Understanding and Treating Obsessive-Compulsive Disorder in Diverse Populations

August 2, 2023 By Dr. Jada Carter, PsyD

Obsessive-Compulsive Disorder (OCD) is a prevalent and often misunderstood clinical condition, affecting millions of people worldwide. Because OCD is also a term that is used casually in our modern-day dialect to refer to a range of transient or non-interfering thoughts and behaviors, misunderstandings surrounding the true nature of OCD are common. Most of us occasionally have anxious, obsessive moments in daily life, or find ourselves periodically shaking off intrusive thoughts about things we would rather not imagine happening. You may occasionally feel the need to check if you locked all the doors, ruminate on your drive to work about whether you turned off the stove, or even find yourself enjoying a particularly clean home with the declaration, “I’m so OCD, my home has to be pristine!” By contrast, true OCD is a debilitating mental health condition, characterized by the presence of distressing obsessions and repetitive compulsions that significantly interfere with daily functioning.

In the context of an OCD diagnosis, obsessions are defined as intrusive and unwanted thoughts, images, or urges that increase anxiety, and compulsions are repetitive behaviors or mental acts that typically serve to reduce the anxiety associated with obsessions. OCD symptoms tend to cluster into specific themes, with harm-related obsessions often accompanied by checking compulsions, symmetry obsessions often accompanied by ordering rituals, contamination obsessions often accompanied by washing or cleaning routines, taboo intrusive thoughts often accompanied by mental “undoing” rituals (Ferrando & Selai, 2021), and a range of other related symptoms, such as hoarding, obsessive concerns about appearance, and health/illness anxiety. To qualify for clinical diagnosis, these symptoms must be time-consuming, cause distress, and impact a person’s day to day functioning. Approximately 1.5-2% of individuals experience clinically significant OCD symptoms in their lifetime.

As the field of Psychology has evolved in its understanding of OCD as a clinical condition, we have also gained a more nuanced understanding of ways in which our front-line therapeutic approaches can be tailored to account for the developmental, cultural, and religious contexts in which they are being applied. In this blog post, we will discuss gold-standard evidence-based therapies, and will also introduce emerging, culturally responsive adaptations to our front-line treatment modality for OCD. Whether you are a clinician or someone seeking information about OCD, this article aims to provide accessible knowledge on this complex disorder and its treatment.

Evidence-Based Therapy for OCD

Exposure and Response Prevention (ERP) is widely regarded as the most effective evidence-based therapy for OCD, with dozens of studies showing the efficacy of this treatment modality over the past twenty-five years. ERP involves exposing individuals to their obsessive fears in a controlled manner, while refraining from performing their compulsive rituals to manage the anxiety associated with facing these obsessional fears. This process helps individuals learn to combat magical thinking about the link between compulsions and safety, to decrease the distress associated with obsessions or intrusive thoughts, to engage in new learning about the need for compulsive rituals, to shift their relationship with OCD-related thought patterns, and to increase their ability to tolerate doubt and distress. Studies have consistently demonstrated the effectiveness of ERP in reducing OCD symptoms and improving overall functioning (e.g., Abramowitz et al., 2013; Simpson et al., 2019).

A Brief History of OCD across Cultures, and Culturally Responsive Adaptations to Evidence-Based Therapy

Clinical descriptions of OCD date to ancient civilizations, with accounts of OCD-like symptoms found in texts from cultures around the world. As far back to the first half of the second millennium BC, accounts of OCD-like syndromes can be found in ancient Babylonian medical texts known as Shurpu. The Babylonians introduced the concept of the “oath” idea, stating “the behavior habits being so unbreakable it appeared that the subject had sworn an oath to do or not to do the action involved” (Reynolds & Wilson, 2011). Despite widely varied explanations for the observed behaviors of individuals with OCD, descriptions of OCD-related behaviors continued to appear across cultures and across time as understandings of mental health conditions progressed in the field of Medicine, Psychiatry, and Psychology.

