The trauma/OCD controversy

Over the last few months, I’ve felt overwhelmed by the number of people seeking treatment for OCD who can’t find a qualified clinician. I surveyed my Portland/Vancouver area therapists to find out what they need to know to better treat OCD, and have committed myself to doing SOMETHING to help with this problem. My first attempt at releasing something quickly, is to write some blogs about the topics of interest, for my fellow therapists (and interested members of the general public).

I’m naturally long-winded so I’m going to try REALLY HARD to condense these ideas and expand upon them later, in more formal trainings, consultation, etc.

The most asked-about topic in my “What therapists want to know about OCD'“ survey was the intersection of OCD and trauma. I am going to speak about MY WAY of looking at this, which I think I share with a lot of other behavioral therapists (ACT, CBT, DBT, etc.) and I encourage OCD-therapists to chime in below with comments.

Trauma IS VERY IMPORTANT (but maybe not to the etiology of OCD, specifically)

People endure some horrible stuff and those experiences always leave a mark. That said, I don’t think trauma is a key component in the development of OCD for most people. PTSD and OCD do co-occur and have some relationship, but correlation does not equal causation. There are also so many folks with OCD who have little to no traumatic background so I like to start with what people who have OCD DO have in common.

There is a heavy biological component to OCD. Folks with OCD are usually pretty sensitive to bodily sensations, notice them, and derive meaning from them. They often are perfectionists who find value and meaning from safety, prudence, responsibility, and achievement. True OCD goes beyond perfectionism though, and always involves inflexible/ineffective responding relative to actual threats at hand. It almost also involves a degree of magical thinking that the individual partially believes and cannot shake, while also having some insight into the fact that their thinking is magical (What if the door unlocked ITSELF?!).

Trauma might contribute to the narrative of why an individual is perfectionistic, but it doesn’t explain how to undo the anxiety and behaviors, so behaviorists tend to dismiss it.

Honoring trauma without it being core to conceptualization

Where I think CBT therapists sometimes “get it wrong” is by not explaining why they’re not focusing on the trauma. They jump to cool evidence-based techniques before they develop sufficient rapport with the client to do this. Thanks, insurance companies. Those insurance folks want us to treat OCD in 12 sessions and if that’s what we’ve got, we have to start fear-hierarchy development within the first couple of sessions, which is really not person-centered or trauma-informed.

I like to take the time to get to know the person while also getting to know their OCD-processes. In this rapport-building phase, we can use self-compassion to honor that trauma and use collaborative treatment planning to talk about why we aren’t going to address it now. I explain that I want to arm them with the skills to differentiate OCD processes from more values-based interests in resolving trauma, before they begin deeper trauma treatment. It probably sounds backwards to a lot of trauma therapists but people with OCD tend to hyper-focus in an unhelpful and unhealthy way during many traditional psychotherapies. If we first use behavioral approaches to treat the OCD, they can eventually go into trauma processing in a value-centric way where they don’t develop unhealthy obsessions and compulsions to address their past.

Focusing attention differently is not dissociation

I can’t tell you how many times I’ve had a client with OCD in my office whose previous or primary therapist tells them that disengaging with their “OCD-Monster” is dissociation. I train clients to treat their “OCD Monster” like a rowdy (but harmless) passenger on public transportation - we acknowledge it and neither indulge it nor push it away. We just let it ride the bus along with us while we do our own valued behaviors. We don’t sit it down and ask it to have a conversation with us. People with OCD do NOT benefit from that conversation and it only makes the OCD stronger.

More on that, later.

So all this to say, I think trauma matters greatly to our clients but behaviorists tend to dismiss it in treating OCD because we have to get our clients to the point where they can manage their day to day, sufficient to even consent to traditional trauma processing therapy. Trauma therapy will not solve most cases of OCD on its own.