People with OCD Prefer Exposure to Alternative Treatments

Mad in America published a summary of a recent study that surveyed people with OCD about treatment preferences. I spent the last hour trying to track down a copy of the actual research article, which has not been officially published yet, but I was unable to locate a pdf and read it myself.

One of the authors is Dr. Helen Blair Simpson, whose brief information video about OCD is a good one.

The study

The researchers surveyed 216 people with OCD about their treatment preferences. Most people preferred Exposure and Response Prevention (ERP) as a 1st line treatment. The 2nd most popular treatment was serotonin reuptake inhibitors (i.e., antidepressants). Based on how the abstract was worded, there may be no statistically significant difference between preference for ERP (55%) and preference for antidepressants (45%).

Interestingly, people who preferred antidepressants were more likely to have higher income, private insurance, and a longer history of OCD treatment. According to the Mad in America article:

The researchers theorized that this may be due to this group having “received high-quality psychiatric care that afforded them the time and attention to discuss and resolve concerns about medication.” That is, people without these resources may have had poor experiences with medication management in which they felt pressured or their concerns were not heard. Psychotherapy may have provided an approach tailored to their individual concerns, making it more desirable.

People with OCD didn’t want antipsychotic drugs

People with OCD already taking antidepressant medication preferred ERP as an adjunct treatment over augmenting the antidepressant medication with an antipsychotic. In a prior post, I wrote about research that suggested that antipsychotics were not a useful adjunct treatment for OCD.

Acceptance and Commitment Therapy (ACT), an evidence-based treatment that we offer, was also well received among alternatives to ERP and medications. In a prior blog I used to write for, I wrote about a study on the use of ACT for OCD without deliberate exposure, and OCD researcher Dr. Michael Twohig has a page about ACT and OCD on the IOCDF website.

One theme that stood out to me reading about the study was how well-informed the sample of people with OCD is. Their preferences are remarkably consistent with current research about OCD treatment.

You can read the Mad in America article here, and an abstract of the research study here.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website, where I described how I use Acceptance and Commitment therapy to help enhance exposure and response prevention.

The Importance of Treating OCD Earlier: The Washington Post Article on Ethan’s Struggle from Childhood OCD through Adulthood

In people who develop obsessive-compulsive disorder, there are often signs in childhood. However, OCD in children can be hard to distinguish from childhood fears and age-appropriate magical thinking. For OCD Awareness Week, The Washington Post published an article by Sarah Maraniss-Vander Schaaf about the experiences of Ethan, a young man who developed OCD in childhood. It’s an effort to help people look past the stereotypes of people with OCD as being excessively clean and organized or washing their hands excessively. As the writer notes:

“…true OCD is often unspoken. It’s hard to recognize, as well, when growing up in a family where anxiety is normal, or in a school where behavior might be labeled school avoidance, or when no one else talks about the secret rituals that are too private to mention.”

The article traces the development of Ethan’s OCD from early childhood, though college, and the following decade of adulthood. It documents how OCD obsessions and rituals can escalate when left untreated and unchecked, and it provides a sober illustration of how the accommodation by the loved ones of someone with OCD’s obsessions/rituals—however well-meaning—can have disastrous consequences over time.

I’ve written in other posts about how some people with OCD have difficulty accessing appropriate treatments. Ethan was eventually accurately diagnosed and offered effective treatment, but it took several attempts before he was fully willing and able to engage treatment. He was even kicked out of OCD Institute at McLean Hospital, one of the leading residential treatment programs for people with OCD. Ethan didn’t recover from OCD until he was willing to commit to proper treatment—particularly exposure and response prevention. Ms. Maraniss-Vander Schaaf writes:

His improvement came when he accepted CBT and Exposure Response Prevention (ERP). He was taught to develop a new relationship with his thoughts. He learned to live with the uncertainties of life and not push away anxiety with obsessive-compulsive thoughts and actions.

Ethan’s story is inspiring as, even after 2 decades of struggling with severe OCD, he is currently enjoying a productive and independent life. As I work with adults, I don’t often have a full view of how OCD progresses across the lifespan in the clients I see. I found this article of Ethan’s personal journey into OCD illuminating in how it presents a narrative of someone’s struggles with OCD across more than 2 decades, and the way OCD symptoms can change, transform, and evolve over time.

You can read the full article here.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website.

If you want to learn about OCD, here’s post about a great introductory book, Tompkins’ OCD: A Guide for the Newly Diagnosed.

The Difficulties of Accessing Effective Treatment: OCD as an Example

I resonated with a recent article in Psychology Today about the difficulties people have in finding therapists who offer effective treatment. The authors Dean McKay and Scott Lilienfeld—especially Dr. Lilienfeld—have been extremely active in promoting science-based psychotherapies.

