McKay, D., Abramowitz, J. S., & Storch, E. A. (2021). Mechanisms of harmful treatments for obsessive–compulsive disorder. Clinical Psychology: Science and Practice, 28(1), 52–59. https://doi.org/10.1111/cpsp.12337

Key Points

Obsessive-compulsive disorder (OCD) is a serious condition associated with significant impairment. While effective treatments exist, many individuals receive inappropriate or even harmful therapies that can worsen symptoms.
Harmful treatments include cognitive-behavioral approaches not specifically tailored for OCD, misapplied evidence-based OCD treatments, and interventions lacking an empirical basis of support.
Ineffective treatments like relaxation training, energy therapies, ungrounded self-help methods, and dietary supplements waste client resources without providing benefits.
Conceptually, certain treatment approaches are hypothesized to increase doubting, frustration, anxiety sensitization, and other OCD symptomology.

Rationale

Prior to efficacious therapies, OCD was considered nonresponsive or even exacerbated by treatment attempts (Kringlen, 1965).
There are few effective treatments, and there are several other plausible interventions that are actually harmful to individuals with OCD.
It is important to understand the mechanisms causing iatrogenic harm in OCD treatment in order to ensure appropriate, helpful care.

Method

Conceptual literature review
Evaluated theoretical bases of existing OCD treatments in adults, focusing on those causing symptomatic worsening
Covered both direct evidence of harm as well as conceptual reasons predicting harmful effects

Results

Cognitive-Behavioral Treatments

Thought-stopping trains OCD patients to suppress intrusions, which typically backfires and strengthens obsessions (Purdon, 2004)
General cognitive therapy provides excessive reassurance and fails to address core OCD issues like intolerance of uncertainty and doubt (Neal, Alcolado, & Radomsky, 2017).

While effective cognitive therapy protocols exist for OCD (Wilhelm & Steketee, 2006), many therapists mistakenly try to debate obsessional fears with patients, asking them to gather evidence for or against them.

This resembles the endless reassurance seeking driving OCD, failing to address core issues like responsibility overestimation and certainty pursuit. Sufferers already exhaustively gather evidence to no avail, finding the process deeply frustrating. Well-intended reasoning attempts merely provide “high-tech” rituals, reinforcing OCD.
Misapplied exposure therapy risks anxiety sensitization or lacks proper stimulus targeting (Foa & Kozak, 1986).

The primary mechanisms of harm come through either (1) Taking too aggressive of an approach up the feared stimulus hierarchy without proper habituation time or (2) Failing to accurately identify and target the stimuli most related to an individual’s obsessions in a tailored way.

Psychodynamic Approaches

Psychodynamic approaches tend to increase doubt, uncertainty, and philosophical rumination, which are countertherapeutic in OCD (Samuels et al., 2017).
Framing intrusive experiences as symbolic manifestations of inner turmoil leaves OCD patients ruminating without solutions. Sufferers already fatigue themselves by ruminating about the “what ifs” behind their fears. Expanding this rumination is countertherapeutic.

Ineffective Interventions

Relaxation training (e.g., progressive muscle relaxation), energy techniques (e.g., tapping meridian points of the body), unvalidated self-help methods, and dietary supplements waste resources without alleviating OCD.
Progressive muscle relaxation fails to alleviate OCD because it only provides superficial anxiety relief without addressing the root obsessional thoughts causing distress. Unlike exposure-based techniques directly targeting intrusive thinking, relaxation pleasantly alleviates downstream somatic tension while leaving primary symptoms intact.
While generally benign in their immediate effects, investing major time, effort, and hope into these unsupported methods can deeply waste the motivation, financial resources, and openness-to-change of OCD sufferers.

Insight

This review clearly demonstrates that obsessive-compulsive disorder requires highly specialized psychosocial treatment approaches centered around empirically-supported modalities like exposure and response prevention (ERP) or cognitive therapy specifically tailored to OCD.
Even gold-standard techniques like ERP carry risks of worsening anxiety, frustration, doubt, and overall symptoms if implemented improperly, indicating providers require extensive training and supervision.

Strengths

Comprehensively reviews and organizes harmful OCD interventions from various modalities
Balances evidence review with theoretical analysis
Authored by leading OCD experts

Limitations

Lacks systematic data on actual rates and predictors of treatment-induced harm
Focused only on adult OCD

Implications

Demonstrates the serious risks associated with misguided OCD treatment and reinforces the need for specialized, expert-guided therapy.
Clinical trials should report the statistical evaluation of possible benefits and harm from treatment, through routine reporting of the number needed to treat (NNT) and the number needed to harm (NNH; Shearer-Underhill & Marker, 2010).
Can inform treatment guidelines and practitioner training:
Professional bodies and accreditation organizations may need to strengthen competency standards and training requirements for OCD therapy provision.
Referral networks and therapy directories could also screen providers based on their demonstrated expertise in evidence-based OCD protocols.

References

Primary paper

McKay, D., Abramowitz, J. S., & Storch, E. A. (2021). Mechanisms of harmful treatments for obsessive–compulsive disorder. Clinical Psychology: Science and Practice, 28(1), 52–59. https://doi.org/10.1111/cpsp.12337

Other references

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Kringlen, E. (1965). Obsessional neurotics: A long-term follow-up. British Journal of Psychiatry, 111, 709-722. https://doi.org/10.1192/bjp.111.479.709

Neal, R. L., Alcolado, G. M., & Radomsky, A. S. (2017). How do I say this? An experimen-tal comparison of the effects of partner feedback styles on reassurance seeking behaviour. Cognitive Therapy and Research, 43, 748-758.

Purdon, C. (2004). Empirical investigation of thought suppression in OCD. Journal of Behavior Therapy and Experimental Psychiatry, 35, 121-136. https://doi.org/10.1016/j.jbtep.2004.04.004

Samuels, J., Bienvenu, O. J., Krasnow, J., Wang, Y., Grados, M. A., Cullen, B., Nestadt, G. (2017). An investigation of doubt in obsessive-compulsive disorder. Comprehensive Psychiatry, 75, 117-124. https://doi.org/10.1016/j.comppsych.2017.03.004

Shearer-Underhill, C., & Marker, C. (2010). The use of the number needed to treat (NNT) in randomized clinical trials in psychological treatment. Clinical Psychology: Science and Practice, 17(1), 41–47. https://doi.org/10.1111/j.1468-2850.2009.01191.x

Wilhelm, S., & Steketee, G. (2006). Cognitive therapy for obsessive-compulsive disorder: A guide for professionals. Oakland, CA: New Harbinger.

Keep Learning

Here are some potential discussion questions for a college class:

Do all treatments carry some risk of harm? How should clinicians balance those risks against potential benefits?
Could factors like OCD subtype or comorbid conditions predict worse outcomes from certain therapies?
How might a clinician discern whether a treatment is conceptually incompatible with OCD before attempting it?
What safeguards and oversight measures could reduce rates of iatrogenic harm in OCD treatment?
Are ineffective treatments necessarily benign just because they don’t directly worsen symptoms? What implications do they have for client motivation, resources, etc.?

Mechanisms of Harmful Treatments for Obsessive–Compulsive Disorder