Finding an Intersection of DBT and ERP in OCD Treatment: A Clinician's Perspective

Addressing Obsessive-Compulsive Disorder (OCD) in treatment can be a complex endeavor. Obtaining an accurate diagnosis alone can take a decade or more, underscoring the challenges in the process. While there is a growing number of clinicians well-versed in OCD treatment, a comprehensive understanding within the broader mental health community remains somewhat limited. Over the past several years, my work with clients grappling with OCD has revealed a common trend. Many have sought assistance from well-intentioned therapists employing Dialectical Behavior Therapy (DBT) as a means of support. However, my extensive experience, spanning over 12 years with DBT and approximately 5 or 6 years with Exposure and Response Prevention (ERP), suggests that DBT? is not effective for OCD. In fact, clients often encounter setbacks when utilizing DBT, leading to periods of regression. This article delves into my perspective on the matter, exploring the overlaps, if any, where DBT and ERP can synergistically contribute to OCD treatment.

What is Dialectical Behavioral therapy?

Dialectical Behavior Therapy (DBT) is a therapeutic approach developed by psychologist Dr. Marsha M. Linehan in the late 1980s. Originally designed to treat individuals with borderline personality disorder (BPD), DBT has since expanded its application to various mental health conditions characterized by emotional dysregulation. The historical background of DBT traces back to Linehan's recognition of the limitations of existing treatments for individuals with intense emotional and interpersonal difficulties. Drawing inspiration from cognitive-behavioral therapy, mindfulness practices, and dialectics, Linehan formulated DBT to integrate acceptance and change strategies. The term "dialectical" reflects the balance between acceptance and change in therapy, emphasizing the synthesis of opposing forces to promote behavioral transformation. Over the years, DBT has proven effective not only for BPD but also for conditions such as depression, substance use disorders, and eating disorders, making it a widely recognized and utilized therapeutic modality.

Dialectical Behavior Therapy (DBT) encompasses a range of skills designed to help individuals effectively cope with intense emotions, and one such category involves the use of distraction as a valuable coping skill. Distraction techniques aim to redirect attention away from overwhelming emotions, allowing individuals to regain control and navigate challenging situations. Examples of distraction skills in DBT include "Wise Mind ACCEPTS," where activities such as A - Activities, C - Contributing, E - Emotions, P - Pushing Away, T - Thoughts, and S - Sensations offer diverse options for diverting focus. Additionally, the "TIP Skills" suggest using Temperature (changing body temperature, like holding a cold pack), Intense Exercise (brief and vigorous physical activity), and Paced Breathing (altering the pace of breath) to create a shift in emotional states. These skills highlight the versatility of distraction as a coping mechanism within the comprehensive framework of DBT.

Why is DBT counterproductive for OCD treatment.

While distraction techniques are fundamental to many Dialectical Behavior Therapy (DBT) skills and can be beneficial for managing intense emotions, it's essential to recognize that their core principles may pose challenges for individuals undergoing treatment for Obsessive-Compulsive Disorder (OCD). Exposure and Response Prevention (ERP), an evidence-based approach for OCD, diverges from distraction-focused strategies. ERP necessitates participants to confront anxiety-provoking thoughts and situations without engaging in compulsive behaviors. The six things' participants are encouraged to cease, including distraction, highlight the importance of directly facing anxiety triggers. Therefore, an overemphasis on distraction within a therapeutic context does not align with the principles of ERP and could potentially hinder individuals' progress in OCD recovery. A balanced and tailored approach, considering the specific needs of individuals with OCD, is crucial to ensure that therapeutic interventions align with evidence-based practices and contribute positively to the recovery process.??

I have hands-on experience working directly with DBT, particularly with the adolescent population, for several years before incorporating ERP into my practice. Utilizing both DBT and CBT as comprehensive approaches, I addressed a wide range of concerns commonly experienced by adolescents. While I had treated a handful of patients with OCD, it was only when examining my own statistics that I recognized my limitations in providing quality treatment specifically for the OCD population. Acknowledging my shortcomings as a clinician in this context, I actively sought answers and guidance from a mentor to enhance my ability to better serve clients with OCD.

