Verified by 
Key points
- Evolution in OCD treatment involves specific treatment protocols and strategic therapeutic communication.
- Exposure and response prevention (ERP) is effective but has high dropout rates.
- Brief strategic therapy (BST) offers a nonconfrontational, rapid-change approach.
''….The chains of habit are too weak to be felt until they are too strong to be broken'' —Samuel Johnson, 1783
Cognitive behavioral therapy (CBT) is widely used to treat OCD. It suggests that obsessions and compulsions result from abnormal learned responses. CBT focuses on identifying and changing destructive thought patterns and reframing dysfunctional beliefs. Patients are gradually exposed to triggers that cause their OCD symptoms, learning to tolerate anxiety and resist compulsions.
Despite the benefits of CBT, many OCD cases do not achieve remission, and some patients see no improvement at all (Reid et al., 2021; Sharma et al., 2014). The principal method in CBT for OCD is exposure and response prevention therapy (ERP), where patients face anxiety-provoking situations without performing their usual compulsive behaviors. While effective, ERP has high dropout rates, is stressful to perform, and often requires a therapist's presence, which can be impractical (Boncheck, 2016) and costly (Vitry et al., 2022).
Cognitive therapy (CT), without a behavioral element, which is often the case in treatment these days, focuses on changing maladaptive thoughts without behavioural components like ERP. Although CT can be effective, it does not demonstrate superior outcomes to ERP and often does not significantly improve severe OCD cases (Anholt et al., 2008; Emmelkamp, 2002; Wilhelm & Steketee, 2006). The rational dialogue of CT may also not adequately address the seemingly irrational nature of severe OCD or lead to a feeling of being understood (Gibson, 2016, 2022,2021).
Limitations of Exposure and Response Prevention (ERP)
- High Dropout Rates: About 50 percent of patients refuse treatment, drop out, or relapse, indicating a need for better methods to increase motivation and adherence (Abramowitz, 2006).
- Challenging Regimen: Directly confronting compulsions can be overwhelming, as many seek help because they cannot manage their behaviors (Abramowitz, 1996).
- Therapist Presence: ERP is more effective with a therapist present, limiting its practicality and increasing cost significantly, thus reducing efficiency (Meyer, 1966).
Brief Strategic Therapy Versus Cognitive Behavioral Therapy
While often mistakenly confused with cognitive-behavioral therapies, brief strategic therapy (BST) differs in key ways. Both approaches view the patient as actively constructing their reality, and both models use empirical methods to validate practice. However, CBT derives from learning theory, guiding patients through voluntary efforts to manage their problems. In contrast, BST uses therapeutic stratagems, tailored to the specific form of OCD, that act to create emotional experiences and alter how patients perceive the problem, thus allowing patients to also use these techniques later in therapy voluntarily to consolidate the changes.
In CBT, change happens rationally and progressively as patients learn to try to control their thoughts and actions (Reda & Pilleri, 2013) through conscious effort, often in contradiction to how they feel. In BST, change occurs rapidly, with therapeutic techniques focused on shifting the patient's perceptions and reactions that maintain their problem. In BST, non-rational or non-ordinary logical techniques (Gibson, 2021, 2022; Nardone and Portelli, 2013; Nardone and Balbi, 2012), such as "prescribing the symptom," where patients are instructed to engage more in their compulsive behavior and numerous others kinds of stratagems are also utilized to transform the pathology with minimal resistance and conscious effort. This kind of paradoxical directive leverages natural resistance, transforming an uncontrollable behavior into a controlled action, reducing resistance and increasing compliance (Nardone, 1996; Rabavilas, Boulougouris, & Stefanis, 1977). This can bypass the strong resistance often encountered in OCD cases.
The Effectiveness of Brief Strategic Therapy Lies in Its Approach:
- Minimizing Explanations: Providing minimal rationale prevents over-analysis and resistance, focusing on actions rather than discussions (Gibson and Portelli, Papantuono, 2022; Nardone & Watzlawick, 2005).
- Collaborative Approach: Using the patient's language and framing problems positively creates a supportive environment (Gibson, 2022; Nardone & Watzlawick, 2005).
- Questions With the Illusion of Alternatives: Presenting choices that all lead to progress gives patients a sense of control (Gibson, 2022; Nardone, 2007).
Therapeutic Communication
The BST model uses specific treatment protocols for various psychopathologies (Gibson, 2021, 2022, Nardone and Portelli, 2013). Clinicians have guidelines for all therapy phases and strategies to address varying dysfunctional interactions. A key feature of this evolved model is the emphasis on the consolidation phase, which focuses on developing and reinforcing the patient's awareness of their resources after disrupting the pathological pattern. In this scenario, "insight" is a consequence of change, not a precursor (one of the shibboleths of psychotherapy).
