Obsessive-Compulsive Disorder Treatment
We provide expert Exposure and Response Prevention (ERP) to treat Obsessive-Compulsive Disorder.
What is OCD?
Obsessive-Compulsive Disorder (OCD) is disorder in which distressing and unwanted thoughts, images, or impulses (obsessions) result in strong urges to engage in repetitive thoughts or behaviors (compulsions) to attempt to reduce or alleviate this distress.
Obsessions and compulsions can be distressing and time consuming to the point of interfering with important activities such as work, school, and spending time with family or friends. These symptoms can feel embarrassing because individuals with OCD often realize their fears and compulsions are excessive and that they may not make sense. About 1-2% of the population has OCD (1 to 2 people out of 100).
Understanding OCD
Obsessions
Obsessions are thoughts, images, or impulses that cause extreme anxiety, disgust or doubt and lead to strong urges to reduce the anxiety by doing a compulsion. For example, a person may worry about becoming contaminated or dirty and contracting an illness. However, there are a wide range of fears that people with OCD report.
Compulsions
Compulsions are repetitive thoughts or behaviors that are intended to reduce distress generated by obsessions by neutralizing, counteracting, or undoing them. In some cases, compulsions may take the form of a prolonged mental struggle to make sense of or disprove obsessive fears while for others they may involve repeated behaviors like excessive hand washing or checking.
What causes OCD
The causes of OCD are not fully known, although genes, biology, and the environment all appear to be involved. Research has shown that OCD is a disorder that affects areas of the brain involved in identifying and managing danger. In a person without OCD, these brain areas become highly active when a real threat or danger is present and they help to initiate actions to prevent or avoid harm.
In a person with OCD, these brain areas may become highly active in the absence of a true threat or danger (like a false alarm), which causes distressing thoughts and strong urges to avoid or neutralize these thoughts and emotions. This is why people with OCD can feel like their fears don’t make sense at times while still being highly distressed and feeling strong urges to do compulsions. Fortunately, effective treatments exist.
We Offer In-Person, Online, and In-Home Sessions to Treat OCD
Our clinicians can deliver therapy through multiple contexts, helping people apply the therapy where they live and work
Themes of OCD
OCD can manifest in an unlimited variety of ways. A few common themes of OCD are:
Fear of Dirt and Germs/ Moral Contamination
People with Obsessive-Compulsive Disorder (OCD) with a contamination theme report a wide range of obsessions, including intrusive thoughts about being dirty or poisoned, coming into contact with viruses or other germs, contracting an illness or giving one to another person, or becoming morally contaminated.
People experiencing this type of OCD fear contamination for a variety of reasons. Many dread the negative health or social consequences of viruses such as herpes or AIDS. Others’ obsessions are focused on the feelings of disgust or discomfort that arise from contact with dirt or germs. Those with this type of obsession often report that they do not fear illness but instead how intensely distracting feeling contaminated is. Another common fear can be about becoming contaminated with chemicals such as household cleaners, poison, or other types of toxic materials.
Individuals can also fear emotional or moral contamination. In such cases, the person experiencing OCD may obsess about contamination from any number of sources, such as hearing foul language, seeing disturbing images, or being near a person who has undesirable characteristics. In such cases, a person may need to shower, clean their ears, and even wash their face, eyes and mouth if they hear a triggering word or encounter a person having characteristics they find aversive. Other individuals with this type of OCD may engage in mental rituals to neutralize the threat of contamination.
Example 1
Jason is a 26-year-old businessman who has had OCD since age 15. Jason is afraid of coming into contact with or being in the presence of anything he associates with feces, urine or bodily fluids. These things make him feel “unbearably disgusting and gross” even though he is not afraid that he will become sick or diseased as a result of such contamination. Jason feels disgusted by coming into contact with animal or human feces, urine, or vomit, or anything he imagines might have been touched by these (e.g., a stained sidewalk or public bathroom). Even pictures or videos of feces, urine or vomit or hearing someone mention these or related words (e.g., bathroom, dog walker) will make him feel dirty; he then feels the urge to wash. Jason washes his hands at least 20 times per day, with each episode taking him up to 10 minutes depending on how dirty he feels. He also showers for an hour in the morning and evening, during which time he follows an elaborate ritual of cleaning his mouth, nose, and body of all perceived contamination until he feels clean.
Jason also has a fear of being morally contaminated by gambling. His brother had a gambling problem and lost a significant amount of money. Since that time, Jason has been afraid to be near his brother, anyone who looks like or reminds him of his brother, or places like casinos or even games that might involve gambling for fear of becoming contaminated by gambling. He reports feeling anxious and dirty when he encounters these cues and he must go through his usual washing rituals as well as repeating several prayers at the same time to feel “cleansed of the contamination”. As a result of his compulsions, Jason has been late to work and for meetings on several occasions, which has jeopardized his job. These obsessions have also interfered with his social life, to the extent that he has no romantic relationships. He was also unable to be around his brother or any other family member or close family friend, since he felt they were all contaminated by his brother.
