Today I am flying solo to discuss my own experience of learning about Exposure and Response Prevention Prevention and why I ultimately went back to using EMDR to treat OCD.
- The reason ERP is so widely recommended for OCD treatment
- The problem with psychological studies: People are complex
- Problems I saw firsthand with ERP
- Benefits of using EMDR to treat OCD
Exposure and response prevention for obsessive-compulsive disorder: A review and new directions: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343408/
Studies on EMDR and OCD: https://www.emdria.org/public-resources/emdr-therapy-and-ocd/
Welcome to Hope for Anxiety and OCD, episode 18. On today’s show, it’s a solo episode. So you just get me and I want to continue this conversation that I started with Sarah about EMDR as a treatment option for OCD. I’m really excited to share this with you because I feel like when people start talking about OCD, that the very next thing they start talking about is exposure and response prevention (ERP)
I’m not saying that there’s anything wrong with exposure and response prevention, or as we’re going to call it ERP for this episode. What I am saying is that there are more options than just ERP for treating OCD. ERP has helped a lot of people. And so if it’s helped you then more power to you, that’s awesome.
I’m so thankful and glad but if you feel like you’ve struggled with ERP or you feel like you want to learn about a potential different option then this show is for you.
The reason that ERP is so most often recommended for OCD is because this treatment option has been researched more than others treatment options. And let me tell you about psychological studies and how those typically work. When someone is studying a condition such as OCD, they’re typically trying to only study OCD. And a lot of times we’ll rule out people who have what we would call dual diagnosis. They have more than one diagnosis on record. [00:02:10] I had a hospital reach out via email several years ago saying, “Hey, we saw that you see people with OCD and we are trying to do this research study. Would you let people know?” And I emailed them right back. And I said, “well, would my clients be ruled out if they also had PTSD.” And they said, “yes, they absolutely would be rolled out.”
At that point, I realized that whatever they were studying ceased to be relevant to the actual clients that I see in my practice. I often see people who are not only dealing with OCD, but they also have a history of childhood trauma. The other thing I want to bring up about psychological studies is that there’s a lot that we don’t know. Psychology is a relatively young science. While we’ve learned many things over the years about how the brain works and how different methods of therapies work and how some therapies are better for certain diagnosis, there’s still a lot that we don’t know. And the types of people that we see in counseling, they don’t fit. Just say standard one size fits all profile. Something that often happens. Whenever I go to a new training, you will learn about something like, “Oh, we have this really great method,” and they’ll show you the success stories. They may even show you video of it working well with a client that they worked with with permission. Obviously, we don’t just videotape people. We ask for their permission for learning and education purposes. But they may have these great examples. And then inevitably you will take that back and you’ll say, “Hey, can I try this new technique with you that I learned?” And it may work on the first person that you try it with and you may try it with a few other people. [00:04:18] And inevitably it doesn’t matter what the psychological technique is, you will run into someone that it just doesn’t work for that you have to revamp or adapt it differently or use something else entirely. And that’s one of the reasons that I want to expose you listeners on the show to a wide variety of mental health treatment options for anxiety and OCD because I don’t think that there is a one size fits all. And a lot of times when people look at counseling. They lump it as one big thing. I tried counseling and then, you know, that didn’t really work for me but there are many different types of counseling and I hope this show is kind of helping you and exposing you to some of that.
So let’s talk about my background with ERP that I wanted to share with you. I had an experience where I went to a two-day training on exposure and response prevention. The reason that I sought out that training in the first place was because I was seeing a lot of clients with anxiety that was really starting to become a niche of my practice. [00:05:40] So seeing people with trauma and people with anxiety, And I started to see that when certain clients would have peak levels of stress, they would start to engage in some OCD compulsions. And it made me realize that if I was going to see people with anxiety, I was really going to have to understand more about OCD, how it’s approached and try to figure out how to help these people who were experiencing OCD symptoms in peak stress points.
So I went to this training. It was very professional training, excellent information on OCD, excellent information on exposure and response prevention, how to start utilizing it in your practice. It certainly didn’t make me an expert on it or anything, but it was enough to get me started, to start working with some people that, had a diagnosis of OCD, not just had a few symptoms here or there. That point. I started seeing some people who were coming out of inpatient treatment, where they had received treatment for OCD and they needed some follow-up with their ERP. There were some patterns that I was starting to notice and particular patterns that I wasn’t comfortable with. One pattern I noticed with these individuals was that they seem to be carrying a lot of shame. It was either shame related to past trauma, self-esteem issues or even just having the OCD diagnosis in general and having to deal with that on a day-to-day basis. So that was a level of concern for me because I don’t want people to be stuck in shame. I had to ask myself, is it a win if people stop engaging in compulsion? if they’re still carrying around a baggage of shame. That just didn’t seem to jive with me or, or feel good in my practice. I also worried about whether or not ERP could be contributing to some of that shame because part of the process of ERP at times is to track certain behaviors, such as times where you engaged in a compulsion and times where you didn’t. I noticed these clients also had an untreated trauma history as well, which since I was a trauma therapist, that concerned me.
The main issue I had with ERP though seem to be what I call a glorified whack-a-mole process. Really targeting symptoms instead of getting to the root of the issue. This seemed horribly inefficient because one you would target one theme or one compulsive behavior then another obsessional theme with another compulsion would pop up right behind it.
What I’ve learned from trauma therapy is that you can treat symptoms all day long, but if you don’t treat the issue underneath that’s driving the behavioral symptoms, you’re not going to get very far. It’s going to be a lot harder. It’s going to be a struggle like swimming upstream.
