Therapy for Obsessive Compulsive Disorder

David Small, Registered Psychologist

Overcoming Obsessive Compulsive Disorder (OCD) is a challenging task for many sufferers. Individuals diagnosed with OCD struggle with obsessions, compulsions or both. Obsessions are characterized by intrusive unwanted thoughts, images or urges which causes the sufferer anxiety while compulsions involve behaviours or mental acts that a sufferer feels compelled to do in order to neutralize an obsession. Often, the time that a sufferer spends on the obsessions or compulsions is significant and may begin to interfere with other areas of functioning like school, work, leisure or important relationships.

Sufferers may seek out therapy before or after a diagnosis has been made. The key feature that drives OCD sufferers into therapy is the degree to which their symptoms begin interfering with an activity or goal they would like to achieve, but feel may be impossible.

Often, sufferers experience a large gap between their private and public lives. This disparity is emotionally taxing and can further contribute to feelings of anxiety that can make every day tasks a challenge. Sometimes, the connection between an obsession and a compulsion may appear reasonable. For instance, if I leave home for the weekend, I may check that I locked my door before leaving. An individual with OCD will struggle to limit their checking behaviour to occasional circumstances and they may have other compulsions they employ which take up a lot of time and energy. Alternatively, there may be no apparent connection between an obsession and a compulsion. For example, a sufferer may try to neutralize anxiety that arises from an obsessive image of a billboard by turning in a circle three times. The connection between the obsession and the compulsion in this example is less obvious and certainly appears less reasonable. Whether the compulsion appears reasonable or not, the sufferer spends significant time each day engaged in their OCD behaviour. In severe cases a sufferer will stop functioning at school, work or in their personal relationships.

Approximately 2-3 percent of the population has OCD. However, based on my experience it is likely that this number is under-reported since many OCD sufferers don’t seek treatment or have been misdiagnosed. The most common OCD categories include (1) contamination, (2) checking, (3) order, symmetry, counting and movement, and (4) primary mental obsessions. Although these issues are most common, the specific obsessions and compulsions within each category are limitless which is why it is important to begin with a thorough assessment. This also means that each treatment plan is unique.

Education itself does not help sufferers resolve this problem. In fact, most sufferers report that their obsessions are irrational. That does not change the intensity of those obsessions or the compulsions that temporarily reduce their anxiety. OCD arises from a combination of neurobiology and learning. A common approach to treatment involves medical intervention to address neurobiological factors and therapy to address the learned component of OCD. Your therapist can discuss treatment options with you and, with your consent, communicate with your doctor if necessary.

Loved ones often become affected by the sufferers’ OCD. Family and friends play an important role in convincing a sufferer to seek out treatment because they are in a position to observe the negative impact of OCD symptoms. For instance, if a sufferer does not let their parent leave home without checking to ensure that all of the taps in the home are shut off, the fridge is closed and the oven knobs are off then family visits may become fraught with tension.

At first glance, many obsessions and compulsions seem reasonable. If I happen to drive too quickly over a speed bump, I may think “what did I hit?!” and it would be reasonable to even check my car to see if I damaged my tires or undercarriage. A specific type of OCD involves “hit-and-run” scenarios where a sufferer is obsessed about the possibility of hitting, or having hit, a pedestrian and they engage in multiple checking behaviours (compulsions) to reduce the anxiety related to those obsessions. For instance, a hit-and-run sufferer might always drive during the day and avoid night-time driving. They may avoid driving down a busy road, or avoid rush hour, to reduce the likelihood that they will hit someone. They may drive around the block multiple times just to make sure that they didn’t hit a person. Even after they arrive home, they may check their vehicle again and again to make sure there are no dents, or blood, on the vehicle that would indicate they hit someone. They may take the compulsion further by turning on the news to determine if there have been any hit-and-run reports in their community that might tell them that they are the responsible party. No degree of compulsive checking will ever satisfy an obsession completely. It is the uncertainty that cannot be accepted and accepting uncertainty is a normal part of life. The difference between a sufferer and non-sufferer is that a non-sufferer may have one of the thoughts listed above but be able to dismiss it and move on. Sufferers cannot. If this sounds like torture, it is. However, sufferers can break free from the constant strain of obsessions and compulsions with effective treatment.

Therapy for OCD involves a specific evidence-based treatment called Exposure Plus Response Prevention (ERP); my work is guided by the ERP model outlined by Jonathon Grayson (2008). There is no other type of therapy that has been proven to be as effective at overcoming OCD. Currently, there is only one way and therapy is not easy. However, most sufferers are living a life that is already challenging. Since the fears associated with obsessions are often catastrophic it may seem counter-intuitive to face them directly through ERP. That is why therapy requires a commitment to one important goal before proceeding. That goal is to answer the following treatment question with a “yes”: are you ready to live a life of uncertainty? If the answer is yes, then you have accepted the challenge of ERP therapy and you may begin your progress toward recovery. If the answer is “no” then you are not yet ready to proceed and your therapist will work with you on comparing your current life to the future life you want, and that you deserve, to help you develop motivation to answer the question with a “yes”. Therapy for OCD requires courage. Courage is not an emotion. Courage is what you do when you are afraid.

