An Alternative to Exposure and Response Prevention for OCD

An Alternative to Exposure and Response Prevention for OCD

Numerous studies have now shown that Exposure and Response (or Ritual) Prevention (ERP) remains  our most effective treatment for obsessive-compulsive disorder (OCD).  In ERP, clients deliberately confront feared stimuli while learning to refrain from engaging in compulsions.

Even with the effectiveness of ERP, the search continues for how to get even better results, as not everyone benefits from ERP and some clients are resistant to it. Recent research on Acceptance and Commitment Therapy (ACT) suggests that other approaches—such as learning to observe obsessions without engaging or “buying into” the content of the obsessions—can supplement ERP. One of the core ideas of ACT is helping clients to mindfully observe obsessions with greater distance.

I recently came across a new paper that focuses on these newer approaches to OCD and thought it might be helpful for clinicians working with OCD. The authors provide a nice summary of recent research on the use of ACT, Dialectical Behavior Therapy, mindfulness-based approaches, and Metacognitive Therapy in the treatment of OCD.  They also provide some background on the roots of ERP in behaviorism and (later) cognitive therapy. The authors summarize what makes these approaches unique in the treatment of OCD:

In general we agree that most approaches to OCD address the function of inner experiences to some degree; in addition arguing that what makes the approaches covered here unique is the greater or complete shift toward addressing the function of inner experiences and a substantial reduction in categorizations of types or styles of inner experiences. (p. 34)

I would like to emphasize that none of these newer strategies are incompatible with ERP. I often find they are a useful complement to exposure work in my clinical work. My sense is that these strategies can help us expand our range of effective treatment interventions for OCD to help prepare clients for exposure work or as an alternative for those who are not willing to engage in ERP.

If you’d like to read the paper, you can currently download a pdf for free here. For a list of other blog posts I’ve written about exposure, click on this link.

More Avoidant Therapists Are Less Likely to use Exposure in OCD Treatment

More Avoidant Therapists Are Less Likely to use Exposure in OCD Treatment

In a previous post, I linked to a blog post about therapist reluctance to use exposure therapy. Exposure therapy is one of the most effective interventions for anxiety-related problems but, sadly, remains under-utilized by clinicians. It is an intervention that has been a major focus on my posts on this blog.

A recent study out of Drexel University looks at the role of experiential avoidance in therapist reluctance to use exposure therapy to treat OCD. Experiential avoidance (EA) refers to a tendency to avoid uncomfortable thoughts, feelings, and bodily sensations, and is a cornerstone in the model of psychopathology in Acceptance and Commitment Therapy.

Methods

The researchers recruited 172 clinicians who identified as cognitive behavioral therapists. Each participant completed self-report measures of EA, attitude towards evidence-based practice, thinking style, and treatment approaches. These therapists watched 2 of 4 possible video vignettes featuring actors portraying people with OCD based on scripts that were vetted by OCD experts. The therapists then rated how much time they would allot for different therapy techniques in treating the case example.

Findings

The researchers found that therapists who scored higher on experiential avoidance (EA) reported they would devote less time to using exposure for treating OCD clients in the vignettes they watched. This is striking as exposure is the gold standard treatment for OCD. Additionally, therapists who scored higher in EA showed a lower preference towards evidence-based practice. An interesting gender finding was that women exhibited a greater preference for evidence-based practice than men.

As the authors note, it’s impossible to derive a causal relationship between these variables. For example, they speculate that therapists who are more experienced in exposure may develop lower EA because of they themselves get used to doing exposure. In support of this view, the authors note that therapists who spent a larger portion of their time doing clinical work exhibited lower EA.

Overall, this study suggests that higher experiential avoidance may be a barrier to using exposure therapy and evidence-based practices.

Check out the article!

If you’re a member of the Association for Contextual Behavioral Science, you can download a copy of the article here if you log into your account.

Why Understanding Theory is Important in Conducting Exposure Therapy

Why Understanding Theory is Important in Conducting Exposure Therapy

In a special issue of Behavior Therapy on “The Theory-Practice Gap in Cognitive Behavior Therapy,” Jonathan Abramowitz, PhD, authored an interesting paper on the importance of understanding theory when doing exposure therapy. Dr. Abramowitz is a well-respected OCD researcher, and I was attracted to this article as part of my ongoing interest in exposure therapy.

