How Much Is Too Much? (Taking a more humane approach to behavioral therapy)

By Fred Penzel, Ph.D.

Following a panel discussion entitled “The Ethics of Exposure: When and Why to do ERP, And Is There Such a Thing as Too Far?” at the International OCD Foundation’s 2009 Annual Conference in Minneapolis, it seemed to me that this was a topic that merited some follow-up in the IOCDF’s newsletter as a matter of importance to OCD consumers. Although I kept a record of what was said, I neglected to note who said what, so I will simply credit the panel members, Drs. Patrick McGrath, Charles Mansueto, Jonathan Grayson, Robin Zasio, Eda Gorbis, Alec Pollard, Lisa Hale, and Brad Reimann with having contributed some of the points I will be mentioning here. This isn’t a transcript of what was said; rather, I will simply discuss the issue in a more organized way, together with some thoughts of my own.

The whole topic of how behavior therapy for OCD should best be conducted is an important one. Behavioral therapy (BT) for OCD first began with the publication of Victor Meyer’s 1966 study, which was a single case report in the journal Behavior Research and Therapy. Since then, the field has greatly expanded, with many different professionals weighing in with their studies and views on how therapy should best be conducted. Behavioral therapists do not all work from the same ‘cookbook.’ They each put their personal stamp on a set of accepted principles. What we have now is a whole range of individual approaches to BT, varying from the conservative to the more radical.

The overarching concept behind what we do in behavioral therapy for OCD is this: That sufferers can learn to overcome their fears by gradually facing those fears and by challenging their theories about what will happen if they do. There is no way someone can overcome anxiety without facing it in one way or another. The question here is how they can best do this – i.e., how far to go in facing fears, and how rapidly it should be done. This is not a matter to be taken lightly, as it can spell the difference between success and failure for each patient.

For example, a new patient related to me how he had dropped out of his previous treatment after the first exposure session. He had been taken out into the community for the first day of what was to be a three week course of intensive treatment. The therapist was a fairly new one, and she asked him to touch several things in a public place. He recounted, “The things she asked me to touch were right at the top of my list of fears, even though this was our first treatment session. I did what she said, even though I was totally freaked out. I wanted to say something, but since she was my therapist, I didn’t think I should be telling her how to do her job. I decided to not go back the next day. It took me several days afterwards before I could calm down.” While it could be said that this was simply a mistake on the part of a novice therapist, it also highlights a more important issue: Therapists relative to patients are in a position of authority. They have power and influence in the therapist/patient relationship. Patients are paying the therapist, willingly putting themselves in their hands, and hoping to get approval and positive feedback about their progress. This authority, like all authority, can be misused, no matter how well-intentioned. While it is true that patients have some shared responsibility for their own treatment and should ideally give the therapist feedback, some may not have the confidence or assertiveness to question or challenge what they are being asked to do. This is because they may be in a state of depression, be distracted by their thoughts, be in an anxious state, or feel weak and poorly about themselves. It is also the responsibility of the therapist to be able to read the patient and create a treatment plan that is practical and realistic for that particular person and tailored to his/her specific needs. Therapists can push patients too far in different ways for a variety of reasons. Inexperience is the most obvious one, and possibly the most common. Other reasons might include a kind of zeal and perfectionism about treatment where they feel they have to go in with all guns blazing. Some may even take a strange kind of pride in being more radical and creative than other therapists. They may even brag to colleagues about how far they have gone with patients. Others may simply be insensitive to patient distress or have poor clinical judgment.

What is being advocated here is for therapists to take a reasonable and humane approach. It all begins with good training and supervision of therapists in training. Beyond this, there are several other points that should be made here. The importance of the proper assessment of patients cannot be stressed enough. Only by making a careful behavioral analysis of each patient’s symptoms can we know exactly what we are treating, the circumstances, the function of each symptom, and the severity of each symptom, both individually and relative to all other symptoms. One of the reasons we do this is to be able to create a rank ordering of symptoms from the lowest level to the highest. Therapy tasks are then drawn from such a list. The goal in treatment is to gradually build feelings of success and effectiveness as patients work their way up the list, and see that they can gain control over their disorder. Guiding patients to then work on their tasks is the next step, and it is a crucial one. There is a fine line between encouraging someone who is merely overcautious, and pushing someone who simply isn’t ready to do something. This should be done with finesse rather than brute force or coercion. It could be seen as the difference between attacking the problem with a scalpel versus a sledgehammer. It also calls for creativity and even humor at times. By this, I don’t mean being creative in going further than any other therapist. It is creativity in finding exposures that are the most efficient and intelligent, and that cause the patient to face no more anxiety than is really necessary. It is creativity in pacing the patient’s overall therapy, from the first exposure to the last. It is why we don’t begin to teach people to swim by throwing them into the deep end of the pool. Therapists should focus on the difference between graduated exposure and sudden total immersion, although a kind of gradual and total immersion is the ultimate and long-term goal. There are times when negotiation with patients is called for, as a way of gradually approaching therapeutic goals. Patients, after all, need to be partners in their own treatment and should always be regarded as such. If something cannot be done in one step, perhaps it can be divided into two or more. Therapists should be asking themselves, “What are all my options? How can I do the most with the least?” If it appears, at first, that a fairly high-level exposure or one that the patient is reluctant to do is called for, the therapist needs to consider, “Is there some other way? Is there another way I can get the patient recovered without this?” If there genuinely is no other way, this must be clearly explained to the patient. This does not mean that therapists must be timid or hesitant when it comes to treatment. There are clearly times when boldness and decisiveness are called for, but these must be guided by logic and judgment.

Some particular areas of OCD treatment that need to be handled with care would include:

• Religious scrupulosity
• Thoughts of harming others (morbid obsessions)
• Obsessions about suicide
• Compulsive perfectionism (when directed by the patient at their own treatment)

When treating religious scrupulosity, we walk a fine line between giving effective assignments and infringing on people’s deeply held beliefs. It can sometimes help to get advice on this from religious authorities. In the case of treatment assignments for murderous or violent thoughts, we must beware of how much risk we are asking patients to take with themselves or others. Suicidal obsessions must be carefully assessed so the therapist can determine that they are merely obsessions and not symptoms of a concurrent major depression. Certain patients need to be protected from themselves. They may have doubtful obsessions telling them that if they do not do therapy perfectly, they may never recover. This can sometimes lead them to go to extremes of their own in doing assignments, sometimes going way beyond what was intended by the therapist. This needs to be recognized in patients, and they usually need to have their assignments clearly spelled out for them, with limits clearly defined. They may even have to be exposed to the obsessive thought that they are doing therapy imperfectly and will therefore not recover.

Let me conclude by saying that beyond our main principle of doing patients no harm, there are several other principles that therapists might want to consider including as part of their approach to treatment. These would include:

• Never ask a patient to do anything that might humiliate them.
• Do not ask patients to do anything that would violate the true principles of their religious beliefs. Do not hesitate to get advice from religious authorities on these matters.
• Do not use a more extreme approach if a less extreme one is available. If possible, try to divide up tougher assignments into manageable bites.
• Before asking patients to do something, be sure to first determine if the patient is ready or willing to do it.
• Give patients choices and encourage them to be partners in their own treatment, rather than simply dictating to them. They are more likely to carry out assignments that they have had a hand in choosing.
• Don’t do assignments along with patients if doing so would compromise the therapist/patient relationship.
• Overall, be humane and treat patients the way you, yourself, would want to be treated.