Charles Mansueto on Obsessive Compulsive Disorder

Charles Mansueto on Obsessive Compulsive Disorder

by Victor Yalom
OCD expert Charles Mansueto explains the fundamentals of evidence-based treatment of OCD and related disorders, as well as common misperceptions therapists have about the nature, course and effective treatment of OCD.


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OCD and Its Misconceptions

Victor Yalom: We can assume that our readers who are therapists and students of therapy or counseling or social work know something about obsessive compulsive disorder, but may not have a great deal of expertise. So what are a couple of things that therapists don't know or may misunderstand about OCD?
Charles Mansueto: Well, the first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not. It appears that that the treatment that’s clearly effective and has been well tested is cognitive behavior therapy. The second kind of treatment that is available is pharmacological treatment that typically impacts the serotonin system.
The first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not.

Because it’s widely thought of as a brain-based or biological disorder having a biological substrate, one misconception is that it needs a biological solution, that a person must be treated with medications to correct whatever anomalous conditions exist when OCD is present. That’s not the case. The learning-based treatment, Cognitive Behavior Therapy (CBT), has been established and continues to be emphasized as the treatment of choice in the vast majority of cases.
VY: We hear that about so many conditions now that they are biologically based, and I think many therapists are skeptical. What’s the evidence for OCD being biologically based?
CM: The evidence comes from basic studies of brain scans. Some early research, for example, identified the activity in the brain that occurs when OCD is present as identifiably abnormal. I participated in a study with Judith Rapoport using Pet Scan imaging. We found that when the cortex, the thinking brain, perceives a danger of some sort, it transmits a signal down to deeper structures of the brain. In people with OCD, the caudate nucleus seems to not be able to regulate these worrying signals. But when OCD has been treated successfully, either by the serotonergic drugs or by cognitive behavior therapy, there’s a degree of normalization of brain function. There’s a lessening of that repetitive activity within the communicative structures in the brain.
VY: So with brain studies, there’s some clear differences between people with OCD and the “normal population,” and there’s a difference between pre-treatment and post-treatment OCD. Is that what you’re saying?
CM: Exactly.
VY: But I’m sure looking at the brain you could find brain differences in many groups of people. That doesn’t prove that it’s a neurologically-based. That’s correlation. So what other type of evidence is there?
CM: Well, there’s the family studies that show a greater-than-chance-alone incidence of OCD within families. So there’s a suggestion that there’s a genetic element to the transmission of OCD. There are other possibilities, of course—cultural transmission, social transmission—but there’s strong evidence for some genetic linkage.
VY: And then there’s some more intriguing evidence of OCD being related to Tourette’s syndrome, which I know you have done a lot of research on.
CM: Those of us who treat OCD frequently often come across the co-existence of OCD and tics and Tourette’s syndrome, most often in children. There is often great difficulty in distinguishing between complex tics in adolescents, for example, and compulsions. So the question comes up often: Is this is a tic? Or is it a compulsion? Now those have important treatment implications because we have different sets of tools for OCD versus Tourette’s. But there are a lot of close similarities and an intriguing connection between the two that hasn’t been well-clarified in the literature.[editquoteThe question comes up often: Is this is a tic? Or is it a compulsion?]

Strep Throat and OCD

VY: I recall hearing in the past that there was some potential linkage between Tourette’s syndrome and strep throat. Is that true?
CM: Yeah. It’s called “PANDAS,” Pediatric Autoimmune Neurologic Disorder Associated with Strep. Cute name but not a very cute disorder. Sue Swedo and others have pointed out that there seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.
There seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

More recently, there’s been speculation that other diseases, such as Lyme Disease, might also be able to initiate or exacerbate symptoms of OCD and some of these other related kinds of problems. Now that it’s been identified as such, we’re seeing more and more children who are presumed to have a biological-based onset—or infection-based onset—of OCD and these related problems.
VY: So there are multiple ways that this might manifest, in terms of symptomatology—a lot of complexities there.
CM: Well it adds the possibility of environmental causes. So it’s not just that a traumatic incident or a biological vulnerability are the only causes, but relatively common infections may also be implicated in the etiology of OCD.
VY: Has the traditional psychoanalytic/psychodynamic explanation for it been totally discredited?
CM: Well, it’s certainly very interesting and compelling, but it’s very hard to prove in research, as you might guess. But more importantly, treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD, at least in the cases that have been researched.

