Treatment challenges, such as underdiagnosis and undertreatment of OCD, as well as treatment resistance and recovery avoidance are common.

Fortunately, effective treatment that helps most people with OCD achieve significant relief from their symptoms is available.  But getting appropriate help and sticking to the treatment plan are key to getting relief from OCD.  Even when treatment gains are made, it can be difficult to sustain improvement.  That’s why being knowledgeable about OCD is so important.  Knowledge is a powerful tool that’s linked to success in treating this disorder; understanding barriers to treatment and knowing what to expect ahead of time can enhance your ability to help the people you counsel.

Underdiagnosis and Undertreatment

OCD is too often underdiagnosed and undertreated, even though it’s a relatively common illness and effective treatment is available.  There are a number of reasons why:

  • Hiding symptoms:  Some people hide their symptoms and do not seek help.  Many don’t know that OCD is treatable, while others are reluctant to admit they need help.  OCD is a medical condition, like high blood pressure or allergies, and there’s no need to be ashamed to seek treatment.
  • Compulsive avoidance:  Avoidance isn’t always recognized as an OCD symptom.  Many people with OCD avoid places, events, objects and even people because of uncontrollable, irrational fears.  For example, a person with contamination obsessions may avoid public restrooms or refuse to borrow a pen from another person.  In these cases, avoidance is a compulsion.  Continued avoidance strengthens obsessions and worsens the disorder. 
  • Discomfort discussing symptoms:  OCD can involve unwanted thoughts with disturbing content, including violence, sexuality (e.g., homosexual, paraphilic, or pedophilic obsessions), blasphemy and illness.  Some people with OCD are uncomfortable discussing these thoughts, even with a treatment provider.  A person with OCD normally has no desire to act on these thoughts, which recur precisely because they are so upsetting.  Cognitive behavior therapists are trained to work with people whose lives are impaired by such intrusive thoughts.
  • Fear of change:  Change can be difficult.  It takes courage to make changes and face fears, particularly if the obsessions and compulsions have existed for many years.  Some people with OCD are afraid to begin treatment; their counterproductive ways of coping create an illusion of safety, and control may be very difficult to give up.  But living with untreated OCD is far more painful than any discomfort associated with treatment.
  • Difficulties with diagnosis:  Not all physicians and mental health clinicians know how to diagnose and treat OCD.  At routine check-ups, many doctors fail to ask questions about a patient’s mental health.  Some professionals – even psychiatrists – lack training in recognizing symptoms of OCD. 
  • Ineffective or inappropriate treatment:  Some psychologists and psychiatrists still rely on unproven, ineffective therapies to treat OCD.  Psychoanalysis and therapies that focus on family dynamics, early childhood trauma or issues of self-esteem are not effective treatments for OCD.  While certain forms of therapy, such as marriage and family counseling, can help with relationship problems and other difficulties that frequently accompany OCD, only Cognitive Behavior Therapy (CBT) can reduce the actual symptoms of the disorder.  In some cases, treatment providers only prescribe medications to treat OCD because they’re unfamiliar with CBT and don’t realize it’s the treatment of choice for OCD.
  • Treatment affordability:  Some people with OCD are unable to afford treatment. Those without health insurance or whose insurance policies do not fully cover mental health care sometimes struggle to get the treatment they need.  Some cognitive behavior therapists offer sliding scale fees – fees based upon one’s ability to pay – making therapy more affordable.  If a therapist recommends the use of medication in conjunction with CBT, patients may be able to obtain drugs at a reduced price.  A number of resources offer information about prescription assistance, including the Partnership for Prescription Assistance (1-888-4PPA-NOW or http://www.pparx.org) and NeedyMeds (http://www.needymeds.com/).

  • Unrecognized symptoms:  Like avoidance, there are many common, but less familiar, symptoms that may not be recognized as signs of OCD.  The disorder can take many forms and isn’t limited to the more well-known or obvious types of OCD such as compulsive washing or checking.  Examples of symptoms that can go unrecognized include:
    • Procrastination
    • Difficulty making decisions or inability to make a decision
    • Asking repetitive questions
    • Continual reassurance-seeking 
Clergy can powerfully influence behavior. You can help someone who is struggling with OCD recover by understanding the common forms of treatment resistance and recovery avoidance.