I had one experience where a very skilled and trained ERP therapist told me that she banned prayer for a client that was dealing with scrupulosity. That bothered me as well because I’m not going to ban a behavior that’s crucial and critical to someone’s faith practice. The idea of exposure and response prevention, which we’ve talked a little bit about in previous episodes is that, ultimately your goal is to have a client be able to sit with the obsession without acting on the compulsion. Doing this inside of session with the therapist, as well as outside of the session for practice, for homework. And the ideas to be able to sit with that until the anxiety level drops. That can be really challenging and very distressing for clients. If they’re able to get through it, then there is a certain level of success and accomplishment that they feel. But sometimes the difficulty level of ERP contributes to the dropout rate.
One study that I read that I will put in the show notes for you is that ERP has a 20 to 30% dropout rate and ERP has a 50% success rate in terms of symptom remission. So here we have a lot of people promoting ERP as a treatment option for OCD, and there’s a 50% success rate.
I want you to just think about that for a minute. There’s few things that we would recommend that had a 50% success rate. If you’re dealing with obsessions and compulsions that are wrecking your life, 50% sounds like a pretty good gamble of something to bet on that it may work for you. The problem that I have is hearing from other professionals that this is an automatic go-to treatment and this is what’s been studied and you really shouldn’t look into anything else. Sometimes other treatment options are discouraged and I have a problem with that because I think that we all should remain humble as professionals and recognize that different people need different things or different approaches.
I want to tell you a little bit about what I’ve been able to do with EMDR therapy with clients who have OCD. Ultimately, I decided to go back to what I knew and to adapt EMDR for the treatment of OCD. One of the things that I like about it is that it helps reduce the body level internal distress that people experience. A lot of times what I’ve seen is that individuals with OCD are able to go in their head. They’re able to solve problems. They’re able to kind of mentally escape from emotions and difficult distressing physical sensations. So by utilizing EMDR we’re able to work at a body level on reducing that physiological distress that people experience.
In the initial preparation phases, I’m working with people on things like mindfulness, distress tolerance skills to be able to sit with difficult emotional experiences. And often as they’re able to do that, they start to feel a little bit better. We definitely target the shame piece with education about OCD. Sometimes, that’s the first EMDR target is dealing with that shame versus trying to deal with the OCD. What I’ve found is that if people can release the shame first, then that helps them be able to engage in the next part of therapy, dealing with the obsessions and compulsions. EMDR starts with what’s going on in the present and then looks at what past memories may be contributing to the present experience because it approaches things that way. You’re really able to get down to the root of what’s going on instead of just working on various symptoms.
Sometimes the root has to do with control, either dealing with things that are outside of one’s control or feeling this need to be in control or be perfect in some way. Sometimes it has to do with vulnerability. There can be all kinds of different things underneath that layer.
So this is a process. There’s a process of dealing with the shame piece and developing self-compassion. There’s a process in learning some skills to manage day-to-day when the OCD arises. And then there’s this deeper layer of really getting to the root of what experiences contributed to this development in the first place. And what I’ve found is when you’re able to do those things with that process, people feel a lot better about themselves and they may still have some OCD symptoms, but it’s more like, “okay, I’m noticing that that’s there and it’s in the background and I’m a lot better able to ignore it than when I started therapy.” And that’s huge. That’s absolutely huge for people.
Anytime that you can get to a place where you’re managing the obsessions and compulsions and noticing that they’re there but not getting roped into them, that’s an absolute huge win. And however you get there, whether you use ERP or whether you use some people are using ACT, Acceptance and commitment therapy for OCD, or whether you’re using EMDR or another method, just know that there are different options for you. You don’t have to be locked into one treatment option because of your diagnosis, regardless of what that diagnosis is. I’m going to include some information for you in the show notes about exposure and response prevention and the article that I read regarding that, which was a review of the research and then some studies on EMDR and OCD. And you can look for yourself and evaluate. It’s often helpful to incorporate more than one therapeutic technique together.
I believe this is where people, especially who have complex presentations, are able to see the best results. So you certainly could incorporate EMDR with ERP. I’ve done that for clients before, especially more so in phobia situations where they needed kind of like a gradual way to ease into getting over a certain fear.
Today’s story of hope starts with me crying in a parking lot in Target because I couldn’t build a website in 2017. I was in the process of building my business By The Well Counseling, trying to get everything off the ground. There’s a lot that goes into starting a business and I was running on fumes. I was working full time, seeing clients. And then in the evenings, I would be working on stuff to start the business. One of the things I believed I needed to get going was a website. Someone had recommended a certain site for me to build my own website. And I could not figure it out on my own, hence the crying in the Target parking lot. Everything had just reached a boiling point. I was overwhelmed and in tears and just thought I cannot do this anymore. Fast forward, Now I’ve built several websites. I had a former blog website that I’m not using anymore that I built. I built a completely brand new website for my counseling practice on a different platform about a year ago and I partially built the Hope for Anxiety and OCD website. I did get some help from a professional on that one to make it look more snazzy. But what I learned that I thought I couldn’t do, which was build a website, I could actually do. I just didn’t know it yet. So maybe there’s something in your life right now that you feel like, “I can’t do it. There’s no way,” but you may be looking back a few years later and say, “Wow! That very thing that I thought I couldn’t do, I can do it now.”
That’s my story. Do you want to share your story of hope with me? I would love to hear it. You can contact me through our website anytime at hopeforanxietyandocd.com.
Hope for Anxiety And OCD is a production of By The Well Counseling in Smyrna, Tennessee. Our original music is by Brandon Mangrum and audio editing was completed by Benjamin Bynam.
Until next time. May you be comforted by God’s great love for you.