If you treat OCD for a living – unless you’ve been hiding under a rock for the past couple of years – you know that there has been an ongoing debate over newer treatment strategies. In particular, whether these newer approaches are “evidence-based” enough to recommend, or sometimes even talk about. And neither side can seem to agree on what makes a new approach “evidence-based” enough.
I believe I actually have the answer to this question. But first, let me share a personal story that has nothing to do with OCD, and everything to do with my answer.
When my father was my age, he was dying of a rare form of cancer. After his last round of chemotherapy failed, his doctors had nothing more to offer him. So then I did my own research and got him signed up for a clinical trial for his cancer type, offering a potential 15% chance of survival.
Sadly, my dad ultimately wasn’t one of the lucky ones. However, the hope of a second chance was priceless for him, and we had him for nearly two more years before he died. So why didn’t his doctors suggest this clinical trial?
Now, back to OCD. When I had a major relapse of my own OCD a few years ago, evidence-based treatment delivered by clinicians with rock-star pedigrees not only didn’t work, but left me housebound and traumatized. Then I eventually got well using an approach with emerging literature support, after finding a more open-minded OCD clinician. So why didn’t my previous therapists suggest other approaches?
Let’s look at why well-intentioned people continue to debate this issue – and more importantly, how we can fix it.
Why we have a “research” debate in the first place
So, is health care inherently full of evil people who would rather let my father die, or keep me suffering from OCD, rather than give us options?
In general, no.
Rather, there are two competing agendas. One side feels it is important to protect people from unproven or harmful treatments. The other side feels it is important to try new ideas when old ones don’t work.
Both sides have a point. We wouldn’t have wanted my dad wasting time, money or false hope on quack cures for his cancer, or me trying to find my inner child (as one licensed therapist actually suggested) to treat my OCD. This is a particular hot button issue in the OCD treatment community, because according to the IOCDF it can take up to 14-17 years before many sufferers find effective treatment.
However, as a profession, we generally didn’t talk about the other side of the coin – that even the most widely researched treatments for OCD still fail nearly half the time.
What changed? Primarily, clinicians with lived experience who finally met, compared notes about their own (and their clients’) previous treatment experiences, realized they weren’t alone, and got fed up. In many cases, after being told that it was their fault they were failing “evidence-based” therapy, and to come back when they were “ready.” Then when they discovered other strategies that finally helped them, they started speaking out.
You see, many of us heard explanations for our struggles that were reminiscent of Descartes’ demon theory (e.g. every physical phenomenon is caused by tiny demons – gravity is demons speeding things towards earth, friction is demons pushing back, oil drowns demons, etc.). In other words, therapy wasn’t working because we needed even more exposure, we weren’t doing it right yet, we weren’t motivated enough to get well, and so forth. Much like how Freudian analysts told me decades ago that I wasn’t getting well because I needed more Freudian analysis.
So, this isn’t fundamentally a battle between different approaches. More accurately, the other side sees this as a battle against the hubris, tribalism and gatekeeping many of us experienced privately behind closed doors in treatment – which some of us feel our profession’s messaging has unknowingly cheered on.
The debate over “good enough”
So now you have one side that wants to hold new approaches to a high standard of proof – for the same reasons they don’t want therapists treating OCD with chanting and mud baths – and another side that wants better answers than to keep doing more of what isn’t helping, or even making things worse.
So, we all turn to research. Which, in turn, often leads to debates around things like how many studies you did, how big your samples were, whether they were random controlled trials, whether your random controlled trials were biased because YOU conducted them, and so forth.
If you are trying to navigate this debate, understand that all science has an agenda. Well-meaning, of course. I’m not accusing anyone of academic fraud here. But nearly every study in every field is based on hypotheses designed to show something that you believe works, works. Which, in turn, gently informs what you choose to study in the first place, and what its research parameters are.
I actually have first-hand experience with this, in my long-ago technical career in computer graphics. Ever had a CAT scan? I published the first algorithm for optimizing them, in a refereed conference paper. (Google my name and “span filtering” sometime.) But once the ink was barely dry, others jumped in claiming they had better ideas, and now my legacy is them saying, “We’re 20 times faster than the Gallagher algorithm.”
And this was actually more than fine with me – because it meant better CAT scans for everyone. So how do we get from where we are now to better OCD treatment? Read on.
The answer: full disclosure
So here is my answer to this article’s question: Go ahead and use whatever your favorite approaches are. Then if they aren’t helping, discuss other emerging treatment approaches, with full disclosure that they are emerging approaches. Then listen to what the client says.
Do you feel Idea X is nowhere near as proven as your current approach? Or that its research isn’t up to your standards? Or that it is too early to tell if it is a good idea? Fine. Tell the client that. Live it up.
Just don’t say their only options are to (a) keep doing more of what isn’t working or (b) pound sand. Or worse, imply that they failed. If you do any of these things, you are gatekeeping and favoring your tribe over what might actually be best for the client. Conversely, if you disclose other options to the client – including full disclosure of how much you do or don’t like them at the moment – you are at least giving your client a voice in the process. Which, in my view, they always deserve.
While we’re at it, I feel you owe it to clients to at least acknowledge approaches whose concepts don’t follow your particular religion. For example, if you normally preach no accommodations, and your client wants to try using safety behaviors (which, by the way, was how I got well), oh well – try it and if it doesn’t work, stop doing it. Same with nearly every other concept that practitioners hold sacred – after all, this is psychotherapy, not taking people’s gall bladders out. The golden rule should always be that first, things should work for the client in front of you.
Meanwhile, how do we protect OCD sufferers from the mud bath types? Simple – just change your focus. Instead of debating how high a bar we have to set before we can talk about new ideas, go ahead and exclude ones that lack any credible evidence of effectiveness.
If your attitude towards new ideas is that we have to wait for five years of RCTs before we can talk about Bruno, I’d like to invite you inside my head. Learn how much I suffered because I was only offered one flavor of treatment – and what a happy and functional guy I became after finding a strategy that worked. Think hard about how long you would want yourself, or a loved one, to keep suffering because their therapist treats their approach as a religion instead of a tool. Then let’s start delighting in each other’s ideas, and work together to help EVERY sufferer of OCD get well.
Great article Rich! Keep them coming!
Thank you so much Tom!
So well written and sheds light on your beautiful voice of advocacy for the suffering human being sitting in front of us. Thanks, Rich!
Thank you Thai-An! And thank YOU for your amazing advocacy for the OCD and anxiety community!