The Importance of the Therapeutic Relationship in the Treatment of Obsessive Compulsive Disorder

I started treating OCD somewhere between 1-2 years ago. After discovering that it runs in my family, I became interested in how the treatment works and why exposure and response prevention (ERP) is almost always pointed to as the gold-standard treatment. I’d never been very interested in Cognitive Behavioral Therapy (CBT) modalities prior to this time because they struck me as automated and less personal than more relational or insight-focused types of therapy. I’d like to share more of what I’ve learned since I’ve begun treating clients with OCD about how important the therapeutic relationship actually is.

To have some background, our training doesn’t do much to help us identify OCD in clients. Recently, as I was “Konmariing” my office with the rest of America, I came across my old (OK, really old) “abnormal psychology” paperwork. Sure enough, I found the criteria for OCD, indicating that I did actually cover OCD in school. But what this class did not do for me, was to make OCD real in a way that I could understand how it shows up for people, and how I might identify it in clients.

Here is how the IOCDF.ORG website (an incredible resource) defines OCD:

“Obsessive Compulsive Disorder (OCD) is a mental health disorder that affects people of all ages and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images or urges that trigger intensely distressing feelings. Compulsions are behaviors an individual engages in to attempt to get rid of the obsessions and/or decrease his or her distress.”

What this description and the description I found from my old notes don’t indicate is how incredibly terrifying the obsessions can be for people who suffer from them and the intense responses that result. People with OCD can be in the middle of fight, flight, or freeze responses over and over and over, without relief. Many fears can’t be avoided as they often can with phobias, because it is thoughts that are driving the pattern.

Another very important point these brief descriptions omit is that many types of OCD include “non-observable” compulsions. The does eventually go more into the type of mental compulsions I’m addressing here, which can include a sort of “heavy analysis” or excessive attempts to “figure out” an obsessive problem or situation. Here is an example. A common theme in OCD includes the obsessive thought: “What if I am a pedophile?” Importantly, this is in the absence of any actual inclination to behave as a pedophile. However, the obsessive thought feels real and terrifying to the sufferer. The compulsion arises as attempts are made to talk oneself out of the obsession. “But I’ve never wanted to hurt a child… But I love my baby…But I’ve always enjoyed children…” All these rationalizations can be countered by very creative “What ifs…”, such as “What if I am a pedophile and I’m just realizing it now?” Or the very clever: “What if I’m in denial?”. In addition to the mental compulsions/rationalizations, a sufferer might start to avoid children. This is especially sad when we think of a new mother or father avoiding their baby. To increase the isolating nature of OCD, it is not hard to imagine someone feeling hesitant to tell their therapist: “What if they report me to CPS and I lose my child?” This is a very common theme, and so common in the OCD world it is called “pedophilia OCD”, or pOCD.

Sometimes obsessions can center around more typical life problems, such as in romantic relationships (rOCD). Some sufferers worry about whether or not they are attracted to their partner. They might find themselves unwillingly focused on a perceived imperfection, then begin to try to talk themselves out of this concern. Hours can be spent in worry about if they love their partner. This issue can also bring up feelings of guilt, which the client might think will be relieved if they confess to their partner about their struggle, thereby causing the partner confusion.

Anxiety tends to be about avoidance. If I have an unpleasant feeling, I avoid that thing that I think caused it. With OCD, the difficult thought/obsession creates an unpleasant (often terrifying) feeling. The compulsion is one’s attempt to neutralize the difficult feeling and thought… and it might work initially. However, as the distressing thoughts continue to arise, more compulsive attempts are made to try to neutralize the thoughts and feelings. Over time the OCD takes on a life of it’s own.

This is where exposure and response prevention (ERP) comes in. With ERP, and the gentle help of a therapist, the client gradually “exposes” him/her/themself to the distressing thought and feeling. This experience can be both terrifying and exhilarating for clients after they have been trying to suppress the thoughts and feelings, often for years (on average it takes 14-17 years for OCD sufferers to find the support they need). The therapy process can be incredibly liberating for clients and very rewarding for therapists as clients reclaim their lives.

So what I’ve learned through treating OCD using ERP is because I am asking people to do things that cause them to feel like their lives are going to fall apart, the therapeutic relationship is crucial. A metaphor is often used for OCD that says that being in the middle of an OC cycle is like standing on a train track with a train coming toward you, but you are the only one who can see it. This is a terribly isolating picture. Consider how comforting it would be to have a therapist to step into that world with you.

 – Lucy Grantz, LMFT









The above article is a Letter to the Editor. Opinions expressed in the MAMFT NEWS do not necessarily reflect the opinions of the Editors or of MAMFT.