Eight Reasons Why Some Patients Fail in OCD Treatment

Here are the main reasons why some patients don’t benefit from ERP.

Posted Sep 20, 2018

Cognitive Behavior Therapy (CBT) that emphasizes a method called exposure and response or ritual prevention (ERP) is far and away the most effective and scientifically validated treatment for Obsessive-Compulsive Disorder (OCD). Still, even when properly done with motivated patients, ERP does not always help OCD sufferers.

Here are eight reasons why CBT driven ERP sometimes fails to produce meaningful therapeutic benefit. While these factors are not listed in order of commonality or importance, they generally run the gamut of the usual explanations.

1.  Lack of Insight:  Basically, OCD is classified as one of two types: with insight, meaning the individual understands that the OCD beliefs are irrational or untrue; and without insight, meaning the individual thinks the OCD beliefs are probably true. In some cases, insight can be totally absent, making the OCD beliefs rise to the level of delusional intensity. Obviously, good insight carries a better prognosis than poor or absent insight because delusional beliefs are much more stubborn than irrational ideas. That is, irrational beliefs can usually be reduced with behavioral evidence that disconfirms them while delusions are extremely resistant to change even in the face of overwhelming evidence they are wrong.

2.  Lack of Motivation:  Despite sincerely wanting to beat their OCD, many people are not adequately motivated to succeed. As I’ll discuss below, ERP requires that people deliberately trigger their anxiety and wait for it to diminish or resolve without doing any discomfort reducing or safety seeking actions (i.e., rituals). Obviously, facing some of one’s greatest fears takes a lot of drive and determination. Simply put, if a patient tells me “I’ll try,” I’ll reply “You will almost certainly fail.” If he or she says “I’ll do my best,” I say “You will probably not succeed.” It is only when people commit to “Doing whatever it takes!” that I say “You will very likely succeed.” Hence, the requirement of deep, intrinsic motivation to “do whatever it takes” is vital for success.  In fact, in many cases, working with patients to strengthen their motivation and readiness for positive change is part of the art of CBT. In other words, helping them move from “I’ll try” to “I’ll do whatever it takes!”

3.  Inability to Tolerate Therapeutic Distress: As suggested above, since ERP involves deliberately triggering intense anxiety and discouraging patients from engaging in maladaptive OCD actions to neutralize it, ERP requires real grit and well as strong motivation. Unfortunately, many people with good insight and high motivation believe they lack the psychological strength or fortitude to withstand the necessary distress of doing ERP.  Here, again, facilitating people along the spectrum of readiness for change is often needed so they can connect with their inner resources and see for themselves that they do indeed have the right stuff to successfully combat their OCD.

4.  Under Reporting Symptom Severity:  It is common for people in CBT for OCD to underreport the true extent of their rituals. This results in ERP and other therapeutic challenges being too weak to “break the back” of their OCD. For example, if a person reports that touching a public toilet’s handle is at the top of their anxiety trigger list, but fails to tell their therapist that they use a half a roll of toilet paper after a bowel movement, clearly, important therapeutic stones will remain unturned. Therefore, it is essential that therapists do thorough initial assessments and remain vigilant for clues that crucial rituals have not been reported.

5.  Family Members Enabling OCD Behaviors: In most cases, it is important to enlist the cooperation (if not the actual involvement) of the OCD sufferer’s family or significant others. Otherwise, kind and well-meaning people can inadvertently undermine the therapy’s effectiveness. Hence, at a minimum, this means encouraging them not to provide anything that could be anxiety relieving to the sufferer. So, not providing reassurance or doing specific actions to prevent the sufferer from experiencing naturalistic anxiety. For instance, not repeating an answer to a question; not answering any questions that are being asked to gain reassurance; not avoiding touching things the sufferer doesn’t want touched; not buying extra cleaning supplies for the sufferer; and basically not doing anything to help the suffer avoid or escape from anxiety.

6.  Comorbid Depression or Other Complicating Conditions: If a person with OCD is also struggling with clinical depression, psychosis, substance use disorders, PTSD, panic, or various medical illnesses (e.g., IBS, immune deficiencies, etc.) treatment can be much more challenging. While these common difficulties will not necessarily render ERP ineffective, they can be serious complications that, if not appropriately managed during therapy, can result in poor outcomes.

7.  Therapists Not Doing Effective ERP Because of Their Own Anxiety or Lack of Experience:  A common “rookie mistake” is when OCD therapists under challenge their patients during ERP.  Failing to evoke adequate anxiety during treatment will lead to weak results and ultimately suboptimal outcomes. This happens either because of mere inexperience but also, ironically, because of therapists’ own anxiety preventing them from engaging their patients in more robust and effective exposures. If therapists won't “eat their own cooking,” it dilutes the efficacy of ERP as well as the therapists’ credibility. For example, if a therapist won’t model for a patient touching a toilet handle, a community trash receptacle, a bathroom floor (etc.) without washing his or her hands, how is the patient likely to interpret that information? It sure won’t inspire confidence, right? So the “do as I say, not as I do” approach is usually lethal for success whereas the “do as I do” approach is often vital for it. (While some OCD experts might see therapist modeling as providing reassurance, it is more likely that it enhances the therapist’s credibility and emboldens the patient to take the emotional risk of doing the modeled exposure.)

8.  Not Doing Homework Assignments or Self-Directed ERP Between Therapy Sessions:  Just as rituals are strengthened through consistent repetition (like a habit), eliminating them requires consistent and repetitive practice, too. Therefore, it is very important that patients doing ERP practice exposures and therapeutic challenges between sessions. For instance, if someone wanted to learn a new skill (e.g., the piano) but only practiced during formal instruction, he or she will not gain proficiency nearly as quickly or well as if he or she practiced daily between instruction sessions. Hence, effective CBT driven ERP requires that patients do consistent “homework” between therapy sessions by engaging in repetitive ERP practice.

For more on understanding and beating OCD check out some of my previous posts in my “Think Well” blog.

Remember, Think well, Act well, Feel well, Be well!

Copyright Clifford N. Lazarus, Ph.D. This post is for informational purposes only. It is not intended to be a substitute for professional assistance or personal mental health treatment by a qualified clinician.

To find therapists near you, see the Psychology Today Therapy Directory.

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