Obsessive-Compulsive Disorder (OCD) is recognized as a severe and debilitating psychological illness. The purpose of the present study was to investigate the effectiveness of paradox therapy on patients with OCD. The present study recruited eighteen patients with OCD. Participants were assessed on the Yale Brown Obsessive-Compulsive Scale (YBOCS). Subsequently, they underwent six sessions of the PTC model of paradox therapy, each lasting approximately 45 minutes. A single group with pre- and post-assessment was adopted to evaluate the changes in the participants in response to the intervention. A linear mixed effect model with an unstructured residual covariance matrix was fitted to the data. A significant effect was evident for time, F (2, 17) = 108.8, p < .001. Direct comparison of mean scores showed a significant reduction from baseline to post-treatment; the mean difference = 20.22, SE = 1.5, p < .001, d = 2.1, and a significant but small reduction from post-treatment to follow-up, the mean difference = 1.56, SE = .41, p = .002, d = .16. The residuals were approximately normally distributed, skewness = .51, kurtosis = .7, and there were no extreme outliers. All participants showed a reliable change, i.e., a change more than expected from measurement error. Also, the improvement for all participants was clinically meaningful. The findings of the present study suggest that the PTC model of paradox therapy is efficacious in reducing the severity of obsessive-compulsive symptoms in patients with OCD.

• Paradox therapy; Obsessive-compulsive disorder; Psychotherapy; Psychoanalysis; Ego-strength.

Besharat MA, Mazloomzadeh M (2025) Evaluating the Effectiveness of Paradox Therapy for Obsessive-Compulsive Disorder. Ann Psychiatry Ment Health 13(2): 1205.

Obsessive-Compulsive Disorder (OCD) is recognized as a severe and debilitating psychological illness. It is characterized by unwanted, repetitive thoughts (obsessions) and time-consuming and repetitive behaviors (compulsions) that cause significant clinical distress and functional impairment [1]. Three specific components characterize this disorder. The first component, obsessions, is defined as intrusive and unwanted thoughts, images, or ideas, as well as doubts about actions. Obsessions are usually in specific areas, such as horrific images (such as blasphemy, sexual ideas, or violent images), thoughts of contamination, or doubts about not doing certain things. The second component, compulsions, are defined as specific behavioral actions, including covert mental rituals, aimed at neutralizing obsessions or investigating behaviors that are the subject of doubt and that the individual is compelled to perform. To avoid triggering these obsessions and compulsions, people with OCD often engage in extensive avoidant behaviors, which can worsen the condition [2]. Among all anxiety disorders, OCD has the highest prevalence and rate of referral to medical centers [3]. A 1% to 3% prevalence has been reported for this disorder [4,5], and it usually begins in childhood [6].According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), OCD causes significant suffering and significant disruption in ordinary life [1,7]. Due to the variety of clinical characteristics of this disease, several treatment methods have been provided, including psychological and pharmacological interventions and a combination of them [8]. Drug therapy [9], exposure and response prevention therapy [10], and cognitive behavioral therapy [11], have shown relatively acceptable clinical efficacy for OCD [12-14]; however, it has been reported that about 10% to 30% of patients are resistant to these treatments. Low motivation, lack of hope for treatment, fear of drug poisoning, the high number of sessions and problems related to paying for treatment, not paying attention to the past, and simply emphasizing the patient’s knowledge are some of the resistance factors of people with OCD to these treatments. They say, “We know these thoughts are wrong, and these behaviors are wrong; the problem is not that we do not know; the problem is that we cannot stop thinking or doing” [15]. Therefore, perhaps accepting the inability of OCD patients to deal with the disease and focusing only on empowering them in the shortest possible form of psychotherapy, which has rapid effectiveness and creates hope and motivation for patients to recover even without the help of drugs [16]. By doing so, we can increase the chance of curing even those resistant to treatment. This resistance, which is caused by problems related to treatment, patient, therapist, length of treatment, treatment costs, age of onset, number of symptoms, and rate of recurrence [11,17,18], the necessity of accompanying medication with psychotherapy [19], and unnecessary and additional effects of drugs [16,20,21], makes it necessary to invent more efficient psychotherapy approaches. Paradox therapy by PTC1 method is an approach that aims to overcome the limitations and shortcomings mentioned [22]. Besharat [23], has introduced a paradoxical therapy model called PTC, which has integrated various foundations, hypotheses, and theoretical models into a new order, making this therapeutic approach highly effective [23]. The theoretical basis of paradoxical psychotherapy is rooted in psychodynamic approaches including mainly psychoanalysis as well as systems theories [23]. However, when it comes to practice and therapeutic techniques, it is loyal to behavioral techniques [23]. Besharat [16], has shown that the paradoxical method is appropriate for obsessive-compulsive treatment. Paradoxical psychotherapy has strong research support from the American Psychiatric Association [24]. The PTC psychotherapy model for psychological disorders consists of two main components: paradox and timetable. The paradox component involves prescribing the same psychopathological symptoms the patient is experiencing. The therapist prescribes a task/homework for the patient to recreate and experience the whole disorder or symptoms as he/she experience in his/ her daily life. The second component is the timetable, where the patient is tasked to recreate the prescribed symptoms/behaviors at some predetermined times for a specified period of time. The patient should only perform these tasks during the specified times. Combining these two techniques creates a paradoxical timetable [15,23]. Studies have shown that this approach has been effective in treating anxiety disorders [15,23], illness anxiety disorder [22], body dysmorphic disorder [25], social anxiety disorder [26], and couple/marital problems and conflicts [27]. Considering that OCD in all strata of society reduces the efficiency of daily activities and disrupts the normal flow of life, the necessity of conducting this research becomes more apparent. Therefore, the present study aimed to investigate the effectiveness of the PTC model of psychotherapy on patients with OCD.