Roadblocks to Treatment Success

Most people who undergo a course of Cognitive Behavior Therapy for OCD experience a significant reduction in symptoms.  Those who don’t do well in treatment should consider these possible obstacles to success:

  • Recovery avoidance.  When people with OCD avoid getting treatment or don’t fully commit to treatment sessions and the accompanying homework, they derail the treatment process.
  • Comorbid (co-existing) disorders:  A mood disorder such as major depression or bipolar disorder, alcoholism or substance abuse, or another comorbid disorder can interfere with success in therapy and may require separate treatment.
  • Poor communication with therapist:  Open and honest communication about the exact nature and frequency of obsessions and compulsions is essential for the therapist to design effective exposures.  People often fear revealing all of their symptoms, either because they feel ashamed of their thoughts, or because they believe it would be impossible for therapy to help them with obsessions or compulsions that are particularly difficult.  Keeping certain aspects of OCD secret will impair the therapist’s ability to help a person overcome OCD.
  • Insufficient exposures:  Exposures must be sufficiently challenging, and it’s imperative that “homework” – daily exposure exercises – be completed between therapy sessions.
  • Therapy sessions too infrequent:  Therapy sessions are generally scheduled weekly, but in some cases may need to be more frequent or conducted in a residential treatment setting.
  • Improper location for therapy:  Therapy sessions may be more effective if they are held in locations that trigger obsessions and compulsions – in a person’s home, car or outdoors, for example.  Some therapists will conduct sessions out of the office, by telephone, online or via webcam technology, such as Skype.
  • Family interference:  Family members who participate in an individual’s compulsive rituals, provide reassurance or enable avoidance behavior can unintentionally sabotage success in therapy.  A treatment provider may instruct family members to refrain from engaging in certain behaviors that can have a negative effect on treatment, even though they are well-intended.  In some cases, a family member can be trained to act as a “coach” to keep track of exposures and discourage behavior by others that perpetuate the rituals.
  • Wrong choice of therapist:  An individual may not succeed with a particular therapist because the personality fit may not be right, or the therapist may not design challenging, appropriate exposures.  The professional may also lack specific knowledge and/or experience in treating OCD.  The good news is that a person may enjoy excellent results with another therapist.  It’s very important for people to ask for a second opinion, request a referral or interview other therapists to find a good match.
  • Inappropriate treatment:  CBT, sometimes accompanied by medication, is the only treatment for OCD that is supported by scientific evidence.  At this time, there is insufficient evidence to support the use of treatments such as hypnosis, herbal or homeopathic remedies, psychoanalysis, relaxation therapy, eye movement desensitization reprocessing (EMDR) or dietary changes. It’s important to note, however, that meditation, yoga and exercise can complement formal treatment for OCD.  Many people find these tools to be extremely effective in helping reduce anxiety and facilitating the treatment process
  • Lack of support:  Talking to others who have learned to master their symptoms can encourage a person with OCD to undertake the challenge of therapy and boost the likelihood of success.  Joining a local support group, participating in an online support group or contacting Beyond OCD or the International OCD Foundation are good ways to find people with similar experiences.  Note: Non-therapeutic support groups can be extremely beneficial, but they should complement – not replace – appropriate treatment.

If Symptoms Return

Obsessive Compulsive Disorder is a chronic condition.  Symptoms can be managed, but they sometimes resurface in the same or a different form.  For example, a person with checking compulsions may succeed in therapy, but experience contamination obsessions several years later.

Cognitive behavior therapists stress the importance of following through with exposures after the course of therapy is complete and teach people to recognize and respond to new or returning symptoms, particularly during stressful times.  Booster or refresher therapy sessions may be necessary from time to time to reinforce treatment gains.  Typically, follow-up treatment requires fewer sessions than the original course of therapy.

As a member of the clergy, you are in a unique position to provide information and support to those you counsel.  By being knowledgeable about OCD, how it is treated, and some of the challenges involved in treating this disorder, you can serve as a critical resource for individuals with OCD and those who love them.

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