OCD and Obsessive Compulsive Personality Disorder

VY: Is there any correlation at all between what we think of as obsessive compulsive personality disorder and OCD? Or are those two really quite distinct things?
CM: Well, they are distinct, but again they’re curiously related. We do distinguish the disorders, putting them in two different parts of the DSM and they’re differentiated relatively easily from diagnostic criteria. However, my own view is that we’re talking often about how ego-dystonic versus syntonic it is. In other words, how much does a person who is extremely orderly and very concerned about germs and cleanliness— how much do they value that? Do they see that as part of themselves, the way they are? Their own characteristics as opposed to something that happened to them that they would like to get rid of?
Treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD.

With OC personality disorder, one distinction that’s made is that the behavior is ego-syntonic. The person doesn’t necessarily want to give up this part of themselves because it’s well-integrated into their overall functioning, their value system, their dispositions to action and their history. With OCD it’s more dystonic. It’s something that happens to me and I want to get it out of me at all costs.

But we do see a continuum here. We see individuals who are more or less committed to maintaining their particular approach to life, their perfectionistic tendencies, their extreme cleanliness, their methodical orderliness, to the point where they are doing more organizing than they are working; it becomes very dysfunctional. So I’m not convinced that we are talking about two totally different populations. But that’s the way we think diagnostically.
VY: Let’s talk about the course of the disorder. Let’s say someone has classic OCD—hand washing, door checking, those types of behaviors. When does this typically start and if left untreated, does it tend to go throughout the course of their life?
CM: Well, we don’t have perfect information on this because we only see people who are in trouble, when things haven’t resolved. So there may be people out there who experience significant OCD that then resolves, but we don’t see those individuals very often. But typically, OCD occurs in children around age eight, nine, ten or there is another onset cluster in late puberty/early adulthood. Whether they’re identical is up for some debate. There do seem to be differences in many of the childhood cases we see. Some of the work I’ve done with what I’ve come to call “Tourettic OCD” tends to appear more typically in childhood.
Whether a person gets it early or later, it seems to be chronic when left untreated.

But whether a person gets it early or later, it seems to be chronic when left untreated. It does wax and wane though. There probably are many individuals who are able to adapt and continue to live reasonably productive and happy lives. But for many individuals it becomes a true disorder, in the sense that it substantially decreases their ability to be happy and satisfied with the quality of their lives.
VY: Right, you said that obsessive organizing behaviors interfere with work, but I imagine it can also interfere with relationships.
CM: Very much so. We work with a lot of families, and a whole family’s life can revolve around the OCD of one individual within that family.

Treating the Family

VY: Does an example come to mind?
CM: Let’s say an older adolescent or a young adult continues to live with the family, with the parents, and the parents realize that the person is impaired, and very dependent on them. Well, as parents often do, they try to keep the person as comfortable as possible, as comforted as possible, and that means they begin to adapt their life to the needs of that individual. Those needs can often be excessive and very bizarre. It may involve cleaning and separating dirty things from clean things. It may involve strange eating patterns. But the family becomes more and more inclined to revolve and have their home life dominated by those requirements. In that case, we have to often treat the entire family.

Now that’s more typical of children and adolescents, obviously, but we see people who are up there in age and they worry that their child cannot exist without them and their time is limited. Those individuals often reach out in desperation even though their loved one is unwilling to get treatment and just simply wants everyone to continue to cater to their unique and idiosyncratic needs.
VY: It becomes a kind of codependent situation where their attempts to comply or adapt to the OCD sufferer probably reinforces it.
CM: It’s a big problem. At the OC conferences, we often have rooms full of parents who are there because their children—usually adolescents or young adults— wouldn’t come. They’re trying to figure out how to get their children to agree to participate in treatment.
VY: Let’s delve into treatment. You mentioned that cognitive behavioral therapy is the treatment of choice?
CM: Yes. The expert consensus guidelines were developed in the late 90’s, 1990’s, and haven’t been modified since because, except for the addition of a few medications into the treatment approach, the guidelines are still very solid. About 70 or so treatment experts from around the world were asked to put together the guidelines for those who are not experts at treatment.