In general, ERP therapy for OCD involves the following steps:

1. Education about OCD

2. Completion of a detailed OCD assessment

3. Development of personal recovery goals

4. Creation of your ERP program

5. Implementation of, and adherence to, your ERP program

6. Monitoring progress and challenges

7. Re-assessment and development of a relapse prevention plan

Since evidence is required to determine the effectiveness of your ERP plan, your therapist may give you a duo-tang to monitor each step along the way. You should have a clear understanding of each structured step in order to proceed with the necessary ERP at home between sessions. It may feel overwhelming to seek therapy for OCD. However, the time that sufferers devote to treatment is often much less time than they already devote to their symptoms. If you have any questions about OCD treatment, please contact me for more information. You are also welcome to set up an initial consultation to discuss therapeutic options and your own individualized treatment plan.

EMDR: An Evidence-Based Trauma Therapy

David Small, Registered Psychologist

During the covid pandemic, and subsequent lockdown, I accepted the advice of a colleague who suggested that we use our lockdown time for professional development. With limited knowledge of Eye Movement Desensitization and Reprocessing (EMDR) therapy I decided to proceed with this year-long training program, albeit with a healthy dose of skepticism.

I recall a comment from one of my master’s degree professors, citing doubt in the EMDR model when he suggested, “if resolving trauma was that easy why wouldn’t we all just go driving in the rain?” His critique pokes fun at a core component of EMDR therapy that practitioners call bi-lateral stimulation (BLS). The most common form of BLS involves the therapist waving their hand in front of the client’s visual field, back-and-forth, to activate one side of the brain and then other. EMDR theory suggests that BLS mimics Rapid Eye Movement (REM) sleep; the sleep cycle when we dream. EMDR posits that this natural physiological mechanism can be used during therapy in order to process traumatic material that became stuck at the time of a traumatic event. As my professor shrewdly noted, how does this differ from watching your windshield wipers? If metabolizing traumatic disturbance was this simple then watching windshield wipers move back-and-forth should result in similar outcomes while saving the client a significant amount of time and money, right? Since I am a skeptic by nature I shared this belief and avoided this model of therapy for years. Then I took the training.

The founder of the EMDR model, Francine Shapiro, seemed to understand the need for extensive evidence to support her approach to address fears that her approach may be moving into the realm of pseudo-psychology. After all, alternative therapies with little to no scientific evidence still attract public support and can mystify the practice of psychology and undermine our profession. Consequently, Francine began her scientific examination of the EMDR model in the late 80s and there are currently 24 randomized-controlled trials that substantiate EMDR effectiveness. After reading the research methodology, outcomes, and taking the training my skepticism started to fade and I concluded there is much more at play here than a simple windshield wiper could manage. Today, EMDR therapy is recognized as an effective treatment and is endorsed by the World Health Organization as the gold standard of treatment for trauma therapy.

EMDR is an 8-stage protocol-based therapy. The initial stages of treatment include taking a client history and resourcing to help the client manage any distressing emotions that might arise when targeting the specified trauma. For some individuals the treatment target is a traumatic memory or group of memories. For others, the target may be vague. An EMDR therapist will work with a client to determine comfortable targets to be addressed during the core part of therapy. For instance, an individual may have a clear target in mind like a car accident, or an assault. For others they may have a cluster of memories of mistreatment, neglect or abuse which can make it more difficult for a person to know where to begin. Your therapist will work with you to determine a starting point that feels manageable.

Next, the therapist assesses the worst part of the target and begins the eye movement desensitization and reprocessing phase. This phase involves sets of eye movements which replicate the REM system noted earlier. Between each set of eye movements the therapist may prompt the client with a statement, ask questions or just continue with the next set. When a therapist refers to “processing a traumatic event” it is important to describe what they mean. Trauma is stored in one’s body in state-specific form. This means that stimuli present at the time of the trauma were too overwhelming to be filtered out or effectively moved into long term memory. These stimuli include the internal and external cues associated with the trauma, sights, sounds, smells, feelings, physical sensations or thoughts about oneself and others. These stimuli represent the disturbance that a client may carry with them years after a trauma occurred. For many clients the disturbance is extreme, and can interfere with relationships, future goals, and other areas of life functioning. Processing means that stuck material begins moving again. By engaging the bi-lateral system and targeting the disturbance with therapeutic support, clients frequently report a reduction in overall distress. It is common for images to become blurry or change color, for one’s position in the trauma to change, for new thoughts about self to emerge, for expected feelings to emerge, for physiological distress to fade or memory of events that followed a trauma to become clearer. Many times a client will report that the disturbance they felt about the trauma is absent or neutral which can be liberating.

Your therapist will help you determine your readiness to proceed with EMDR work. The goal is to begin as soon as the client is fully informed, has developed resources to manage distress emotions (or to shift emotional states) and there is a clear target in mind. Since distress may initially increase once an individual begins treatment on a traumatic target it is common for EMDR therapists to schedule 90-minute sessions to ensure that a client has enough time to feel grounded prior to leaving the office.

If you hope to begin EMDR therapy you can contact a psychologist who has been formally trained. If you would like to learn more about EMDR therapy please watch the introductory videos listed below or you can go to https://emdrcanada.org/.

EMDR Introduction Video #1 

EMDR Introduction Video #2