Relapse Prevention in the Treatment of OCD
By James Claiborn, PhD, ABPP
Relapse prevention is a part of a cognitive behavioral therapy (CBT) approach to treatment of OCD and most other disorders. The idea of relapse prevention was first developed by people working with substance abusers who are notorious for returning to the problem behavior. It was clear that although treatment seemed to work at least temporarily, a substantial percentage of patients would relapse over time. This discouraging situation led researchers like A. Marlatt to look for a solution. The idea they developed was relapse prevention.
To understand relapse prevention we need to start with the definition of some terms. First, a relapse is defined as a return to the same level of symptoms as before treatment. If an individual is treated well enough and has few or no symptoms they are described as in remission. If they are treated and have some moderate symptoms they would be in partial remission. In either case, if they go from this improved state to being roughly as symptomatic as they were before treatment they are described as having relapsed. A second term used in relapse prevention is a lapse. A lapse would represent a partial or brief return of some symptoms. It is important to make the distinction because as we will see they are often confused and we can often intervene to prevent a lapse from turning into a relapse.
Spreading from substance abuse treatment to other areas of mental health treatment relapse prevention is now seen as an important component of well planned CBT from most disorders and OCD is no exception.
The best treatment for OCD is CBT, which typically includes exposure and response prevention (ERP) and some degree of more cognitive interventions. While ERP is understood as more behavioral approach, where the emphasis is on having the individual behave in a very different way then they typically do, the cognitive part of CBT is more focused on thinking differently. Relapse prevention is more focused on the cognitive aspect of treatment.
Relapse prevention typically comes near the end of treatment, after we work with the patient to gain control over their symptoms. Once we achieve this goal, we then are ready to look at how we can help the person keep their gains.
To understand how this works in treating OCD we need to understand how OCD works. OCD as the name suggests consists of having obsessions and compulsions that cause significant distress and interference with a person’s life. Obsessions are mental events, described as intrusive thoughts images, impulses, etc that are seen as unwanted, upsetting and often foreign. Compulsions are voluntary behaviors (overt or mental) that the individual does to reduce the distress that comes with the obsessions. A classic example might be a person who has an obsessive thought, that they have touched something contaminated and are in danger of getting sick themselves and spreading the contamination to others and causing others to get sick. The person with OCD who has this thought becomes distressed and anxious. They then try to find a way to reduce this distress or anxiety such as washing their hands. They may wash for an extended period of time or in a certain way until they feel less anxious and believe the danger is at least dramatically reduced. Many people believe that the problem in OCD is having these intrusive thoughts, but research has shown that this is not the problem. In fact the intrusive thoughts that cause so much distress for people with OCD are really not much different from intrusive thoughts experienced by everyone. This has important implications for relapse prevention because if the person with OCD assumes that having the intrusive thought is a major problem they are likely to assume treatment has failed. Part of what needs to change in treatment is the thinking about the intrusive thought.
Successful treatment to partial or full remission of OCD will leave the person with a much reduced frequency of the intrusive thoughts but they will still have some of them since they are in fact a normal part of human experience. Relapse prevention includes changing a distorted thought about having intrusive thoughts. The distortion is one that can be described as thinking in absolute terms.
If we go back to the origins of relapse prevention in substance abuse for an example it will be clear how this is a problem. The person with a substance problem may classify themselves either as a user or non user. There is no in between. They may say if I have one drink, I am a drunk. This represents confusing a lapse with a relapse. The one drink is a lapse and is not always followed by a binge but if the person thinks in absolute terms they may assume it will and relapse.
For the person with OCD this may take the form of having an obsession triggered after a period of relative freedom from obsessions. If the person has a lot of distress and concludes they need to engage in some compulsive behaviors, then they have experienced a lapse. If they then engage in some absolute thinking, such as all my hard work in ERP is a waste because I still have obsessions and I have to do the compulsions they are on the path to a relapse.
Next I will describe how we engage in relapse prevention. We need to begin by working on the problem of absolute thinking. This may have been discussed explicitly earlier in treatment but often in a restricted way. For example the patient and therapist may have talked about the need for certainty, excess responsibility, perfectionism or over estimation of risk. These problems in thinking all involve absolute thinking. We also need to understand the connection between a lapse and relapse. While a lapse may be followed by a relapse there is no necessity that this happen and as an alternative a lapse can be seen as an important learning opportunity. If a lapse occurs it is a great time to identify what went wrong. This can lead to planning how to respond to similar situations. As an example the person with contamination obsessions my find they were very anxious when using a dirty public restroom and found themselves doing excessive washing. This would be a good time to identify a lapse, the situation that triggered it and develop a plan for how to deal with it in the future. Part of relapse prevention is teaching the patient to expect lapses to happen and developing a plan for dealing with them.
One important part of that plan is remembering what worked in treatment. If the patient can remember that when they had a fear before they tackled it by systematically exposing themselves, stopping themselves from engaging in rituals and tolerating the anxiety, then they can repeat that process, although at this point it is likely to go much more quickly.
Since some of the experiences that are part of OCD such as intrusive upsetting thoughts are bound to occur, part of relapse prevention is developing an understanding of this and planning on how to deal with it. This includes recognizing high risk situations. If the person knows what situations are likely to trigger a lapse, they can make plans to deal with them and not be taken by surprise or make the cognitive error of absolute thinking.
One high risk situation that can be identified for almost everyone is experiencing some distressing event. When we are under pressure or feeling stressed everyone is likely to experience an increase in intrusive thoughts. If the person understands this, then they can effectively deal with it. If the person thinks it represents some sort of failure they are back to the absolute thinking trap and at risk for a relapse. We need to keep in mind that progress is typically not uniform. There will be ups and downs.
It is also useful to think about how life after treatment will be different. If the person has been spending lots of time doing compulsions, what will they do with the newly freed time? It is worth thinking about what the person wants to do or things he may have been avoiding because of OCD and how he can move forward.
If a person is working with a therapist who is experienced in treating OCD, it is likely that the therapist will bring up the topic of relapse prevention as treatment approaches an end point. If the therapist doesn't, it is a good idea for the patient to bring up the topic. As treatment ends it may be helpful to consider booster sessions. Sometimes the person may want to plan these formally or they may be comfortable with a plan that they will contact the therapist as needed.
For the person doing self-directed treatment, it is important to do one's own relapse prevention. Consider what are high risk situations, review what has worked before, take a look at your own thinking being especially alert for episodes of absolute thinking. It is also helpful to discuss relapse prevention with significant others. Tell them about your difficult situations and ask for support in not going back to compulsions. Remember that lapses do happen but relapses don’t have to happen.