CBT uses "logical-rational" and "instructive" communication, typical of explanations and formal teaching. BST type uses "performative" (Austin, 1962; Loriedo, Nardone, Zeig, 2011) and "injunctive" communication, which is more evocative and persuasive in tone, engaging emotions in the patient before understanding. This kind of communication involves the use of logical and analogical language, suggestive metaphors, and post-hypnotic assonance. These methods fit with theories of learning and change, essential for establishing a new, healthy balance (Gibson, 2021, 2022, 2024, Nardone, Balbi, 2008; Mahoney, 1991). Traditional CBT approaches often instruct patients to stop their rituals completely, which can be counterproductive and more likely a strategy the patients themselves have already tried and failed to do. Strategic clinical dialogue can address the emotional and cognitive barriers to treatment, enhancing success, effectiveness, and efficiency (a growing area of focus in psychotherapy research) (Vitry et al., 2022).
To find a therapist near you, visit the Psychology Today Therapy Directory.
References
References
Abramowitz, J. S. (1996). Variants of exposure and response prevention in treatment of OCD: A meta-analysis. Behavior Therapy, 27(4), 583-600.
Abramowitz, J. S. (1998). Does cognitive-behavioural therapy cure obsessive-compulsive disorder? A meta-analytic evaluation of clinical significance. Behavior Therapy, 29(2), 339-355.
Abramowitz, J. S. (2006). The psychological treatment of obsessive-compulsive disorder. Canadian Journal of Psychiatry, 51(7), 407-416.
Anholt, G. E., Kempe, P., de Haan, E., van Oppen, P., Cath, D. C., Smit, J. H., & van Balkom, A. J. L. M. (2008). Cognitive versus behaviour therapy: Processes of change in the treatment of OCD. Psychotherapy and Psychosomatics, 77(1), 38-42.
Ayllon, T., & Michael, J. (1959). The psychiatric nurse is a behavioural engineer. Journal of Experimental Analysis of Behavior, 2(4), 323-334.
Beck, A. T. (1976). Cognitive therapy and emotional disorders. New York: International Universities Press.
Bonchek, A., & Greenberg, D. (in press). Compulsive prayer and its management. Journal of Clinical Psychology.
Dunlap, K. (1942). The technique of negative practice. American Journal of Psychology, 55(3), 270-273.
Emmelkamp, P. M. G. (2002). Commentary on treatment. In R. O. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment, and treatment (pp. 461-463). London: Pergamon.
Franklin, M. E., & Foa, E. B. (2008). Obsessive-compulsive disorder. In D. Barlow (Ed.), Clinical handbook of psychological disorders (4th ed.): A step-by-step treatment manual (pp. 164-215). New York: Guilford Press.
Gibson, P., Castlenuovo, G., Pietrabissa, G., Manzoni, M (2016). Brief Strategic Therapy For Obsessive Compulsive Disorder. A Clinical and Research Protocol, BMJ Open 2016;e10009018.
Gibson, P., (2021). Escaping the Anxiety Trap. Strategic Science Books.
Gibson, P., Portelli C., and Papantuono, M. (2022). The OCD Clinic. A New Understanding For Obsessive Compulsive Disorder, including Binge Eating, Bulimia and Vomiting. Strategic Science Books.
Gibson, P. (2024) When the Bubble Bursts: A New Approach to Understanding and Treating Depression. Strategic Science Books. (In press)
Gibson, P. (2020) The 12 Most Common Mental Traps. Strategic Science Books.
Gibson, P. (2021). The Persuasion Principle. Communication Strategies to Persuade and Influence. Strategic Science Books.
Frank, J. D. (1973). Persuasion and healing: A comparative study of psychotherapy (2nd ed.). Baltimore: Johns Hopkins University Press.
Gibson, P. (2023). Persuasion Principle. Strategic Persuasion. Strategic Science
Laborit, H. (1979) Le Nouvelle Grille.
Nardone and Portelli (2013) Obsessioni, Compulsioni Manie. Ponte Alle Grazie.
Gibson P., Pietrabissa G, Castelnuovo G, Jackson JB, Rossi A, Manzoni GM. (2019). Brief Strategic Therapy for Bulimia Nervosa and Binge Eating Disorder: A Clinical and Research Protocol. Front Psychol. 10(373).
Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour Research and Therapy, 4(4), 273-280.
Nardone, G. (1996). Brief strategic solution-oriented therapy of phobic and obsessive disorders. Northvale, NJ: Jason Aronson Inc.
Nardone, G. (2007). The strategic dialogue: Rendering the diagnostic interview a real therapeutic intervention. London: Karnac Books.
Nardone, G., & Watzlawick, P. (2005). Brief strategic therapy: Philosophy, techniques, and research. Northvale, NJ: Jason Aronson Inc.
Rabavilas, A. D., Boulougouris, J. C., & Stefanis, C. (1977). Compulsive checking diminished when over-checking instructions were disobeyed. Journal of Behavior Therapy and Experimental Psychiatry, 8(2), 111-112.
Riggs, D. S., & Foa, E. B. (1993). Obsessive-compulsive disorder. In D. Barlow (Ed.), Clinical handbook of psychological disorders (2nd ed.): A step-by-step treatment manual (pp. 189-239). New York: Guilford Press.
Wilhelm, S., & Steketee, G. S. (2006). Cognitive therapy for obsessive-compulsive disorder: A guide for professionals. Oakland, CA: New Harbinger Publications.
