Desensitization is the opposite of reassurance, and is a key part of effective therapy. Exposure + confidence = competency.
Good therapists boost resilience, not dependency. I think there are many well-intentioned yet poorly equipped counselors who were essentially taught (or not disabused of) the notion that therapy = "professional validation/reassurance." It is not that, and is so much more: the equipping of a patient with greater distress/ambiguity tolerance.
I really like your takes Dr. Muir, and this post is no exception. I liked it so much I decided to summarize the thesis in my own words:
The most effective psychotherapy for OCD is exposure response prevention.
I have read and witnessed first hand that ERP for OCD has a drop-out rate of 50%. That must leave an impression on the undertrained, they must wonder why they ought to push half of the patients away.
Because OCD is unlikely to respond to placebo, using warmth and positive regard without ERP may hook an OCD’er into the wrong therapy costing time, money, and distracting from the actually useful stuff.
Untreated OCD is a significant risk factor for suicide. Therefore, “wheel spinning, vehicle not moving” therapy represents a risk to the patient.
I agree. Too much fluff, not enough actual treatment. Coming from the UK, I do think the economic costs are meted against "outcomes". The doctors and psychiatrists might want to prevent suicide cases but the state doesn't give a toss.
In the same vain I'm sure it's the same situation for insurance companies in the States.
I've never received help for my OCD because of the way the system is structured. Essentially you need to go through two or three courses of treatment with a counsellor who isn't trained specifically in OCD before you can apply for specialist help - and then the waiting lists are hugely long and you're not guaranteed funding anyway.
What should happen is that people with any mental health disorder should be looked after. If they stop receiving treatment because it's too painful or whatever, the therapists should check up on them from time to time, or at least keep them on the back burner. All too often once people drop off they have to go through the entire process all over again.
I live in the UK and actually finding a therapist who understands OCD is virtually impossible. I was diagnosed nearly twenty years ago and gave up looking for help fairly quickly because I felt like every "professional" I spoke to had no real understanding and either wanted to use talk therapy (as opposed to ERP) or throw drugs at the problem which made me feel worse.
I was doing well for well over a decade when I hit rock bottom again a few years back. I thought I'd go about asking for help again, thinking that surely with all the stuff in the media about mental health that things would be better...
Wrong. Still the same. I went to a therapist once a week for a month or so and felt like I was teaching her what OCD was. After I went back over the same stuff again and again each week (this is what OCD is, after all) she seemed to not know what to say or resorted to offering reassurances.
I could write a book about how dreadful it is to suffer with OCD in a country with national health care, where mental health is just not taken serious at all.
Thank you so much for this reflection! It's important to "know what you are dealing" with as a healer. As a patient, it is important for your healer to "get it."
I think it's just a numbers game. There's just too many people with the condition and never enough trained staff to deal with it.
I do honestly think that one of the problems is that as a society we've chosen to almost over inflate general life stress, and that is having a detriment to people with actual diagnosed conditions since the biggest case load need minimal support. Those who do need additional support get left behind by the system.
So this is one way of looking at it, and I don't disagree with you generally; if you only think about the treatments we have at our disposal today, we have too many people suffering and no ability to scale up the ability to help them. I do think those numbers changed quite a bit if you have more affected treatments, and a more accurate way to screen individuals for that treatment, particularly the treatment we are offering, is very safe and effective. This is the one of the reasons I'm such a fan of transcranial, magnetic stimulation, and other neuromodulator approaches, because there's so much safer than medicines. If we were to treat more people, we wouldn't harm as many in the process. It does require much more large scale screening, and maybe even automated diagnosis, and we're a long ways from that, but not an infinitely long way. One could imagine a world where we had the ability to understand what was in the minds of people who are suffering, and then bring them interventions that didn't require a long time with a highly skilled therapist to get well.
What's the verdict regarding diet? I've read a lot recently on possible connections between inflammatory responses, gut health and the way the brain regulates.
I have been misdiagnosed as having OCD. Fortunately, I was acquainted with THREE psychopharmacologist s who explained the personality "type." I have also been around people who actually had OCD. They have my sympathy! I have seen them cry, and understood how uncontrollable their thoughts and habits really are. 😥😢
I would say reassurance is an important part of graded exposure, in that only by stepping into their discomfort zone can a person then be reassured their fears were not realised. In this way, they are supported to keep systematically expanding their comfort zone.
However, I agree that reassurance at or within this comfort boundary (which is what I think you're referring to Owen) does not result in progress and may actually end up reinforcing it.
Desensitization is the opposite of reassurance, and is a key part of effective therapy. Exposure + confidence = competency.
