Affirming treatment for neurodivergent folks with OCD
There is a lot of confusion about the overlap between OCD and neurodivergence, so much so that it’s quite common for someone to call me because they’re sure they have OCD, only for us to shortly identify that being autistic is a better explanation for their experiences. While other neurodivergences also co-occur with OCD, I find that I tend to work with a lot of autistic folks with OCD so I will focus mostly there. But I think my approach would work well for folks who identify as ADHDers, HSP, SPD, etc.
There are plenty of articles that do a much better job than I can of explaining how autism (in particular) and OCD criteria overlap, leading to difficulty of differential diagnosis. Luckily for most of us doing mental health treatment, we aren’t doing official evaluations for educational or disability services and so we don’t have to exactly identify the differences. We can simply provide neurodiversity-affirming care for OCD that better serves both autistic and neurotypical folks. That’s right: When we do well by our neurodivergent clients, we do better by our neurotypical ones as well!
What are important inclusive practices for the treatment of OCD?
We need to allow each client to define the scope of the problem they bring to therapy rather than stick to rigid diagnostic criteria that was really defined for research purposes. If the symptom isn’t causing the client significant distress, trouble in meeting their life goals, or infringing greatly on the rights of others, we don’t have to address it.
We need to carefully differentiate between OCD-accommodations and reasonable accommodations to make the world better for neurodivergent folks.
OCD accommodations are when loved ones have given up major things of value in their lives to meet what are seen as generally-unworkable demands of the OCD sufferer in a way that makes the OCD symptoms WORSE. We work to reduce and stop these types of accommodations in OCD.
Reasonable accommodations are ways people, organizations, and society can adapt to the sensory, social, communication, and pacing needs of folks with different wiring and needs in ways that makes OCD better. We work to INCREASE these accommodations to help both ND and NT folks’ (but especially ND folks’) lives better.
Clinicians must work with clients to collaboratively define goals and help the client discover the degree of psychological flexibility they need to live a full and meaningful life. Treatment targets can then be set based on those goals. We do not engineer all treatment plans to “no longer meeting criteria for OCD.” We get just enough flexibility to get the client able to live a richer life.
While ERP clinicians often emphasize that trauma is not the ROOT cause of OCD (and I agree), it’s important to provide trauma-informed care, especially for the neurodivergent, to ensure that trauma impacts are woven into the treatment plan in a sensitive and meaningful way.
Conceptualization of client distress must be appropriately inclusive of neurodivergence and shared with the client so that it’s a transparent and collaborative effort.
A crossdisciplinary team should be considered and is often beneficial, with prescribers, primary care doctors, occupational therapy, and other professionals working together to support the client.
Especially when treating body focused repetitive behaviors (BFRBs), we need to differentiate between harmless meeting of sensory needs and harmful picking/pulling that is causing the client distress and damaging their bodies. We can use habit reversal training in ways that honor the sensory need to pick/pull but do so in less harmful ways.
When treating health anxiety, we can support clients in navigating the healthcare system by accounting for “isms” in medicine including ablism, racism, sexism, ageism, etc.
Overall, we can bring flexibility to our processes that honor all types of diversity we encounter in caring for human beings rather than blindly relying on diagnostic criteria, measurement tools, treatment protocols, and exit criteria developed by and for white, neurotypical men.
If we follow these practices, not only do we make evidence-based therapy safer and more effective for neurodivergent folks. We also improve our overall clinical practices for the neurotypical!