Participants

The present study used a single-group experimental design with a follow-up period in three phases. The first phase involved conducting interviews, determining participants, and administering pre-tests. The second phase consisted of five psychotherapy intervention sessions (PTC) for ten weeks. The third phase was a follow-up intervention session three months after the fifth visit. The outcome variable was the severity of obsessive-compulsive symptoms, which was measured using a standardized scale at three-time points. After the announcement of the invitation to the psychotherapy intervention research for obsessive-compulsive patients, 36 people contacted the clinic. After checking the inclusion and exclusion criteria over the phone, 28 were invited to visit the clinic. The age range of these people was between 18 and 35 years old and they were all Iranians. After the interview session and completing the Yale-Brown Obsessive-Compulsive Questionnaire, 18 people were diagnosed with OCD. These people were recruited after completing the informed consent and commitment forms to attend all stages of the study process. The inclusion criteria were: (1) being between 18 and 35 years old, (2) experiencing obsessive and annoying thoughts or behaviors (Y-BOCS >15), (3) being aware of these thoughts, (4) experiencing emotional suffering, (5) disruption of the person’s performance in daily activities, (6) not being currently involved in other psychological treatments and drug therapy. Exclusion criteria were: (1) having active thoughts of suicide or self harm, (2) experiencing a psychotic episode in the past 12 months, (3) being currently engaged in other psychological therapy or planning for such therapy, and starting any therapy during the study period. No participants dropped out after the first session. Participants’ demographic information is demonstrated in Table 1.

Table 1: Demographic and clinical information of participants.

Procedure

After diagnosing and identifying inclusion and exclusion criteria, individuals between the ages of 18 and 35 were selected to participate in the study. They underwent PTC treatment for five visits that took place every two weeks for a total of ten weeks. Data was collected after the fifth visit and a 3-month follow-up visit. After the fifth visit, the participants were given general advice on managing the disease, in case it recurred. Although this disease had a low likelihood of recurrence, the study emphasized the importance of managing it effectively if it did. Participants were instructed not to use psychological or pharmacological treatments during the study.

Measures

Participants completed measures of the following construct at three-time points (pre-intervention, post intervention, follow-up).

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS): The Y-BOCS is a well-recognized and widely used tool to evaluate the severity of OCD symptoms in both clinical and research settings [28,29]. It consists of a checklist to identify the specific types of obsessive and compulsive symptoms experienced by the patient, along with a 10 item rating scale. The scale is divided into two subscales, one for obsessions and the other for compulsions. Each subscale includes five aspects of obsessive and compulsive pathology rated on a scale ranging from 0 (no symptoms) to 4 (extreme symptoms): time spent, degree of interference, distress, resistance, and perceived control over the symptom. The scores of each subscale are added to give a Y-BOCS total score. However, there is a moderate difference between self-reported and clinician rated Y-BOCS scores, with patients tending to rate their symptoms lower than clinicians. The highest correlation is observed for the compulsion subscale [30,31].