Good therapists boost resilience, not dependency. I think there are many well-intentioned yet poorly equipped counselors who were essentially taught (or not disabused of) the notion that therapy = "professional validation/reassurance." It is not that, and is so much more: the equipping of a patient with greater distress/ambiguity tolerance.
and this is why we love members of the frontier psychiatrists community like you, Jeremy.
I really like your takes Dr. Muir, and this post is no exception. I liked it so much I decided to summarize the thesis in my own words:
The most effective psychotherapy for OCD is exposure response prevention.
I have read and witnessed first hand that ERP for OCD has a drop-out rate of 50%. That must leave an impression on the undertrained, they must wonder why they ought to push half of the patients away.
Because OCD is unlikely to respond to placebo, using warmth and positive regard without ERP may hook an OCD’er into the wrong therapy costing time, money, and distracting from the actually useful stuff.
Untreated OCD is a significant risk factor for suicide. Therefore, “wheel spinning, vehicle not moving” therapy represents a risk to the patient.
I agree. Too much fluff, not enough actual treatment. Coming from the UK, I do think the economic costs are meted against "outcomes". The doctors and psychiatrists might want to prevent suicide cases but the state doesn't give a toss.
In the same vain I'm sure it's the same situation for insurance companies in the States.
I've never received help for my OCD because of the way the system is structured. Essentially you need to go through two or three courses of treatment with a counsellor who isn't trained specifically in OCD before you can apply for specialist help - and then the waiting lists are hugely long and you're not guaranteed funding anyway.
What should happen is that people with any mental health disorder should be looked after. If they stop receiving treatment because it's too painful or whatever, the therapists should check up on them from time to time, or at least keep them on the back burner. All too often once people drop off they have to go through the entire process all over again.
I live in the UK and actually finding a therapist who understands OCD is virtually impossible. I was diagnosed nearly twenty years ago and gave up looking for help fairly quickly because I felt like every "professional" I spoke to had no real understanding and either wanted to use talk therapy (as opposed to ERP) or throw drugs at the problem which made me feel worse.
I was doing well for well over a decade when I hit rock bottom again a few years back. I thought I'd go about asking for help again, thinking that surely with all the stuff in the media about mental health that things would be better...
Wrong. Still the same. I went to a therapist once a week for a month or so and felt like I was teaching her what OCD was. After I went back over the same stuff again and again each week (this is what OCD is, after all) she seemed to not know what to say or resorted to offering reassurances.
I could write a book about how dreadful it is to suffer with OCD in a country with national health care, where mental health is just not taken serious at all.
Thank you so much for this reflection! It's important to "know what you are dealing" with as a healer. As a patient, it is important for your healer to "get it."
I think it's just a numbers game. There's just too many people with the condition and never enough trained staff to deal with it.
I do honestly think that one of the problems is that as a society we've chosen to almost over inflate general life stress, and that is having a detriment to people with actual diagnosed conditions since the biggest case load need minimal support. Those who do need additional support get left behind by the system.
So this is one way of looking at it, and I don't disagree with you generally; if you only think about the treatments we have at our disposal today, we have too many people suffering and no ability to scale up the ability to help them. I do think those numbers changed quite a bit if you have more affected treatments, and a more accurate way to screen individuals for that treatment, particularly the treatment we are offering, is very safe and effective. This is the one of the reasons I'm such a fan of transcranial, magnetic stimulation, and other neuromodulator approaches, because there's so much safer than medicines. If we were to treat more people, we wouldn't harm as many in the process. It does require much more large scale screening, and maybe even automated diagnosis, and we're a long ways from that, but not an infinitely long way. One could imagine a world where we had the ability to understand what was in the minds of people who are suffering, and then bring them interventions that didn't require a long time with a highly skilled therapist to get well.
What's the verdict regarding diet? I've read a lot recently on possible connections between inflammatory responses, gut health and the way the brain regulates.
no verdict on diet from me yet--more data to review! however, more information about the science of inflammation is in your inbox right now!
I have been misdiagnosed as having OCD. Fortunately, I was acquainted with THREE psychopharmacologist s who explained the personality "type." I have also been around people who actually had OCD. They have my sympathy! I have seen them cry, and understood how uncontrollable their thoughts and habits really are. 😥😢
These things are complicated! It’s important to understand how much more information, over time, can change an impression!
I would say reassurance is an important part of graded exposure, in that only by stepping into their discomfort zone can a person then be reassured their fears were not realised. In this way, they are supported to keep systematically expanding their comfort zone.
However, I agree that reassurance at or within this comfort boundary (which is what I think you're referring to Owen) does not result in progress and may actually end up reinforcing it.
thanks for the comments! My hope was to highlight the issue for general audiences, who might not be aware this is an issue.