As an example, they offer the experience of “Jerry” (a pseudonym). Jerry struggled with obsessive-compulsive disorder (OCD). Having educated himself on OCD, Jerry knew that exposure and response (or ritual) prevention (ERP, for short) was the most researched and effective treatment for OCD. ERP involve systematically helping people with OCD learn to confront obsessions while resisting the urge to engage in compulsions or rituals.

Despite living in a major city, it took Jerry 3 years to find a therapist who offered and was proficient in ERP for OCD. Jerry’s experiences are similar to those of a Yale graduate student with OCD.

Many clients I’ve seen have similarly struggled. Some were misdiagnosed by prior therapists and did not even realize they had OCD until they did their own research. Some therapists correctly identified them as having OCD but when it came to treatment, they “just talked.”

Most people with OCD with whom I’ve worked have seen at least 1 or 2 therapists who have not been particularly helpful. Hair pulling (trichotillomania) and skin picking (excoriation) are two other problems that people with whom I’ve worked have struggled to find effective treatment.

The article by Drs. McKay and Lilienfeld provides a sober reminder that there are a number of people who would benefit from effective treatments such as ERP but cannot find therapists who practice it or are aware enough of their competency to refer out to a specialist. Unlike Jerry, many people with problems such as OCD, trichotillomania, and excoriation don’t even realize there’s a name for their struggles, let alone effective treatment, and they may drift in and out of therapists’ offices being misdiagnosed and receiving substandard treatment.

Drs. McKay and Lilienfeld recommend that:

The adoption of the new clinical practice guidelines is probably our field’s best hope for placing long overdue pressure on therapists to incorporate scientifically based approaches into their clinical practices. Practice guidelines would also assist mental health consumers with the daunting task of selecting more effective treatments.   


Sadly, there are many licensed therapists who do not believe in science-based approaches. For people with mild to moderate depression/anxiety, generic talk therapy and nonscientific approaches can offer some relief. For people like Jerry with OCD, these unscientific approaches are unlikely to be of much help.

I’m inspired that psychologists such as Drs. McKay and Lilienfeld take time from their busy schedules as full-time professors and respected researchers to promote scientific approaches. You can read their blog post here. I encourage readers to carefully research the therapists you or your loved ones see, and not to stay in therapy with someone who doesn’t seem to be very helpful.

Ketamine for OCD, Too?

I’ve written in the past about the use of a pharmaceutical version of the drug ketamine (known as the party drug, “Special K”) in studies with depression and with bipolar disorder. Recently, I learned researchers have published a new study looking at the impact of ketamine on obsessive compulsive disorder (OCD).

I was on the phone with someone interested in OCD treatment, and she mentioned she had read some promising work at Yale about an experimental treatment that involved increasing glutamate levels in people with OCD. Glutamate is a neurotransmitter in the brain. Ketamine affects NMDA, an important receptor for glutamate, leading to lower levels of glutamate in the brain. I told the caller I wasn’t familiar with this line of research, and she kindly sent me a few links, including the one below.

The IOCDF article
The International OCD Foundation (IOCDF) has an article on their website about the potential role of glutamate in understanding OCD, under the subheading, “Cutting Edge Research on New Medication Options.” It’s written by three doctors associated with Yale University. The authors summarize some research finding higher levels of glutamate in the brain in people with OCD. Although they acknowledge important caveats about what is known about glutamate so far, the authors end the article with pointing to ketamine as a possible treatment for OCD.

The article is reasonably balanced, but at the time it was written, there was no published research on the use of ketamine in people with OCD. A study from 2012 suggests these speculations may have been overly optimistic.

A 2012 research study
I haven’t been able to track down a copy of the full article, so my comments are taken strictly from the abstract. Two of three authors from the IOCDF article are authors on the study. The details are a little unclear but the take-away message is pretty explicit:

“Ketamine effects on OCD symptoms…did not seem to persist or progress after the acute effects of ketamine had dissipated.”

It appears that the effect of ketamine on OCD was very small, and it didn’t last very long. It looks like the enthusiasm in the IOCDF article could use some updating.

Some concluding thoughts
I’d like to be clear that I think the authors of the IOCDF articles are well-intentioned, honest, and excellent researchers. What’s important to keep in mind is that the history of science is littered with ideas that seemed sound or were based on preliminary research, but which were disappointing when studied through controlled research.

As I’ve noted in my other writings on ketamine, I don’t object to ketamine being studied; however, I think researchers should be more cautious about their enthusiasm when talking to the public. Science is a slow progress of trial-and-error, and truly revolutionary treatments are few and far between. Ketamine may yet emerge as useful for depression, but if this study is any indication, its role for OCD doesn’t look very promising.

That said, there’s some exciting research on improving psychotherapeutic approaches for OCD. Cognitive behavioral therapy isn’t as exciting as the promise of a fast-acting drug, but it is effective and the best thing we have for OCD, particularly exposure therapy, something I’ve written about in our therapist blog.

