Actual rituals, mental rituals and reassurance are all similar in one important way. They are all ways in which people with OCD try to reduce the discomfort arising from their worries. We therefore say that they are all ways of 'neutralising' the person's worries. As we explained earlier. The problem is that though neutralising may work in the short term, it makes things worse in the long term. The task in treatment is to find ways to learn that the fears are groundless and can be coped with without rituals.
Assessing the problems
Before treatment begins, your therapist will need to carry out a thorough assessment of your individual problems. Treatment usually follows certain broad guidelines, but it can only be effective if it is tailored for you as an individual. Part of the assessment will consist of interviews in the clinic but usually an important part depends on you. The therapist needs to have a detailed picture of your problems before they can be tackled. Often the best way to get this is for you to keep various kinds of records in your daily life outside the clinic. These 'on-the-spot' records are much more useful than trying to remember everything and tell the therapist in the clinic. Because the rituals and avoidance become such strong habits, it can be hard to notice all the obsessional behaviour you perform. It may be useful to ask yourself some questions:
- What would I not be doing if I didn't have these problems?
- This will tell you something about your neutralising.
- What would I be doing if I didn't have these problems?
- This will tell you about the things you avoid.
What happens In treatment
After your therapist has gathered enough information (usually after 2 to 3 sessions), an individual treatment plan will be made. The prospects for sufferers from OCD had improved dramatically in the last 15 to 20 years. Before then, OCD often went on for many years, or even a lifetime.
With modem treatment, research shows that 70-80% of sufferers will greatly improve within months and will remain well. However we should say that the chances of success depend greatly on you. Modern treatment is very active and depends for its success on your efforts. Your therapist will offer you support and advice but in the end what you put into it is most important.
For most people with OCD, the treatment of choice is what we call 'exposure with response prevention'. As we said before, treatment has to be individually planned, so we can't give you an exact idea of what will happen or how long it will take. However, we can give a broad description.basically,'exposure and response prevention' means that you need to expose yourself to feared objects or situations, whilst preventing the usual neu~alising (rituals, avoidance and so on. In this way you can get used to the things that worry you and learn that nothing terrible actually happens. The details of how quickly you expose yourself to worrying situations and which neutralising behaviour is banned will be worked out with your therapist. This probably sounds like hard work, and indeed it can be. However, most people find that with the right kind of help and support, they can carry out such a programme and overcome their problems.For some people who have few or no rituals, where the main problem is the worrying thoughts, different trea~ents may be needed. These treatments involve learning either to control the thoughts directly, or to become less distressed by them so that they become easier to dismiss.
Some Important points about treatment
It should be stressed that treatment is a joint task between you and your therapist. Though some of the things you are asked to do may be difficult, you will never be asked to do something to which you have not agreed. No surprise will be sprung on you - in the end, it is always up to you to decide what happens. During treatment you may well find that your therapist asks you to carry out tasks which do not seem like 'normal' behaviour. For instance, someone who washes too much may be asked not to wash at all for some period. Clearly most of us do wash our hands in everyday life, but what happens in treatment is not necessarily to be taken as a standard for 'normal' behaviour. if someone breaks a leg, we put it in plaster, but this does not mean that we should all wear plaster on our legs all the time!
Many people find that at some time during treatment they are no longer sure what is 'normal' and what isn't. Don't worry if this happens. Once treatment has helped to reduce your excessive worries, you will be free to decide your own standards, standards which are not controlled by fear.
Most people do become uncomfortable at times during treatment. Do try not to let this put you off sticking to the agreed programme. If you can stick to the programme, the discomfort will decline as you improve. This discomfort is normal, and perhaps even necessary. You cannot lose a strong habit, which has grown over months or years, without any discomfort. It would be much easier for all of us if there were a completely comfortable form of treatment, but so far we do not know of one. Exposure and response prevention offers you the best hope of improvement.
Of course, there are ways of keeping the discomfort within manageable limits. Your family and friends can give you support and encouragement.
How can you get the best out of treatment?
First, please be honest with your therapist about your successes and failures. There may be a temptation to hide any failures in the programme, but this will not help. It is perfectly normal for things to be difficult sometimes, but your therapist needs to know what is happening to be able to help you. 'Failures' may actually have a positive value in helping us to learn more about the problems and be better prepared for future difficulties. Second, please don't hide embarrassing or unpleasant thoughts. By definition, many obsessional thoughts are unpleasant or silly, but your therapist will not be shocked or offended by them. Many other people have had the same thoughts.
Third, try to be strict with yourself in deciding whether behaviour is obsessional or not. Often the best rule is to assume it~s obsessional until you both agree that it is not! This may apply particularly to asking for reassurance. It can be very hard not to get reassurance but it is important that you learn to cope, without depending too much on your family or friends. They can help by supporting your efforts, but not by reassuring you, or by helping you to perform rituals.
Finally, it can be very helpful to have a plan for what to do if you do slip up and perform some rituals. Often the best plan is to deliberately undo' the ritual. For instance, if you wash when you shouldn't have, go back and deliberately touch something 'dirty'. Your therapist can help you work out a plan which will be helpful for you.