Example 2
Dana is a 34 year-old accountant who is married and has two young children. She is afraid of getting a life threatening disease as the result of touching things that she fears may have become contaminated with a deadly bacteria (especially staphylococcus and tuberculosis) or virus (herpes). As a result, she is no longer able to go into crowded public places and spends a significant portion of her day washing and using hand sanitizer, which is causing her to fall behind in her work.
She is also afraid of becoming poisoned by household cleaners (bleach, ammonia, drain cleaner) or environmental contaminants (asbestos, lead, toxic dust) for fear these will cause her to contract cancer or a neurological disorder such as dementia. She goes out of her way to avoid construction sites, congested streets, gas stations, and supermarket isles with household cleaners. She also avoids places that smell of cleaning products and anything on the street that looks to her like it could be spilled chemicals. An overarching fear is that she will become too sick to care for her family and they will be left alone. She is also afraid that her children may become contaminated or poisoned.
Evidence-Based Treatment
Exposure and Response Prevention (ERP) treatment for contamination-related fears involves creating a hierarchy of situations and activities that will activate fears of contamination while refraining from any compulsions. Treatment begins with the person entering and remaining in somewhat distressing situations. As the person gains confidence and has mastered those challenges, s/he works with the therapist to take on more anxiety-provoking situations. These gradual exposures to threatening situations without ritual or escape serve to extinguish the fears and reduce the estimation of threat, subsequently reducing the anxiety and distress associated with them. Ultimately the fear reaction is reduced to be more commiserate with the actual level of threat.
For example, for Jason exposure begins by saying words like “vomit” and “feces” without washing and then by looking at images of these things. He moved on to more challenging exposure work, knowing that his fear was most intense at first, but always improved over time. By attending treatment twice weekly and practicing exposures daily, Jason’s excessive washing and bathing routines were eliminated over the course of 10 weeks. He was also able to start dating, his work performance improved. He was also able to see his family again and eventually re-established his relationship with his brother.
For Dana, intensive daily treatment over five weeks involved going into increasingly crowded places without washing, eating with her hands in a mall, and going into places associated with disease such as hospitals. She also walked down store cleaning product aisles and she bought drain cleaner and carried it around with her as part of her therapy. By practicing exposure and response prevention in this way, Dana was able to do things she had avoided for years such as going to the movies and into busy stores with her family; she was also able to buy and use household cleaners again. Her productivity at work improved and she was able to enjoy time with her children and husband again without the constant fear of contamination.
Fear of Sexual Orientation
Having repetitive, intrusive fears or doubts about sexual orientation is a common, and often misunderstood, form of Obsessive-Compulsive Disorder (OCD). For someone with this theme, obsessions about sexual orientation and the resulting distress often lead to an ever-increasing panicked effort to prove to themselves and others that they are attracted to a certain gender. Someone who has had primarily heterosexual attraction may experience anxiety when they think about someone of their gender; another individual who has had primarily homosexual relationships may fear having thoughts about people of the opposite gender. In either case, no matter how hard the person tries, doubt and anxiety inevitably creep back in and compel a new effort to to prove the nature of their sexuality, often with a re-doubling of effort and distress.
Often, a person can identify the circumstance that triggered the initial fear, such as a joking comment by a friend or acquaintance (‘Are you sure you’re not gay?’), or an ambiguous encounter with someone (‘Was I attracted to that person?’ ‘Did my eyes linger too long?’ ‘Did that person look at me strangely?’). The person then can become hyper-aware of their own movements and body language, fearing that these things tell the outside world something about their sexuality.
Compulsions in this condition often include frequent reassurance-seeking from others and making mental lists of evidence for/against their own sexuality. Others may scour the internet, reading articles on sexual orientation, looking at photos to confirm that they are not turned on, reading articles describing people who are of the feared sexuality to compare to themself, or trying to act excessively specific to one sexuality.
A person with fears about their sexuality may be dating people of the gender they are attracted to, but this typically does little to assuage their anxiety. Typically during intimacy or sex the person is hyper-vigilant as to whether they are sufficiently turned on, enjoying themself enough, or actually attracted to their partner. These intrusive thoughts inevitably increase anxiety and diminish the excitement and enjoyment of the interaction, thus fueling the fears even more. Intrusive sexual images of others may “pop up” during sex with a partner and lead to even greater anxiety and more intrusive thoughts and doubts: “Why would I think that?” These experiences often lead to significant anticipatory anxiety, so that sex and intimacy may be avoided altogether. Over time, these symptoms can have a detrimental impact on romantic relationships.
Example 1
John had engaged in several intimate relationships with women over the years, but one day at work, a co-worker commented on John’s grooming and jokingly asked: “Are you sure you’re not gay?” At first John laughed the comment off, confident that his co-worker was just poking fun at him. But the comment lingered in the back of his mind. He casually asked his co-worker the next day to reassure him that he’d just been joking, which the co-worker confirmed, but after some time the doubt and associated anxiety crept back in. Over the next day or so John found himself repeating the scene over in his head to reassure himself that the comment was in fact said in jest. He started paying much more attention to how he dressed, and began comparing his choice of clothes to other “straight looking” guys he walked by in the street. But every time he convinced himself that “of course I’m not gay” and the anxiety came down, the doubts would inevitably creep back in and the anxiety would rise, compelling him to go over and over all the evidence for his heterosexuality. He began doing research on the Internet about “signs you might be gay,” and visited gay porn sites to confirm he was not “turned on.” Relief was short-lived and minutes a day of worry and compulsions eventually turned into hours. John found himself in a nightmare of doubt and anxiety that interfered with his work and social life.
