MHM Magazine

Issue 5 | 2024 | MENTAL HEALTH MATTERS | 23 MHM Therapists must consider their therapeutic modality and approach to psychotherapy and often adapt their classical approaches to provide treatment that is fitting for their client with OCD. Additionally, therapists also often fall into the role of mediators between a client with OCD and their family, being required to bridge the gap between the experience of the client and the perspectives and concerns of their loved ones, which can be a tall order. Research on OCD clearly suggests that certain therapeutic approaches are more successful in treating OCD effectively and timeously compared to others. While most therapeutic approaches, and particularly longer- term psychotherapies may certainly address the resulting emotional toll of OCD on a client, they may not always be the most effective way to treat OCD. Cognitive behavioural therapy, and specifically Exposure and Response Prevention (ERP), has long been regarded as the gold standard treatment for OCD, providing effective treatment with the highest efficacy and lowest rate of relapse in the shortest period of time. Efficacy and treatment duration for treatment should always be a significant factor in determining the best course of action in treating any mental health condition, but this is particularly relevant in the South African context. Access to mental health care in South Africa is often limited due to resource constraints, a high prevalence of trauma, and economic disparities. Efficient and effective treatments are crucial because individuals may not have consistent access to long- term care, and shorter, high-impact interventions can help alleviate the burden on the healthcare system and the client. ERP is, however, a challenging approach to utilise in treating clients with OCD because it requires clients to confront their greatest anxieties while resisting the compulsions they typically rely on to relieve distress. This process can be highly distressing, often leading to an initial increase in anxiety - the opposite of what may seem to the client like effective treatment. Clinicians must carefully balance pushing clients to face their greatest fears with maintaining empathy and compassion for the immense discomfort they experience. Building trust and a strong therapeutic alliance is therefore key to the process of driving the client towards timely progress while not leading the client to feel as though their efforts and distress through the process are being minimised or undermined. Offering encouragement and pacing exposures appropriately are critical to ensuring the client feels supported while also ensuring therapeutic progress is made without overwhelming them or causing disengagement from the treatment process. Clinicians also need to be cognisant of the nuances of including loved ones in the OCD treatment process. Research suggests that involving loved ones in a structured and supportive way can significantly improve the effectiveness of OCD treatment. The core mechanisms behind ERP suggest that resisting compulsions and accepting the resulting experience of anxiety will lead to a natural plateau in the intensity of the distress before a gradual decline over time in the anxiety experienced by the client. This description can, however, be easily oversimplified to loved ones - to suggest that a family member with OCD just needs to be pushed to not engage in compulsive behaviours and forced to bear the uncomfortable experience that will soon pass. For someone with OCD, compulsions are not a preference but feel like a necessity driven by intense fear or distress. People often understand their obsessions are irrational but feel powerless to stop their compulsions, much to the frustration of loved ones. For someone with OCD, the anxiety from obsessive thoughts or the exposure process can be extremely high, leading the person to feel compelled to take action to reduce the distress. OCD-related anxiety can cause symptoms such as racing thoughts, a pounding heart, palpitations, sweating, hot flushes, shortness of breath, trembling, or the ever-dreaded panic attack. Dissociative experiences where the client may feel detached from their thoughts, emotions, or surroundings as a way to protect themselves from the distress are also possible. For individuals with trauma histories or heightened sensitivity to anxiety, ERP can provoke these dissociative responses when the anxiety becomes too much to process. It’s therefore key to distinguish a loved one's understanding or experience of anxiety from the often overwhelming sensations and dread that an individual with OCD may experience in treatment. On the other end of the spectrum, treatment can be complicated because loved ones may provide reassurance or assist with compulsions, which can unintentionally reinforce the OCD cycle. Loved ones may struggle to stop giving reassurance, as it feels like a compassionate response, but doing so undermines ERP by reinforcing the sufferer's reliance on compulsions rather than learning to tolerate distress independently. Therefore, it’s crucial to take special care to reframe support as encouragement and awareness of the extreme distress that clients experiencing treatment experience. Living with OCD can be isolating, as sufferers often feel misunderstood by others, despite their best efforts. OCD involves more than the stereotypical behaviours, and the anxiety experienced can feel overwhelming. Effective treatment requires confronting anxiety without resorting to compulsions, which can be extremely distressing to a client with OCD. Clinicians must therefore balance the push for progress with empathy to ensure that the client's experience and discomfort are not minimised and the therapeutic alliance is not ruptured. Managing family involvement is also key, as well-meaning reassurance can hinder recovery, while overzealous pressure can do the same. Public awareness and a deeper understanding from clinicians about the nuances of OCD treatment and the role of family involvement are essential in helping clients feel less misunderstood and isolated in their experience and recovery journey. References available on request. MHM | 2024 | Volume 11 | Issue 5 | The Unseen Battle with OCD: Overcoming Isolation, Anxiety, and Misconceptions MHM