Why your Exposure Therapy Didn’t Work
I treat many patients who report they’ve been to an Obsessive Compulsive Disorder (OCD) specialist who used exposure and response prevention (ERP), diligently completed all therapy homework assigned by their clinician, and received no results, dissatisfying results or rebounded to their previous level of OCD within a short period of time following termination.
Rest assured, this is a pattern outside of my personal experience. While the non-response rate to ERP is great compared to other treatments, it remains that 14-31% of clients do not respond to treatment. Even more alarming than this statistic is that 50-60 percent of clients report undergoing at least a partial relapse after treatment!
Over my years of treating hundreds of patients, reviewing well established research of the past 15 years, and receiving guidance from some of the most brilliant OCD specialists of our time, I am confident as to why there are so many cases where exposure therapy didn’t work and what can be done to remediate this pattern. OCD treatment is so effective because we’ve created a brilliant form of therapy for it. OCD treatment is falling short because we are implementing the treatment in not just an unoptimized, but a problematic way.
Emotional processing theory: Well intentioned and outdated
This happens a lot in the field of healthcare. Famously, many medications were developed not because scientists knew exactly how or why they worked, but rather discovered that they do work, and afterwards developed theories as to why. Sometimes the initial theories are correct and sometimes they are not. The research for years now has frequently shown that the model that was developed to explain why ERP is effective has many holes in it.
If you’ve gone through unsuccessful ERP based treatment, you were probably taught how it works along the following lines: The root of OCD is that a broken alarm plays in the brain, warning against a proposed danger, and the OCD sufferer responds to that signal with distressed reaction (compulsing). This is treated through exposures, where the client resists the urge to compulse when they are triggered. As a result of doing so, the client unpairs the brain’s connection between the OCD theme and distress and the distress goes away.
The problem is, this rationale has long been disproven. A number of studies show that:
Habituation is not related to treatment outcome
Complete habituation is not often possible
If the patient’s OCD theme switches, the client will have to start from square one as habituation to a former theme would not apply to the new one. (This point in particular may be why relapse after OCD treatment is so high).
Along with these fallacies comes another issue. Placing pressure on the exposures to reduce distress makes them more likely to become targets of obsessions. Clients become more likely to obsess that they are doing exposures incorrectly and that their distress will never die down, and develop compulsions around their exposures, such as doing them more frequently, to try to assuage that fear. Of course as all compulsions do, this only makes the OCD worse.
Lastly, the ERP model reinforces the maladaptive concept that anxiety is bad and undesirable. As with many thoughts and feelings, the more power we lend a concept by dreading it, the more likely it will be to pop up.
So all hope is lost: ERP has a huge relapse rate and the theory used to explain it is built on a flimsy premise, right? But wait a minute! ERP still works- it has amazing success rates- even though EPT clearly doesn’t explain why. If we can figure out what is really fueling the effectiveness of therapy and focus on that, we can take a great treatment and enhance it even further.
Along comes Inhibitory Learning Theory
ILT is by no means a new and untested theory. A landmark paper on ILT for OCD was written back in 2008 and since then this approach has gained more and more support, with some of the most reputed OCD researchers of our time contributing to its development. A quick academic search of OCD treatment articles written in the last ten years will find a trend of enthusiastic support for this theory. Sadly, as with much of the healthcare world, there is a sizeable gap between research and practice. As a result many modern practitioners have not even heard of this years old shift in theory.
The premise of ILT is built around fundamental truths in psychology. New learning does not replace past learning. When we learn new ways of relating to our OCD themes through ERP, we don’t erase our previous associations with it.
Here’s a metaphor: I used to have a contentious view of my dad, but now we have a great relationship. Our present relationship doesn’t make me forget the difficulties we had in the past: occasionally my dad will say or do something that elicits difficult feelings in me that used to be more frequent in our relationship, but this distress is no longer the default response. Instead, the closeness I have with him today is the louder of those two voices.
The same goes for treatment of OCD. Because someone with OCD has a broken alarm system in their brain, they may always have a predilection to experience a false alarm that something is wrong. However, through exposures they can learn a new way of relating to those signals that becomes the default response they naturally turn to.
By structuring the ERP to work in this way, we can expect much more consistent results. No longer do we view the results of therapy as dependent to a variable that we are not in direct control over (our emotions). Instead, the goal of therapy is very logically within our grasp: it is about establishing a healthier relationship to anxiety by learning how to relate to it in a different way. When we learn to ascribe irrelevance to the brain’s broken signals by not responding to them, we rob those signals of any power or influence they have over our lives. The end result is practicality the same as if the distress was abolished: a patient’s life goes on unaffected and untarnished by the OCD signals. They become empowered to navigate throughout life as if the signals never existed.
So there you have it: the theoretical underpinnings as to why EPT is maladaptive and how ILT fixes those holes. Next I will discuss what concrete changes can be done to the implementation of ERP to reflect this more effective theoretical underpinning.