The behavioral techniques that have proven effective refer primarily to the Exposure and Response Prevention (ERP) model: a real or imagined situation corresponding to the one that produces anxiety or distress is deliberately created, and the performance of the ritual is then prevented or delayed.
This can be understood in two ways: externally directed, meaning that the person is physically prevented from carrying out the ritual, or the circumstances are arranged so that they cannot do so, at least immediately; or self-directed, meaning that the person attempts to develop behaviors whose effect is to delay, distract from, or otherwise prevent them from carrying out the compulsion.
The typical structure of this therapy consists of an initial “intensive” phase, followed by a phase of follow-up or consolidation, with progressively more challenging exercises carried out in real-life environments. The goal is for the person to stop performing compulsions in their natural environment.
There are no large study samples available, but it has nevertheless been possible to establish that the results are consistent and stable over time. These findings must, however, be interpreted in relation to patients who complete the treatment period, which is approximately one in two, and to patients who have voluntarily contacted a psychotherapist while having at least some idea of what the treatment may involve.
Because depressed patients, for example, tend not to seek active involvement—let alone sustained active involvement—in treatment, pretreatment with antidepressant medication has sometimes been suggested for them.
This may nevertheless alter the results, because an antidepressant can itself have an anti-obsessional effect and therefore, in addition to preparing the patient for behavioral therapy, may independently improve the disorder both at baseline and during psychotherapy, regardless of the effectiveness of the psychotherapy itself.
The best, although not the only, candidate for behavioral therapy is therefore a patient who is not depressed, who has overt compulsions that can be addressed through a readily measurable and controllable form of response blocking, and who has one or only a few types of obsessions and compulsions.
The fact that some people request behavioral therapy but subsequently become resistant to it or show little interest in continuing may depend on various factors.
One may be fluctuating severity, whereby the urgency subsides and, with it, the sense that the disorder needs to be treated.
Another may be low individual motivation, or incorrect expectations about how treatment progresses—that is, the fact that treatment requires active participation rather than consisting of a series of exploratory or purely informational conversations.
Furthermore, patients with a more critical mindset, often those who are more educated or intellectually sophisticated, may have difficulty engaging with techniques they perceive as too simple or insufficiently interesting from an intellectual standpoint.
Gradual Habituation to the Obsession
The gradual habituation to the obsession, sometimes referred to as “Mithridatism,” is broadly comparable to ERP, with the difference that in this case the emphasis is less on preventing the response and more on refusing to accommodate the rituals.
The interaction with a therapist or family members who do not accommodate the person’s obsessions therefore initially produces an increase in obsessive tension, which is then followed by a stable and relatively long-lasting reduction in that tension.
This is the mechanism through which many occasional obsessions naturally disappear: they are extinguished because they do not find a solution.
By contrast, finding a ritual provides a mechanism for maintaining and expanding the obsession. The obsession never reaches maximum intensity, but precisely for this reason it is never fully rejected by the brain.
Another technique consists of instructing the person to perform a ritualistic behavior that is inserted into, or added to, the normal behavior, in such a way as to saturate the compulsive mechanism and reduce the brain’s drive toward compulsions.
Treatment-Resistant OCD
Treatment-resistant obsessive-compulsive disorder improves when behavioral therapy is added. The improvement is not decisive—approximately 30%—but it remains stable over the medium term, around one and a half years, when considering all types of obsessions and compulsions and all types of treatments previously attempted without an adequate response.
The Cognitive Perspective
Cognitive theory views the belief in the usefulness and reasonableness of obsessions as a basis for their becoming chronic.
However, it should be noted that a person caught up in compulsions tends to develop an attachment to the obsessions precisely in order to carry out the rituals more effectively, as though they were doing something useful and rational.
The belief in the usefulness of the obsession is often the first bastion to collapse during OCD treatment, with the patient beginning to complain, sometimes with irritation, about their own obsessions and compulsions.
It is therefore as though the cognitive aspect were more a complication of OCD than a primary factor in its origin and maintenance.
Erroneous beliefs about obsessions may therefore be a factor that interferes with insight into the disorder, and consequently with the transition from the idea that one has a problem to the understanding that the problem is being driven by the obsessions themselves.
Psychoeducation
Information about OCD can itself be used as a way of directing the patient toward specific techniques, or of alternating theoretical discussions with practical exercises that are “explained” in light of the discussions held during previous sessions.
This technique, known as psychoeducation, can be applied both before treatment has begun, during treatment itself, and after treatment.
In the post-treatment phase, a person who is doing well may be able to look at the dynamics of their obsessions with greater detachment and consolidate certain concepts without the instinctive resistance typically shown by a patient who is still caught up in the mechanisms of ritualizing and reassurance seeking.
Psychoeducation is particularly useful when obsessions concern not individual gestures or actions, but thoughts about subjects that exist independently in everyday life, such as illnesses, jealousy, relationships with other people, or one’s own mental abilities.