PLEASE NOTE: PORTLAND PSYCHOTHERAPY IS NOT INVOLVED IN KETAMINE TREATMENT.

Exposure Therapy on TV – “My Extreme Animal Phobia”

Not long ago my girlfriend stumbled across a YouTube video from Animal Planet’s show “My Extreme Animal Phobia.” It features a segment from the show involving a tough-looking, heavily tattooed man who is terrified of pit bulls. The fear is so intense the man breaks down in tears when a psychologist takes him to a park and confronts him with a pit bull puppy.

Since then, I continue to see the video pop up in unexpected places and thought I’d comment on it.

What Kind of Therapy is THAT?!

The man’s name is Marvin. He’s 47 years old, and according to his interview, he’s been terrified of pit bulls since he was a young child and he watched a neighbor friend viciously attacked.

The man in the video received some form of what’s called exposure therapy. Exposure therapy has been around for several decades and is one of the most effective treatments out there, particularly for fear and anxiety-related problems. For someone interested in getting over an extreme fear of dogs, some form of exposure therapy is the best bet.

However, I was little concerned by how the exposure therapy comes across in this segment. My concern: although I think it’s great that a well-researched, effective treatment such as exposure therapy is getting press, I worry that the way it is dramatized on TV may scare people away from it.

Full disclosure: I turned down an offer once—for many reasons—to  conduct on-camera exposure therapy for a TV show about people who claim to have experienced some sort of supernatural or paranormal experience.

The Therapist

According to her website, the therapist Robin Zasio, Psy.D. is a licensed clinical psychologist and licensed clinical social worker. Dr. Zasio appears to have reasonable credentials and seems to specialize in exposure-based treatments.

Exposure Therapy is Usually Conducted in Graduated Steps

When conducting exposure therapy, it’s common for the therapist to come up with a list of feared situations or experiences–commonly called a “fear hierarchy”–and rank them. Collaboratively, they then choose exposure sessions of increasing difficulty.

In the video, as they enter the park, Dr. Zasio says something really striking: “You don’t go to parks, do you?” Marvin says he stays away because “they’re dog friendly.” It’s quite likely Dr. Zasio already knew this, and that her question was for the audience—Marvin mentions in another part of the segment that he doesn’t go to parks with his family because of his fear. Regardless, if I were working with this person, going to the park would be an exposure exercise in itself. Given Marvin’s fear of parks, I think that most exposure therapists would discuss with him to possibility of having him visit the park several times as an exposure exercise in itself. The goal might be to eventually have going to the park be an enjoyable activity for him and his family.

However, this isn’t how it plays out on the show. Instead, while Marvin is seen reeling from being at a park, someone suddenly comes up with a pit bull puppy on a leash. The segment is obviously edited down, so it’s unclear how much time it takes for the puppy to get to Marvin. Dr. Zasio comforts Marvin as he reacts with fear and cries.

It’s a little stagey, but okay. Then Dr. Zasio says something that disturbs me. She tells Marvin, “I know you’re going to be scared but you’re going to have to touch the dog before you leave, I’m sorry.”

Excuse me? He’s going to “have to touch the dog?” I still tense up as I write this.

Even with a graduated approach, exposure therapy is often very intense for people. It’s part of the therapist’s job to gently guide the client through it. The details of it are agreed upon in advance (e.g., “For 30 minutes, you’ll stand within 5 feet of the snake”). It’s possible that Dr. Zasio and Marvin agreed in advance that Marvin would pet the dog. It’s not implied in her command, but it’s quite possible. The way she phrases it though—“you have to”—veers dangerously close to bullying, in my opinion. Marvin doesn’t “have to” do anything. He may choose to. He may even have agreed to. But he doesn’t have to.

Concluding Thoughts

I realize that it makes for better TV for fewer to watch an intensely distraught Marvin get over his fears by petting a pit bull puppy in the park. I get it. It doesn’t make for good therapy, though. My concern is that viewers watching don’t get a sense of how gradual and collaborative exposure therapy should be. Ideally, the therapist and Marvin would plan out steps in advance while gradually working up to Marvin petting a pit bull. There would be no surprises and nothing would be planned without Marvin’s explicit consent. As I mentioned, it’s quite possible that this all happened and was left on the cutting room floor.

Exposure therapy can be very intense for people. No doubt about it. At the very least, I hope the show is able to humanize how painful these sorts of experiences can be for people like Marvin. (Sadly, from comments I’ve read, some people find the juxtaposition of a tough-looking guy brought to tears by a puppy amusing—which is really unfortunate.) For these reasons, it’s important that exposure be conducted in a safe and collaborative fashion—with no surprises.

