Obsessive compulsive disorder - OCD treatment and therapy from NOCD

How important is virtual ERP therapy for OCD? A Q&A with Dr. Jeff Szymanski about recent research released by JMIR

By Julissa Gonzalez

Jun 02, 202212 minute read

Results were just released from the largest study of OCD treatment ever recorded. Validated by the Journal of Medical Internet Research (JMIR), one of the most respected journals in healthcare research, the peer-reviewed study examined the treatment outcomes of virtual exposure and response prevention (ERP) therapy by analyzing over 3500 people at NOCD Therapy over 1.5 years.

The findings are remarkable: the adults receiving online video ERP experienced a decrease in OCD symptoms, resulting in dramatic improvements in depression, anxiety, stress, and overall quality of life. These results were achieved in under half the therapy time needed for traditional ERP therapy in an outpatient setting, resulting in substantial monetary and time savings. They also maintained these outcomes over a 12-month period.

NOCD’s Chief Clinical Officer Dr. Patrick McGrath recently sat down with Dr. Jeff Szymanski, Executive Director of the International OCD Foundation (IOCDF), for a conversation about the significance of treating OCD virtually. They discussed the benefits of virtual ERP therapy for OCD and the impact of the recently published research on the effectiveness of NOCD’s treatment model.

Their full conversation can be found here. Below is an excerpt from the Q&A. This interview has been edited for length and clarity.

Why is ERP, the gold standard OCD treatment, an underused treatment?

As the gold standard OCD treatment, ERP is an evidence-based, specialized therapy that has consistently demonstrated excellent outcomes in the treatment of OCD. However, despite the extensive evidence of the efficacy of ERP, it’s still an underused treatment.

Dr. Patrick McGrath:

Hey Jeff, thanks for being with us today; really appreciate your time on this. You know, of course, there are challenges we’ve all witnessed with accessing ERP, and it can be quite difficult in rural areas. Not every state even has an IOP (intensive outpatient program) or a PHP (partial hospitalization program). Those are some things I’ve seen that maybe make ERP go underused. 

So even though it’s a quite successful OCD treatment, what are some reasons why it might not be used by all clinicians, even though it’s the gold standard of treatment for OCD?

Dr. Jeff Szymanski:

I mean, there are tons of barriers to mental health access for all kinds of people in all kinds of situations. So let’s just go down the list: You mentioned rural access—absolutely. We hear people are going two or three hours each way to see the only provider in their state. But that assumes that you know what you have, right? People still don’t even know what their symptoms are, and that they are part of a psychological disorder. 

So there are lots of barriers. “I don’t know what this is. If I know what it is; where do I go?” And then you do go, if you do manage to get to a mental health professional, you may encounter even more barriers.

You and I both have PhDs. This is the lie of being a clinical psychologist: you have a PhD, and they’re like, “go out and help everyone; help the world.” We aren’t competent to help the world with just our PhDs. We had to get specialized training for certain disorders—and with OCD, that’s one of the things where you need specialized training. 

[So the story might go from] “I don’t know what I have” to “Okay, now I do know what I have now. I’ve been misdiagnosed three or four times. Now I have to drive across the state to get access to care. And now I have to find someone who knows what they’re doing.” 

So there are lots of barriers. Things like teletherapy are important tools that help us increase access. It is increasing access in terms of, “I don’t have to drive two hours.” It increases access because if I’m a mom, I don’t have to get childcare for my kids [while I go to therapy sessions]. There are lots of ways in which we need to problem solve and figure out how to break down all these crazy barriers.

Dr. McGrath:

I think there are still a lot of people who assume therapy has to happen in an office. Not everyone truly understands that the notion of therapy can happen virtually.

Dr. Szymanski:

There are so many outdated notions about what therapy looks like. You go in, you talk about your problem. That’s the worst part of psychotherapists who think they know how to treat OCD: Is there something behind that obsession? No, there’s not something behind the obsession. 

So let’s do exposure therapy. Let’s get the family involved because they’re participating in this because they care about you and they’re compassionately doing it the wrong way.

