP like a hot contaminated potato at the first opportunity. And the excuses may seem rational at the time. When they are feeling good: “I’m doing fine without it and can take a break”. Or if feeling bad: “I just don’t need that ERP stress right now”. Reducing or dropping ERP before reaching therapy goals can well be the precursor to a relapse. It really is like going to the gym - stop tensing that discomfort muscle and it starts to break down. Each client is unique, but in general, we recommend an initial intense 6 week period of ERP with a phased program extending over 6 months to a year.
Not focusing on cognitive work: since behaviour work (ERP) is the ‘B’ in CBT, the ‘C’ stands for cognitive work - a crucial part of an OCD program. ERP may seen the sexier, albeit more difficult, part of the therapy so cognitive work is often under emphasised by therapists. The same may be true for clients who aren’t aware of its value and may find it tedious. Since cognitive work is designed to bring about the more subtle but no less crucial philosophical and cognitive change in clients, it underpins the ERP and provides resilience in the face of future episodes and new obsessions. Moreover, psychological flexibility really is the cornerstone of longer, more meaningful change. We recommend cognitive work daily for clients in treatment and then a phased program of cognitive work supported by some reading and exercises in the longer term.
If you have OCD and the word ‘relapse’ sounds horrific, focusing on the solution and not the problem is the way forward. Fortunately the chance of relapsing is greatly reduced following effective & specialist CBT treatment. Any viable treatment programme should focus on relapse prevention and provide guidance towards an accessible support network, should you need it. Most importantly, try to view any relapse as an opportunity to get even stronger.