Psychotherapy involves face-to-face interactions with a therapist. It is seen as more personal than drug therapy and can be individualized to meet the needs of the client. Generally, psychotherapy is more focused on addressing a person's life situation and subjective understanding of his or her psychological problems.

There are two main approaches to the psychological treatment of OCD: Exposure Response Prevention (ERP) based and Cognitive Therapy (CT) that targets the dysfunctional beliefs that turn everyday intrusive thoughts into obsessions.

Exposure Response Prevention (ERP) 

ERP is based on the Behaviourist approach in psychology that suggests that our behaviours, both normal and abnormal, are learned. This means our behaviours are shaped by environmental experiences, as opposed to being hardwired by our genes. So, if behaviours are learned, this should mean that undesirable behaviours can be unlearned if the person is exposed to the "right" learning environment.

In the case of OCD, this process depends on the client being able to identify environmental cues that trigger obsessional thoughts. The therapist will help the person to do this, for example, by talking about certain places, people, and objects that may trigger their symptoms. These cues may also be automatic thoughts in response to physiological reactions; for example, aches and pains or a racing heart may trigger the cascade of obsessive thoughts. The therapist will also talk through the exact nature of the person’s obsessions and compulsions and how the two are related, including the person's fears about possible outcomes if compulsions are not carried out.

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The video argues that the virus may have undermined OCD treatment.  Can you explain what is meant by this statement?

A significant part of treatment is to realize that the world is not as threatening as one believes. The pandemic appears to contradict this advice.  Also, the pandemic reinforces many of the irrational beliefs of people with OCD - for example, the compulsion to clean one's hands and the need to do it perfectly in order to prevent harm to oneself or loved ones.

What suggestions does the video propose to help people with OCD during the pandemic?

One suggestion is to make sure that people with OCD are not socially isolated.  They need to interact with others, even if it is over Zoom. Friends need to make sure that they do things that help distract them from the pandemic so that they are not focused on the need to be clean or the uncertainty of the world. Friends should not check in to make sure that they are following all the necessary precautions - or discuss those that are not following the rules.  This will only make the situation worse.

ERP is similar to systematic desensitization, a therapy that is often used with people with phobias. Both ERP and systematic desensitization make use of fear hierarchies. The client and the therapist work together to rank different situations from the least anxiety-provoking to the most to create a hierarchy. The next step is for the ERP therapist to gradually expose their client to each situation in the hierarchy, starting with the least anxiety-provoking. Central to the success of ERP is the process of habituation, whereby stimuli that once were associated with distressing thoughts and anxiety become neutralized. This occurs through response prevention. During therapy, people are not allowed (prevented) to engage in their usual compulsions (responses), in order to neutralize their thoughts. Instead, they are forced to learn that intrusive thoughts can pass without becoming overwhelming and that their anxiety can, and will, dissipate in the absence of their usual compulsions. ERP also involves helping the person to generalize their new learning to other situations in their everyday lives, thus reinforcing the new learning and combatting relapse.

The following video outlines the therapy.

ERP sometimes also involves imagining the most feared outcome, e.g. having to attend the funeral of a family member who died of salmonella due to their poor hand hygiene. This imaginal exposure (also called in vitro) helps the person to recognize that their thoughts bear no relation to actual events in the real world.

After the exposure and response prevention, the therapist and their client will discuss the experience, exploring how the reality was different from their initial expectations and what they have learned. Therapists often set homework tasks between sessions and the extent to which the client engages with these homework tasks often determines the rate of progress. Gradually, the client will work their way through the whole hierarchy supported by the therapist, who will conclude the treatment by creating a relapse prevention plan.

The whole program is usually completed with around 15 sessions, each lasting between 1.5 and 2 hours.

Evaluating ERP

There is a great deal of empirical support for ERP and it has been shown to be more effective than other therapies including relaxation therapy and anxiety management, (Hezel and Simpson 2013). It has also been shown to be effective across a wide range of treatment settings including inpatient and outpatients, as well as with people with varying severity of symptoms in a range of cultures.

In a meta-analysis by Eddy et al. (2004), ERP led to a clinically significant improvement for about 68.8% of participants who completed the program compared with 56.6% making a comparable level of improvement upon completion of cognitive therapy (CT). However, CT did have a higher recovery rate of 49.8% compared with 38.2% for ERP. Overall, ERP was deemed the most effective in reducing symptoms of the psychological therapies examined in this study. However, for those who were able to complete the cognitive therapy treatment, they were more likely to recover from the disorder.

Foa et al (2005) found that augmenting ERP with medication (e.g. clomipramine) did not improve its success rate, yet ERP plus medication was more effective than medication alone, providing further support for the role of ERP. Furthermore, Simpson et al. (2008, 2013) found ERP was more effective in increasing the effects of SSRIs than either stress management training or an additional drug, such as risperidone.

