By Amy Mariaskin, PhD, author of Thriving in Relationships When You Have OCD
Cognitive behavioral therapists are often seen by others in the field as structured, efficient, and logical. We are the humorless automatons of the treatment world, following protocols without deviation. And when it comes to working with anxiety and obsessive-compulsive disorder (OCD), this stereotype can be even less favorable! For example, exposure, an intervention for these concerns, was initially characterized by one of my teenage clients as “low-key torture” (she did change this position a few sessions in). However, my experiences both as a practitioner and recipient of cognitive behavioral therapy (CBT) have not upheld this grim depiction. In fact, nothing could be further from the truth. CBT can be structured without being rigid, efficient without being impatient, and logical without edging out warmth. And most shockingly of all, it can be fun.
In graduate school, future clinicians learn that much of success in therapy can be attributed to “nonspecific factors,” such as warmth, trust, and collaboration. These are thought to be shared across therapy methods and not specific to any one style of treatment. Basically, the theory goes, if you’re a nice person with decent social skills, you’re already most of the way toward being a good therapist.
Concentrating only on nonspecific factors can be misleading for certain mental health concerns, like severe anxiety and OCD, which necessitate more targeted treatment like CBT to spark progress. However, excellent CBT therapists still recognize and honor their importance when implementing treatment. We know that a strong therapeutic alliance and collaboration are crucial for creating and sustaining change in our clients. Below are some of the ways that CBT can reinforce these important aspects of therapy without diluting the effectiveness of its evidence-based techniques.
The Power of Play
My youngest clients are the best teachers when it comes to keeping CBT fun. Having been brought into therapy by others, children are often neither bought into the treatment model nor eager to change their behavior. Their buy-in comes from nurturing the therapeutic relationship through play. While many CBT therapists bristle at the notion of play therapy as a stand-alone intervention, the most skilled ones already weave playfulness into their sessions. Play can help make facing challenges more palatable and engaging. Kids are naturals with this, as their innate goofiness hasn’t yet been socialized out of them. Connecting through creative play—naming their anxiety, acting out role-plays, drawing pictures of goals, creating songs, and so forth—all happens organically.
But it’s not just for kids. One of my clients with contamination fears was reluctant to retrieve things from the washing machine, lest his head touch cleaning chemicals. However, when we made our exposures into a competitive game (who can retrieve the most socks from the dryer in ten seconds) he was more motivated to work toward it. I’ve also played word games like swapping trigger words for each letter of the alphabet in quick succession, guided clients on grown-up treasure hunts for avoided items, and used bingo cards with exposure targets on the squares. Getting absorbed into some form of play teaches people that they can experience other positive emotions along with the fear, disgust, or embarrassment that often accompany behavioral change.
Rewards and Checkpoints along the Way
Have you ever nearly sprained your wrist while wiggling your Apple Watch arm to close a ring? Uhhh, me neither. But certainly, you can understand the urge to do something ridiculous to get that sweet hit of dopamine from earning a reward. We love prizes, a holdover from our days of earning Scouts badges and stickers on behavior charts. Integrating rewards into therapy can inject the work with motivation and excitement.
These rewards can be as simple as praise, or the opportunity to do a desired activity at the end of a session. They can be tangible things like getting a latte at the nearby café provided that the client is tolerating social anxiety to order it. Or they can be the act of filling in a few notches on a fear thermometer as progressively harder tasks are completed. I have an activity in my book that allows for people to color in areas of their home that they have reclaimed from OCD symptoms. I also encourage clients to set up rewards and checkpoints for themselves. If you’re meeting your goals, do something to signify and celebrate it at home or with a loved one.
Laughter is the Best Medicine
Even if play and rewards feel awkward (or even invalidating) to clients, there’s usually room for some humor in therapy. Anxiety can be downright oppressive in its seriousness, and introducing a humorous spin on it can be transformative. After all, it’s difficult to be laughing and terrified at the same time. Plus, anxiety can seem heavy and shameful; turning a witty lens on it can help transform self-criticism into levity.
Integrating humor depends on how you authentically express humor, e.g., absurdism, dry humor, wordplay, etc. And part of it depends on embracing the creativity that bubbles up when you have two people together doing complex work. One of my clients named each of her OCD subtypes after a different ex-partner from her past, and another likened his claustrophobia to Superman’s kryptonite. A third created an absurd version of her worst fears, such that any time she began to worry, she took the story to an outlandish conclusion (“…and then I’ll get uncontrollable diarrhea in front of everyone and slip on it while running away”). Repositioning the punchline at the anxiety’s expense can shrink fears and empower clients.
Get Wise to the Why’s
In the early days of CBT, potential exposures were generated solely based on what the client would find uncomfortable. Therapists felt that having clients lean into anxiety-provoking situations would blunt their anxious response over time in a process called habituation. While this can be part of the process, many of us now focus on tolerating the difficult emotions that arise while doing valued activities. For example, instead of arbitrarily choosing things that provoke fear, we help clients choose things that are valuable to them—their reasons for being in therapy in the first place—and then tolerating the anxiety as it arises. This shifts the focus from gritting through anxiety and hoping that it resolves to rediscovering the important things in your life—the whys of therapy.
Fun isn’t usually the first word that comes to mind when considering research-backed treatment for anxiety. But with a little creativity and collaboration, CBT can be as enjoyable as it can be challenging.
Amy Mariaskin, PhD, is a licensed clinical psychologist with fifteen years of experience treating obsessive-compulsive disorder (OCD), anxiety, and related disorders. She is founding director of the Nashville OCD & Anxiety Treatment Center, faculty of the International OCD Foundation’s Behavior Therapy Training Institute, and adjunct professor at Vanderbilt University. Mariaskin has provided individual and group therapy to adults, adolescents, children, and families affected by these disorders. She strives to create a sensitive and affirming therapeutic experience for her clients, and incorporates humor and creativity into evidence-based practice.
Part 2: What to Do When a Client Is Participating in Self-Judgment?