I found ERP!

Exposure and Response Prevention (ERP) is a highly effective and evidence-based therapeutic approach used in the treatment of Obsessive-Compulsive Disorder (OCD). At the core of ERP is the principle of exposing individuals to anxiety-provoking thoughts, images, or situations while simultaneously preventing the accompanying compulsive rituals or avoidance behaviors. This exposure allows individuals to confront and tolerate the distress associated with their obsessions, breaking the cycle of anxiety and compulsive responses. Over time, through repeated exposures, individuals often experience a reduction in the intensity of their obsessive thoughts and anxiety, leading to significant improvements in their ability to manage and cope with OCD symptoms.

ERP is designed to challenge the fear hierarchy that underlies OCD, gradually exposing individuals to situations that trigger their obsessions. By resisting the urge to engage in compulsions or avoidance, individuals learn that the feared consequences they anticipate are unlikely to occur.? Many with OCD already know this but struggle to tolerate the discomfort they experience. ERP empowers individuals to confront their fears, ultimately promoting a shift in their response to intrusive thoughts and reducing the impact of OCD on daily functioning. This therapeutic technique has demonstrated remarkable success in helping individuals regain control over their lives and alleviate the debilitating effects of Obsessive-Compulsive Disorder

Common ground

While I continue to utilize Dialectical Behavior Therapy (DBT) successfully with clients not dealing with Obsessive-Compulsive Disorder (OCD), I have abstained from employing any dialectical behavioral therapy techniques specifically for my OCD clients over the past five or six years. This prompted me to explore potential overlaps that could be beneficial for individuals with OCD. In my search for this answer and with a commitment to collaborative evidence-based treatments, I identified only one skill within the DBT Skills Modules that significantly supports OCD treatment.

Opposite Action in DBT is a vital skill for emotion regulation. It involves acting in a way contrary to the initial emotional impulse, particularly when the impulse is unhelpful. The goal is to change behaviors to influence and modify emotions positively. For instance, if overwhelmed by sadness and the impulse is to isolate, opposite action may entail engaging in social activities. This intentional counteraction of emotion-driven behavior promotes positive changes in emotional experiences over time.

I find potential in initiating the therapeutic process with opposite action, especially for individuals who have undergone extensive Dialectical Behavior Therapy (DBT) programming without substantial improvement in their Obsessive-Compulsive Disorder (OCD) symptoms. Viewing opposite action as a strategic starting point, it serves as an entryway for discussions regarding the necessity and advantages of incorporating exposure work. Opposite action acts as a bridge, allowing for a smooth transition into conversations about the nuanced and tailored nature of exposure therapy, presenting a valuable opportunity to explore the potential benefits of this evidence-based approach in addressing OCD symptoms comprehensively. By leveraging the familiarity individuals may have with DBT and introducing opposite action as a precursor to exposure work, we can potentially enhance engagement and receptivity to the therapeutic process, fostering a more holistic and effective treatment experience for those grappling with OCD.

In conclusion, the journey of addressing Obsessive-Compulsive Disorder (OCD) highlights the complexities involved in obtaining an accurate diagnosis and underscores the need for evolving and evidence-based therapeutic approaches. While the historical background of Dialectical Behavior Therapy (DBT) showcases its effectiveness in various mental health conditions, my extensive experience suggests its limitations in treating OCD, often leading to setbacks and periods of regression. The article delves into the nuances of utilizing DBT in OCD treatment and explores the contrast with the highly effective Exposure and Response Prevention (ERP) approach. ERP's success lies in its ability to challenge fear hierarchies and empower individuals to confront anxieties directly. Recognizing the distinct needs of those with OCD, the integration of DBT's Opposite Action skill serves as a potential starting point, bridging the gap to discuss the benefits of incorporating ERP. This collaborative approach aims to enhance engagement and receptivity, providing a more comprehensive and effective treatment experience for individuals navigating the complexities of OCD.

If you found this article intriguing or compelling and would like to engage in a discussion, or if you're interested in a training session on the fundamental assessment and treatment of OCD, feel free to reach out to me. I welcome any inquiries or conversations related to the topics discussed in the article.