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

How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. 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.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC