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Dr. David Tolin: Setting a Positive Example for the Profession of Evidence-Based Practice in Action

June 19, 2010

Usually the topics I discuss in this blog involve potentially harmful or pseudoscientific practices, but this posting is an exception and just the opposite. I have some good news, for a change.  Dr David Tolin is an expert in treating Obsessive Compulsive Disorder (OCD) and in the reality show, The OCD Project, people can watch evidence-based practice in action. Dr. Tolin uses Exposure and Response Prevention (ERP) on the six participants on the show.

In spite of this, Dr. Tolin has his critics, as there are those who are ignorant about the strong evidence base the therapy he practices have, and have made some very harsh comments, calling him cruel for doing the kinds of heavy duty exposures that are necessary to successfully treat OCD. The latest episode featured a scene where one of his colleagues was doing an exposure session on Arine, a client with a fear of contamination where she was instructed to dunk scones in a toilet and then eat them. This toilet dunking may look like a kooky, crazy therapy but it really is not. There is a sound, evidence-based reason for having clients to this far with their exposures because the research shows that the mild exposures just don’t cut it. This is what it takes for people to get over OCD. So yes, I am defending dunking scones in toilets as an effective exposure-based therapy for people with OCD who have a fear of contamination!

It is instructive to observe the differences between the way Dr. Tolin deals with criticism and the way proponents of questionable therapies deal with criticism. Dr. Tolin responds to criticism by presenting actual evidence that ERP is highly effective.  He never personally attacks his critics. He doesn’t have to because he can refute them with evidence. In contrast, proponents of questionable therapies do not refute their critics with evidence. Instead, they engage in ad hominem attacks, arguments from authority, straw man arguments, sue their critics and engage in all out libelous smear campaigns.

Legitimate mental health professionals with evidence-based practices have no need to do that. Dr. Tolin calmly presents his evidence and is very civil to critics, attempting to educate them but acknowledging they have the right to disagree with him. No need to sue and write nasty letters to deans or any of the rest of the nasty things certain other people have done to their critics. Proponents of questionable therapies promote them before the evidence is in. Tolin waited until after the research was done, to disseminate ERP and he serves his clients well.


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  1. Elly permalink

    It’s good to read a review of the show by someone who is familiar with CBT and ERP. I have read a couple of articles that really bash Dr. Tolin’s methods, but it is clear that they know very little about OCD and how to treat it. One article suggested that talk therapy would be a much better way to treat OCD. The writer argued that instead of having Arine drive around the parking lot hitting strollers, they should have just sat her down and explained that it is very rare for people to hit pedestrians. Ridiculous!

  2. Good point, Elly. It would become obvious to anyone who has ever worked with a client who has OCD or knows someone well who has OCD that providing such information does no good at all. People with OCD are not delusional (unless they have a dual diagnosis) and most are already aware of such information. Same goes for people with phobias. Most already know that the fears are irrational and yet they persist. There is a ton of research showing that the only way to treat these types of problems is with an exposure-based therapy and the intense ones have been shown to work the best. Talk therapy just does not cut it.

    Successful treatment with exposure based therapies for OCD and various anxiety disorders is the biggest evidence-based success story, thus far, in the history of the mental health professions. I am really glad that this show exists to properly educate people about this fact. Surveys of mental health professionals have shown that an astonishingly low percentage actually use these evidence-based exposure therapies and they use unproven ones instead. Shows like this really help to change things at a grassroots level because they will make the clients aware of how OCD is properly treated, so they can then challenge any therapist they go to who tries to use other approaches that are not so effective. These therapists using unproven methods are probably not going to change, but clients can vote with their feet and choose to go to people who are.

