Behavioral Therapy for OCD

Effective Help for Obsessive-Compulsive Disorder

Starting therapy for OCD can be daunting. Knowing ahead of time what to expect can help put your mind at ease and make the treatment feel manageable. Below are the major components of cognitive behavior therapy (CBT) specifically for OCD.

• Psychoeducation
• In Vivo Exposure
• Imaginal Exposure
• Response/Ritual Prevention
• Cognitive Therapy

Psychotherapy for OCD

Exposure and ritual prevention (EX/RP or ERP) is the most effective type of treatment for OCD. Also called, exposure and response prevention The word "response" in EX/RP is often replaced by "ritual" as the word "response" is very broad — not all responses are compulsions. Though behaviorally-based, EX/RP includes both behavioral and cognitive techniques. A more cognitive approach, called simply "cognitive therapy (CT)," is advocated by some and may be useful for clients who are not responding well to behavioral strategies. However, EX/RP and CT both typically include behavioral and cognitive elements. EX/RP has been used in a variety of formats, including individual and group treatment, family based treatment, computer based treatment, self-help techniques, and intensive programs. This article will describe the important components of EX/RP and CT for OCD.

Psychoeducation

Therapy starts with collecting a detailed history of the OCD symptoms and concerns, followed by psychoeducation — educating the client about their OCD and the treatment. This is usually followed by treatment planning, or developing a list of problems to be conquered.

In Vivo Exposure for OCD

Exposure is the cornerstone of EX/RP treatment. In vivo exposure has been shown to reduce obsessions and related distress. This technique involves repeated and prolonged confrontation with situations that cause anxiety. Exposure sessions may last anywhere from 30 minutes to two hours. The immediate goal is for the client to remain in the situation long enough to experience some reduction in anxiety and to realize that the feared "disastrous" consequences do not occur. With repeated exposures, the peak of the distress as well as the overall distress decreases over sessions. Thus, the client habituates to upsetting stimuli in two ways, within the session and between sessions.

Typically, exposure is gradual and the client begins by facing objects and situations that result in only moderate levels of anxiety. Constructed in collaboration with the client, the list of distress-evoking stimuli are placed in a hierarchical manner, beginning with the least distressing stimuli and gradually proceeding to more distressing ones. A rating scale of 0-100 (often called a SUDS scale for Subjective Units of Distress/Discomfort Scale) is used to rate the expected amount of distress associated with each item. After an item from the hierarchy is confronted in session with a therapist, the client then practices self-exposure to the same item as daily homework.

Once mastered, the client faces the next progressively more distressing object or situation. The client learns:

1. that the feared consequence will not occur,
2. to better tolerate anxiety, and
3. that anxiety diminishes over time even without performing the rituals.

As the client progresses up the hierarchy, each next items become a bit easier.

Imaginal Exposure in OCD

In some cases it is not possible to construct an in vivo exposure to a client's fear, and in these instances an exposure can be done in the imagination. Situations especially appropriate for an imaginal exposure are those in which the client fears he may change in a fundamental way (e.g., shifting in sexual orientation or becoming a serial killer), cause a distal catastrophe (e.g., starting a chain of events that results in harm coming to unknown people), or that the outcome of failing to do a ritual is far in the future (e.g., going to hell or dying from cancer).

To conduct an imaginal exposure, the therapist and client develop a detailed scene together based on the client's worst fear. The story will describe a catastrophe befalling the client and/or loved ones as a direct result of the client's failure to perform rituals. The therapist might first recount the story aloud and then have the client do the same, ideally in the present tense to make the events seem more real. SUDS levels are taken at various points throughout the narrative (i.e., every 5 minutes) to assure that the story is evoking enough anxiety to be productive. The exposure is typically recorded for repeated listening as homework.

Imaginal exposure is effective when it evokes the same distress in a person as the actual obsession. A person with OCD typically fights the obsession because they believe that if they entertain the ideas, the feared outcome will be more likely to occur. However, fighting the obsession only strengthens it. By repeating the distressing ideas in the form of a narrative, the person with OCD habituates to the fears and also learns that dwelling on the thoughts does not make them happen. The person gains a new perspective on the fear and is able to attend to it more objectively.

