by Joye C. Anestis
A few weeks ago, I described the symptoms, course, and correlates of obsessive-compulsive disorder (OCD). I also briefly mentioned treatments which have empirical support for OCD. The frontline psychotherapy for OCD is exposure and ritual prevention (also called exposure and response prevention; EX/RP). Multiple clinical trials have demonstrated that EX/RP is more effective than a variety of control treatments (e.g.,Fals-Stewart et al., 1993; Lindsay et al., 1997; Marks et al., 1980) and antidepressants alone (Foa et al., 2005). The utility of EX/RP has also been demonstrated in real-world clinical settings (as opposed to the rigorous efficacy findings; Franklin et al., 2000). These treatment gains are maintained at follow-up (Foa & Kozak, 1996). Below I outline the major components EX/RP, which is a short-term cognitive-behavioral therapy specifically for OCD.
In general, EX/RP involves prolonged exposure to obsessional cues in conjunction with procedures aimed at preventing compulsive rituals. For example, a person who fears they will accidentally burn the house down by leaving a curling iron plugged in is asked to leave the house without checking to see if the curling iron had been unplugged. Prolonged and repeated exposure provides evidence that the feared catastrophic outcome does not occur (e.g., not checking to see if the curling iron is plugged in does not result in the house burning down). Continued confrontation with disconfirming information promotes habituation to anxiety. The hallmarks of EX/RP are discussed below:
- Exposure: Exposure for OCD requires clients to face a variety of fears in real life (known as in vivo exposure; e.g., the curling iron example above). This obviously can be a very aversive idea for many clients; thus, a significant amount of education is necessary beforehand. Before embarking on any exposure, the therapist should provide a clear rationale for why EX/RP works. This is a time to display significant empathy for the client, as the treatment is difficult, while also building the client's confidence in their ability to engage in the therapeutic tasks. It is also critical for clients to understand that no exposure will be done without their permission. One misperception that people have of exposure therapies is that the client will be forced into interacting with their most feared stimuli. For example, popular culture seems to reinforce this idea (I've seen a clip from the Maury Povich in which a woman with a pickle phobia had pickles just thrown at her with no way to escape). In real life, exposure is done gradually and consentually. Just as in the treatment of specific phobias, the client and therapist make a fear hierarchy, which lists the client's fears from least to most anxiety-inducing. Exposure then progresses up this list, beginning with moderately scary stimuli and ending with the most frightening. It is interesting to note that it actually doesn't matter if you conduct exposure in a gradual manner or in an abrupt manner (i.e., beginning with the most feared stimuli). There is no difference in the reduction of OCD fears between the two methods (Hodgson et al., 1972); however, clients prefer the gradual approach, and this approach serves to enhance client motivation and makes clients more likely to agree to the treatment. Additionally, it is important for the exposure to be prolonged and continuous and for it not to end until the client experiences significant anxiety reduction. This is more effective than short, interrupted exposure (Kozak et al., 1988).
- Imaginal: When a client fears specific consequences from refraining from compulsive rituals, these can be tackled via imaginal exposure (i.e., envisioning it in the mind). In particular, many individuals fear consequences that cannot be created in real life (e.g., burning in hell, burning down a house). Imaginal exposure allows clients to confront these types of thoughts. Furthermore, often individuals with OCD engage in cognitive avoidance strategies when doing in vivo exposure, not allowing themselves to fully consider the consequences during in vivo exposure. Imaginal exposure can help prevent this. Imaginal exposure is not necessary for all clients receiving EX/RP, but research indicates that it may enhance long-term maintenance for some clients.
- Ritual prevention: In OCD, compulsions are utilized to counteract or neutralize the obsessive thought. For example, the thought "I will die from touching this doorknob" could result in hand-washing or avoidance of the doorknob. In the exposure component of EX/RP, clients are exposed to the very situations that trigger the obsessive thoughts. At the same time, they actively avoid engaging in their compulsive rituals. Ritual prevention does not generally involve the therapist physically preventing the ritual (e.g., manipulating water supply to prevent washing). Instead, clients are given instructions and encouragement by the therapist in order to voluntarily refrain from ritualizing. For example, an individual who takes 3 hour-long showers every day might be instructed to not exceed one 10-minute shower a day (many EX/RP manuals provide sample instructions for a variety of compulsions). As you can imagine, this is not an easy task for clients to undertake! Before embarking on ritual prevention (and exposure, for that matter), the therapist should conduct a thorough assessment of the client's obsessional content and compulsive behaviors. Compulsions can be physical activities as well as mental rituals (e.g., counting up to a certain number). In order to help the client fully refrain from all rituals, the therapist needs to clearly understand the nature, quantity, and frequency of the rituals. The exposure component and the ritual prevention component work on different pieces of the OCD syndrome, thus it is the most beneficial for the client that both of these components be implemented concurrently. This produces the greatest and most durable treatment gains (Foa et al., 1984).
- Homework: Homework is a key component of EX/RP. Clients are instructed to engage in exposures themselves in between sessions, as well as avoid ritualistic behaviors. Therapists work with the client to plan out homework exposures and create lists of instructions for ritual prevention out in their world.
- Home visit: For some clients, it can be very beneficial to conduct one or more sessions in their home (how many depends on the individual client). Home visits serve to promote generalization of skills into real life. Depending on the client, the content of home visits can vary. For some, it might involve contamination of the home and conducting additional exposure sessions to the home or workplace. In another example, the client might be asked to turn the curling on and off without checking and leave the house with the therapist. For OCD clients with hoarding rituals, almost all of the sessions may need to take place in the home.
- Family involvement: Many EX/RP manuals encourage involving the family in treatment. The therapist can educate the family about OCD and the treatment. Furthermore, it may be important to provide family members with instructions on how to encourage the client to engage in EX/RP activities at home, and what to do about client reassurance-seeking and/or violation of EX/RP rules in between sessions.
- Frequency of sessions: The optimal frequency of treatment sessions has not yet been determined. Intensive therapy programs produce excellent results by seeing clients daily over a month or so, and often for 4-5 hours a day. Less frequent sessions are perhaps more feasible for clients and therapists and also seem to be effective. For example, Ambramowitz et al. (2003) found that EX/RP was equally effective at post-treatment and follow-up for clients who received daily sessions for 3 weeks and clients who twice-weekly therapy for 8 weeks.
In this article, I have attempted to explain the overall protocol for EX/RP. It is an intense and complicated treatment - but one that is so highly effective that it is worthwhile becoming proficient in. It is actually quite amazing for both the therapist and client to witness such drastic symptom reduction in such a short amount of time! Obviously, there are details of the treatment that I haven't discussed, and factors that differ between clients that influence the application of the treatment. In fact, while the basic idea remains the same, the structure of EX/RP sessions will differ greatly depending on the specific obsessions and compulsions of the clients. Below I have listed several treatment manuals which provide more information about EX/RP. I have also listed facilities which train therapists in EX/RP (for CE credits, etc.). And, as always, I encourage you to leave your thoughts in our comments section. If you have specific questions, I can answer them there or in a future post!
- Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
- Stop Obsessing!: How to Overcome Your Obsessions and Compulsions (Revised Edition)
- Center for the Treatment and Study of Anxiety at the University of Pennsylvania
- The American Institute for Cognitive Therapy
- The Beck Institute for Cognitive Therapy and Research