I think just under two-thirds were medical people, MD’s, and across the board, CBT was recommended for individuals with OCD, sometimes in combination with medication for more severe cases. But medication alone was seen to be a second best treatment, except in the case of more severe adults. Essentially CBT is the treatment of choice, and we do biofeedback, relaxation training, assertiveness training, all under the umbrella of CBT.

The Experts Agree: The Solution is CBT

VY: We’re a field that doesn’t always easily come to a consensus about what to do when you’re sitting with another human being in the room to help them with their malaise, but it sounds like at least for the treatment of OCD, there is a higher consensus than we typically find.

Let’s get into the specifics of CBT treatment. Let’s take a prototypal case—a hand washer or a checker who’s checking the locks or checking to make sure that the stoves are turned off. Let’s say this is someone who is coming voluntarily to your office and wants to get some help. How do you start out?
CM: Education first. There are things to know about OCD.
It can feel very mysterious and just because someone has it doesn’t mean they understand it.
It can feel very mysterious and just because someone has it doesn’t mean they understand it. So the first step is to help explain that there are understandable relationships between symptoms and elements within OCD. It’s important to explain this because it suggests that there are proper lines for treatment.
VY: I assume you have to do some kind of assessment on what type of OCD they have, what’s the severity, what they’ve tried so far.
CM: Most people have received some treatment when they first come to our treatment center, but not proper treatment—not CBT and often not even the appropriate medications.The letters themselves tell something about the problem. First there are the obsessions—whether it’s about germs and contamination, or locks and safety from marauders, or fear of displeasing God—whatever the nature of the obsession, there’s typically a belief in a threat that must be avoided at all cost. These obsessions have a negative emotional impact; there’s often a great deal of anxiety and shame that accompanies them.

Next we have compulsions. There are two ways of being compulsive. One way of being compulsive is to avoid any circumstance that arouses those ideas and fears associated with the obsession. So I might try to avoid thoughts that are negative towards other people if I fear that God is displeased by that, or lascivious thoughts. Or I might try to avoid touching doorknobs or coming in contact with people’s hands because I fear that I may pick up some disease.
VY: So those are the avoidance type of compulsions.
CM: Yes, those are avoidance compulsions. The other type of compulsions are the rituals, which are used when certain things can’t be avoided. So pleading with God for forgiveness for having improper thoughts, praying over and over in certain ways to ensure that God realizes that I wish to be forgiven and am unhappy with my behavior.

Or the washing that’s done in order to get rid of the possibility that there are germs on me, and the obsessive scrubbing and showering and cleansing of clothes and so forth. Or the checking of locks over and over because maybe I missed the lock or I accidentally unlocked it instead of locking it. Or that just looking at it isn’t enough. I have to check it physically or ask others to reassure me that the lock is, in fact, well secured.
VY: Listening to this, I’m imagining psychodynamic-oriented people finding these behaviors rife with potential meaning, but you don’t go there in your approach, right? You don’t put too much effort into figuring out what the meaning of these things are?
CM: Well, there are situations where some traumatic or highly stressful experiences of the individual might have preceded certain kinds of problems. But that’s not critical. The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for. So we think of insight into the origin of the problem, or understanding the meaning of it and so forth, as somewhat autonomous from the alleviation of the problem itself.

Avoidance and Its Discontents

VY: So getting back to treatment—once you’ve done some sort of assessment and have a sense of what the obsessions or the compulsions are and how severely they’re impacting that person’s life, then what do you do?
CM: Next you point out the way these behaviors often worsen the condition. Let’s take a common example: A child wants to avoid sleeping in the dark, but the parents insist that they stay in the dark, and maybe give them a little nightlight or open the door a crack. If they scream loud enough, will their parents leave the light on? No. Parents will say, “No, we’re going to turn off the light. You know you have to get back to sleep.” Avoidance is a way of maintaining fears.
VY: So if they cave in to the child’s demands and leave the light on, that’s going to reinforce the child’s fear.
CM: Right. It’s like not swimming in deep water isn’t going to help you get confident in your swimming ability in deep water. Not taking the training wheels off the bike isn’t going to make you a confident two-wheel bike rider. What we need is exposure to the experiences that cause us fear so that we can actually gain confidence and overcome our fear.
The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for.