  3. Fear Factor permalink

    I am one of those people who looks upon Dr. Tolin with a bit of critical thinking, mainly due to the fact of the sensationalist aspect of the treatments. I thought the toilet scone business was a bit over the top–I understand that OCD treatment has to be extreme, but the scone thing was just nasty and it gives the appearance of some sort of “anything for the cameras” treatment rather than “anything for the patient” treatment. Evidence? Well, the work of Dr. Ost has demonstrated that it matters not the intensity of the exposure session:

    “One 3 hour exposure session was as effective as 5 one hour sessions of either exposure or cognitive therapy for claustrophobia
    (2001) Behav Res Ther 39, 167. Öst LG, Alm T, Brandberg M”


    “One versus five sessions of exposure in the treatment of flying phobia
    Behaviour Research and Therapy
    Volume 35, Issue 11, November 1997, Pages 987-996
    Lars-Göran Östa, Mats Brandberga and Tomas Alma”

    Both these articles conclude that there is no difference in outcome, when spreading out the misery (so to speak) so therefore why subject a patient to this extreme methodology, when there is a more humane alternative? Because VH1 wouldn’t have such a shocking reality show then?

    Further, I am also concerned about this notion of Dr. Tolin’s that one is not “trying hard enough” to fight their OCD (or panic, or phobia, or PTSD). He makes it a point that its “my way or the highway” on a number of occasions and that is treading very close to a “blame the patient” mentality that can be very hurtful if not very harmful, as viewers with friends and relatives suffering with OCD and other illnesses will take that comment and run with it–creating vast amounts of blame to heap on the afflicted who get so little support and understanding as it is.

    I can appreciate the research that states that ERP is very effective for OCD. But the long term research is lacking, and to peruse any OCD forum one would find many, many patients that struggle for years with this disorder–are they all people with a “lack of will” to fight? Or as Dr. Tolin himself has suggested, just victims of “bad therapists”?

    Perhaps it is possible that the truth of the effectiveness of ERP lies somewhere in between the sensationalist TV program suggestion, and the obvious numbers of people that remain afflicted in spite of treatment. I can applaud Dr. Tolin’s work but still find that there may be better ways to treat this disorder that have nothing to do with personal fortitude and expertise in therapy delivery. That, is the holy grail that needs to be acknowledged and strived for lest the TV watching public assume a simplistic view of mental illness and its treatment.

  4. One thing to keep in mind, Fear Factor, is that Dr. Ost’s treatments are for specific phobia, not OCD. Studies on flying phobias cannot be generalized to OCD, which is a very different disorder. Yes, specific phobias, which are among the easiest conditions to treat, can be treated in as little as 3 hours, but anyone who is the least bit knowledgeable about anxiety disorders will agree that this is far from the case with OCD, which is not what Dr. Ost’s studies focused on, nor would he ever claim that. Again, ERP is a very well-substantiated treatment for OCD and it sounds to me as if you are letting your distaste for the treatment bias you against it when the data show this is effective. I’m not sure where you get the idea that “long term evidence is lacking”.

    I also do not see he is blaming the patient, nor is he forcing anyone to do anything. There is a big difference between blaming someone and the reality that a person does need to make a choice to participate in a treatment, or not. As he has repeatedly stated, it is the patient’s choice whether or not to continue and he even reminded one of the participants that she was free to fire him at any time. These patients were provided with full informed consent as to the nature of this treatment and they chose to participate in it and the evidence shows they made a very wise choice. Arine, the person who was undergoing the exposure session with the “toilet scones” has made phenomenal progress and it looks to me like she is happy with the benefits she received from the treatment and gave her full consent to participate.

  5. Caitlin Dobner permalink

    I was diagnosed with OCD two years ago, and decided to get help as soon as I found out something isn’t right. The average year that a person gets help with OCD is 7.5 years. The OCD Project on VH1 has hopefully had an impact on all people suffering with this disorder–I know it gave me hope.

    Fear Factor: “…Dr. Tolin’s that one is not “trying hard enough” to fight their OCD (or panic, or phobia, or PTSD)”

    I can speak for almost everyone that has OCD, we hate it. We don’t want this disorder, but we also don’t want to fight it. It’s terrifying. It’s embarrassing. During my own therapy, my own psychiatrist called me out on not wanting recovery as bad as I should have. There are times when sometimes, like Kristen on the show said, “I’d rather just live with OCD.” Put into my perspective, I think Dr. Tolin is a God. He truly understands the disorder in a way that I think a lot of people don’t–especially if you don’t have it.

