I recently had the opportunity to attend an intensive two-day workshop on Obsessive-Compulsive Disorder (OCD)¹. The workshop, lead by Brynjar Halldorsson, provided me with valuable insights and practical strategies for treating this complex condition. In this blog post, I’ll share some key takeaways that can benefit both clinicians and individuals struggling with OCD.

TABLE OF CONTENTS

Let’s begin by developing a shared understanding of what OCD entails.

What is OCD?

OCD is characterized by persistent, unwanted thoughts (obsessions) and repetitive behaviors (compulsions). Intrusive thoughts are normal, but OCD involves excessive importance placed on these thoughts.

DSM-5 Diagnostic Criteria for OCD

According to the American Psychiatric Association, OCD is defined by the following criteria:

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Common Symptom Patterns of OCD

The most common symptom patterns of OCD have been collapsed into four main OCD symptom dimensions: symmetry/ordering, hoarding, contamination/cleaning, and obsessions/checking (Mataix-Cols et al., 2005).

Below are some examples of common symptom patterns that individuals presenting with OCD experience (Grant, 2014):

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Insights From the Workshop

Now that we have begun developing a shared working understanding of OCD, let’s get to the takeaways from Brynjar Halldorsson‘s workshop!

1. The Core of OCD: Misinterpretation and Safety-Seeking Behaviors

One of the fundamental aspects of OCD is the misinterpretation of intrusive thoughts. It’s not the thoughts themselves that are the problem, but rather how individuals interpret and respond to them. This misinterpretation often leads to safety-seeking behaviors, which ultimately perpetuate the cycle of OCD.

It’s not the intrusive thoughts themselves that are necessarily problematic, but rather how they are interpreted.

A Simple Case Formulation for OCD

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2. The Role of Heightened Responsibility

In OCD, the interpretation of intrusive thoughts is what becomes problematic. This interpretation is often influenced by a heightened sense of responsibility, which is a key vulnerability factor for developing OCD. Individuals with OCD often feel an overwhelming need to prevent harm, leading to compulsive behaviors. Recognizing and addressing this heightened sense of responsibility is thus crucial in treatment.

3. Cognitive Behavioral Therapy (CBT) for OCD

CBT remains a cornerstone in OCD treatment. According to clinical guidelines, recommended treatments for OCD include CBT and SSRIs. However, we don’t fully understand the causes of OCD, which makes me somewhat wary of drug treatments. It’s worth noting that my view is heavily biased! After all, I’m on the path to becoming a licensed clinical psychologist.

Interestingly, the workshop emphasized the importance of tailoring CBT approaches, especially when dealing with mental contamination OCD. The differentiation between contact contamination and mental contamination was not something I had thought about in detail before the workshop and am currently reading up on how treatment can be tailored accordingly (see e.g., Radomsky et al., 2018)².

Nonetheless, the important insight here is that flexibility in treatment is essential for addressing the diverse manifestations of OCD.

4. The Power of Behavioral Experiments

Behavioral experiments are a crucial component of OCD treatment. These experiments challenge the client’s beliefs and provide real-world evidence against their OCD-driven fears. As therapists, we must be willing to engage in these experiments ourselves to effectively guide our clients.

Therapy insight: You have to overcome your own fears to effectively help others so practice doing what bothers you! 

In other words, a therapist providing OCD treatment should not device behavioral experiments that they themselves would not be willing to do. Even more so, the therapist should be willing to go a step further. For instance, if I were to instruct a client to touch the inside of a toilet then I might put my whole hand in the toilet. 

5. Addressing Safety Behaviors

Identifying and gradually eliminating safety behaviors is key to OCD treatment. This includes both overt (visible) and covert (mental) safety behaviors. It’s important to be vigilant in recognizing these behaviors throughout the treatment process.

It should be stated though that safety behaviors are not necessarily bad. Evidence for an alternative explanation of the intrusive thought can still be gathered, even if safety behavior is being performed. This is particularly the case in the early stages of treatment. However, as treatment progresses, safety behaviors should be eliminated. 

6. The Importance of Cognitive Work

While behavioral experiments are crucial, the workshop stressed the importance of cognitive work. Helping clients process and internalize what they’ve learned from these experiments is essential for long-term change. This includes deriving alternative explanations for the feared meaning of the intrusive thought/obsession and gathering disconfirming evidence. In clinical settings, this process is encapsulated in the Theory A/B scheme.

Let’s take an example to illustrate Theory A and Theory B³

Theory A/B: Example

Scenario: I come home from work and find my wife in the shower. Then I see a text from a friend saying “Nice to see you this morning.” My mind immediately jumps to a conclusion.

Theory A (Problem of danger):

• • My wife is cheating on me.

