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Key points
- ERP is the gold standard for OCD treatment, and talk therapy can in some cases worsen symptoms.
- Still, for some with OCD, ERP without talk therapy is not enough, or leaves them feeling misunderstood.
- Both/and thinking enables the use of competing theories to creative a more powerful synthesis.
- Integrating approaches like internal family systems therapy could help return you to the center of your story.
If you have obsessive-compulsive disorder (OCD) and have sought treatment for it, you may have encountered the following scenario:
You tell your therapist about an obsession du jour and hope to talk further. Maybe you're curious to explore a connection to your trauma or relationship history or just need witnessing to make meaning out of confusing thoughts and feelings. Yet just as you start to share, you're met with:
"Remember, obsessions don't mean anything, and it's not helpful to provide reassurance. The real question is: Are you willing to just accept whatever you fear about your OCD today?"
With that, you suddenly remember treatment protocol: Talking through obsessions isn't part of exposure and response prevention therapy, or ERP, the gold standard of OCD treatment. For some, this reminder is useful. Yet for others, having their attempts to share seemingly rejected triggers shame and disappointment; they may feel distant from parts of themselves they sincerely wish to clarify.
Is Talk Therapy for OCD a Waste of Time?
There are important reasons a lot of OCD specialists don't quickly endorse talk therapies. Research has found they certain types can be particularly ineffective and countertherapeutic and often delay many from receiving the care they truly deserve.
ERP springs from the core belief that OCD is meaningless chatter, full of sound and fury, signifying nothing. What's to talk about if your psyche is just a "Seinfeld" show about nothing? Talking about obsessions, the theory goes, just gives them more ammunition.
Yet in the course of my work, I have heard from several people with OCD who feel the talk therapy taboo has prevented them from truly finding relief. As one OCD sufferer put it:
"ERP helped me so that when I feel like sh*t, I don't engage in compulsions. But at the end of the day, I still feel like sh*t."
Happily, it's not so all-or-nothing as the old days when talk therapy for OCD was seen as doing more harm than good. Recent clinical work shows that certain talk therapy modalities, like the evidence-based psychotherapy known as Internal Family Systems, can be quite responsive to the person left hanging in the scenario above.
Even more exciting, the OCD community is beginning to embrace the integration of IFS with ERP for OCD treatment. Consider that the highly popular podcast "The OCD Stories" features three well-regarded therapists in the field of OCD treatment (Melissa Mose, Rob Fox, and Charlene Colwell) doing just that.
Although more research is needed to determine if and how much talk therapies like IFS help OCD, there are promising early indicators. Because of its gentler and more compassionate approach, IFS could perhaps help the nearly 20 percent of clients who drop out of ERP (Ong et al, 2016) stay the course. It might even attract those with OCD who decline ERP in the first place (Begley, 2018).
One More Time With Feeling
Although ERP is an effective short-term strategy for OCD, its strong suit isn't processing the shades of emotional gray so prominent in talk therapies like IFS. Like a popular break-up song by The Raconteurs, ERP is quicker to see many shades of black in talking about your OCD, but what if those shades of black—found by uniting ERP with IFS or another type of therapy—are the parts of the story necessary for full healing?
ERP without talk therapy leaves some OCD sufferers feeling alone or in a kind of limbo. Barred from sharing what's deep in their hearts with their therapists, family, friends, or romantic partners—lest they commit the cardinal sin of reassurance-seeking—something festers inside. Some blame themselves; after all, if the gold standard treatment isn't working, it must be their fault, right?
Why Talk Therapy Can Be Powerful, Even for OCD
The power of talk therapies, including IFS, derives from feeling seen and heard, companioned in the darkest places so that you're not alone in the penitentiary of your mind. It helps you connect with contradictory aspects of yourself so you arrive at new understandings of who you were and are only now becoming. In the case of OCD, you can even befriend your disorder itself so you can engage it with mindful curiosity and compassion.
I argue that ERP and talk therapy can be compatible in some cases. Aligned with the both/and thinking that won management thinkers Wendy Smith and Marianne Lewis the Thinkers 50 Breakthrough Award for their book Both/And Thinking: Embracing Creative Tensions to Solve Your Toughest Problems, I take a hopeful view that solutions to impossible problems emerge by embracing contradictory truths.
A Both/And Approach to OCD
Treating OCD from both a behavioral and talk therapy perspective can be possible. On the ERP side, OCD is meaningless, overexaggerating concerns about cleanliness, order, control, responsibility, health, or harm. On the talk therapy side, OCD is meaningful, providing valuable feelings and thoughts waiting to be integrated, precisely what therapy is set up to do. IFS, in particular, views OCD as either an exile—a part of self that has been traumatized and wounded and needs to be cut off—or a firefighter, a side of self that activates in an emergency to keep this exiled part from coming into full awareness.
Like a magician, OCD performs a unique both/and sleight of hand. OCD sufferers are distracted from the trick's secret, yet they persist because they want to learn how the trick is performed. Both the magician and the audience, OCD sufferers are in a unique predicament, and it takes subtlety and skill to work the both/and sides of OCD as a clinician.
An overconcern with contamination, for example, might distract from a crucial emotional focus: a need for clearer boundaries, a fear of being overwhelmed, or another unique "trick" we only glean by clarifying your unique story. In a prior article ("Why the Anxiety?: Befriend Your OCD and Get Back to Yourself"), I showcased how a health concern can be both a distraction and an area of renewed focus, neatly in line with both an ERP and IFS perspective.
You Deserve to Be the Hero of Your Story
ERP highlights the need to take cognitive and behavioral risks to face your OCD fears (i.e., thinking and acting in a new way toward your OCD). Talk therapies like IFS can enable you to take emotional and relational risks in entertaining the fuller narrative of your OCD.
The best part, in my view, is that you become the hero of your story again. Like Odysseus, Katniss from The Hunger Games, or Harry Potter, your OCD has you temporarily leave home to new places. And, yet, by mining your adversity, you find yourself changed and the same, once again.
This is the unique magic that could be found by integrating the talk therapy of IFS with OCD. I am hopeful, that with more study and deeper listening, we'll see more clinicians embracing it to keep the people with OCD square in the center of treatment.
References
Begley, S. (2018). CAN’T JUST STOP: An investigation of compulsions. Simon & Schuster Paperbacks.
Ong, C. W., Clyde, J. W., Bluett, E. J., Levin, M. E., & Twohig, M. P. (2016). Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say? Journal of Anxiety Disorders, 40, 8–17. https://doi.org/10.1016/j.janxdis.2016.03.006
Smith, W. K., & Lewis, M. W. (2022). Both/and Thinking: Embracing Creative Tensions to Solve Your Toughest Problems. Harvard Business Review Press.