Similarly with OCD, what we do is provide methodical and manageable levels of exposure to the feared elements, with the assumption—and borne out by our experiences—that the person will eventually become less fearful; and when the fear is lessened or extinguished, they have no longer have to perform rituals or compulsively avoid the original cause of their fear.
VY: You’re talking about exposure and response prevention.
CM: Mental exposure to things that cause us unwarranted fear, and then response prevention: encouraging the person to forego any abrupt reductions or eliminations of their fear, because the nervous system needs time to adapt. With repeated exposures, and saying, “Yes I know you’re anxious, but don’t wash your hands. Let’s let your nervous system get used to the fact that you have a great deal of nervousness and fear about this”—over time, what we typically see is a person becoming more comfortable with higher levels of fear-invoking distress.
VY: So how do you actually do that? These people are very invested in their symptoms so it can’t be easy. What are the steps? What do you do in the first session, the second session?
We have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast.
In orthodox, standard treatment, there’s the cognitive therapy component, where there’s a great deal of education about the way these things work—why their efforts to remain comfortable are thwarting their wishes to overcome their OCD. This educational component is key and we have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast. We have to do it in a way that allows them to experience some of these corrective measures, so that they can say, “Whoa. I’m much more comfortable doing this than I ever imagined I could be.” That’s the first step out of the pit.
VY: So you start by explaining how the treatment’s going to work and establishing yourself as an expert so that they’ll do what you tell them to do.
CM: And the proof’s in the pudding.
VY: So with the hand washer, will you give them some homework in the first week?
CM: Yes.

"Do You Know Somebody Who Got AIDS from Touching a Doorknob?"

VY: Do you tell them to go cold turkey?
CM: Not usually, because these fears are heavily entrenched and have been reinforced over a lifetime. So there has to be a great deal of preparation, cognitive therapy, correcting of misconceptions and identification of distorted thinking to help prepare the person for more experiencing and tolerating of their discomfort.
VY: So how do you do that? If these people have a very strong belief, bordering on delusional, that they’ll get AIDS from touching a door knob, for example, how do you get them to start touching door knobs? Clearly just presenting them with their distorted thinking isn’t going to be enough, right?
CM: Well, you start with simple observations like, “Other people seem to be touching doorknob quite regularly. Are your friends who touch doorknobs dropping like flies from AIDS? Do you know somebody who got AIDS from touching the doorknob? Have you ever heard an expert who understands disease processes suggest that we should all avoid touching doorknobs because AIDS or some other deadly diseases can easily be transmitted?” You start point out flaws in the thinking process.
VY: So having a logical discourse can be effective?
CM: It helps. It establishes a foundation of looking at things differently. These people are not crazy; they’re very intellectually competent, in fact, so they’ll begin to take notice of the many inconsistencies in the way they address these things. They might have a magical way of ensuring that they don’t get a disease—for example rubbing their hands on their pants six times.
We might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?”
So we might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?” And they’ll go, “Wow. Yeah, now that you mention it, it sounds kind of silly.” We begin to undermine their notion that this makes sense.

Nobody wants to live life like this. They’re just so afraid of giving it up. So they really want to believe you when you say that they can get over it, because life can be such hell for them otherwise.
VY: So cognitive preparation can be helpful. What do you give them as homework the first week?
CM: Well, homework might be to monitor. The chunks of useful information for setting up treatment are the many things they avoid. Why? Because avoidance exposure is the opposite of avoidance. Anything they avoid doing is potential fodder for the exposure experiences. So they don’t touch doorknobs; they won’t eat off a fork that hasn’t been rubbed with a disinfectant wipe; they won’t shake hands with people; they won’t use public restrooms or touch any surfaces in a public restroom. All of the things they avoid doing become useful information to develop the exposure experiences. And on the other side of the coin, all of their compulsive behaviors—their washing, their separating clean things from dirty things, their asking for reassurance from others—all of those become the elements for response prevention. Those are the easy escapes, and we can’t have that during the course of the treatment, in order for it to be successful. So in the early stages of treatment, our goal is to get a wide array of potential exposure treatments, those things that they tend to avoid that ordinary folks don’t.
VY: So in the early stages of treatment, you first want them to be more aware of what they’re doing. And then you’re giving them some alternatives?
CM: You’re gathering information to become a collaborator in treatment. You’re saying, “You’re going to hate exposure. You’re probably a little nervous about it. But I’m going to help you understand why avoidance has been so detrimental to your life. You’ve worked so hard, but you’re more afraid than you’ve ever been about these things.”

