Does therapy work?
You know how it looks: someone sitting on a couch, a therapist starting at them from across the room and scribbling notes on their clipboard, a box of tissues between them. The therapist keeps asking vague questions about their client’s past, until suddenly the client experiences a breakthrough and reaches for the tissues.
This is the TV version of therapy, and although it’s not completely wrong, therapy is hard to understand until you’ve tried it. There are many types of therapy, but the stuff that works for OCD usually doesn’t involve vague questions. It involves coming up with a treatment plan, working on precise goals each week between sessions, and finding ways to change your behavior, not just the way you feel about the world. It’s not that feelings are unimportant– but this type of therapy is based on the belief that the best way to feel better about yourself and the world is to change the way you behave in response to your symptoms.
Traditional talk therapy– the kind you see on television where the therapist works with the patient to figure out why they’re feeling bad and what might be causing it– can be very helpful for improving other aspects of your mental health, but it usually won’t help with the OCD symptoms. Even among licensed therapists, there’s a lot of misinformation about how to deal with OCD, or even what it is. If a therapist doesn’t recognize OCD symptoms for what they are, they can make things worse as patient and therapist enter a cycle of compulsions and reassurance.
Let’s use a quick example. A patient comes in and says “Every single time I’m in a doctor’s office I’m struck by all these thoughts about how I’ve definitely just caught a deadly illness but won’t know until I’m dying from it.”
The therapist says, “Let’s challenge those thoughts and see if they stand to reason. What makes you think you’ve caught a deadly illness? Are there deadly illnesses in the doctor’s office? How might you know they’re there?” Now the therapist has guided the patient into performing the same compulsion that has become problematic: trying to figure out whether or not they might caught a deadly illness. And when a therapist encourages you to go through that process it feels like it might not be such a bad thing to do
Alternatively, the therapist might say: “People are in doctor’s offices all the time and they don’t get sick. I think you’ll be just fine.” In this case, the therapist has filled the patient’s compulsive need for reassurance.
In either case, the OCD symptoms are not going to improve. A better response to this OCD patient, even though it might sound brutal at first, is something like: “You’re absolutely right. You might have caught a deadly illness while you were in the doctor’s office.” This is true, and it’s this kind of uncertainty that people with OCD find it so hard to tolerate.
If the goal is to learn to tolerate it so you spend less of your life doing compulsions and feeling terrible, facing the possibility head-on and learning that you are able to tolerate it is a much better treatment objective than briefly feeling better during therapy only to find that the obsessive-compulsive symptoms will soon reappear.
What types of therapy work?
The predominant form of therapy for all sorts of mental health conditions over the past few decades has been Cognitive Behavioral Therapy, or CBT. The main idea of CBT is that the way you assess a situation, and not the situation itself, determines how you feel about it. If you could change some of your thoughts and beliefs, you would end up feeling better. For example, someone doing what they call personalization always feels like the things that people do must be in response to them. You’re at dinner with some co-workers, you notice that everyone seems kind of quiet, it must be because they don’t really want you there. This kind of thought, which they called a cognitive distortion, leads you to feel bad in a whole lot of situations that don’t really merit it.
Some CBT concepts work well for OCD, while others can be less useful or even harmful, depending on someone’s symptoms. But there’s a more specific form of CBT called Exposure and Response Prevention, or ERP, that is widely considered the most effective form of therapy for OCD. The basic idea of ERP is this: you expose yourself to situations that cause obsessions and thereby distress; then you prevent yourself from doing the compulsions you’d normally turn to. Over time, you habituate to the terrible thoughts and sensations– meaning they don’t bother you anymore.
The exposure part means you work with your therapist to put yourself, little by little, into situations that bring on your obsessions. Whatever you’ve been avoiding because of your obsessions and the distress they cause, your therapist will help you get back into that situation. This has to be carefully planned to make sure it’s effective, and so that you’re gradually building toward your goal rather than moving too quickly and getting completely overwhelmed.
Exposure can be really uncomfortable, but it’s worth it if you’re tired of feeling so anxious and afraid. Sometimes exposures are just about imagining yourself doing something, and other times they involve actually going out and putting yourself in the stressful situation. Often your therapist will work with you to build a hierarchy of exposures. Let’s say you’re avoiding taking your kid to a playground because you get these horrible thoughts about your kid getting hurt. First you might talk about playgrounds with your therapist; then you could look at pictures of playgrounds; next you might go to the playground alone; and finally you would take your child with you.
The response prevention part is probably even more important. It means preventing yourself from turning to your usual response– those compulsions– once you’ve started the exposure. This is the part where you learn to tolerate uncertainty and the distress it causes, and teach yourself over time that you’ll be fine even when it doesn’t feel like it.
A lot of people will say that it’s about learning to “just sit with your anxiety,” but this is kind of unclear. Are you really supposed to just sit there resisting your compulsions until you feel less anxious? Maybe sometimes. In other cases, response prevention has to be done on the fly. For instance, if you’re exposing yourself to anxiety at work or around friends, you usually aren’t able to just quietly sit there doing nothing for a while.
