I believe that each therapist brings to the table his or her own style and insights that make them unique. Some therapists I have worked with are tough and don’t like to hear “no” for an answer. Some therapists use a very structured approach with workbooks and daily homework assignments. Others are empathic and go at a pace at which the client wants to work. I find that I utilize all of the above with my own perspective and creativity.
It’s important from the start to really get to know your clients’ strengths and struggles and what they are willing to tolerate in therapy. Is your client committed to working on reducing the symptoms of obsessive-compulsive disorder, or is he or she being pushed into therapy by a parent, for instance? Motivation is a huge factor in treatment outcomes.
If clients truly understand that the lives they are living are not their own but OCD’s, then we have a nice inroad into getting the clients motivated to take back their lives. Some clients don’t believe that OCD is really such a problem in their lives, but possibly their parents do. What this could tell me is that there may be resistance, and possibly the client will try but not fully commit to getting better.
Each client is an individual with his or her own reasons for coming to therapy. It is my job to build trust and hopefully open communication early in the therapy process. I share some stories about my journey with OCD early on and gauge how they react and take in this information. I ask many open-ended questions about what they want to get out of therapy. I want to know what OCD has taken from their life. I even want to know if there is anything about OCD that they might like as a reason for them to hold onto the symptoms.
Believe it or not, some clients find a certain amount of comfort in their compulsions. Others can’t stand living with OCD anymore and will do whatever it takes to overcome the disorder. I want to know how willing they are to engage in Exposure and Response Prevention and their willingness to stay with uncomfortable thoughts and feelings. Are they in treatment for themselves, or are they just trying to placate their loved ones?
I believe that the most important aspect of the therapy relationship is an ability to explain OCD in a way that makes sense to the client. I like to explain the fact that OCD is a brain disorder that is treatable, but that the more we engage OCD, the more powerful it becomes. On the flip side, the more we are willing to accept obsessions as misinterpretations that increase our anxiety, the more likely you will be to resist a compulsion. In other words, knowledge of how the OCD brain works can help clients step up to the challenge because they now know what they are up against. As they say, knowledge is power. The less we give into what OCD wants us to do, the less power it has over us.
I give examples of my OCD-specific symptoms from decades of living with OCD and how I overcame the need to ritualize even though it felt truly agonizing at times. I remind my clients that with everything that OCD throws at you, it can in no way hurt you. It can only make you feel uncertainty, distress and anxiety. Whatever thoughts you may be having are coming from a misfired message that leaves us feeling exposed or in a state of high alert.
OCD plays a pretty smart game. It finds its way into our minds when we are feeling vulnerable. Our fight or flight response to thoughts makes us feel that something needs to be done or it will only get worse. Part of the battle is knowing that this thought can be challenged, and that means accepting that an adrenaline rush is no more dangerous than a stubbed toe.
If a client comes in for the first time and tells me that they can’t touch doorknobs because of contamination fears, I will have them holding a doorknob by the end of the session so that they will leave having done something they have been afraid to do for months or even years.
When I work with clients who have perfectionist tendencies such as symmetry and order difficulties, I will rearrange my office by tilting artwork, pushing the tissue box halfway over the edge of the table and making other areas of the office look imperfect. They will enter the office, and there will often be an increase in their anxiety. We will sit down and discuss what this feels like and what the OCD wants the client to do.
The client will often say that they don’t like things out of order because it feels strange. I remind them that the OCD is telling them that this feels strange, but that they have a choice. I give them a choice to move things back into place with the caveat that if they do, they are giving validity to OCD’s demands. When they stay with the discomfort of sitting in this imperfect room without engaging the OCD, I want to know their subjective units of distress score (SUDS) from 1 to 10. Often at the beginning they will share that the anxiety might be at an 8 or 9, for instance. As we discuss the cycle of OCD and how it seeks to keep you anxious from feelings of uncertainty and doubt, we revisit that SUDS score throughout the session. By the end, it is rare for their anxiety to have gone up, and often they will see the numbers come down.
At this point I get to discuss habituation (the process of feeling your anxiety come down on its own without needing to engage in rituals). When they experience this for the first time, they are often puzzled and surprised that they went through a whole one-hour session without ritualizing. This doesn’t mean they will go home and seize to ritualize. It means that a seed has been planted to show the client that OCD is effective only if you continue to play its game.
— Jonathan Lukas MFT is a psychotherapist specializing in cognitive behavioral therapy. He is in private practice and runs The OCD Treatment Center of Santa Barbara, working with adolescents and adults with anxiety disorders. Click here for more information or call 805.453.2347.