People sometimes make jokes about being OCD or anal retentive or type A and might even see the terms as interchangeable. You might run across articles in popular magazines like Women’s Health that explain the difference between the terms. But despite the term’s popularity as a punch line on sitcoms, it is not a laughing matter.
Simon Rego’s Treatment Plans and Interventions for Obsessive-Compulsive Disorder is part of a series published by Guilford and edited by Robert Leahy that gives therapists guidelines on evidence-based practices for working with clients with specific problems such as OCD, bulimia, depression and anxiety, and insomnia.
Rego does a nice job of explaining just what obsessive-compulsive disorder is and putting it into the context of everyday thoughts and behaviors. Everyone has thoughts and feelings from time to time that, as Robert Louis Stevenson once said, “would shame hell.” With OCD, the person has trouble differentiating themselves from those thoughts, and the level of insight within the person changes over time. At one point, the person may see that it’s just a thought and an irrational one at that, but at other times he or she might be convinced that the thoughts are accurate and be very distressed. Rego also gives a history of the diagnosis going from the days when the person was thought to be possessed to the current revisions in the DSM 5. He includes theories of the cause or causes of OCD and the rationale for treatments.
While many, if not all of us, have intrusive thoughts from time to time and rituals to get us through the day, they generally do not cause us distress. Rego’s discussion of OCD has gotten me interested in the cultural aspects of behavior. For instance, how does religion factor in? I have worked with individuals who converted to Catholicism because the rituals of the Church brought them comfort and reduced anxiety. Confucianism is based on ritual, and the rituals are there to teach you to be able to react in the way of virtue in any situation by rehearsal of ritual. It is a question of when ritual becomes problematic. Are you late to work because you have to check that you locked the door fifty times before leaving? Are you unable to use a public toilet because of fear of contamination? Rego gives examples of people for whom the fears, obsessions, anxiety, and rituals cause them great pain. He points out that in the United States, the lifetime prevalence of OCD is about 2.3%. It is the fourth most common psychiatric diagnosis in the U.S. Even with that commonality, it takes about fourteen to seventeen years for a person to receive an accurate diagnosis and treatment.
The treatment in this manual is based in exposure and ritual prevention, or Ex/RP, and is similar to exposure therapy in cognitive behavioral therapy that is used for conditions such as phobias and PTSD. Rego also references adjunct therapies such at metacognitive therapy, acceptance and commitment therapy, and biological treatments for those who do not respond to talk therapy and/or medication. He does give an overview of medications that have proven effective and gives the evidence as to how that may work.
Rego gives a very comprehensive and detailed guide to working with an individual with OCD. He covers the phone interview before the first appointment, what is included in the evaluation, how to form a treatment plan geared to the individual, and a sixteen session treatment regimen. He has educational handouts on CBT, evaluations, and more that are included as handouts that you can copy from the book or download from the Guilford website. Homework is very important for success in this model, and whether the person does the homework may have more of an effect on the outcome than the number of sessions. Throughout, he emphasizes working with the person in front of you and working collaboratively rather than trying to fit the person into the model. He includes how to do the exposure therapy and includes an optional home visit and how to set that up and carry it out. He is very attentive to confidentiality and ethics throughout. He has a wealth of resources at the end of the book — websites, books and more that clinicians can use both for their own learning and for their clients to use. The final session is on relapse prevention.
He ends with a case study that takes the reader through each session and shows how to work with issues that come up. He also shows how measuring desired outcomes consistently is important in working collaboratively with the person. For example, the person may actually feel worse and lose motivation at the beginning. Ex/RP is based on a person giving up the rituals that have brought them anxiety relief, but in doing so reinforced ritual continuation, which increases anxiety. Sometimes working with the person to help them stick with the process can be a challenge, and Rego includes motivational interviewing as part of this method. Each chapter ends with a “take-home message” and each session ends with “based on what we have accomplished today, what have you learned and how will this change how you live your life?” I like that very much and have begun using it myself with clients.
Treatment Plans and Interventions for Obsessive-Compulsive Disorder
The Guilford Press, April 2016
Paperback, 222 pages