Psychotherapy can seem nebulous at the best of times but I have been reminded this week that we, as professionals, have to do our utmost to ensure it isn’t. Historically we can now, more than ever before, be precise about what is effective for OCD and what isn’t. Drawing on the considerable research to prove CBT is an effective therapy for OCD and BDD, the UK NICE (National Institute for Health and Clinical Excellence) guidelines clearly and unambiguously state:
188.8.131.52 When adults with OCD request forms of psychological therapy other than cognitive and/or behavioural therapies as a specific treatment for OCD (such as psychoanalysis, transactional analysis, hypnosis, marital/couple therapy) they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments.
In other words, as therapists, we have a duty to inform clients that CBT is, as yet, the only scientifically proven intervention for OCD. Even across the Atlantic, the Practice Guidelines for the US National Institute of Mental Health, states that:
‘There are no controlled studies that demonstrate effectiveness of dynamic psychotherapy or psychoanalysis in dealing with the core symptoms of OCD.’
Yet the number of people with OCD considering or undergoing therapy other than CBT is considerable. I am of the opinion that 3rd generation acceptance-based therapies such as ACT (Acceptance Commitment Therapy) and mindfulness are an exception. They very much appear to have application and efficacy for OCD but the reason they aren’t mentioned in the guidelines is because they are somewhat recent, albeit in an applied sense. Mindfulness and relational frame theory (upon which ACT is based) are not recent, but their application as psychotherapeutic interventions has developed within the last 10 years. They haven’t had time to achieve scientific gravitas whereas psychoanalysis has been around for a century or more and hasn’t yet gained evidential support as a treatment for OCD or BDD.
So what is the problem? Why are OCD clients not receiving CBT? Are therapists not telling clients that CBT is the scientific standard? Are therapists not aware themselves? Unlikely, since in the UK and US we cannot fail to be aware of NICE and NIMH guidelines. Are therapists relying on the fact that clients aren’t clear what treatment approach they are following or furthermore, what CBT should look like? So in an effort to set the record straight, what does CBT look like?
1. CBT for OCD should be a balanced mix of cognitive and behavioural work
2. Cognitive work is focused on cognitions or thought patterns which usually follow a model loosely based on an ABC framework. Initially the therapist will identify the triggers (obsessions) of your OCD, represented by ‘A’. These will then be used to formulate a belief represented by ‘B’ and identify your ‘C’s’ which are the consequences of holding your belief
B. The C’s will consist of your OCD behaviours (compulsions), emotions and additional thoughts that arise from that trigger. The goal will be to adapt these ‘irrational’ beliefs to rational ones that are more flexible and realistic. This is the basis of the cognitive work and might not be as formal as this, depending upon the therapist’s style
3. Behaviour (or exposure) work should be exercises or tasks based around your triggers, A’s, that generate a challenging but not overwhelming level of anxiety whilst at the same time showing you ways in which to tolerate that anxiety leading to a gradual desensitisation to that trigger. This is sometimes known as ERP or Exposure & Response Prevention since it exposes you to triggers and anxiety and gradually helps you to stop responding emotionally or behaviourally. Another term is de-sensitisation. These tasks could be written, visual, physical, mental, imagery-based, etc. but they will have a common thread of generating anxiety. Much like Marmite, I'm not sure a client can be in the dark about behaviour work, i.e., if you’ve tried it, you’ll know!
4. There will be an emphasis upon homework. A characteristic of CBT will be the work you do between sessions to develop a self-help mindset and encourage you to be your own therapist. If the therapist doesn’t set homework this would be highly unusual.
5. CBT is skills-based. There should be a sense that you are learning skills to cope and use outside the session. Ideally you will be making notes during the session of homework plus techniques or new skills you will be trying to help you not respond to your thoughts and emotions.
6. CBT for OCD does not emphasize your history or childhood. Although some discussion of causation may be interesting, CBT will move quickly to your present environment and coping skills (or lack of them). Unlike psychoanalysis, CBT is directed towards the solution and not the problem.
7. CBT is 'directive' in style whereas psychoanalysis is 'non-directive'. In non-directive therapy, the client takes the lead and growth and outcome is expected to occur as a result of the client analysing, talking through or processing their issues. In directive therapy, the therapist takes the lead to teach specific skills, assign tasks and set agendas. My preferred form of CBT, REBT (rational emotive behaviour therapy)' is ‘active-directive’, in other words, the therapist directs the client to take action to manage their OCD. In all styles, the client should set their own goals. It isn’t difficult to see why a non-directive approach is not conducive to managing OCD - what happens when someone with OCD analyses, processes and discusses their OCD concerns? Enough said.
It seems widely accepted that the future of psychotherapy will be empirically based and increasingly integrative and will combine approaches for best outcomes. However, this also implies that those very approaches need scientific grounding. I fully foresee a time when the recommended treatment options for OCD will include ACT and mindfulness alongside CBT or REBT as I do in our protocol (hopefully a little ahead of our time...) but until then, CBT for OCD please. At the very least………….