Therapies and treatments outside of CBT with ERP

There are a number of therapies and mental health treatments out there that can help with a variety of things, and that are sometimes suggested or sought out for treatment of OCD.

Apart from medication, Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) is the only therapy type recommended by the National Insitute for Health and Care Excellence (NICE) for treating OCD. This is based on research that has been done, and continues to be done, around what does and doesn’t get results for people who have OCD. This research has shown that somewhere between 70% and 80% of people who engage with CBT with ERP and stick with it find that their symptoms are significantly reduced or even gone completely.

Research on other types of therapy or treatments has not shown a significant reduction of symptoms of OCD, but that’s not to say they can’t be helpful in other ways. Below you can find a description of how these therapies work and what they can be helpful with. For all of these, though, the benefits will not extend to reducing the intrusive thoughts brought on by OCD or helping to control the compulsions.

A likely reason why these therapies don’t affect the symptoms of OCD is that they have a focus on emotions and the self. While OCD does have a strong effect on someone’s emotions and the way they think or feel about themselves, it doesn’t work the other way around – your emotions and thoughts about yourself aren’t causing the OCD to happen. OCD is the result of an obsession – anxiety – compulsion cycle, and while it can be triggered by events or emotions, it is not caused by them. Therefore, emotional relief or understanding is unlikely to cure or treat the OCD itself.

 

But what if I’ve had CBT and it didn’t work for me?

 

CBT is an umbrella term for a more general type of therapy that is based on the connection between your thoughts, behaviours, and feelings. General CBT is helpful for a lot of things, like anxiety, depression, or phobias, but on its own doesn’t usually work for OCD. The CBT for OCD is a more specialised version of it that must include ERP and psychoeducation, which means learning about your OCD. We have other factsheets that can take you through how CBT for OCD works and what it should or shouldn’t include.

Sometimes, though, someone might have had the right type of CBT for OCD and still not see any results. This can be for a number of reasons, but doesn’t mean that CBT won’t work for you. It could be that you didn’t get along with of fully trust your therapist, and so weren’t able to be completely honest about your intrusive thoughts, or that you didn’t engage completely with the homework because it wasn’t the right time for you. It might be that you didn’t get CBT at the right level of intensity and specialisation for your OCD, and need to be stepped up within the NHS care model. It is also possible that the therapy you had helped in a more subtle way, and has made you able to get much better results if and when you go through it again.

Individual CBT with ERP is the ideal when treating OCD, but in some cases other forms of it can be offered.
Web based CBT may be offered for mild to moderate OCD and can be helpful if supported by a mental health worker. This might be offered if there are long waiting lists for individual CBT.
Group based CBT may be offered for mild to moderate OCD and can be helpful if the group is made up specifically of people with OCD. This is especially true if everyone has a similar manifestation of OCD, so that support can be offered in doing exposure within the group session. However there should be a choice if you prefer individual CBT.

 

What are the other therapies out there?

 

Counselling/psychotherapy

There are a lot of different schools of psychotherapy out there, all of which can be great for self-exploration, increasing self-esteem, expressing how you’re feeling, or just having someone there to support you. Living with OCD can be really difficult, and the effects of it on various parts of your life, or even the disorder itself, can bring up a lot of upsetting emotions around shame, hopelessness, guilt, or loss. The symptoms of OCD won’t be improved by attending counselling or psychotherapy, but it can be helpful in exploring or coping with some of those emotions.

Often people will be referred for counselling or psychotherapy no matter what mental health issue they are being seen for. This is most likely because even mental health professionals aren’t always aware of the best practice recommendations for every single condition. Showing them the NICE guidelines for OCD (which you can find on our website) can help you get a referral to the appropriate therapy.

 

Psychoanalysis/Psychodynamic therapy

Psychoanalytic therapies focus on looking for the roots of current issues in your past experiences, like why you might always play the same “role” with certain types of people or in groups. We know through both research and hearing about the experiences of people with OCD that finding out what caused your OCD or why your intrusive thoughts are around specific topics doesn’t bring people closer to recovering from it. Some people know or have a theory about where their OCD started, and this might help with how some people feel about their OCD, but it does not have an effect on their symptoms. Other people don’t have an idea or any interest in what the “cause” was or don’t think there was one. Research has found that around 40-50% of OCD is genetic or heritable, which this approach wouldn’t be helpful with.

 

Cognitive Analytical Therapy

CAT is a combination of CBT and Psychoanalytic work, which looks at how past experiences affect current ones within the context of looking at the connections between thoughts, behaviour, and feelings. It can be useful for self-exploration or understanding yourself better. Like with psychoanalysis, one issue is that looking at the past doesn’t help treat OCD. The other issue is that, being based on generalised CBT, the lack of exposure within this treatment also means the symptoms of OCD aren’t being treated.

 

Eye Movement Desensitisation and Reprocessing

EMDR is a therapy used to treat the symptoms brought on by traumatic experiences, such as PTSD (Post Traumatic Stress Disorder). These symptoms are brought on by the experience not being recorded into the brain as a memory, so that the brain and body react to it as if it’s still happening, even years later. This therapy works by helping the brain to process the experience and turn it into a more ‘normal’ memory. It can still be painful and scary, but it will feel like it happened in the past rather than the present.