Originally they see the compulsions as the solution. “I’m going to avoid touching things that make me feel dirty. I’m going to do things that make me feel clean.” But soon they’re doing those things for hours and they feel more scared than ever.
VY: Okay. So the first week or two, what do you specifically give them to do as homework? Or tell them to do?
CM: There’s no one formula for how you start, how fast you move, and so forth. In fact, individually gearing it to the person, to their readiness, to the level of preparation they need and how much help they need with the exposures—these are all very important elements to ascertain before moving ahead with the treatment. And this is where the expertise of the practitioner comes in.

We might do a more traditional once-a-week treatment, or an accelerated treatment where people come more than once a week. There may be in vivo components in or outside the office where they’re getting exposure to the stressor. We can have intensive treatment, where over a shorter period of time, let’s say a month, people are getting very intensive daily hours of treatment.

But the general thrust of early treatment is to gather the correct information to build a road map for the treatment. And that involves the patterns of avoidance, the patterns of rituals that are used, and so forth. Then we develop a hierarchy, which is the essential part of the roadmap. Which things produce very little discomfort, which things seem outrageously anxiety producing, etc. Then we bring them through the different stages. So as they learn at each stage that they won’t meet their demise, we lead them through increasingly more difficult exposures.

Hierarchy for a Hand Washer

VY: What would be a hierarchy for a hand washer?
CM: Early on I’d try to find something relatively easy to work with. So if a client feels safe in their bedroom but not safe touching the bedposts because her mom touches them when she changes the sheet, I’d ask her to rate her discomfort on a scale of 1 to 100. The name of the scale we use is “SUDS,” Subjective Units of Distress. So I’d ask how anxious the bedposts make her and she’d say, “just a little bit.”
Our job is to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing.

So I would ask, “Would you be willing to just come in contact with that bedpost, and see what the emotional experience is like? Is it going to be awful? Is it going to be reasonable? Can you forego the washing? If so, for how long?” We try to probe into how people actually react. Sometimes it worse than they think, and sometimes it’s easier than they think.

Our job is then to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing. That’s the only reason why a person would move forward and give up all their safety mechanisms and participate in treatment.
VY: Alright. So in the hierarchy, the bedpost might be relatively low. The refrigerator door might be higher and the faucet in a public restroom might be a lot higher than that.
CM: Right, and typically we start with some exposures in the office, where it’s a safer environment and they don’t have a history of a great deal of compulsivity. The therapist becomes kind of a guide and a confidante and a trusted companion on the journey.

As we go, we learn more about how the nervous system reacts and what’s going on in the mind of the individual, and then we can apply cognitive therapy and wait for the habituation as the nervous system reaches it’s kind of asymptote, and then begins to decline. It’s a very interesting and powerful experience for individuals. “Wow. I don’t feel as nervous now. When I think about it, it kicks up a bit, but somehow it doesn’t bother me as much as it did before.”
We emphasize the techniques, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.

So there’s a lot going on, as you can see. We emphasize the techniques, the exposure response information, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.Just knowing that whatever comes up, we’re going to know how to deal with it. That’s why the experience and the special training helps. At some point along the way, we’ll touch on how a person might go about getting that additional training that enables them to be confident at whatever their previous kinds of approach to therapy might have been.

No Reassurance Allowed

VY: Let’s carry this through a little further. So in an ideal scenario, you graduate, move up the hierarchy. They may have a feared response but, if all goes well, they’ll find that if they wait a bit and, with repetition, and with reassurance and—
CM: Well, not reassurance so much. Reassurance is an escape mechanism. We might even say, “Who knows? You might get AIDS. I can’t promise you won’t. You know, things happen.” So we can’t reassure them too much in the process, or it can become a type of ritual in itself. We have to allow them to address the uncertainty of their situation.
Reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty.