And what do we know from exposure therapy? You have to generalize it into different settings. So what am I able to do inside my office? It’s the same thing with hoarding disorder—all of your difficulties are at your house. So why are you coming to my office? Why aren’t we doing teletherapy, so that we’re dealing with the problems that are happening in your actual environment?

What’s the impact of the increased accessibility of ERP delivered virtually, and how can it make treatment more powerful?

Due to limitations in the access to care for the majority of individuals with OCD and related conditions, virtual ERP enables more people to access the life-changing care they need. Now, the study published by JMIR additionally validated that ERP delivered through a technology-assisted video teletherapy treatment format results in clinically significant symptom and quality of life improvements on a large scale. 

For many people with OCD, ERP therapy is also more effectively delivered in a virtual setting than in an in-person one. In addition to overcoming the major geographical and accessibility barriers that many people with OCD have, therapists can more easily help patients manage their fears in the environment where they are most triggered, as opposed to in an office. 

Dr. McGrath:

It has been amazing to do teletherapy in people’s homes—just so incredible. Here we are, on your phone, and we’re doing the work. 

So you’ve personally seen through the IOCDF the delivery of virtual care and its impact on the OCD community. Obviously, at NOCD, we hear all the time about the appreciation of virtual therapy, but I want to go broader than that. What are the stories you hear from people about finally having access to treatment in a virtual setting? 

Dr. Szymanski:

Again, it first addresses the barriers we talked about: I don’t have to get childcare; I don’t have to drive two or three hours—or even just half an hour. You have to find parking, and you have to wait in the waiting room, just to have your 45- or 50-minute session. 

But there’s so much more, beyond addressing the barriers and increasing accessibility. If you’re a good ERP therapist, you’re not spending a lot of time in your office with your patients. You’re out in the community.

I’ve been saying this for years: for a big chunk of folks, I actually think virtual therapy is more effective because you’re getting the treatment in the context where you’re getting triggered, which is your house [or another environment]. Or again, you can just get your phone, and we can have a conversation. I don’t have to drive half an hour to meet you at a mall to go do community-based exposures. I don’t have to charge you for my transportation or my time—this way is super-efficient—and you can still do these community-based exposures. You can do these exposures where they’re happening in naturalistic environments. Again, I just think it’s more effective.

What else does virtual therapy do? It increases accessibility to people of color, people who are LGBTQ, people who are Spanish-speaking [by providing them with more therapists they can work with]. These are all things that matter. You’re going to have an intimate relationship with your therapist, so [it’s important to] find someone you like, find someone you connect with, find someone you identify with, and find someone who’s going to be maximally helpful to you. I think when we go virtual, we also increase access to all of those providers that are hard to find.

How much of an impact does shorter overall treatment time have for people with OCD?

The study further proved that people receiving video teletherapy treatment achieved meaningful results in less than half the total time in treatment, compared with standard once-weekly outpatient treatment.

Dr. McGrath:

One of the cool things that I thought came out of the recent JMIR study was you can do virtual therapy in about half the time that a lot of people have done it individually [in person]. Again—I think goes back to what you were saying— this is because you’re in their environment. 

You’re not coming here [to my office] and doing imaginal work. And then going home where you do your homework and then coming back next week to tell me how it went. With the ability to be in someone’s environment—and now with technology allowing for messaging that’s [HIPAA]- compliant—, we can dive deeper quicker with people to get them the help that they need. So this doesn’t have to be the long haul that people might be afraid of; it might not have to be that long at all. 

Dr. Szymanski:

I think that’s true. There’s a weird paradox in old myths of what psychotherapy is supposed to look like. You’re supposed to go in, and you’re supposed to tell all of your secrets, and you’re supposed to develop this very important relationship with this person. But if anything, I think sometimes ERP therapists don’t spend enough time developing a relationship; they’re just like, “let’s get you better.” 

[For the person receiving therapy,] it may come from a feeling of “I don’t need to be close and intimate with my therapist; I just need them to help me. I only need to be connected with them enough in order to do that.” And as a result, I totally can see people getting better more quickly because we can be super-efficient with solving the problem that is most prominent right now [OCD].

What do the study’s findings suggest about treating OCD as a root cause?

