Behavior Therapy in the treatment of Compulsive Disorders

The great advances in our biological understanding of these disorders as well as exciting developments in pharmacology has led to a focus on medications in the management of such conditions. While medications are effective, they are usually not enough to control the symtoms. Also, some people may not be able to tolerate the medications for various reasons.

Several types of non-medication therapies have been tried. Traditional psychotherapy has been studied extensively with little success in most OCSD. The goal of this therapy has been for the person to gain insight into their thoughts and feelings as a means of changing behavior. On the other hand, behavior therapy has developed over the years as one of the most effective therapies in OCSD and may be used with or without medication to produce dramatic changes in people’s lives.

Behavior therapy is based on the belief that changing the behaviors directly will lead to less uncomfortable thoughts and feelings. This treatment works by breaking the association between obsessions and compulsions. Obsessions are disturbing thoughts that cause anxiety such as fear of being contaminated by germs. A compulsion is an action in response to an obsession to help relieve the discomfort from the thought. An example may be compulsively handwashing to prevent the spread of germs.

The therapist works with the person to experience the obsessional thought without performing the compulsion. An individual with fear of contamination may be asked to gradually expose themselves to places they may fear as sources of contamination such as a bathroom door or faucet. The therapist prescence discourages the person form the compulsion of washing his hands. Eventually the anxiety goes away and the fears dissipate.

Exposure and response prevention are the key features of this type of treatment. Exposure occurs when the individual confronts that which they fear without performing the ritual which would normally follow (response prevention).This means experiencing the anxiety without succumbing to the usual compulsions or rituals. Eventually, the anxiety wanes (habituation) as one becomes accustomed to being confronted with the fearful stimuli (cues) without resorting to unhealthy or irrational rituals. In the fear of contamination, the exposure is touching a bathroom door handle while the response prevention is not allowing the person to hand wash.

While this may be a simple concept, initiating and completing this type of therapy requires a skilled behaviorist to arrange the treatment in a way that feels safe and slow enough for the person while also being effective. The first step involves a thorough behavioral assessment in which the therapist is educated about the obsessions and compulsions and the circumstances triggering them. There are several helpful scales and checklists used to obtain as much information as possible such as the Yale -Brown Obsessive-Compulsive Scale (Y-BOCS) and Maudsley Obsessive-Compulsive Inventory. The most common symptoms include cleaning and checking compulsions. Many therapists ask their patients to use use a diary to document the details of their symptoms as they occur during the day.

The next step is to develop a hierarchy of symptoms from the least to the most anxiety-provoking. Usually the focus is on only a few of the behaviors which are distressing yet the patient feels they are able to confront. Over a gradual period of time, the person is exposed to increasingly distressing cues while rating their level of discomfort (Table1). Exposures may require three sessions (lasting sometimes two hours per session) for each cue. Research in this area supports longer and more frequent sessions over a shorter period of time for the most effectiveness. While the individual tolerance and severity of symptoms must be taken into consideration, many therapists try to tackle the most difficult exposure within four weeks. Homework assignments are often given with clear exposure goals for the week while documenting the level of anxiety before and after (Table 2).

Since treatment involves performing anxiety- provoking tasks, the biggest obstacle to recovery is often lack of follow through on the client’s part. The individual must make a commitment to a certain number of sessions to overcome the initial distress of the therapy. Having families involved and educated about the treatment is often helpful. Family members may not know how to be helpful at home between sessions. They can also encourge and support throughout the therapy. Group therapy with others suffering from OCSD provides a safe place to get support form one’s peers and motivation to stay with the program.

Behavior therapy is a proven treatment for many obsessive-compulsive spectrum disorders that works quickly and effectively. Exciting advances continue in this field such as the use of computers and virtual reality to enhance exposure opportunities. Researchers are even looking into behavior therapy to treat post-traumatic stress disorder, eating disorders, and phobias. For obsessive-compulsive disorders, behavior therapy is an powerful tool to gain back control of one’s life.