The article is lucid, well-written, and I think would be of value to anyone beginning to work with exposure therapy. He offers anecdotes about where therapists go wrong and makes a good argument for why understanding theory enhances exposure therapy. Dr. Abramowitz writes from a strictly cognitive behavior perspective, so this work does not cover exposure in Acceptance and Commitment Therapy, something I’ve been writing about; however, he does cover the controversy with the emotional processing theory and why habituation is not a good marker of learning.

The point that struck me most in this piece is the importance of being able to convey to the client why exposure is important. This is something that has been increasingly apparent to me—in particular, in working with people with OCD—but which I had not quite put the words to. When you’re asking someone to do scary things, it’s vital for people to understand the reasons. More importantly, understanding the theory behind exposure helps clients to become exceptional collaborators, in my experience.

Recently, I was working with a client with OCD in coming up with a particular exposure for her harm-related obsessions. Without any prompting from me, she anticipated a likely safety behavior (e.g., looking behind her to see if she had inadvertently hurt someone) that she predicted she would need to deliberately block. I was so focused on designing the exposure that I hadn’t even thought to ask about safety behaviors until she brought it up. She could not have done so if she hadn’t understood the theory behind what we were doing. I had another client create and implement his own exposure exercise that was right on when something unexpected came up between sessions! Understanding theory is especially helpful for clients engaging in spontaneous exposure when appropriate situations come up.

Because the article is straightforward and engagingly written, there’s no point in offering a summary here. If you’re interested in reading it for yourself, I found a free pdf available here.

Cognitive Behavioral Therapy Superior to Antipsychotics for OCD

Cognitive Behavioral Therapy Superior to Antipsychotics for OCD

A practice I’m seeing more often that concerns me is the addition of antipsychotic medications on top of antidepressants when the antidepressants aren’t working. If someone isn’t showing improvement on an antidepressant alone, a prescriber may add an antipsychotic medication—the idea being it will increase the effectiveness of the antidepressant. The research for this is a little questionable, especially as the side effects for antipsychotics can be pretty bad. I’ve felt strongly enough about this issue that I wrote an editorial about it that the Oregonian published in 2012.

Antipsychotics and obsessive-compulsive disorder

In previous post, I wrote about a study that found that giving an antipsychotic in people with posttraumatic stress disorder (PTSD) provided no additional improvement. A recent study looked at whether adding an antipsychotic medication would be helpful to people with obsessive-compulsive disorder (OCD). Results are extremely clear that the answer is, “No!”

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (EX/RP). (Note: in other posts, I abbreviate exposure and response prevention as “ERP” but use “EX/RP” here to remain consistent with the article.) There is some research that suggests that antidepressant medication can have a small impact on OCD-related problems, but EX/RP remains the gold standard treatment

Another study showing that CBT does the best with OCD

A 2013 study in JAMA Psychiatry examined a group of people with OCD who were already taking an antidepressant but were still experiencing moderate or worse OCD symptoms. These individuals were divided into 3 treatment groups.

  1. Some received psychotherapy—cognitive behavioral therapy with EX/RP.
  2. Some received an antipsychotic—Risperidone.
  3. Some received a placebo (i.e., inactive) pill.

CBT with ERP was much more effective

The results were striking. The researchers found that only 23% of people showed improvement on the antipsychotic; moreover, this result is even less impressive given that 15% showed improvement on the placebo (e.g., sugar pill). In fact, statistical analysis suggests there was no difference between the antipsychotic and the placebo—this means that the antipsychotic and a sugar pill performed about equally.

By contrast, 80% of people who received cognitive behavioral therapy with EX/RP improved.

80% vs. 23% is a big difference, especially since the latter is more of a placebo effect than a response to an active treatment.

One quibble

In the Conclusion section of the abstract, the writers make a subtle statement that really bothered me:

Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered EX/RP before antipsychotics given its superior efficacy and less negative adverse effect profile.” [bolding is mine.]