    To conclude, I believe there is no better “humane” way to treat OCD. Tolin has a point, OCD puts some crazy thoughts in our minds, and we have to do some crazy stuff to combat it.

  6. Charles permalink

    FearFactor is correct. Also, although this mode of treatment may help, I’m asking myself, “What is the real intent?” Is it to show how Dr. Tolin “saves the day” in the end or really to help these people, not just in the short term, but in the long term as well.

    Also, in the scene where he asked the fellow to leave the house, why was it so abrupt? Where was the “cool down” period? Who told that lady to have him pack his bags?? He wasn’t even finished saying good bye. Shame on how that was handled. After all the editing skills I’m sure they have, it still turned out like that? If they have no follow-up with him on the show, I and and many others will be very disappointed.

    • Charles, if you watch the final episode, you’ll see that they did, indeed do a followup on the guy who was asked to leave the program. Dr. Tolin acted responsibly in doing so, because he was not benefiting from the program, which obviously wasn’t right for him. He was referred to a local therapist, which was completely funded, and did ERP at the pace he needed. As a result, he is much improved and he doesn’t seem to hold any hard feelings at all towards Dr. Tolin. Yes, the show is edited and we didn’t get to see everything that went on with regards to his being asked to leave the program. On the program, it happened in minutes, but that is not necessarily how it went down in real life. The final outcome for him, however, was quite positive.

      Charles and Fear Factor might be interested in knowing one more detail, which is that ERP has been around for much longer than reality TV has. It was developed by Edna Foa and having talked to people who went through her program, the exposures she does with her own patients are every bit as extreme and dramatic as the ones shown on The OCD Project. So no, this was not sensationalism concocted for reality TV. The show accurately depicted a treatment that has been done this way long before there ever was reality television.

  7. Fear Factor permalink

    Dr. Ost has been critical of extreme exposure and flooding in one of his books; the title escapes me at the moment, but I have seen other literature that also criticized these techniques as unnecessary and unwarranted given that there are alternatives. I get the idea “that long term evidence is lacking” from the LACK of long term evidence. If you would like to provide me with some studies that look at people more than 5 years out, that would be interesting, because there are very few of such studies. What is not in short supply are the hundreds (perhaps thousands) of people that frequent support groups for OCD, phobias, panic disorder, PTSD and other anxiety disorders that tell a very different tale of their treatment experiences and their lives many years down the road. A tale of frustration and lost hope. A tale that includes blaming the patient and blaming “bad therapists”, but never blaming the treatment.

    While you will probably come back at me with something to the effect that these experiences are not “evidence” but anectdotal, I will tell you that all discoveries begin as an anecdotal finding, and therefore to discount people’s personal experiences is the height of malpractice…the very thing that got George Washington killed by bloodletting until some bright physician put together all the anecdotal evidence that bloodletting kills people rather than cures them. This is the exact moment that we are in with the treatment of mental illness. There is a climate of cultism surrounding the treatment of diseases like OCD, where psychiatry and psychology are hiding out in their various camps clinging to “treatments” that are downright cruel, when the fact of the immense struggle by patients to do these treatments is staring the doctors right in the face. By not acknowledging the limitations of these “treatments” and the patients’ frustrations in being able to do them, you are making it a certainty that no one will be finding new, and better treatments. It is easier to go with the flow and keep forcing people to do what they don’t want to do which is torture themselves for years, or take medications that will also bring on a host of unpleasant and frequently sickening side effects.

    My distaste for treatment has biased me in the same way that your “evidence” has biased you. You talk about “evidence based medicine” but the type of “evidence” available in both psychiatry and psychology is sketchy at best, given that no one can definitively know with any certainty if a patient is even suffering from a particular mental illness, as there is no way to scan the brain to look for mental illnesses on the molecular level. The idea that “improvement” can somehow be transposed to mean “effective treatment” is another big flaw in the majority of psychological literature. Patients may be “improved” but what is their quality of life? Are they able to work? Enjoy their friends, family, travel, have a better quality of life? Many are fooled into believing that washing their hands 20 times a day instead of 100 times is a great improvement, and statistics won’t know the difference between someone like that and someone that washes 10 times a day–they are all lumped into the same meta-analysis as “improved”, and yet you know both these people have very different lives. One may be able to work. The other may not. So, I don’t see that as “effective treatment”. I see that as a force of personal will, and when the will is lacking relapse is oh so easy…Why? Because “treatment” is not really treatment. It is a facade.

