As therapists, we want to be able to help as many people as possible. Learning how to treat clients with obsessive-compulsive disorder (OCD) is an important step in expanding the scope and efficacy of our therapeutic efforts.
But learning how to treat OCD has yet another benefit: it helps us with other interventions, for other disorders. And that is because one of the main techniques used to treat OCD, known as exposure, involves many skills and dynamics that translate into therapy more generally.
By the end of this article, you will know the process of exposure, how it can benefit clients with OCD, and how learning it can improve our therapeutic skills more generally.
The self-reinforcing cycle
Before we can explore how exposure works, we must first understand the clinical situation presented by OCD. Once considered as a kind of anxiety disorder, OCD is now recognized as its own diagnostic category, involving the presence of distressing thoughts, called obsessions, and behaviors taken to alleviate them, called compulsions.
Although OCD can involve various levels of insight, in most cases clients consider their symptoms to be undesirable — especially, their compulsions, which can be time-consuming, exhausting, and a source of embarrassment or shame.
However, despite their adverse reaction to the compulsions, clients can actually end up inadvertently reinforcing them. As difficult and disruptive as they can be, they can provide short-term relief from the anxiety of the obsessions.
And here we find one of the more pernicious aspects about OCD: it persists as a self-reinforcing cycle, with the compulsions becoming a reinforced act, but still resulting in overall distress and reduced functioning.
Exposure-response prevention
How can we help clients to break the vicious cycle of their OCD symptoms, regain control of themselves, and improve their lives?
Luckily, a technique called exposure has been developed as part of a treatment modality known as exposure-response prevention (ERP). This treatment, which emerged from research in the behaviorist tradition in psychology, has been shown to be an effective treatment for OCD.
The first step in ERP is to conduct a thorough assessment of the nature of the client’s experience of the OCD symptoms. While every client will be different, research has shown that there are three broad categories of obsessions and compulsions:
- Obsessions about contamination, with compulsions involving decontamination
- Obsessions about being responsible for harm, with compulsions involving reassurance-seeking
- Obsessions about repugnant thoughts, with compulsions involving absolution or thought suppression
Once the therapist has gained an understanding of the client’s unique experience of OCD, they can move towards the collaborative phase. This involves creating with the client a ‘hierarchy of exposures’, ranked from least distressing to most distressing.
Next comes the actual technique of exposure: the therapist helps the client to confront specific situations or ideas during the session without resorting to the compulsion. It is expected that over time, the client will feel less compelled to perform the compulsions in response to the obsessions, which thereby become less distressing.
As with any intervention, there must be a way to assess progress over time. Within the session, the client can be prompted to give a subjective rating of their distress associated with the obsessions. After confronting the obsessions and refusing to use the compulsions, they can again rate their distress to see whether it decreases.
In addition, monitoring of symptom severity over the course of multiple sessions can be accomplished using the Yale-Brown Obsessive-Compulsive Scale.
Other techniques utilizing exposure
As we have read, ERP involves the use of exposure in an intentional and controlled setting. But exposure is also a part of other treatment modalities, and for that reason, they can also be utilized to treat OCD.
Acceptance and Commitment Therapy (ACT)
The premise of ACT is that patterns of avoidance, both in our own mental experience and our environment, prevent us from behaving in ways that reflect our values.
As a consequence, a key part of the treatment involves allowing clients with OCD to get in touch with internal experiences that are making their symptoms worse. This includes, for example, feelings that the client considers too unacceptable to work though. Instead of resorting to thought suppression, in the course of ACT, the client will be encouraged to confront these feelings and work with them.
Mindfulness-Based Cognitive Therapy
Like ACT, mindfulness-based cognitive therapy involves developing an openness to mental experiences in order to work more flexibly with them.
When clients with OCD become more accepting of distressing internal experiences, they are less likely to utilize compulsions against them. This is particularly effective for symptoms which involve the intrusion of unwanted thoughts. Mindfulness allows the client to learn about the transient nature of thoughts, allowing them to run their course rather than utilizing their compulsions to neutralize them.
How does exposure work?
So far, we’ve seen how therapies utilizing exposure — whether as part of ERP, or closely-related interventions — can be used to treat OCD. But by what mechanism do these exposure-based therapies actually work?
We can divide the benefits of this therapy into three broad categories: behavioral, cognitive, and self-conceptual.
The behavioral mechanism
From a behaviorist perspective, exposure is therapeutic because it causes a deconditioning of the compulsion. As we read, compulsions are self-reinforcing because they result in short-term relief of the distress associated with the obsessions, resulting in a negative reinforcement program whereby the compulsion is made more frequent by the removal of a negative stimulus.
When the client learns to bear the distress of the obsession without resorting to the compulsion, they learn that it isn’t necessary to rely on the compulsion to treat it. This results in the decline of the compulsion over time, and a more flexible way to cope with the obsessions.
The cognitive mechanism
From a cognitivist perspective, exposure is therapeutic because it prompts the client to challenge and reassess dysfunctional thoughts. For example, a client may believe that the presence of an unwanted thought means that they are guilty of being a bad person. By undergoing exposure thereby, they can challenge this cognition by recognizing that the thought simply comes and goes.
The self-conceptual mechanism
Finally, exposure is beneficial because it improves on our self-concept, specifically our perception of self-efficacy. When clients learn to tolerate their distress and disrupt their OCD cycles, they gain a newfound confidence in themselves and their ability to change for the better. This in itself can be therapeutic, and it can also feed into later parts of the treatment.
The bigger picture: challenge and growth
The process of using exposure with clients involves several transtheoretical components that strengthen the therapist’s skills more generally.
First, exposure highlights the importance of education and transparency in the therapeutic process. Because exposure necessarily involves a degree of discomfort, it becomes important for the therapist to educate the client about its benefits and possible harms, and to set an expectation of honesty during the course of the treatment.
Exposure is also a powerful example of the ‘therapeutic window’: the ideal amount of challenge necessary to facilitate growth. This is exactly what the therapist and client aim for while “moving up” the hierarchy of exposure, which gradually builds up the client’s strength and ability to withstand distress.
The skills involved with education, transparency, and operating within the ‘therapeutic window’ are applicable to all clients, and utilizing exposure gives the therapist a crucial opportunity to practice them.
Conclusion
Exposure is a technique for treating OCD which involves gradually and intentionally tolerating the distress of obsessions without resorting to compulsions for relief. It is utilized both as part of ERP and other forms of therapy like ACT and mindfulness-based cognitive therapy, and has been shown to be effective by empirical studies.
The therapist who incorporates exposure into their therapeutic toolbox benefits not only from the ability to treat clients with OCD, but also from practicing core processes applicable to all clients: education, transparency, and striking the balance between challenge and empathy.