• • The text message is evidence of her infidelity.

• • I need to confront her and find out the truth.

Theory B (Problem of worry about danger):

• • I’m jumping to conclusions based on limited information.

• • There could be an innocent explanation for the text message.

• • My worry is causing me to interpret things negatively.

After persistent questioning, it turns out that my friends were planning a surprise anniversary celebration for us, which explains the text message. This scenario demonstrates how our initial interpretations (Theory A) can be misguided, and it’s important to consider alternative explanations (Theory B) before drawing conclusions.

An excerpt from the workshop slides included this phrasing to explain Theory A and Theory B:

“You’ve been thinking of the problem as one of [danger] which I’ll call Theory A. There is another way of thinking about this that i want to put to you..that this problem is one of [worry] which I’ll call Theory B”
— Brynjar Halldorsson (2024): Workshop slides⁴

7. Responsibility in Treatment

An interesting point raised was about the transfer of responsibility during treatment. It’s important to encourage clients to take responsibility for their recovery, rather than relying solely on the therapist.

This reminded me of a quote I heard from Sævar Már Gústavsson recently in the context of generalized anxiety disorder but is equally relevant here. He emphasized that we therapists should attribute therapeutic progress to the client and treatment failure to ourselves (BUT we cannot allow ourselves to feel bad about it, the most important thing is that we learn from our failures).

8. Caution with Prescriptive Advice

The workshop cautioned against giving prescriptive advice about what’s “normal.” Instead, the focus should be on reducing OCD symptoms first, with discussions about normalcy reserved for later stages of recovery.

9. Useful Tools and Techniques (incl. metaphors)

Several tools were discussed, including responsibility pies, structuring questionnaires like behavioral experiments, and using metaphors. These tools can be valuable in helping clients understand and challenge their OCD beliefs.

Memorable Metaphors From the Workshop

The most memorable metaphor discussed at the workshop was the builder’s apprentice metaphor. I found an excellent description of it written by Daniels and Loades (2017), and have included it here below:

“… the [Builder’s apprentice] metaphor describes the long suffering builder’s apprentice who holds up his newly built wall, for fear that it may fall or collapse if he does not support it. The question is: how will he discover whether he needs to continue to hold up the wall? He must test it. This relates to evidence gathering within the scientist approach, specifically the testing of [safety-seeking behaviors] SSB.”

Reference: Daniels, J., & Loades, M. E. (2016). A Novel Approach to Treating CFS and Co-morbid Health Anxiety: A Case Study. Clinical Psychology & Psychotherapy, 24(3), 727–736. https://doi.org/10.1002/cpp.2042

Another memorable metaphor I want to share is the insurance policy metaphor. It is used to explain the difference between Theory A and Theory B in the context of OCD treatment.

The insurance policy metaphor helps clients understand the excessive nature of their OCD-driven behaviors (Theory A) compared to a more reasonable approach to managing risks (Theory B). It encourages them to consider the high “cost” of their OCD in terms of time, energy, and quality of life, and to contemplate adopting a more balanced perspective.

Let’s illustrate this more clearly.

Theory A (OCD perspective, Problem of danger):

• • This is like an extremely expensive insurance policy that costs 100 million to cover everything.

• • In OCD terms, this represents the excessive precautions and safety behaviors that individuals with OCD engage in to prevent perceived catastrophes.

Theory B (Alternative perspective, Problem of worry about danger):

• • This is compared to a regular home insurance policy.

• • In OCD treatment, this represents a more balanced and realistic approach to managing risks and uncertainties.

The metaphor encourages client’s seeking treatment for OCD to consider “What is OCD costing you?” and “Which insurance policy would you prefer to buy?“

10. Continual Learning and Resources

The workshop highlighted the importance of continual learning in this field. Resources like “Oxford Guide to Metaphors in CBT” and “Cognitive Behaviour Therapy for Obsessive-compulsive Disorder” were recommended for further study.

I am reading Cognitive Behaviour Therapy for Obsessive-compulsive Disorder at the moment (as it is more relevant to my current PhD related responsibilities at this stage), but have added the Oxford Guide to Metaphors in CBT to my reading list; looking at the synopsis, it is extremely relevant for my clinical responsibilities!

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Conclusion

This OCD workshop has reinforced the complexity of the disorder and the need for a nuanced, tailored approach to treatment. By focusing on misinterpretations, addressing safety behaviors, and employing a mix of cognitive and behavioral strategies, we can provide more effective help to those struggling with OCD. As an up-and-coming mental health professional, ongoing education and willingness to engage in the treatment process alongside our clients are crucial for successful outcomes.

Key Clinical Points (Grant, 2014)

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