Monday, September 13, 2010

Part 1: History of Exposure Therapy for OCD: Dr. Victor Meyer and Ritual Prevention

Turn Away

The first obstacle to writing about the history of Exposure Therapy is, of course, my rituals of researching things indefinitely in hopes of being absolutely certain I haven't missed anything, and a long pattern of information hoarding. But here I am, after realizing I need to construct this series of posts as an Exposure--ie. pick a place to start without exhaustive information or a PhD thesis.*

The history of Exposure and Response Prevention Therapy(ERP) is scattered in journal articles and introductory paragraphs in books about anxiety disorders. A site that gathers information together for a fascinating read is The History of Obsessive Compulsive Disorder, written by an anonymous historian who suffers from OCD.

A name that appears often is Victor Meyer, British psychologist, who published a key article, Modification of expectations in cases with obsessional rituals. (Behaviour and Research Therapy 1966 Nov;4(4):273-80) This article isn't available in free full text, but I found a subsequent article that caught my interest [There's a lot of OCD noise in my head right now, 'just one more search,' 'you aren't done.' Yeah, I know.] Ritual prevention in obsessional patients, by Meyer and Levy, Proceedings of the Royal Society of Medicine. 1971 Nov;64(11):1115-8.

I am sobered by the bleak picture painted in much of the early and mid 20th century writings on the treatment of severe OCD, and the 1971 article refers to repeated leucotomy(ie. a kind of lobotomy) in some cases. Levy and Meyer report on a follow-up study of patients treated by interruption of their rituals. The fear had been that if someone interrupted a ritual, the person with OCD would have overwhelming anxiety or aggressive outbursts. These therapists ventured forward, and named the treatment "apotrepic therapy" from the Greek word meaning to turn away, deter or dissuade.

The sufferers were inpatients, incapacitated by their OCD, and with whom other methods of treatment had failed. I am trying to imagine this pivotal moment, a kind of stepping into the fray to break up a fight and fearing getting punched in the process. At least the researchers knew these people had OCD and that interfering with their rituals could be difficult. A couple years ago, I met someone who as a child had aggressive outbursts when his rituals were prevented by parents or teachers, and no one knew he had OCD and he was sent away to a school for kids with severe behavior problems.

Meyer's treatment consisted of instructing nurses to continually supervise patients during waking hours and preventing them from carrying out any rituals, either through engaging in distraction, discussion, or mild physical restraint(only resorted to with the patient's agreement.) The prevention of rituals was maintained for 1-4 weeks, during which the patients were gradually exposed to situations that evoked the rituals in the first place, and then supervision was also gradually diminished.

The results showed not only that compulsive behavior decreased, but that instead of the emergence of overwhelming anxiety, there was usually a decrease in anxiety and depression. The study was preliminary, but very intriguing. Some of the factors the authors attributed to the success were:
  • Incorporating ritual prevention into family life, since family members often get drawn into helping complete rituals.
  • Modeling by the supervisor who would perform whatever action the person with OCD was avoiding, ie. if they wouldn't touch a doorknob, the nurse would repeatedly touch the knob.
  • "Alteration in Expectancies"--Meyer's assertion that failure to perform the ritual does not necessarily lead to the feared consequence.
The frustrating part for the authors was the stressful and time consuming nature of the treatment for all involved. For Meyer and Levy, they were trying something novel and very different from leucotomy or psychoanalysis, and they saw great potential, but also were aware of the difficulties, which eerily foreshadow some of the moments on VH1's The OCD Project. I end with a quote from the end of the article about interruption of rituals:
. . .we urge that this should only be done where the staff concerned can have the closest supervision and the fullest support. The line between firm but sympathetic control and unpleasant and inhumane bullying is a thin one indeed and all too easy to cross when one has devoted a lot of time and energy to a patient who relentlessly and monotonously pursues an unchanging course.

*This is way shorter than it would've been in the past, before I got treatment for my OCD, but man, it does still seem somewhat thesis-like. . .


  1. Expwoman, This is really a fabulous idea that you have. I am very interested in what you find out from your "healthy level" of research. You write beautifully, both here and in your comments. Another great idea is that you are using this research and writing project as an exposure. I will be checking in for the next post.

  2. I tried to comment yesterday and then my browser refused to cooperate and froze when I clicked "post." Here's to hoping that attempt #2 goes better!

    First, congrats on using this as an exposure! When you previously mentioned that you were going to be writing about the history of OCD treatment, I was impressed. In school (and even now) the idea of having to research a subject and distill all those facts into a reasonably short summary made me want to shudder. It always seemed like such a daunting task. How would I know if I had gotten enough information? And once I did complete my research, how much was too much to include in my essay/report/project? What was "important" and what wasn't? Looking back, I probably agonized over those little decisions a bit more than most, and I can appreciate how it sometimes takes more effort to write less than it does to write more (clearly I still have issues with that as evidenced by the length of my comments...). I think you made your point here quite well and succinctly.

    That said, your post reminds me how grateful I am to have treatment for my OCD (that doesn't involve drilling into my skull and lesioning some part of my brain) and to be able to interact with others who understand the nature and thought processes behind the compulsive and often bizarre behaviors that OCD bring about. Clearly there is still room for improvement in our treatment methods, but we certainly have better (and more humane) ways to deal with this disorder than we did before.

  3. Thank you for the encouragement! At first I was frustrated that my old OCD patterns were acting up, and getting sidetracked with research, but I am glad I finally wrote the post! In the past, I might not have gotten that far.