Although OCD symptoms have been noted for centuries across a range of cultural contexts, it is important to note that the development of our current gold-standard therapies for OCD has happened largely within a Western, white-dominant cultural framework. Cultural factors can influence how OCD symptoms are both expressed clinically and perceived by others. It is therefore essential to acknowledge that current representations of OCD in academia and mass media, modern diagnostic practices, and “standard” practices for application of ERP may all be heavily influenced by the cultural norms and biases of the systems in which these understandings of OCD and corresponding treatment modalities emerged.

Recognizing and effectively treating OCD across cultures requires providers to apply evidence-based therapies in a highly contextualized manner, understanding and respecting a client’s cultural norms, beliefs, and practices when delivering treatment. This can include modifying treatment materials to be culturally sensitive, involving family members in therapy, and addressing any cultural stigma surrounding mental health.

Only in recent years have our leading academic institutions and OCD-focused organizations started to define and train others in gold-standard practices for culturally responsive ERP. The first annual training for Treating OCD in Communities of Color was offered by the International OCD Foundation in 2022. Clinical Co-Director of this same training program, Dr. Monnica T. Williams, has developed guidelines for providing culturally competent care in the treatment of OCD for ethnically, racially, and religiously diverse clients. According to the model proposed by Dr. Williams and her colleagues (2020), clinicians can adapt evidence-based treatment models to make them more culturally competent, using a combination of specialty knowledge (for example: awareness of cultural variations in OCD symptom expression, awareness of personal biases and knowledge gaps, and the ways in which stigma and oppression may impact obsessional content) and specialty skills (for example, culturally-informed outreach practices, integrating client perspectives into the treatment planning process, distinguishing OCD symptoms from cultural and religious practices, and devising culturally-appropriate exposures). By using these adaptations to front-line OCD treatment approaches, clinicians can increase the acceptability and cultural responsiveness of OCD treatment for diverse populations.

Bottom Line

OCD is a clinically impairing mental health condition with well-established evidence-based treatments that continue to evolve in their applicability to diverse populations. Understanding the complexity of this disorder and dispelling misconceptions about both OCD and its varied manifestation across cultures are crucial steps towards supporting individuals in their journeys to recovery. By embracing evidence-based therapies, such as ERP, and implementing culturally responsive adaptations of our gold-standard treatments, clinicians can provide comprehensive and effective care to a diverse range of individuals living with OCD.

If you are experiencing symptoms of OCD, you are not alone, and expert help is available.

For those seeking more information and support on OCD, the International OCD Foundation (IOCDF) offers web-based resources that are credible and free to access: https://iocdf.org/

References

Abramowitz, J. S., Taylor, S., & McKay, D. (2013). Obsessive-compulsive disorder. The Lancet, 381(9865), 371-382.

Ferrando, C., & Selai, C. (2021). A systematic review and meta-analysis on the effectiveness of exposure and response prevention therapy in the treatment of Obsessive-Compulsive Disorder. Journal of Obsessive-Compulsive and Related Disorders, 31, 100684.

Foa, E. B., & Goldstein, A. (1978). Continuous exposure and complete response prevention in the treatment of obsessive-compulsive neurosis. Behaviour Research and Therapy, 16(2), 119-129.

McGuire, J. F., Ung, D., Selles, R. R., Rahman, O., Lewin, A. B., Murphy, T. K., … & Storch, E. A. (2016). Treating obsessive-compulsive disorder in very young children: An initial evaluation of exposure and response prevention. Journal of Child and Adolescent Psychopharmacology, 26(3), 213-220.

Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour Research and Therapy, 4(4), 273-280.

Reynolds, E. H., & Wilson, J. V. K. (2014). Obsessive compulsive disorder and psychopathic behavior in Babylon. Journal of Neurology, Neurosurgery & Psychiatry, 83, 199–201.

Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. E. (2019). Patient adherence predicts outcome from cognitive-behavioral therapy in obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 87(7), 639-644.

Storch, E. A., Caporino, N. E., Morgan, J. R., Lewin, A. B., Rojas, A., Brauer, L., … & Murphy, T. K. (2011). Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Research, 189(3), 407-412.

Williams, M. T., Rouleau, T., La Torre, J., & Sharif, N. (2020). Cultural competency in the treatment of obsessive-compulsive disorder: Practitioner Guidelines. Cognitive Behaviour Therapist, 13, e48