Additionally, the study found that people not only experienced an average decrease in OCD symptoms, they also witnessed dramatic improvements in depression, anxiety, stress, and overall quality of life. 

Dr. McGrath:

We are excited that our study that just came out with over 3,500 participants showed the effectiveness of ERP, but it didn’t just affect OCD, it affected stress, anxiety, and depression as well. You and I have seen this personally, too, in the work that we do when we treat OCD: we improve the whole person, not only the OCD. What other areas have you seen where treating OCD improves life outside of just the OCD? 

Dr. Szymanski:

I mean, it’s really interesting, right? When you think about what happens, you don’t have to have OCD to know this experience: When you get anxious, you get tunnel vision. Why do you get tunnel vision? Because your brain is telling you that you might be in danger. If you’re in danger, pay attention to the danger. Well, if you’re paying attention to the danger, you’re not paying attention to everything else. 

You and I have worked with people in their 20s and 30s and 40s. If their OCD first happened at 15 and captured all of their attention, they didn’t do all the other things that 18-year-olds and 22-year-olds and 28-year-olds do. 

When you treat people who are less symptomatic, they can usually pick up their life and actually begin living it. Unfortunately, for some folks, they have to pick up from where they left off 10 years ago. So what you’re seeing in the OCD treatment world is that ERP can make you less symptomatic, but we also need to look at grief and loss and shame and guilt, as well as all these other experiences about how you are as a human being. 

We don’t treat OCD; we’re treating a person. It’s really important to keep track of all of that. 

What is the impact of the study’s findings on people who resist or delay getting treatment because their OCD symptoms aren’t “severe enough”?

Finally, the reduction in OCD symptoms and response rates were found to be similar for those with mild, moderate, or severe symptoms.

Dr. McGrath:

At NOCD when people will call in, they’ll say either, “I don’t know if I want to do therapy because I’m afraid you might tell me I don’t have OCD” or they’ll say “I’ve watched some videos and I don’t think I’m symptomatic enough to do therapy.” Or they might even say “I’m too symptomatic to do therapy, and I’m just stuck.” We always are trying to work on that motivation piece. 

What have you seen that has been really helpful to move people past the very “stuck” thought processes that they may have?

Dr. Szymanski:

The average person doesn’t know that it’s counterintuitive to respond to negative feelings by trying to push them away, trying to avoid them, or trying to drink them away. We know that the actual medicine for difficult feelings is to lean into them, keep your eyes wide open, and embrace them. If you are contemplating therapy for any reason, you don’t have to have a good reason, just go in and someone’s going to weigh in. Someone is going to have another alternative. Someone is going to have another idea. And you don’t have to do it, but just go in and find out if there’s another option.

I have had people come in and say, “alright, I’ve heard about the ERP thing. I’m not going to do that.” We don’t have to do [anything you don’t want to do]. There are all kinds of things we can do to get you there. But at the end of the day, I’m going to tell you that there’s a profound experience—OCD or not—of moving towards things that are difficult. That’s a basic life skill. What you learn in ERP treatment is it’s a life skill to move into difficult feelings. It has a payoff, but we don’t have to start there. 

And you don’t have to be a hundred percent confident that it’s going to work for it to work. You don’t have to be of a certain level or below a certain level of whatever you think you have for it to work. Therapy works if you give it the opportunity to work. 

At the end of the day, if you don’t like how your life is being lived, ask someone to weigh in, ask someone for a different alternative, then try it out and go experiment. What I always tell people is if you put your hand on a doorknob and you twist the doorknob and it opens the door every single time you engage in that behavior, you’re going to open a door. You know the outcome. If every time you avoid it because you’re anxious, you’re going to stay anxious until you change your behavior. Nothing is going to change. So go and find out how to change things. 

If you’re struggling with OCD and are looking for treatment that can help you get better, NOCD is here for you. Our licensed therapists deeply understand OCD and are specialty-trained in treating OCD with ERP. We work side-by-side with the OCD experts and researchers who designed some of the world’s top OCD treatment programs – and that means the best care for our members. You can book a free 15-minute call with our team to get matched with one and get started with OCD treatment. 

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