 

This statement implies that, even though EX/RP is superior to antipsychotics, that antipsychotics are still a viable treatment. This seems a bit disingenuous, however, as the researchers’ own analyses indicate that whatever improvement antipsychotics demonstrated was likely a placebo effect.

If anything, a sugar pill should be offered before an antipsychotic since they are equally effective, and the former has fewer side effects.

Concluding thoughts

Although I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to be of much help for someone with OCD, the superiority of ERP over medication for OCD isn’t new information.

There’s already a solid base of research that suggests the EX/RP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study makes it pretty clear that antipsychotics should not be considered for people with OCD.

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

This post was featured on our client-centered blog The Art and Science of Living Well, but I thought it would be of interest to therapists as well.

The post is about a finding from a meta-analysis by Cuipjers and colleagues that looked at studies comparing medication against psychotherapy in the treatment of anxiety disorders and depression. For obsessive-compulsive disorder, the researchers found a clear advantage of evidence-based psychotherapy for OCD above medication.

You can read the post by clicking here, and it includes links to the original article, which you can download for free.

UPCOMING TRAINING EVENTS


Using Acceptance and Commitment Therapy to Guide Exposure Therapy: The Basics

Brian Thompson, PhD, Brian Pilecki, PhD, and Joanne Chan, PsyD
September 17th, 2021 from 12-3pm

This is a beginner workshop intended to provide the foundations of exposure therapy including types of exposure interventions and design effective exposure exercises for various anxiety disorders and OCRDs. Participants will learn how to use ACT processes to guide the implementation of exposure techniques and how ACT processes may be enhanced by traditional exposure methods. This workshop will provide some background in theory and will emphasize applying exposure to clinical contexts using case studies, exposure demonstrations, and the practice of new skills by participants. Read More.


Overcoming Barriers to Effective ACT-Informed Exposure Therapy

Brian Thompson, PhD and Brian Pilecki, PhD
October 15th, 2021 from 12-3pm

This workshop will offer a brief introduction to Acceptance and Commitment Therapy-informed exposure and focus on practical ways to address common problems in implementation. Case examples will be provided to illustrate common client barriers such as lack of buy-in and difficulty grasping core ACT concepts. Strategies for overcoming these barriers will be offered and participants will have the opportunity to practice newly acquired skills through role-plays and break-out rooms.Read More.


An Introduction to Psychedelic-Assisted Psychotherapy for Clinicians

Brian Pilecki, PhD and Jason Luoma, PhD
October 22nd, 2021 from 9am-12:15pm

Psychedelic assisted therapy is emerging as a highly effective form of mental health treatment. This workshop will provide health care professionals an overview of this new clinical area. The workshop will highlight the importance of preparation and integration, as well as how to use a harm reduction approach to provide therapeutic support to clients using psychedelics on their own. The current legal status of psychedelics will be reviewed, including Oregon’s developing a legal psilocybin-assisted therapy program. Finally, diversity issues around lack of access for underserved and non-majority populations will be explored, as well as the prevalence of cultural appropriation and colonialism in modern psychedelic medicine. Read More.


Acceptance & Commitment Therapy – An Experiential & Practical Introduction

Jason Luoma, PhD and Jenna LeJeune, PhD
November 13th and 14th, 2021 from 8:30am-4:30pm
at Milagro Theatre- El Zocalo
This two-day in-person workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, observe models, or receive feedback while using the ACT model. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Brian Pilecki, PhD and Jason Luoma, PhD
November 19th, 2021 from 9am-11am

There is an increasing demand from clients seeking therapeutic support in their personal use of psychedelics. However, many clinicians interested in psychedelic preparation and integration are unsure as to how to provide these services as psychedelics mostly remain illegal. In this workshop, we will outline legal and ethical frameworks relevant to providing therapy to clients around their personal use of psychedelics, as well as describe how harm reduction approaches are suitable for this developing clinical area. Read More.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 18, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

October 8th, 2021Psychedelic-Assisted Therapist Training: Current Perspectives and a Look Forward with Dr. Elizabeth Nielson

November 12th, 2021Psychedelic Research: Implications for Palliative Care and End-of-Life Existential Distress with Anthony Bossis, Ph.D.

December 10th, 2021Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div., M.S.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD