Forming a Doctor-Patient Alliance During COVID-19 to Enhance Treatment Outcomes for Obsessive-Compulsive Disorder

The outbreak of the novel coronavirus disease (COVID-19) pandemic in early 2020 has caused or exacerbated mental health problems, with growing research evidence of increasing levels of anxiety and depression in both psychiatric patients and the general population (1). However, there may be no group of individuals for whom the pandemic has heightened symptoms more than those with obsessive-compulsive disorder (OCD) (2, 3).

OCD is characterized by persistent intrusive and upsetting thoughts, images, or urges (obsessions), as well as repetitive behaviors or mental acts (compulsions) that are performed to reduce discomfort (4). In the United States, the lifetime prevalence rate of OCD is estimated at 2.3% (5). Common obsessions include contamination fears, checking and doubts about responsibility for harm to self or others, hoarding, and intrusive “forbidden” thoughts (6). Studies have suggested that, overall, an increase in obsession and compulsion severity has emerged since the beginning of the COVID-19 pandemic. The impact has been especially incapacitating for individuals with contamination and responsibility for harm symptoms (2, 3, 7). In addition to an increase in symptoms, the COVID-19 pandemic restrictions may interfere with access to optimal OCD treatment (3).

The psychotherapeutic treatment of choice for OCD, in both adults and children and backed by numerous clinical trials, is cognitive-behavioral therapy (CBT), particularly exposure with response prevention (ERP) (8). In addition, selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice and are associated with improved health-related quality of life (9). There has been ongoing interest in the effectiveness of the specific treatment (i.e., ERP) versus the common factors of therapeutic alliance and treatment expectancy in the treatment of OCD. Vogel and collaborators (10) found that the quality of the therapeutic alliance was the most important variable in predicting symptom improvement. On the other hand, Strauss and colleagues (11) found that treatment specificity (ERP) predicted symptom reduction in OCD, with a relatively minor effect of therapeutic alliance. In fact, they found that it was positive symptom relief that was associated with stronger alliance, rather than vice versa. This was in the context of a highly structured research setting, in which patients committed to the assigned treatment.

Although ERP is an efficacious treatment for OCD, only about half of patients report complete or mostly complete symptom resolution at the end of treatment. Treatment refusal (25%–30%) and dropout rates (28%) negatively affect symptom improvement (12). Hagen and colleagues (13) attempted to parse out the components of the working alliance that may be predictive of outcome in the treatment of OCD. They concluded that the therapist’s ability to establish agreement on the tasks and goals at the initiation of treatment was significantly predictive of positive treatment outcome. The study stressed that the therapist’s engagement of the patient in the first few sessions of psychotherapy (ERP) was “of utmost importance in order to socialize and persuade the patient to partake in the treatment” (p. 98). Wheaton and colleagues (14) had similar findings, noting that the therapeutic alliance around jointly identified tasks of therapy predicted treatment outcomes. Mediating this outcome was that better agreement on the tasks of therapy improved treatment adherence.

Establishing a Working Alliance During the COVID-19 Pandemic

Individuals with OCD may be expected to fare poorly during the isolation and fear of illness associated with the COVID-19 pandemic. A study by Wheaton et al. (3) suggested that 76.2% of respondents on OCD-specific forums and websites reported worsening OCD symptoms after the onset of the pandemic. Individuals with contamination fears may be particularly affected by the pandemic threat, as has been reported for previous pandemic illnesses (15).

There is substantial variability in the degree of insight individuals display about the accuracy of the beliefs that underlie their obsessions and compulsions. Those individuals with good or fair insight are the most likely to seek and engage in effective treatment. Individuals with more limited or absent insight are less likely to engage in treatment and are often resistant to efforts to eliminate compulsive behaviors, being convinced that these compulsions are their sole method of ensuring control and safety. For those patients, considerable clinical acumen is required to foster the collaborative working relationship required for effective treatment. Clinicians who emphasize patient-identified concerns as the focus of treatment and optimize shared decision making regarding treatment decisions are more likely to engage the patient in the difficult work of ERP (16).