Some local therapy services have recently been referring people with OCD to EMDR, but this is due to a lack of understanding around how OCD works. Some people believe or know that their OCD is partially resulting from trauma, but even in a case in which a traumatic experience has brought on the OCD, what is happening neurologically (in your brain) is different for OCD than the issue described above that EMDR works to resolve, so EMDR wouldn’t reduce the symptoms.

In some cases, where intrusive thoughts include images related to traumatic memories, EMDR or similar techniques can be helpful as a part of CBT with ERP, but not by themselves instead of it. In these cases, the EMDR is not treating the symptoms of OCD, but rather reducing the emotional impact of the intrusive images.

 

Dialectical Behaviour Therapy

DBT is a very specialised style of CBT that is used to work with people diagnosed with Borderline Personality Disorder. This therapy is based on intense levels of reliability and challenges to the person attending it. So far research doesn’t show that this helps with the symptoms of OCD.

In some cases, where issues around impulsive behaviour or difficulty with tolerating emotions interferes with CBT with ERP, taking part in DBT can help someone be in a better place to engage with CBT with ERP. In these cases, the DBT is not treating the symptoms of OCD and it would still be important to take part in CBT with ERP afterwards in order to do so.

 

Hypnotherapy

Hypnotherapy makes use of altering the client’s state of mind through hypnosis, and is considered a complementary therapy because there is no strong research based evidence to suggest that it helps with mental health issues. Some people have found it very helpful with emotional problems or breaking habits.

Because it is used in helping to break habits, some people use it or recommend it for people with OCD. By taking part in compulsions, a person with OCD increases the strength of their intrusive thoughts bit by bit, so hypnotherapy could be used as a management or coping tool to slow down this cycle, but there is no evidence that it will reduce it.

 

Mindfulness

Mindfulness is a technique that uses focusing on the “here and now” and being very aware of what’s happening in your mind, body, and emotions, to ease symptoms of mild anxiety or depression. Being more aware and focused on these things can help someone react differently to things.

A person with OCD will act out compulsions to ease anxiety, and this increases the strength of their intrusive thoughts bit by bit, so mindfulness could be used as a management or coping tool to slow down this cycle, but there is no evidence that it will reduce it on its own. Some of the principles of Mindfulness, such as noticing thoughts without engaging with them, are included within CBT with ERP.

 

Intense treatment/commercial courses

There are a few private services that advertise intensive courses that will cure or reduce OCD in a few days. Because these private centres do not make their data public, we have no way of knowing how many of the people who attend them actually get better. Often, these courses use a lot of the same techniques and structures as CBT with ERP, but also include their own additions or edits of these. Usually, the people running them don’t have the recommended medical or mental health qualifications. Some of the people we have spoken to who have tried these without success have said that the lack of time to build up the challenges and let the “learning” sink in might be the reason why it didn’t work for them.

Intensive treatment is sometimes available through the NHS or with accredited private therapists, and have found to be successful in the appropriate cases. In order to determine whether an intensive course would be appropriate for someone, they should go through a careful assessment with someone experienced on OCD.

 

What about neurological interventions?

 

There are three types of neurological intervention that have been researched or used as treatment for OCD, these are Lesion Surgery, Deep Brain Stimulation (DBS), and Transcranial Magnetic Stimulation (TMS).

 

Lesion Surgery

Lesion surgery has been around since the 1960s as a treatment for the most extreme cases of OCD. This involves interrupting a brain pathway or ‘circuit’ by destroying a part of it. This can be done by drilling into the skull and using intense heat, or through the use of radiation. Studies on the positive and negative effects of this type of surgery show it to be both safe and beneficial.

Lesion surgery is offered in the UK through the NHS, but only to the most extreme cases. In order to be considered for this surgery, a person must have taken part in multiple trials of both medication and CBT with ERP from specialist and intensive services, and their OCD must be significantly debilitating.

 

Deep Brain Stimulation

DBS is a form of neurosurgery that has been historically used to treat Parkinson’s disease and is now being researched as a treatment for OCD. This surgery involves the insertion of thin wires into specific areas of the brain, which are connected to a battery pack placed in the chest wall, and which stimulate specific areas of the brain. The National Institute for Health and Care Excellence (NICE) states that current findings are not yet strong enough to say whether this is a reliable treatment, but also that experts are seeing more and more evidence towards this. DBS is very expensive, easily costing around £250,000.

DBS is not currently available for OCD in the UK, apart from within ethically approved research studies. In order to be considered for such studies, a person must have taken part in multiple trials of both medication and CBT with ERP from specialist and intensive services, and their OCD must be significantly debilitating. There are currently no such studies happening.

 

Transcranial Magnetic Stimulation

TMS is currently used to treat migraines and depression, and is being explored as a possible treatment for OCD. TMS involves placing powerful magnets to the outside of the skull in order to reduce activity in specific areas of the brain on a temporary basis, and repeating this regularly for a specific number of sessions. Aspects that are still being explored around applying this to OCD are the possibility that stronger magnets might need to be used to penetrate deeper into the brain and what frequency and number of sessions needed for lasting results would be.

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