The importance of behaviour work in OCD recovery

At OCD Excellence, I talk a great deal about behaviour work, also known as exposure work, ERP, de-sensitisation and habituation. As a practice, we stress the importance of this component as part of a successful OCD treatment programme.

We also have to ‘walk the talk’ since, as therapists with OCD, we've backed up our theory with practice over time to maintain our own ‘OCD wellness’. With regard to our clients, we have compiled a 500 + list of behaviour tasks, compiled over 17 years and delineated by sub-type or trigger.

However, there still seems to be some confusion around behaviour work and I would like to try and offer some clarity as follows:

• Behaviour work is the ‘B’ component of CBT (Cognitive Behaviour Therapy) or our OCD Excellence-preferred REBT (Rational Emotive Behaviour Therapy)

• The ‘B’ (Behaviour) and ‘C’ (Cognitive) work are designed to be done concurrently and mutually reinforce the other

• The premise behind behavioural therapy is that dysfunctional behaviour can be both learned and unlearned

• An effective OCD behavioural plan will involve the concepts of both classical conditioning, e.g., flooding and desensitisation, and operant conditioning, e.g., a therapist-led system to reinforce positive and helpful behaviours

• Targeted behaviour work is always required for treating OCD, even for clients with no physical compulsions

• As yet, there is no alternative to behaviour work although clients understandably try to circumvent or avoid it. No amount of cognitive work alone will produce optimum results

• Even with ‘Pure O’ OCD, where there are no physical compulsions, behaviour work is still recommended since there will be mental compulsions

• Since behaviour work is uncomfortable, clients can opt to start gently and step up over time but there is no scientific evidence that this step-up approach is more effective. It’s a little like tentatively wading into cold water – it’s ultimately less painful and quicker to jump right in

• If therapists set the correct tasks and clients are mentally prepared, behaviour work is highly effective with a steep recovery curve…

• ….however, unless the behaviour work is supported with an equal amount of robust and skilled cognitive work, the results will be short-lived due to the adaptation of OCD (OCD is treatment resistant) into enhanced or entirely new triggers

• If a client has a history of family, friend or partner collusion (others becoming involved with OCD) and this level of collusion remains unchanged throughout therapy, then the success of behaviour work will be limited or entirely undermined. This is why we work with carers to set specific guidelines and skills

The legacy of the behaviourists has resulted in an assumption that behaviour work or ERP alone will be sufficient for clients with OCD to make a full recovery. In the case of OCD, this is simply not the case! When I worked in the US, the term ‘behaviour modification’ described the entire approach of some therapeutic practices. Behaviour work is a vital and unavoidable treatment component but it is part of a solution which must include extensive cognitive work and a ready focus on environmental & clinical factors, such as collusion and medication.