In addition to potentially exacerbating symptoms, COVID-19 has interfered with optimal ERP treatment. COVID-19 was reported to interfere with treatment by predominating the focus of treatment and by complicating the patients’ ability to complete ERP because of pandemic-mandated lockdowns. Treatment during the COVID-19 pandemic has typically switched from in-person to telemedicine or phone appointments. During the pandemic, it is even more important to engage patients with OCD by clearly explaining the treatment process, listening carefully to and validating the patient’s fears and misgivings, and embarking on a collaborative treatment plan to improve adherence and enhance symptom reduction (8).

Clinical Vignette

It was 10 minutes past the hour, and Mr. Sanders had not yet arrived for his first telepsychiatry appointment with Dr. Brown, his OCD treating psychiatrist. The phone rang, and Dr. Brown answered quickly.

“Hello, Doctor. This is Jerome Sanders.”

“Hello, Mr. Sanders,” Dr. Brown replied. “Is everything all right?”

“Well, yes. Well, no. Oh, I can’t figure out how to get on the video,” Mr. Sanders said irritably, his frustration obvious.

“I’ll help, Dad,” Dr. Brown heard in the background. It was Mr. Sanders’s 10-year-old daughter. Within another few minutes, Mr. Sanders appeared, mumbling with annoyance but smiling when he peered at the camera.

“Well,” Dr. Brown observed, “This technology is quite the challenge. I’m glad you stuck with it to come to our appointment.”

“Thanks to Jennifer, you mean,” Mr. Sanders quipped. “Kids these days can figure this stuff out in no time.”

“Indeed,” Dr. Brown smiled and nodded empathetically. “Well, shall we get started?” Dr. Brown began by explaining the evidence behind and the process of exposure and response prevention. “Mr. Brown, you reported during the initial evaluation that you are most bothered by needing to disinfect and wash your hands constantly, because you are fearful of becoming sick or having your family members become sick. You had to cut your work to half-time because the disinfecting was taking hours. And you are working at home. Is that still the case?”

“Yes,” replied Mr. Sanders. “Well, with COVID and all, how can I be sure we won’t get sick? And what if we do get COVID? What happens then?”

Dr. Brown validated Mr. Sanders’s distress. “It is a concerning time. How difficult it must be to manage your regular obsessions and fears—and then to add on worries about COVID.”

“You got that right!” Mr. Sanders replied emphatically. “How am I supposed to even get groceries? I haven’t been able to find N-95 masks, and when my wife goes out for groceries, I know she is going to get sick. And then spread it to the kids and me. I am spending hours trying to disinfect everything. My hands are raw with washing. And how in the world do you disinfect broccoli?”

“I can tell this has been really difficult. We all need to be careful about COVID exposure. Do you think you are overly concerned? Meaning, do you feel that your OCD is making you overreact?” Dr. Brown queried.

“That’s what they say,” Mr. Sanders replied. “You know, my primary care doctor, wife, sister. Still, how can I be sure?”

“It seems that your OCD symptoms are really severe. Considering government safety recommendations, we need to find a plan that fits your needs and optimizes safety.”

“And that might be?” Mr. Sanders inquired.

“Well,” mused Dr. Brown. “Let’s identify the primary symptom that you want help with first and make a plan around that.”

They discussed Mr. Sanders’s excessive handwashing. He agreed that his extreme handwashing had left his hands red, raw, and sore and perhaps more vulnerable to an infection. Mr. Sanders and Dr. Brown agreed on a plan to decrease the length of time that he washes his hands—no more than 30 seconds (just over the Centers for Disease Control and Prevention [CDC] guidelines of 20 seconds). They practiced relaxation techniques to use when he felt compelled to wash his hands unnecessarily. They agreed to start sertraline medication for treatment of OCD while they constructed an appropriate ERP plan to assist with compulsive behaviors. Mr. Sanders also reported that, with cutting his hours to part-time and working remotely, he has been spending hours watching the news, reading online media sources, and focusing on the spread and danger of COVID-19. They agreed it would be helpful to limit this media exposure.