Response/Ritual Prevention for OCD

The ritual or response prevention component involves instructions for the client not to engage in compulsions or rituals of any sort. This is important because clients perceive that the rituals prevent the occurrence of a feared outcome. Only by stopping the rituals do clients learn that rituals do not protect them from their obsessional concerns. In the vast majority of cases, rituals have a functional relationship with the obsessional thought (i.e., "washing will prevent me from becoming ill," or "if I don't wash I will be distressed forever and will fall apart" ); many times this functional relationship is logical (e.g., "checking will prevent me from making mistakes"), but sometimes it has a magical flavor (i.e., "If I tie my shoes 4 times the right way, my pet will be hit by a car.") Sometimes clients cannot articulate any negative outcome that is prevented by performing the rituals. Rather, the performance of the ritual "just feels right;" in this case the function of the ritual is to reduce anxiety or discomfort, and the disastrous consequence is psychological, such as falling apart.

The implementation of ritual prevention involves a detailed analysis of all compulsions or rituals performed by the client. Typically, clients are asked to keep daily logs of all rituals performed. The therapist uses these logs initially to identify the rituals that need to be stopped, and, as treatment progresses, it is used to identify areas of difficulty that need more therapeutic attention.

Cognitive Therapy for OCD

OCD clients feel anxious or distress when engaging with their obsessional thoughts or images, because they interpret them as warnings of events that are dangerous and likely to occur. CT is designed to help clients identify these automatic unrealistic thoughts and change the interpretations of the thoughts, resulting in decreased obsessions and distressing compulsions.

In the first stage of CT, clients are taught to identify their worries as obsessions and their rituals as compulsions. The client keeps a daily diary of obsessions, called a thought record. In the thought record, clients write down their obsessions and the interpretations associated with the obsessions. Important details to record may include what the client was doing when the obsession began, the content of the obsession, the meaning attributed to the obsession, and what the client did in response to the obsession (usually a compulsion).

The therapist reviews the thought records with the client with an emphasis on how the obsession was interpreted. Using reasoning and Socratic questioning, the therapist helps the client challenge their unrealistic beliefs. This helps the client to identify the cognitive distortion, typically a faulty assessment of danger, an exaggerated sense of responsibility, or fears that thinking something negative will make it come true (called "thought-action fusion").

Once clients are able to identify their obsessions and compulsions as symptoms of OCD, the therapist initiates a few behavioral experiments to disprove errors in thinking about cause and effect. For example, if a client believes that smoking three cigarettes will prevent her family from being harmed in an auto accident, the therapist may instruct the client to smoke only two cigarettes and then wait to see if family members are actually harmed that day in an auto accident. The therapist may then use the results of this experiment as material for discussion about other types of magical thinking. Over time, clients learn to identify and re-evaluate beliefs about the potential consequences of engaging in or refraining from compulsive behaviors and subsequently begin to eliminate compulsions.

Read more about getting exposure and ritual prevention for OCD in person or online.

Scientific Sources

Co-Authored by Dr. Monnica Williams, Clinical Director

Williams, M., Powers, M., & Foa, E. (2012). Obsessive-Compulsive Disorder, Chapter 13. In P. Sturmey & M. Hersen (Eds.), Handbook of Evidence-Based Practice in Clinical Psychology, Vol. 2 (pp. 313-335). Hoboken, NJ: John Wiley & Sons, Ltd. ISBN-10: 0470335440.

Williams, M. T., Mugno, B., Franklin, M. E., & Faber, S. (2013). Symptom Dimensions in Obsessive-Compulsive Disorder: Phenomenology and Treatment with Exposure and Ritual Prevention. Psychopathology, 46, 365-376. doi: 10.1159/000348582

Williams, M. T., Sawyer, B., Ellsworth, M., Singh, R., & Tellawi, G. (2017). Obsessive-compulsive and related disorders in ethnoracial minorities: Attitudes, stigma, and barriers to treatment. In J. Abramowitz, D. McKay, & E. Storch (Eds.), The Wiley Handbook of Obsessive-Compulsive Disorders (p. 847-872). Wiley. ISBN: 978-1-118-88964-0

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