Why OCD Treatment Has to Change After the COVID-19 Pandemic

My therapist stands up, walks over to the bookshelf in his office, and picks up two red apples that are sitting on one of the shelves. The apples look out of place next to his personal library of psychology books, collection of fidget toys and various decorations.

He grabs two plastic knives from the same shelf and hands me a knife. He hands me one of the apples. Silently, he then sits on the floor, cross-legged, and waits for me to join him.

I am reluctant; I know what is coming.

I finally take a seat on the floor, cross-legged as well. I can feel the carpet beneath my legs as I hold the apple in my left hand and the plastic knife in my right.

My therapist begins to cut into his apple. He cuts it flawlessly into slices, an impressive feat since we are using plastic knives and just cutting the apples in our laps without the use of a table or other hard surface.

A few seconds later (though these seconds feel like days), I begin to slice my apple as well. I am not as talented at this freestyle cutting as he is. My slices are jagged and uneven.

My therapist then places an apple slice on the floor and rolls it around. He makes sure each side of the apple slice touches the carpet multiple times as he rolls it over and over. I am cringing on the inside. But I know what I must do next.

I slowly place my apple slice on the floor. I roll it over once, then twice, then a third time. I pick it up and look at it, disgusted. I can’t help but think of all the germs that are on that floor, embedded in the carpet, and now on my apple slice.

My therapist picks up his apple slice and holds it near his mouth. I know he is waiting for me to do the same.

In another short period of seconds that felt like days, I begin to raise my apple slice to my mouth as well. I stare at it, examining it as if I could physically see all the germs that now tarnish it. Sometimes, I expect that I actually will see the germs; but, of course, I never do.

My therapist and I are there, stuck in what can only be described as an excruciating time vortex, preparing to eat apple slices off the floor. We stare at each other for a few seconds. He can sense my hesitation, my disgust, my anxiety. Alternatively, I can sense his support, encouragement and faith in me. We share these feelings without ever saying a word.

I look down at my apple slice and then raise my gaze again to meet my therapist’s eyes. He waits for me, patiently.

With our eyes still locked, I move my apple slice closer to my lips. He mirrors me, doing the same.

And then we both take a bite.

Exposure and response prevention therapy, or ERP, has long been considered the gold-standard treatment for obsessive-compulsive disorder (OCD). ERP is in the family of cognitive behavioral therapy, or CBT. ERP often looks a lot like what I just described above; a trained therapist encourages their clients to face their fears head-on and then refrain from engaging in any sort of compulsive or compensatory acts. This particular “exposure” I described is based on my irrational and debilitating fear of germs, contamination, and illness. Over the course of many months, my therapist and I worked through a series of exposures in which I was intentionally confronted with a feared situation (germs) and encouraged to face these fears head-on (as I did when I ate the apple slice off the floor). Over time, ERP retrains the mind, and the feared stimulus becomes less and less threatening. The idea is that ERP serves as a bit of an “overcorrection” — in other words, eating apple slices off the floor in my therapist’s office for a couple of months ultimately allowed me to be able to eat out at restaurants without having a full-blown anxiety attack if I didn’t have my hand sanitizer with me.

To paint an even more graphic picture for you, eating apple slices off the floor was not the most harrowing exposure I did to try to combat my fear of germs. Over a series of months, my therapist and I rubbed apple slices on public restroom sinks, doorknobs, elevator buttons and the backs of toilet tanks. Each time, I shook my head, said I could not do this, and stared at the apple slice waiting for the germs to appear. I thought if the germs appeared, or if I felt them in my hand (which I sometimes believed I did), I could say, “Look! I was right!”

But the germs never appeared. My therapist was always patient, yet always unwavering. He never forced me to do anything, but encouraged me nonetheless. And, eventually, I (almost) always ate the apple slice.

As you may have surmised by now, these events took place months ago. I have not seen my therapist in-person for quite some time now, and I do not know when we will physically meet again. Treatment of OCD has entered uncharted territory due to the threat of the coronavirus (COVD-19); it is no longer expected, advisable or safe for clinicians to conduct ERP in the way I described above. The “illogical” fears of many people living with OCD have suddenly become logical; people without OCD are engaging in cleaning and sanitizing behaviors that go well beyond the “normal standard” prior to the pandemic. For those of us with OCD — the fears we have spent months (and years) trying to untangle and strip of power have suddenly become quite real, with no foreseeable end in sight.

I have the unique experience of being both a person with OCD and a therapist myself. I wonder how clinicians like myself (and my own therapist) will have to adapt and change the way we treat OCD going forward. The “gold-standard treatment” is not so gold anymore. The way we treat this disorder will have to be reflective of the times we are living in.

Understandably, not much research has been done yet with regard to OCD treatment in the midst of a global pandemic. But some researchers, clinicians and other professionals have begun to devise a new and improved discourse for treatment of this disorder, given the circumstances.

According to Fineberg et al. (2020), clinicians should give consideration to the use of medication for the treatment of OCD during this time. Specifically, “based on the risks associated with exposure and response prevention (ERP) in the pandemic … pharmacotherapy should be the first option for adults and children with OCD with contamination, washing or cleaning symptoms during the COVID-19 pandemic.” ERP as it has been done traditionally (as I described above) is no longer safe for either the client or the therapist. Therefore, medication (when prescribed by a doctor and taken with compliance) might be a helpful option for clients with OCD to consider and discuss with their treatment team. In particular, the use of selective serotonin reuptake inhibitors (SSRIs) has evidence of success in alleviating the symptoms of this disorder.

Additionally, Fineberg et al. (2020) offer suggestions from a cognitive-behavioral perspective regarding how to adjust one’s ERP treatment plan during this time. Fineberg et al. (2020) recognize that it may “be difficult to disentangle OCD-related cleaning and checking compulsions from rational COVID-19-related safety behaviors.” Therefore, the authors “recommend significantly tailoring CBT to take into account the CDC guidance.” Clients with OCD should no longer be expected to stop washing their hands completely, even if this was part of their exposure plan prior to the pandemic. Instead, Fineberg et al. (2020) suggest, the therapist should focus on supporting their clients and “trying to prevent them from deteriorating.” The authors suggest using activity scheduling and behavioral activation with clients to combat the unfortunate reality that “obsessions often expand to fill a vacuum of time.” With too much time on their hands and fewer in-person exposure opportunities (as well as the looming threat of a global pandemic), clients with OCD can be more prone to increased obsessional thoughts and compulsive acts.

Treatment providers who see clients diagnosed with OCD are currently facing a unique and unprecedented predicament. My therapist often helped me realize that my fears around germs were irrational, or at least not as bad as the catastrophic scenario my brain had concocted. Now, however, he has his own fears around contamination and illness related to the pandemic. He has to take care of himself and his loved ones. It would be unsafe and inadvisable for us to continue engaging in ERP the way we had been doing it for many months.

The way we treat OCD has to change; there is simply no way around it. Treatment protocols will have to be adjusted for the foreseeable future, and possibly forever. I am curious to see how this pandemic and its aftermath impacts both my treatment and that of my clients. We have no choice but to use the information at our disposal from both OCD experts and public health officials to make the most educated decisions moving forward. Only time will tell how COVID-19 influences OCD symptoms, diagnosis, and treatment in the long term. But I believe we can say with certainty at this point that I will not be eating apples off the floor of my therapist’s office again for quite some time.

Struggling with anxiety or OCD due to COVID-19? Check out the following articles from our community:

Obsessive-Compulsive Disorder (OCD)

Why OCD Treatment Has to Change After the COVID-19 Pandemic

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