At the end of the session, Mr. Sanders and Dr. Brown had co-constructed a written plan, including a daily schedule with media consumption confined to 30 minutes twice daily, homework, a timer to set for 30 seconds when he washes his hands, and informed consent to start sertraline.

“Are you comfortable with this plan?” Dr. Brown inquired as they prepared to end the session.

“Hey, I helped make the plan, so I better like it,” he replied, smiling a genuine smile for the first time that day.

Tips for Forming a Working Alliance With Individuals in Treatment for OCD, With Modifications for the COVID-19 Pandemic

The nature of OCD, with the need for rituals, constant doubting, rigid adherence to self-imposed rules, a frequent need to feel in control, and a fear of giving up symptoms for fear of tragic consequences, requires special skill for the clinician in negotiating a working alliance. The clinician needs to anticipate that the patient may agree to a plan but then avoid sharing a lack of adherence to homework assignments because of feelings of shame and fear of disappointing the clinician (8). The COVID-19 pandemic has complicated ERP treatment, especially for individuals whose symptoms primarily involve fear of contamination or responsibility for harm. Establishing a collaborative mutual partnership in which the therapist and patient work together to set realistic goals and complete treatment tasks is particularly important in the crafting of a successful OCD treatment. A few tips are provided for managing OCD during the COVID-19 pandemic (2, 13):

1. Highlight from the first interactions the importance of forming a strong working alliance, which consists of shared decision making and strong agreement on the tasks and goals of the therapy.

2. Use telemedicine, as appropriate. Ensure that the patient has access to reliable Internet service.

3. Adapt communication style to the patient’s needs and capacities, explaining symptoms in understandable terms and demystifying the disorder.

4. Clearly specify the treatment approach, choices, and philosophy of joint treatment planning. Consider modifications and adaptations needed during the COVID-19 pandemic.

5. Carefully assess the OCD symptoms regarding most impairing symptoms and how these symptoms may or may not be affected by COVID-19.

6. Provide psychoeducation with balanced information about the known risks and impact of COVID-19 on physical and mental health.

7. Help the patient make a daily schedule and routine that includes exercise, structure, mindfulness techniques, and other stress-reduction methods.

8. Inquire about Internet and news consumption about the pandemic. Consider an appropriate balance of media consumption to stay informed about the pandemic but to minimize triggering symptoms. About 30 minutes twice daily of media consumption may provide that balance. COVID information should be accessed from scientific and reliable sources.

9. Consider beginning an SSRI medication for early symptom relief while individualizing effective and safe methods of ERP for the patient, in compliance with CDC pandemic recommendations.

10. Assess for new symptoms or exacerbation of symptoms during the COVID-19 pandemic. Evaluate for co-occurring symptoms, such as depression, which may need to be a secondary focus of treatment. Ask about suicidal thoughts or impulses.

11. Stress that treatment is an ongoing dialogue, requiring acknowledgment of lack of agreement with the treatment plan and working this out.

12. Write down agreed-upon goals and treatment plans and share a copy with the patient. Refer to these regularly. If a medication trial is agreed upon, specify how long it will be followed and the indications for a change in the medication plan.

13. Specify a plan for communication outside of appointments for reassurance, to answer questions, and to clarify instructions. Ensure that communication is possible, but set appropriate limits to decrease dependence.

14. More severe OCD may warrant a collaborative team approach, with regular and specified methods of team communication with each other and integrating the patient into these discussions whenever possible.

15. Encourage involvement of caregivers in treatment planning, including support services for them. Caregivers of patients with OCD are at increased risk of developing stress-related disorders.