It’s a balancing act. In a certain way, preparing them cognitively is also reassuring them that we know what we’re doing, that they can overcome their problem. But we have to watch out for specific reassurance when their anxiety is up that is designed to reduce it. You see? It feels important to distinguish this because reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty. We often reassure our patients in treatment, but with OCD, you have to be particularly careful or you’re just colluding in the compulsivity of that individual.
VY: Coinciding with the publication of this interview, we’re releasing two videos with Reid Wilson, whom you know, and he even takes it a little further than what you’re saying. His approach really emphasizes the lack of certainty—not only do they have to tolerate the uncertainty, but to welcome and invite it.
CM: Yeah. And that’s very important, dealing with uncertainty, because we don’t know everything about this world. Our patients often come to our office on the beltway. They know people die on the beltway. Are they certain that they’ll make it? That they’ll go home? That they’ll be alive when they get home? The answer is no, they’re not certain. I’m not certain. The reality of the world is that uncertainty is part of the picture.

We don’t know what happens after we die. We don’t know if there’s a God that is so vindictive that one false move and we’re forever tortured in hell. We don’t know that for a fact. We have to help people live with realistic uncertainty. With kids, you have to be a little more careful. If a kid believes the number 3 is a bad number and if they eat three M&M’s their parents may die, you have to be a little careful about saying, “Your parents may die, we can’t know for sure.” How that’s handled is extremely important. There are certain people who are going to be much more ready to deal with that part early on, and others who have to be handled very carefully along the way.

But Reid and others of us who work in this way realize that reassurance is a way to help people feel safe, and we can’t do that. We have to expose them to the idea that it may not be safe, but that we have to live our life as if it were safe, the same way we do when we go on the highway, or we eat unknown food. The food may send our body into some convulsive shock, but we eat it because we are willing to accept some uncertainty.
VY: So, following the roadmap that you’ve laid out, they would progressively move towards behaviors that are higher on the hierarchy, and in a good case scenario, they would experience some anxiety, but over time it would diminish or eventually even go away entirely.

CM: In most cases, there are some remnants of OCD symptoms. However, it’s like a person who was once a drinker and now is abstaining—they have to be a little cautious, recognize the danger signs, know what to do. An alcoholic wouldn’t go hang out at a bar; somebody who used to be very overweight doesn’t go shopping when they’re hungry or keep Halloween candy around the house for weeks before Halloween. We teach people how to recognize OCD, how it works, and essentially how to become their own therapist.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life.
We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life. It is important to understand that there is a potential for people to totally overcome their OCD and live a life that’s free of those problems, but realistically speaking, we have to prepare people for the likelihood that they have to remain vigilant to a certain extent, and have to retain the skills necessary to remain functional and symptom-free as possible.

"You Actually Do That?"

VY: With all therapies, there are usually stumbles and hitches along the way—setbacks, relapses. What are some typical challenges therapists and clients face along the way of navigating that hierarchy?
CM: Well, sometimes people cut corners. They cheat a bit. They may succumb to their compulsion and end up washing and separating at some point during the week. So compliance is extremely important. And because we’re dealing with a very anxious group—and rightly so, they’ve lived a life that’s been drastically altered by their fears and beliefs—we have to prepare them for the importance of compliance with the therapy. So that’s one challenge: people who aren’t quite doing what they tell you they’re doing.
Therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie...

The other, as I mentioned earlier, is people’s families. Families can be a problem themselves. We have kids who we’re trying to wean from hand washings, and Grandma says, “You’re not coming to the table without washing your hands, are you? Go right over there and wash them and be sure and use soap.” Well, that’s a bit of a problem. That’s why it’s important to educate the family about what we’re up to and why we’re doing it. Because therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie. We don’t think it’s really going to kill us, but it’s a yucky, you know?
VY: You actually do that?
CM: Sure. Because we’re asking people to go far with this, so that when they leave treatment, it goes back to normal. If you just bring them up to almost normal, there’s a tendency to backslide. So we want to take them to some rather “notable experiences,” I’ll call them, “memorable experiences,” where they say, “Wow, I did that, and I survived. So I’m willing to live my life in a more ordinary way.”