What I hope people take from this is: 1) yes, exposure is a remarkably effective treatment for a range of fear and anxiety-based problems and 2) exposure should always be conducted safely and collaboratively.

Anxiety Treatment at Portland Psychotherapy

 Not long ago my girlfriend stumbled across a YouTube video from Animal Planet’s show “My Extreme Animal Phobia.” It features a segment from the show involving a tough-looking, heavily tattooed man who is terrified of pit bulls. The fear is so intense the man breaks down in tears when a psychologist takes him to a park and confronts him with a pit bull puppy.

Since then, I continue to see the video pop up in unexpected places and thought I’d comment on it.

What Kind of Therapy is THAT?!

The man’s name is Marvin. He’s 47 years old, and according to his interview, he’s been terrified of pit bulls since he was a young child and he watched a neighbor friend viciously attacked.

The man in the video received some form of what’s called exposure therapy. Exposure therapy has been around for several decades and is one of the most effective treatments out there, particularly for fear and anxiety-related problems. For someone interested in getting over an extreme fear of dogs, some form of exposure therapy is the best bet.

However, I was little concerned by how the exposure therapy comes across in this segment. My concern: although I think it’s great that a well-researched, effective treatment such as exposure therapy is getting press, I worry that the way it is dramatized on TV may scare people away from it.

Full disclosure: I turned down an offer once—for many reasons—to  conduct on-camera exposure therapy for a TV show about people who claim to have experienced some sort of supernatural or paranormal experience.

The Therapist

According to her website, the therapist Robin Zasio, Psy.D. is a licensed clinical psychologist and licensed clinical social worker. Dr. Zasio appears to have reasonable credentials and seems to specialize in exposure-based treatments.

Exposure Therapy is Usually Conducted in Graduated Steps

When conducting exposure therapy, it’s common for the therapist to come up with a list of feared situations or experiences–commonly called a “fear hierarchy”–and rank them. Collaboratively, they then choose exposure sessions of increasing difficulty.

In the video, as they enter the park, Dr. Zasio says something really striking: “You don’t go to parks, do you?” Marvin says he stays away because “they’re dog friendly.” It’s quite likely Dr. Zasio already knew this, and that her question was for the audience—Marvin mentions in another part of the segment that he doesn’t go to parks with his family because of his fear. Regardless, if I were working with this person, going to the park would be an exposure exercise in itself. Given Marvin’s fear of parks, I think that most exposure therapists would discuss with him to possibility of having him visit the park several times as an exposure exercise in itself. The goal might be to eventually have going to the park be an enjoyable activity for him and his family.

However, this isn’t how it plays out on the show. Instead, while Marvin is seen reeling from being at a park, someone suddenly comes up with a pit bull puppy on a leash. The segment is obviously edited down, so it’s unclear how much time it takes for the puppy to get to Marvin. Dr. Zasio comforts Marvin as he reacts with fear and cries.

It’s a little stagey, but okay. Then Dr. Zasio says something that disturbs me. She tells Marvin, “I know you’re going to be scared but you’re going to have to touch the dog before you leave, I’m sorry.”

Excuse me? He’s going to “have to touch the dog?” I still tense up as I write this.

Even with a graduated approach, exposure therapy is often very intense for people. It’s part of the therapist’s job to gently guide the client through it. The details of it are agreed upon in advance (e.g., “For 30 minutes, you’ll stand within 5 feet of the snake”). It’s possible that Dr. Zasio and Marvin agreed in advance that Marvin would pet the dog. It’s not implied in her command, but it’s quite possible. The way she phrases it though—“you have to”—veers dangerously close to bullying, in my opinion. Marvin doesn’t “have to” do anything. He may choose to. He may even have agreed to. But he doesn’t have to.

Concluding Thoughts

I realize that it makes for better TV for fewer to watch an intensely distraught Marvin get over his fears by petting a pit bull puppy in the park. I get it. It doesn’t make for good therapy, though. My concern is that viewers watching don’t get a sense of how gradual and collaborative exposure therapy should be. Ideally, the therapist and Marvin would plan out steps in advance while gradually working up to Marvin petting a pit bull. There would be no surprises and nothing would be planned without Marvin’s explicit consent. As I mentioned, it’s quite possible that this all happened and was left on the cutting room floor.

Exposure therapy can be very intense for people. No doubt about it. At the very least, I hope the show is able to humanize how painful these sorts of experiences can be for people like Marvin. (Sadly, from comments I’ve read, some people find the juxtaposition of a tough-looking guy brought to tears by a puppy amusing—which is really unfortunate.) For these reasons, it’s important that exposure be conducted in a safe and collaborative fashion—with no surprises.

What I hope people take from this is: 1) yes, exposure is a remarkably effective treatment for a range of fear and anxiety-based problems and 2) exposure should always be conducted safely and collaboratively.

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