What to expect after good quality treatment for OCD

Professor Paul Salkovskis

This week is OCD Awareness Week, and each day we will be publishing a different account of Obsessive-Compulsive Disorder.

During OCD Awareness Week we have heard some honest and candid stories from some brave people, some of whom have commented that they know they will always have to live with OCD. So we asked an OCD specialist to talk to us about recovery and if people will always have OCD. Professor Paul Salkovskis shares his view...

What to expect after good quality treatment for OCD: Recovery, Cure, Resolution or just learning to live with it?
By Professor Paul Salkovskis (Professor of Clinical Psychology and Applied Science, Department of Psychology, University of Bath).

For OCD Awareness week 2016, I have tried to briefly tackle this tough issue at the request of OCD-UK. This is just a short piece written quickly, so please forgive me for the various things I have undoubtedly left out, and for the misunderstanding which may arise from my clumsy phrasing. 

What is the issue?
Over the years I have been involved in frequent discussions about whether or not OCD can be “cured”. For entirely understandable reasons I know that it can be upsetting for those who have suffered and fought to overcome their problems and either not progressed or not progressed as much as they want. I can understand why it might seem that there are unpleasant or even critical implications of the idea that OCD can be fully overcome. However, I believe that it is important to unambiguously declare that sufferers can rid themselves of OCD, and that to say this need not have negative or critical implications for those that do.

What’s in a name?
First, let’s look at terminology. “Cure” is a frequently used word, and is simple and to the point. However, there may be a problem, and that is the medical implications of the word. At this point, we simply do not know what causes OCD, and there are reasons to believe that it may have a negative impact to suggest that mental health problems are based in biology. So it’s a word that I do use, but have reservations about for those reasons. “Learning to live with it”: that’s OK to start with, but I don’t want to settle for that because of the implication that that is what the person with OCD has to do. In my opinion, this is only an option when the sufferer and their loved ones choose it. “Resolution” is pretty good in my view because it suggests that the person has got to the point that their OCD is not a problem. Finally, “Recovery”. That has come to have a special meaning in mental health and I am using it in a slightly different sense. I like this because it suggests a journey, which ends in…. Complete Recovery, which is similar in my view to Resolution. Does it matter what we call it? Maybe. But in the end, it’s about whether or not the person who has OCD can get to the point where they don’t have it, and my view is that the answer to that is a resounding “Yes”.

What is needed to get recovery going?
How does that fit with the fact that there are those who, despite their brave and, frequently, superhuman efforts still find themselves suffering from this problem? The answer is, of course, very complicated.

Starting with the basics: we have a very good understanding of the psychological mechanisms involved in keeping OCD going……in jargon, what maintains the problem. We know, for sure, that if someone with OCD is able to CHOOSE to confront their fears without avoidance and without “fixing” them using compulsive and neutralizing responses (in terms of what they actually (rituals) do or what they try to do in their head (covert rituals) OCD fears will diminish and extinguish. They will go away. BUT ITS NOT THAT EASY, otherwise the brave souls who suffer from OCD would overcome it by their effort of will.

That’s where better understanding, support from loved ones and therapists all come in.

What are the basics of OCD?
The process of choosing to confront ones fears whilst being determined not to undo is both tough and frightening. The process of being able to do that involves (a) understanding how their particular unique pattern of OCD works and gathering evidence that this is really so. In “Break Free from OCD” we try to help people see how they might get that understanding. It’s not about discovering that your fears don’t happen, it’s about understanding how the fears work and trap you. For many, a good therapist can help with that. A bad therapist, on the other hand, can make it harder and undermine that process.

(b) being able, with support, to put this understanding into practice, which involves not just not doing the rituals, but actively attacking the fears, provoking them with the firm intention of not undoing. Without that intention, it’s likely that the person will simply suffer prolonged anxiety, discomfort and distress until they finally carry out their rituals/neutralising. That’s torture, not therapy.

(c) At the same time, the person needs to reclaim their life and focus on what they want to really do; in doing so, they starve the OCD of the Oxygen of attention and effort. In the end, no-one wants “They were really good at doing compulsions” to be their epitaph. OCD is a thief and a liar which steals the dreams of good and capable people; it’s very important that people are able, as part of recovery, regain their dreams or find new ones.

What are the problems which are involved in people not recovering?

Is it that easy for everyone? Yes, and No.

So, it’s complicated. No, surprise there.

Yes, because what I have described above is a summary of how OCD keeps itself going through a load of feedback loops and vicious circles, and we know for sure that if you can break these, OCD can be resolved.

No for lots of reasons, many of which relate to the help people with OCD receive or don’t receive…much of this boils down, in my opinion, to “Too Little Too Late”. In no particular order, these include the following.

Collateral damage and the human cost
I have already said that OCD is a thief; what is steals is time, opportunities, education, money, love….and on and on. On average it starts in its full-on form around the age of 16-24; for some younger, for some older, but in this period for most people. Then it takes many years (on average 6-8) for the person affected to seek help. Add a few years before diagnosis. Add some more years to get evidence based treatment. So we have added 10-15 years of suffering before most people get the help they need and are entitled to. Think about the cost of this period of Hell which those who suffer go through. For many it destroys not just happiness but friendships, love, education….and on and on. When treatment is finally accessed, it’s not just about the OCD, it’s about helping the person to undo this additional damage. And if they can, then to help them deal with their sense of grief about the losses they have suffered. Most also become understandably demoralized and depressed, and that cuts a deep groove in their life which both makes the OCD worse (and harder to overcome) and creates problems of its own. A range of “secondary” problems can and for some do follow on from OCD, and treating the OCD may or may not reduce or eliminate these. Often not.

Bad Treatment
Bad treatment from hopeless therapists (in all senses of the word hopeless) can and do make things worse, in many and varied ways. The sufferer often has to overcome these issues.

Vulnerability issues
OCD does not occur in a vacuum. It is quite clear at present from a great deal of research that we don’t know what causes OCD, but that it is unlikely to be simple. The idea of a “biochemical imbalance” is, at best, useless and misleading. The idea of a brain area being “wonky” is unhelpful and untrue. The brain is the organ of the mind, but that really doesn’t help; everything we do and feel happens in the brain, doesn’t mean that there is anything wrong with it. In fact, we know from a range of excellent experimental work that all of the components of OCD are there in everyone, which takes you to psychological explanations. Again it’s not simple. Some types of childhood or adult experiences are linked to the development of psychological problems, but then again some people are clearly resilient to things like abuse, neglect and trauma. Anyway, its complicated, and it’s likely that people may develop OCD as a result of a “perfect storm” of multiple psychological and other factors. So far, it doesn’t look like these are just about OCD, which means that when OCD is treated some of the problems linked to its development may still be there, and continue to make life difficult. Resolving OCD will not necessarily resolve problems such as low self-esteem, the after effects of traumas such as bullying and abuse and so on. OCD occurs in people, and people are both wonderful and complicated. 

What else?
There are more issues likely to mean that full Recovery is not possible in the short term for all; some of these may occur in one or two individuals, others in thousands. The and help. point is, in my view, that although it is complicated in this way, I still assert that OCD is an Unnecessary Illness and that recovery is possible in everyone given the right circumstances, support in my view, alongside working with those who are struggling with their OCD now and need more and better help and support, we should be working to prevent OCD from starting and from worsening. Prevention and Recovery are both possible; its time we recognised that and got on with the job.


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