So we tell them along the way, “This is yucky. I don’t like doing this. I don’t like reaching into a dumpster and rubbing my face with garbage.” But part of the training is to understand that our own sensitivities mustn’t interfere with therapy. It’s important to get experience and training in this so that we really understand what we’re up against, what people are up against.

The stress of life can also undermine treatment. Whatever we’re trying to do—whether it’s exercise more or get along better with our co-workers—when we’re under stress, it’s easy to slip back into old behaviors. That’s why so much preparation goes into relapse prevention. The latter part of treatment is mostly about preparing people to be their own therapist, and creating a plan that they can follow through on for different expected moments of weakness or the recurrence of some feelings that were perhaps attenuated for a while but, for reasons unknown, come back with a vengeance.
VY: So what might be an example of a relapse prevention plan?
CM: Self-managed exposure and response prevention would be one example. Let’s say I have a fear of dust and dirt and I’ve been doing a lot better after treatment, but one day I notice dust on me and I start to worry. I think, “What would my therapist say? Well, he’d say, ‘Hey, it’s just dust. It’s probably not radioactive material!”
VY: It’s not anthrax.
CM: “So now what do I do? I go and intentionally take a little of that dust and perhaps put it on me, put it on my shirt, so that it makes me feel uncomfortable. It’s kind of foolish to do. No normal person would do that, but I understand I have to use the most powerful tools that anybody knows about to fight back against OCD. ERP—exposure response prevention.” So they do those kinds of things. Self-managed exposure response prevention. It’s very important.

But if they’re having trouble, they may need to call up their therapist and say, “I need a booster session. I just took a step backward, I tried to handle it on my own, but I think I may need some help.” So we’ll plan a little systematic approach and a little mini-therapy session. Relapse prevention is preparation for the inevitable human failings, setbacks, weaknesses, and so forth.
VY: So even though it’s a fairly structured form of therapy and there is a lot of technique involved—a roadmap—there’s a lot of creativity involved as well.
CM: Absolutely. We learn from every patient. There are always new twists. The OCD is a product of the person’s own imagination and creativity, so everyone has their own twists and turns.

Training for Therapists

VY: From what I can gather, therapists who don’t have specific training in treating this and just kind of incorporate it into traditional talk therapy are unlikely to have effective results.
CM: Well, it depends on the case. Some cases are relatively simple and a highly motivated individual with a therapist who grasps things well enough not to make some of the common mistakes in treatment can do quite well. So it is possible to pick up a book about it—there are some good manuals out there that tell therapists how to do this as well as some good self-help books that therapists can use. It’s possible to be effective in some cases without extensive training.

On the other hand, more difficult cases are challenging even to the most experienced therapists. There are going to be cases that are difficult to treat under any circumstances and that’s where more experience, more heads in on the treatment make a difference. Creativity and troubleshooting problems can be essential to moving smoothly through treatment. It rarely goes according to the cookbook, you know?
VY: If someone reading this interview wants to get more in-depth training, where would you suggest they go?
CM: An excellent place to get that is through the International Obsessive Compulsive Foundation’s Behavior Therapy Institute. It’s a wonderful three-day certificate program. It’s been developed over almost two decades, and provides excellent preparation for individuals who may never have had much experience, or any experience, with OCD. After the training there is follow-up guidance, supervision by phone—people can get really a huge jump in competence in treating OCD.

It’s so important to develop more practitioners. As it is, there aren’t enough trained competent practitioners to deal with the large numbers of individuals with OCD. There are whole states where there are very few places to get competent treatment. Not only is it important from the standpoint of the sufferer, but for practitioners. This is an extremely rewarding area to work in.
We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life.
We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life. That isn’t so common with some of the problems we treat.

Just the fact that we’re there and we know what we’re doing ensures that we’re going to get lots of love from our patients, because they’ve often been through some harrowing times when they didn’t understand what was going on, when they got misguided advice from professionals; so when they finally feel that they’re getting competent treatment, there is very often a great deal of positive emotion generated by that alone.

