Episode 126: Psychotherapy for Obsessive- Compulsive Disorder

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Article Authors: Chantel Fletcher, BS, David Puder, MD

On this podcast episode, we interview Dr. Fred Penzel who received both his MA and PhD in School and Clinical Psychology from Hofstra University in 1985. In 1989, he founded Western Suffolk Psychological Services in Huntington, New York, where he is the executive director and a practicing psychologist. Since 1982, he has been involved in the treatment of numerous disorders including OCD, body dysmorphic disorder, body-focused repetitive behaviors such as hair-pulling disorder (Trichotillomania) and excoriation disorder (compulsive skin-picking), panic and agoraphobia, phobias, and post-traumatic stress disorder. He specializes in the treatment of these disorders within his practice. He is a founding and active member of both the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the TLC Foundation for BFRB’s Science Advisory Boards. He is also a member of advisory board of the United Kingdom’s Anxiety UK organization. In addition, he is an adjunct faculty member and community supervisor for the doctoral psychology program at Long Island University (C.W. Post campus). He is the author of Obsessive Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2017) and The Hair Pulling Problem: A Complete Guide to Trichotillomania (2003). He has no conflicts of interest to report.

OCD Treatment That Works

Obsessive compulsive disorder (OCD) was once viewed as an untreatable disorder, frustrating patients and practitioners alike in treatment attempts. However, an effective therapeutic modality called exposure and response prevention (ERP) therapy eventually was successful in demonstrating that this notion was false. With proper treatment, OCD patients could get better. Since its inception, ERP has remained the standard in the successful treatment of OCD. Additionally, the development of numerous effective medications has further enhanced the treatability of OCD and the ability of patients to recover and live productive lives.

How OCD is Wrongly Used in the Public

OCD is often wrongly characterized as simply being highly organized and perfectionistic (which is more high conscientiousness). It is also falsely assumed to require the presence of specific obsessions and compulsions, such as handwashing, rather than to include the understanding that obsessions and compulsions can be virtually anything.

It is important to understand the differences between OCD and other disorders. 

What are the Differences Between OCD and PTSD?

It is also important to be aware of and recognize related disorders. Obsessive compulsive spectrum disorders include body dysmorphic disorder (BDD), trichotillomania (TTM), anorexia nervosa, bulimia, excoriation disorder, compulsive nail biting, and Tourette’s syndrome/tics.

“If we had to sum up the majority of obsessions, two words would be sufficient—pathological doubt.” 

- Dr. Fred Penzel

Doubt is an essential component of OCD. In fact, OCD was referred to as the “doubting disease” in the 19th century. Doubt prevents OCD sufferers from feeling assured enough to move past the question, “How do I know for sure?” Compulsions are an attempt to eliminate risk and create certainty (or what feels like certainty).

How to Find an OCD Therapist

When trying to find a suitable therapist, patients should look for the following qualifications: expertise, proper training, experience, and a clear understanding of OCD. If a trainee is selected as the therapist, it is imperative to ensure they have proper supervision. Not taking these steps when attempting to find a therapist increases the risk of being treated with ineffective treatment methods. According to Dr. Penzel, many non-evidence based treatments have been tried for OCD including, but not limited to, EMDR, relaxation and meditation, psychoanalysis, and hypnotherapy. Exposure and response prevention therapy is the only treatment modality that has adequate evidence to support its efficacy.

In addition, a strong therapeutic alliance will set the foundation for success and is an important aspect of helping patients stay in therapy. Therapy requires collaboration between patients and therapists. Of course, sound knowledge, proper technique, and careful planning are necessary for patients to actually get better. 

“There is nothing which persevering effort and unceasing and diligent care cannot overcome.” - Seneca

Retraining the brain to respond to obsessions and compulsive urges in a healthy way takes time and effort. OCD is stubborn and patients must also be stubborn to overcome it. Letting patients know what to expect so that they are not caught off guard aids them in this process. Progress is not linear and they should expect the process to be difficult.

The key components of exposure and response therapy include identifying patients’ fears, gradually exposing them to those fears, and simultaneously helping them refrain from engaging in compulsions. Doing this gradually is key, as starting off with highly difficult exposures may cause too much distress for patients and lead them to drop out of therapy. The distress should be in the moderate range, so that there is enough for the exposure to be challenging, but not too overwhelming.  Examples of what therapy can look like include, but are not limited to, having patients write out their fears 25 times each day, watch videos about the situations, events, etc. they fear happening to other people in real life and then agreeing that those things are going to happen to them. While appearing counterintuitive, having patients come into agreement with their thoughts actually decreases the power the thoughts have over them. Essentially, the ultimate goal is for them to become bored by the thoughts because they hear them so often.

Cognitive therapy, while not directly effective in treating OCD, can help OCD sufferers overcome issues that OCD may contribute to in their lives, such as relationship issues, job issues, etc. It can also assist in breaking down barriers the patient may have towards the aforementioned behavioral therapy (ERP). 

The goal of therapy is to help patients behave in ways that are conducive to living with a normal or average amount of anxiety. With that being said, it is helpful to have a benchmark for what normal looks like. Drawing on the experiences of those unaffected by OCD and/or widely accepted guidelines can work well for this. For example, someone suffering from OCD as it pertains to germs could work towards being comfortable with simply adhering to CDC guidelines around the issue.

The Role of Medication

Some patients find it too difficult to effectively engage in therapy without medication, as their fears may be too intense. Thus, medication can be utilized from the beginning to ensure the best opportunity for successful therapy treatment. Medication can also be helpful for those with less severe symptoms because they can lower the intensity of the symptoms. Finding the medication that works for the patient frequently requires trial and error, so persistence and adequate time to evaluate effects is critical. 

In the event that a patient wants to stop taking medication, it is paramount that it is done very slowly over months and months. It is important to note that there have been reports of the patients getting back on their previous medications and finding that they no longer work. This is a “phenomenon” that is not very well understood. If they have been effective for a patient, It is often recommended that patients stay on their medication as long as they are not experiencing adverse effects.

“Most powerful is he who has himself in his own power.” - Seneca

Self-Help and Staying Well

Proper therapy equips patients to be their own therapists. In order to stay well, patients need to understand that OCD is chronic and will thus need to be managed. This does not in any way mean that the patient cannot live a happy, productive, and normal life.; it will simply be important for them to hone their awareness of their symptoms so they can recognize potential flares. In the event that patients find themselves experiencing an increase in symptoms, they can make use of old therapy homework, schedule maintenance therapy sessions, or other widely-available, vetted resources. 

Conclusion

“The vast majority of people have the ability within themselves to recover.” - Dr. Fred Penzel

Living with OCD can be challenging, but help is available and it does not have to be faced alone. Awareness and effective treatment is becoming increasingly available for sufferers. While the road to recovery is not perfect, with persistence and the right help, patients can go on to achieve major accomplishments and enjoy their everyday lives with minimal OCD impact. 

Acknowledgements: 

This article was supported by “Mental Health Education & Research”.