The intervention followed the PTC model introduced by Besharat [15,17], and focused on obsessive-compulsive symptoms. The intervention consisted of five sessions problems, and limitations of the implementation of the tasks, the consequences of doing the tasks, estimating the percentage of possible treatment changes by the patients, and the possible necessity of continuing the previous tasks (for instance, we will review the first session’s assignment again, correct the functional problems in implementing the assignments, and then continue with the assignments from the previous session). Sessions 3 & 4: Behavioral analysis, examining how to implement the tasks of the previous session, possible problems, and limitations of the implementation of the tasks, the consequences of doing the tasks, estimating the percentage of possible therapeutic changes by the patients, the possible necessity of continuing the previous tasks (for example: prescribing the continuation of the tasks of the previous session by the patients), determining and prescribing new assignments. Session 5: Description of the patient’s self-treatment plan in the future, if needed, in the final session, completing the questionnaire and research scales. Session 6: Follow-up

Data analysis

First, the participants’ scores were analyzed using descriptive and inferential statistics. The scores on the three assessment occasions (pre-test, post-test, and follow-up) were compared to the linear mixed-effect model (LMM). As the variance of scores was substantially reduced after treatment, an unstructured residual variance-covariance matrix was used. The Restricted Maximum Likelihood was used for estimation. To ensure a reliable conclusion, residuals were inspected for normality and the presence of outliers. Also, we calculated Cohen’s d as a measure of effect size. For calculating d, due to our small sample size, we used the standard deviation reported in previous investigations [32]. We calculated the reliable change index (RCI) and minimum clinically relevant change index. The first indicates whether the change is beyond what would be expected from measurement error (more than two standard errors of measurement); the second indicates whether the change is clinically meaningful (more than one standard deviation). We reported the percentage of participants who showed such improvement. As our sample size was too small to estimate internal consistency reliability and score dispersion accurately, we used previous studies’ estimations. Using a standard deviation of 9.61 and a reliability index of .95 [32], the RCI is 4.3.

The participants were a group of 18 Iranian adults (18-35 years). There were 11 (61%) females and 7 (39%) male participants. Participant characteristics can be seen in Table 1.

Table 2 shows that 33% of the participants had obsessions of contamination, while 11% had aggressive obsessions,16% had magical obsessions, 38% had somatic obsessions, and 27% had religious obsessions. 38% of the study participants had miscellaneous obsessions. Among compulsions, checking (50%) and Repeating (50%) were the most common, followed by Washing (28%) and miscellaneous (11%) compulsions and counting (5%).

Table 2: Content of obsessions and compulsion amongst the participants based on CYBOCS symptom checklist (n = 18).

The descriptive indices for obsessive-compulsive scores are presented in Table 3.

Table 3: The descriptive indices for obsessive-compulsive scores.

A linear mixed-effect model with an unstructured residual covariance matrix was fitted to the data. A significant effect was evident for time, F(2, 17) = 108.8, p < .001. Direct comparison of mean scores showed a significant reduction from baseline to post-treatment, mean difference = 20.22, SE = 1.5, p < .001, d = 2.1, and a significant but small reduction from post-treatment to follow-up, mean difference = 1.56, SE = .41, p = .002, d = .16. The residuals were approximately normally distributed, skewness = .51, kurtosis = .7, and there were no extreme outliers. All participants showed a reliable change, i.e., a change more than expected from measurement error. Also, the improvement for all participants was clinically meaningful, i.e., more than one standard deviation.