    The emperor has no clothes.

  8. I would have to caution you against attempting to speak for Ost, which is highly presumptuous of you. First of all OCD is not his area, his area is specific phobias, and second of all I see no evidence that he has been at all critical of ERP — you seem to be leaping to some highly unwarranted conclusions and I notice you are not willing to put your real name to the statements you make. The fact is that Drs. Tolin and Ost are friends, not adversaries, each with different areas of expertise.

    Yes, there are “books” that have criticized flooding, but the evidence has refuted that, since for some conditions such as OCD and panic disorder, flooding works far better than systematic desensitization and this has been known for years now and anyone who has done an actual search of the literature showing the evidence (as opposed to your attempt at polemics) will see this has been verified through many studies. If you can some up with a treatment for OCD that has stronger evidence than ERP and longer term follow up, show me the data, provide me with the citations. Based on all the published reviews I have examined, there aren’t any.

    Your statement “My distaste for treatment has biased me in the same way that your “evidence” has biased you” makes no sense. Evidence is the opposite of bias and the fact remains that ERP has the best evidence available for the treatment of OCD. Hey, I think the treatments are pretty gross too, but that doesn’t stop me from looking at the evidence that they really do help people whereas gentle discussion does not.

    You ask if the results make a real difference in the lives of the patients. Yes, the results have been highly clinically significant. That means yes, the patients have a greatly improved quality of life so again, you have made a straw man argument.

    Yes, anecdotes are a start, but they are not evidence. Some anecdotes have later been supported by evidence but most have not been.

    You obviously have very strong emotions on this topic, the origins of which I cannot even begin to fully understand and the rest of your lengthy polemical rant, which attempts to equate bloodletting with state of the art, evidence-based treatment is quite frankly so convoluted, it speaks for itself and so no further response on my part is needed.

  9. Fear Factor permalink

    How kind of you to accuse me of a polemic argument. By pointing out the obvious flaws in your own diatribe, it does in fact raise the bar enough to warrant the superiority of my case.

    I make no claim to speak for Ost. I was merely reporting some of his concerns. As I indicated, there are others such as Jeffery M. Schwartz, who have also written extensively on the subject of OCD and have been critical of extreme ERP. His specialization is in fact OCD, so maybe that would sit with you better although I doubt it, given that your unmeasured protestation of my response places you squarely into the cult forming around Dr. Tolin. Your facebook posting encouraging people to protest my post here was even more telling.”The lady doth protest too much, methinks… I have found plenty of OCD people writing on blogs that are critical of Dr. Tolin, ERP, and CBT. Should I send them over here?

    My not “coming up with a treatment” is not an excuse to torture people when clearly the need for a better treatment is evident. If I am not happy as a patient, then a doctor’s response should NOT be “well come up with your own treatment, then!” That is just making a mockery out of what should be scientific reasoning and not just ranting on your part.

    A lack of critically looking at evidence is the exact definition of bias, so if you can’t understand my point, then it’s quite clear that no matter how many citations I can’t find, you won’t concede the point that the efficacy of ERP and CBT over the long term is lacking. I asked YOU to provide citations to the contrary, and you have responded instead by placing the burden back on me, as if that were somehow proof of your assertion of effectiveness. Why do you see a straw argument in my post, but do not see the one in your own?

    I never asked if the results make a real difference in the lives of the patients. It was a rhetorical question designed to make the point that what you deem as “high efficacy” I see as a mockery of statistics designed to get more funding to do more studies. The real research is with the thousands of people who are walking around with untreated OCD– that is the real evidence of the lack of good treatments for mental illnesses.