And they pay their bills. The OCD persons are often achieving, smart, and conventional in many ways. So it’s very rewarding. Those of us who specialize in OCD treatment never get tired of it. I have almost 20 people in our center who love to treat OCD and get very excited about new cases that, while challenging, are teaching us new things every day.
VY: Do you treat other conditions as well?
CM: Well, once you treat OCD, you’re going to also be treating things under the broader OCD umbrella. There are many disorders that are now considered OC spectrum disorders—things like body dysmorphic disorder, where people perceive ugliness in themselves and are often very depressed and very distraught. Also hypochondriasis or health preoccupations—the person believes that every ache and pain is some deadly disease and bug their doctors to death, or do doctor shopping, looking for someone who will take them seriously.

I already mentioned that we see a great deal of commonalities in Tourette’s and OCD. We also treat trichotillomania, hair pulling disorder, and excoriation disorder, skin picking and the picking of acne or the picking of skin around the body, fingers, toes, legs, scabs, mosquito bites. That just made it into the DSM-5, by the way.
VY: I understand there were some other changes in the DSM-V in terms of classifying some of these related disorders?
CM: Tic-related disorders are pulled into the mix. There’s now an identification for a subtype where tics and OCD appear within the same individual. We’ve conceptualized something called “Tourettic OCD” that’s very similar, but we don’t believe that its necessary for tics to be present for it to be Tourettic. It’s more that certain kinds of OCD are really discomfort-driven, rather than anxiety-driven, and therefore it’s similar in many ways to the experience of Tourette’s.

Even Asperger’s syndrome, or what the DSM-V now calls Autism spectrum disorders— very often people are referred to us who say they have Asperger’s or they have pervasive developmental disabilities, but they also have OCD. Well, they may or may not. They may fit a sort of OCD configuration, but they may not be exactly OCD. They may have stereotypies, or they may have hyper-interests, where they just love everything about Pokemon or something. But it’s not OCD. These are more repetitively driven things. They’re not driven to do stuff because they feel very uncomfortable and frightened unless they do them. They do things because they just love to do those things.
VY: That’s an important distinction.
CM: It is, because a lot of things we call compulsive—some people love to shop or love to gamble or love to act out sexually—that doesn’t mean they’re obsessive compulsive. They’re exhibiting repetitive patterns of behavior, but the treatment’s quite different. If you treat OCD and identify it as treating OCD, you’ll eventually learn how to distinguish them from each other, and when it’s best to refer them out, in the case of something like internet addiction. People call up all the time saying, “My son is obsessed with the Internet. He plays videogames all the time. I understand you treat OCD.”

“Well, yeah, we treat OCD, but that’s not OCD.” The importance of expertise is to be able to distinguish the subtle differences among some of the repetitive patterns of behavior that are often clumped and misidentified as OCD.

VY: Well I want to thank you for taking the time to share your wisdom and experience with us. You’ve gone into a lot of depth and, as is typically the case, though I’ve been in this field for quite a while, there’s always more to learn. I think our readers will have a similarly enriching experience and will be intrigued and interested in getting further training and expertise in treating OCD.
CM: I hope so. And I thank you for inviting me to participate here.

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Charles Mansueto Dr. Charles Mansueto is the director of the Behavior Therapy Center of Greater Washington. He received his doctorate from Catholic University and completed his post-doctoral clinical training at Temple University School of Medicine. He has over 25 years of clinical experience in the application of behavior therapy to a broad range of clinical problems. Dr. Mansueto is past chair and current member of the science advisory board of the national Trichotillomania Learning Center. He also serves as a member of the science advisory board of the Obsessive Compulsive Foundation and of the medical advisory board of the Tourette’s Syndrome Association of Greater Washington. He is past professor of psychology at Bowie State University, and is on the clinical faculty of the American School of Professional Psychology at Argosy University.
Victor Yalom Victor Yalom, PhD is the founder and resident cartoonist of He maintained a busy private practice in San Francisco for over 25 years, but now sees only a few clients, devoting the bulk of his time to creating new training videos for He has produced over 100 videos, conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and currently leads consultation groups for therapists.  More info on Victor and his artwork and sculpture at

CE credits: 1.5

Learning Objectives:

  • Describe common misperceptions about OCD and its treatment
  • Define the components of exposure and response prevention for patients with OCD
  • Explain the connection between Tourette's and OCD

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here