We investigated the effectiveness of PTC psychotherapy on obsessive-compulsive disorder. We used variables measured before intervention, after intervention, and again at follow-up to achieve this goal. All participants showed improvements from baseline to post-intervention as well as at follow-up. Five participants declared that the symptoms disappeared completely after the intervention, and in the follow-up, they reported that no symptoms returned. Six participants reported a significant reduction in symptoms after the intervention and reported complete resolution at follow-up. Four participants reported that their symptoms had improved significantly after the intervention and then at follow-up. Finally, three participants reported that the symptoms decreased acceptably after the intervention and follow-up. In general, our adaptation of PTC in this study promises a significant treatment for obsessive-compulsive disorder. In the PTC model, patients are required to schedule specific times to retrieve their intrusive thoughts and to re-experience disturbing behaviors. The goal is to recreate the symptoms of their disorder according to the timetable and apply the paradox by prescribing the symptoms. This approach enables patients to experience their symptoms without stress, and through the process of strengthening the ego, their inner psychological conflicts that cause pathological symptoms will be resolved [16]. The findings of the present study are in line with previous studies in this field [15,16,25-36], and can be explained based on several possibilities. One of the effective mechanisms of PTC to produce rapid therapeutic changes is known as “artificializing-ordering” [23]. Based on the paradoxical timetable introduced to the patient by the therapist in the first session, the patient has to recreate and re-experience his/her exact symptoms at certain times during the day. This mechanism of change leads to the symptoms having two key characteristics: being voluntary and artificial (the patient produces them, and they are not spontaneous), which are the opposite to the involuntary and forced nature of pathological symptoms of obsessions and compulsions [15]. For this reason, the imposed, forced, annoying, and unpleasant aspects of the disorder symptoms are removed. This, by effectively reducing anxiety attached to the symptoms, leads to “breaking the relationship between symptoms and anxiety” [25]; another effective mechanism of change in PTC. Based on this breaking mechanism, when symptoms are present without anxiety, they will no longer be considered psychopathological, as they cannot be a source of tension and distress for the person any more. Along with the “artificializing-ordering” and “breaking the relationship between symptoms and anxiety” mechanisms of therapeutic change, the meaning of the symptoms as well as the psychological disorder will quickly be changed for the patient. In other words, as soon as the patient suffering from OCD can recreate and experience the symptoms without feeling worried or distressed, the disorder loses its obsessive and compulsive meaning. Therefore, it is no longer can be considered as a disorder. The process of symptom meaning change is started when the PTC therapist prescribes the exact symptoms and will be continued by the patient when doing his/her homework experiencing the exact symptoms. As mentioned in the introduction, the main and ultimate goal of paradoxical psychotherapy in the PTC model is to strengthen and improve the patient abilities (i.e. ego strength). Having some weaknesses, the ego in people with OCD cannot perform its usual tasks and functions in the coordination of personality organization, management, and regulation of behaviors, feelings, emotions, and intra- and interpersonal interactions. Performing paradoxical timetable from the first session of the therapy by the patient puts forward a confrontation between the patient and the disorder, here say OCD. Structure of the PTC and the way the patient is instructed to perform the therapeutic tasks helps the patient to fight against the disorder in a manner that he/she will always be the only winner of the game! When the patient is going to perform the tasks in preplanned times, he/she may face with two conditions; active phase of the disorder and inactive phase of the disorder. While at the first condition the disorder is in control, at the second one the patient will be in control. Prescribing a paradoxical task three times a day for one or two weeks increases chance of the second condition to be happened. When the patient get chance to be in control then this is he or she that creates the disorder at will. The process of changing an imposed compulsory psychopathological condition to a voluntary one, along with the three mechanisms mentioned above, removes the compulsory features of the disorder, helps the patient to be in control, and makes the ego more powerful and strength. Results of the present treatment study strongly supported the effectiveness of PTC for the treatment of OCD. The results revealed that PTC can quickly, decisively, and powerfully treat obsessive-compulsive disorder. This is the promise of a new era in the field of psychotherapy for obsessive disorders that brings the hope for both patients and psychotherapists. Besides this clinical implication, findings of the present study shed lights on theoretical discussion about the complexity and resistant nature of the disorder. The way PTC treats OCD undermines those ideas that look obsessions and compulsions as resistant to treatment. Care must be taken concerning the effectiveness of the PTC in the present study because of lacking a control group. Experimental designs with a control group allow a more robust and reliable level of effectiveness to be established. Further, it is challenging to infer whether the therapeutic gains are sustained in the long term due to the short follow-up period. The clinical implications of this study highlight the use of the PTC model as the first-line choice for patients with OCD. Randomized, well-controlled trials with larger sample sizes should be done to establish the effectiveness of PTC in patients with OCD.

MAB: Conceptualization; supervision; project administration; data curation; writing-review & editing. MM: Conceptualization; practical implementation of research; data curation; formal analysis; writing-review & editing.

The authors declare that no financial support was received for the research, authorship, and/or publication of this article.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

We thank the Institute of Paradox Therapy for providing training courses in PTC for using in the present study. We thank clients who participated in the treatment study for their cooperation. We thank all volunteers and staff involved in this research.

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