    I stand by my comparison to bloodletting…but perhaps a better comparison could be made with the scientists that supported the ice pick in the forehead lobotomy treatment, or how about insulin shock? Would those examples of people like yourself ignoring evidence of cruel treatment suit your fragile sensibilities better? Probably not. Its hard to break free from a cult. I hope someday you really do learn critical thinking and try to avoid the ad hominem attacks on those that disagree with you… which should be especially embarrassing to you given the nature of this blog. Looks like its time for you to go and re-read some of your logical fallacy texts. Don’t worry. I’ll wait.

  10. Do you really want to know the flaw in your bloodletting analogy? Well, here goes. To point out the obvious, bloodletting never went beyond the anecdotal stage where ERP has. ERP has abundant evidence in the form of RCTs to support its efficacy and also abundant evidence of real life changes — clinical significance. The bloodletting harm was anecdotal, yes, but that doesn’t mean that all anecdotes of harm turn out to be true. Your flawed syllogism is:

    Many things later shown to be true, started out as anecdotes.
    The dangers of bloodletting (or insulin shock and lobotomies) started out as an anecdote and turned out to be true.
    The harm you assert from ERP is anecdotal.
    Therefore ERP, like bloodletting will eventually be shown to be harmful.

    Very flawed logic, to point out the obvious.

    The fact is that ERP has been repeatedly tested for safety and efficacy through RCTs (bloodletting, insulin shock and lobotomies never were) and shown to be safe and effective, when done properly for the population it was designed for. That refutes the anecdotes, which most likely have other explanations. Bloodletting, insulin shock and lobotomies are great examples of authority based practice. ERP, in contrast is based on evidence, not authority.

    Evidence based practice is about using the BEST available evidence. That’s why I asked you if there was anything better that had better results with longer term followup. There isn’t and since there is high quality evidence for ERP, then you do have the burden of proof to find something better if you are against it. Are you suggesting that people don’t do ERP and deprive people of the empirically supported real life benefits it does give people? If you are a mental health professional, which I hope you are not, that would be highly irresponsible. Note this is very different from people asking me to come up with treatments as an alternative to their potentially harmful treatments that lack good evidence. In that case, it is an invalid request.

    As for your argument that if ERP were really so great, there wouldn’t be so many people with untreated OCD, again, that is a completely unwarranted conclusion. Why would you expect someone who hasn’t done ERP to benefit from it? What surveys of licensed mental health professionals show is that most have not been trained in specific empirically supported therapies like ERP and often they use therapies that lack support and so the public doesn’t get them. The problems is one of dissemination and perhaps this is being remedied by shows like the OCD Project, which show clinically significant, real life results. And yes, those are anecdotes but the difference here is that these are anecdotes to support evidence that is already there. They are anecdotes to illustrate an already empirically supported treatment, not to prove anything. People who watched the last episode of the OCD project can see such an illustration.

    Oh, and one more thing. For people who were so concerned about the guy who was sent home and slammed Dr. Tolin for not allowing him to continue, on the final show, he did a followup after responsibly referring him to a local mental health professional who could do ERP with him at a slower pace. He’s doing great with that program, has returned to his art work and by his own statements and what we can see, is much improved.

    I can see that for some reason you are highly disillusioned with the mental health profession and hey, I can relate. Just look at the topic of this blog. There are many good reasons to be disillusioned with the mental health profession with all the unsupported, untested and even dangerous therapies that are out there and state boards that won’t get off their duffs and deal with it. I can give you enough of those to keep you busy for a long time, if that’s what you’re interested in, but ERP is not one of them.

    But hey, thanks for sharing. I feel your pain. I hadn’t realized that there was anyone more disillusioned with the mental health profession with all its nonsense than I am. You have proven me wrong, but please don’t make the mistake of throwing the baby out with the bathwater because ERP is legitimate and I don’t make that statement lightly.

  11. Caitlin Dobner permalink

    I have been reading the comments one after another, and I don’t know if I just didn’t catch it, but Fear Factor, what is the ideal treatment? I obviously can see that you are against Dr. Tolin’s “cruel” ways, so what do you think is the ideal treatment for OCD? Medication only? CBT and ERP? Also, are you a psychologist/psychiatrist? Just wondering where you have gotten such an interest in this disorder.

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