Sometimes doing response prevention means finding other ways to cope with the distress, besides performing your compulsions. But you don’t want to do anything to decrease your anxiety, or you’ll just be finding another form of avoidance and reinforcing your fear of the exposure. The first step is to become aware of what you normally do, because sometimes we do compulsions without even knowing it. Then you can try to do something else. But response prevention, like exposure, is highly individualized– it has to be done on a case-by-case basis.
Without the response prevention part, doing exposures is just unnecessary pain and won’t help you get any better. In order to give yourself a chance to habituate to the distress– that’s when the horrible feelings you’ve been dealing with finally grow weaker– you need to avoid doing anything to get rid of that distress.
As a quick example, let’s say a therapist gets a new patient who’s so afraid of hitting someone while driving that she finds herself looping back whenever she goes over any kind of bump. The therapist might decide that, for an exposure, the patient will repeat out loud while driving, “I just hit someone, I seriously hurt someone back there.” For response prevention, the patient agrees not to loop back and check at any point during her drive. If this is too much right away, she’ll agree not to loop back for five minutes, then ten minutes, then thirty minutes, and finally the entire drive.
It’s important to be honest when starting response prevention about whether or not you might be able to fully resist your compulsions. Sometimes you’ll need to start with a smaller goal, like delaying them for a minute. Then you build up to five minutes, ten minutes, and so on. If you’ve been doing a compulsion very frequently for a long time, it’s unrealistic to expect that you can suddenly stop.
While it can be exhausting and difficult, ERP is currently the most effective form of therapy for people with OCD. With a good ERP plan and a bit of motivation to stick with it, people can see drastic improvement in the amount of time they spend each day on compulsions and the way they feel about their life.
Lastly, there’s another form of therapy that can be helpful when combined with CBT and ERP. It’s called Acceptance and Commitment Therapy, or ACT, because it teaches people how to accept the way things are and the way they feel while also identifying their values and acting in line with them. Together, these two things give a person psychological flexibility, or the ability to enter a situation completely open to whatever it will bring and change your behavior as needed in response to what’s happening.
ACT can be helpful for people with OCD in a number of ways. First of all, knowing your values is very important when ERP treatment gets tough. You might ask yourself, “What in the world am I going through all this pain for?” If you know what you want in life, you know what you’re working hard for. The mindfulness techniques taught in ACT are also helpful during exposures, so you can try noticing things around you and accepting whatever feelings arise in you. Lastly, psychological flexibility can vanish when obsessive-compulsive symptoms begin: you’re not capable of openness to thoughts and feelings because there’s so much fear and anxiety built up around them.
There isn’t a single form of therapy that works for everyone, but there’s a good chance one of these might help you. It’s impossible to say everyone should try therapy, because in many cases it’s really expensive, but if it’s accessible to you and you think you might benefit from it, therapy is worth a try.
What medication is best for OCD?
Ready for an answer you’ve probably heard before? Some types of medication work well for some people and not well for others, and in most cases nobody really knows why. The brain is extremely complex, and there’s no simple fix. The success rate for certain medications is high enough, however, that it might be worth trying them out if therapy isn’t quite doing enough for you.
By far the most commonly prescribed class of medication for OCD is the serotonergic drugs, like SSRIs and SRIs, also the most-used type for depression. Some common ones are Prozac, Paxil, Zoloft, Lexapro, Effexor, and Anafranil. These drugs are usually given in higher doses for OCD than for depression. And it usually takes at least three months to know if they’ll work for you, whereas patients with depression might know sooner. It’s not really clear which of these might work best for you, so work with your doctor to make a decision and try other ones as needed.
Newer research points to the benefits of medication that modulates levels of glutamate, another neurotransmitter like serotonin. Especially when added to a serotonergic drug, things like riluzole, memantine, N-acetylcysteine, and D-cycloserine can be helpful.
If you decide to try medication, you’ll need to take it exactly as prescribed. A lot of people think they can stop as soon as they feel better, but this will land you right back where you started. And suddenly stopping any of these medications can give you really unpleasant withdrawal effects, like insomnia, nausea, dizziness, and feeling amped up.
All doctors can prescribe medication for OCD, but if you’re able to see a psychiatrist this is preferable. Psychiatrists are doctors who specialize in these conditions, so they have the most experience making treatment decisions for OCD and other mental disorders.
If you deal with other mental health conditions along with OCD, medication can get more complicated. For instance, serotonergic drugs might not be an option for people with both OCD and bipolar disorder because they can make those conditions harder to manage. It’s worth discussing with your doctor, and it’s also another reason that therapy is a good first choice for managing the OCD symptoms.
For many people, it takes a combination of medication and therapy to feel better. The medication can make the therapy easier, and vice versa. Whatever you choose, there are plenty of good treatment options so you can start to feel better soon.
For a small number of people, OCD symptoms become so severe that suicide is a risk. If you ever consider suicide, call your local suicide hotline or emergency number right away. In the United States, this number is 1-800-273-8255.
These resources were developed with:
Michael A. Jenike, MD
Founder, OCD Institute at McLean Hospital
Professor of Psychiatry, Harvard Medical School
Christopher Pittenger, MD, PhD
Director, Yale OCD Research Clinic
Associate Professor of Psychiatry and in the
Child Study Center, Yale School of Medicine