Despite the positive findings, around 35 - 40% of people with OCD do not recover completely after ERP; this is associated with poor compliance, lack of insight, (i.e. not recognizing that their thoughts or behaviours are irrational) and comorbid depression. 20 - 30% drop out of treatment because they find it time-consuming and/or too challenging.

Cognitive bias modification therapy (CBM)

Cognitive explanations of OCD focus on the idea that we all experience involuntary thoughts that intrude upon our conscious awareness but it is how we interpret and respond to them that sets apart people who develop OCD from those who do not. Psychologists such as Paul Salkovskis and Stanley Rachman have identified a number of cognitive biases common in people with OCD. For example, people with OCD tend to think of their intrusive thoughts as meaningful and generally negative, e.g. thinking about your father dying might be interpreted as a sign of being a bad person for imagining such an event.

Researchers have identified two different types of negative biases in people with OCD: attentional bias and interpretation bias. Attentional bias occurs when people selectively attend to negative stimuli and filter out positive stimuli, leading to an overestimation of the level of danger/threat. For example, a person may focus on negative news stories, e.g. Coronavirus death rates, as opposed to the positive new stories, e.g. communities coming together to help each other. Interpretation bias refers to the idea that people with OCD have a tendency to interpret ambiguous events in a negative light. If a person perceives the world as dangerous and full of possible threats, they will be more inclined to interpret events in a way that fits with this view. 

Cognitive bias modification aims to reduce the impact of these biases, thus easing a person's symptoms. CBM is generally a computer or mobile phone-based therapy where clients participate in training exercises. CBM-A tasks target attentional bias, shifting attention away from threatening/negative words, images, or faces towards non-threatening/positive stimuli. CBM-I tasks target interpretive biases; ambiguous stimuli are presented, such as words with missing letters and the person is trained to resolve the ambiguity in a positive way, (Derin and Yorulmaz 2020).

The following video explains how these tasks work in practice and how they have been ‘gamified’ for delivery via mobile phone applications. This exciting union of psychology and technology means evidence-based therapy is now accessible to anyone with a smartphone. This said, financial and geographical barriers still exclude many people, especially those in remote areas without network coverage or WIFI connections.

Evaluating CBM for OCD

Williams and Grisham (2013) conducted a laboratory experiment to assess the efficacy of CBM-I with people experiencing OCD symptoms. They found the technique useful in reducing interpretative bias, distress, and the urge to perform compulsions when placed in a situation designed to trigger symptoms associated with thought-action fusion. However, the study failed to show any impact on behavioural tasks tapping into core beliefs associated with perfectionism and the overestimation of threat. On a more positive note, the intervention was equally effective for people with both high and low scores on questionnaires (the DOCS) measuring the severity of their symptoms. It was unclear whether CBM would be effective for people with different types of OCD, i.e. cleaning, checking, order/symmetry, and forbidden thoughts as the researchers did not indicate the nature of their participants' symptoms. Finally, participants took part in only one session of CBM-I and results may have been more positive had the participants integrated regular CBM-I practice into their daily routines. 

Habedank et al (2017) examined the efficacy of CBM-A. Participants completed a minimum of 8 training sessions within four weeks and attentional bias was measured using a task called the dot-probe. Participants have to identify a letter that has previously appeared on their screen. A neutral image and one associated with OCD, e.g. a dirty cooker or sink appear just before the letter. Differences in reaction time to identify the letter indicate where the person tends to look - that is, at the neutral or OCD related stimuli. The CBM-A training sessions comprised dot-probe exercises where the letter always appeared on the same side of the screen as the neutral image, thus participants were primed to look at the neutral image as they knew this is where the letter would appear. In the placebo group, the position of the letter was randomized so participants did not learn to look at the neutral images. Following four weeks of therapy, the experimental group (n=58) showed a significant reduction in attentional bias compared with a placebo control group (n=50). Despite this improvement towards more positive bias, this did not transfer into a significant reduction in daily OCD symptoms. When followed up a month later, both groups self-reported equivalent reduction in symptoms, suggesting positive effects resulted from expectancy (a placebo effect) and were not a direct result of the CBM-A exercises.

Despite these seemingly negative findings, research suggests the CBM may be a helpful augmentation to ERP. Since ERP requires a highly trained practitioner, it is not a very accessible therapy for many people and self-conducted ERP (called sERP) has not had a high success rate. This said, research by Amir et al (2015) has demonstrated that when sERP is augmented with CBM-I it can have very positive outcomes. A sample of 22 people with OCD participated in a 7 week treatment programme and the researchers claim that with just one session with a trained ERP practitioner their participants showed symptoms reduction and functional improvement of a level comparable with ‘gold standard clinician-administered ERP’.  (Amir et al 2015).

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