James[1] sought treatment with one of us for his severe obsessive-compulsive disorder (OCD). His symptoms were primarily intrusive images of harming others, as well as concerns with contamination that led to lengthy hand-washing rituals. James is very successful professionally, he is well-educated, and he arrived for treatment armed with extensive knowledge of what treatment he needed based on his understanding of the research into psychological interventions for OCD. During his initial evaluation, he asked repeatedly if he would receive exposure with response prevention (ERP). The dialog went approximately like this:
James (J): I’ve done research on your work, and see that you have published on ERP. Do you promise, now that you’ve assessed me and know I have OCD, that you will provide this treatment?
Clinician (C): Yes, of course.
J: Now, I hate to seem pushy about this, but really, can you re-assure me that you will, without question, provide ERP?
C: Yes, without a doubt, you are an ideal candidate for ERP.
J: Look, I’ve been told this by three prior therapists, that they would deliver ERP, but when it came time to do so, they didn’t. So, I’m not sure how easily you can convince me, but I cannot go through this disappointment again. Will you swear you will deliver ERP?
C: I can 100% guarantee you will receive ERP.
This encounter was perhaps the most extreme in someone demonstrably requesting ERP, but for this clinician, it is not an isolated incident. A client with true OCD comes seeking therapy after seeking consultation with other providers claiming they will deliver CBT, and specifically ERP, only to receive some other intervention. The client then terminates treatment either with no symptom relief, or possibly with symptoms worse than when they began; as well as reduced hope that they can get better and a loss of faith in the mental health profession.
With OCD affecting around one to two percent of the population, and an increase in the recognition of this problem, many clinicians have begun to hold themselves out to the treatment-seeking public as healthcare providers for this disorder, even if their knowledge of OCD and appropriate interventions are not consistent with the current science. The aim of this article is to highlight how inappropriate, non-evidence-based treatment may be ineffective at best, and even harmful in some instances.