Example 2
Sarah, a graduate student, was meeting fellow students at a coffee shop. She mentioned that she had started dating a guy she had met on an online dating site who lived in another town. One of the girls acted surprised and said “Really?” Sarah immediately thought, “She thinks I’m a lesbian.” This scene lingered with Sarah throughout the evening, and when she had time to herself the thought “Could I be a lesbian?” emerged and sent her into a panic. She began thinking about her relationships with past boyfriends and wondering “Was I really turned on by them? Was I really attracted to them?” She mentally reviewed past sexual encounters to confirm she actually enjoyed them. But each time she felt convinced she was heterosexual, the doubt would return and she would feel compelled again to review all of her encounters. Throughout the day she’d constantly “check out” other women she passed on campus to see if she found them attractive. When the anxiety increased she confided in some trusted friends, and asked them if they thought she could be a lesbian. They would either reassure her that she “probably wasn’t a lesbian” or with good intentions declare that they would still love her either way. This only increased her doubt and anxiety. Equally well-intentioned therapists devoted time to examining the evidence for her sexual orientation, concluding and reassuring her that she indeed was straight. Ending a session feeling confident that she was straight, she found with increasing frustration that she returned the following week anxious, distraught, and needing to explore the question once again.
Evidence-Based Treatment
Exposure and Response Prevention (ERP) is the front-line treatment for someone suffering from doubts about their sexuality. The goal of therapy is not to confirm “once and for all” one’s sexual orientation. This is what the person’s been trying to do all along with disastrous results! The goal is rather to train one’s fear system to tolerate the anxiety of being uncertain. When this happens, intrusive thoughts and doubts become less relevant, and subsequently not anxiety provoking.
This works in part because the fear system doesn’t care about reason or rational arguments; the fear system only learns by watching how we react to the environment. In this case, the “environment” consists of intrusive doubts, thoughts, and images about one’s sexual orientation. So by trying to reduce distress through compulsive reassurance seeking, the fear system “learns” that not being absolutely certain is very threatening. Using ERP, one gradually exposes the fear system to distressing thoughts, images, and uncertainties, without trying to escape the perceived threat, thus demonstrating to the fear system that in fact these fears are not threatening. The fear and anxiety associated with these thoughts, images, and uncertainties is weakened, and the fear system no longer responds with anxiety.
Fears of Moral/Religious Transgression
Scrupulosity refers to a form of Obsessive-Compulsive Disorder (OCD) in which questions related to morality or religious / spiritual matters become the focus of obsessive fears and compulsive and ritualistic behaviors. Some individuals with OCD find that the ambiguity of religious laws or secular morality generates overwhelming anxiety. Whereas a person without OCD might feel satisfied with a “good enough” answer from the leader of her religious congregation or from talking over a moral quandary with family and friends, a person with OCD can feel driven to attain certainty in religious adherence or moral standing. In order to allay their anxiety, they may seek constant advice, reassurance and clarification from their loved ones, acquaintances, and religious leaders. They may also evaluate their behavior according to a narrow definition of acceptability, leading to elaborate rituals and profound avoidance of everyday behaviors.
Example 1
Sam grew up in a religious community, but even the most observant of his family members are perplexed by his behavior. Typically, they pray before meals, but Sam insists that prayers be said in a particular way and that each person at the table assumes a position that he has identified to be obedient. If a person at the table makes a sound while the prayer is said, Sam becomes upset and will not eat until the prayer is repeated in exactly the way he specifies. Sam also prays in a ritualized way at many other points in the day, and must hold his body in a certain position while he does so. If anything interferes with his prayer, he feels overwhelmed by anxiety and will get “stuck” trying to do the prayer in exactly the right way or will abandon the activity it relates to altogether. Sam also has a variety of words that he will say to himself while performing daily tasks that he feels imbue those activities with holiness. If he is not able to think these words because of some distraction, Sam will have to repeat the activity. Sometimes the words do not produce the “right” feeling, and he will have to repeat them over and over until it feels right. These tendencies have caused conflicts with loved ones and have delayed his progress in school because he cannot complete most tasks in a reasonable amount of time.
Though Sam is in his early 20s, he has not initiated any kind of romantic relationship because of fears of transgressing religious rules about sexual thoughts and behaviors, even though his religious leader has assured him that what he is concerned about would not constitute sins. He also has limited contact with peers because they do not comply with his rituals and because they might potentially have a conversation about something Sam considers a sin.
Example 2
Dana, on the other hand, grew up in a religious family but no longer adheres to any particular organized religion. Her obsessions mostly focus on secular definitions of morality and “being a good person.” To this end, she spends a great deal of time considering her behavior, both present and past. If Dana notices that she might have done something that could have been rude, she alleviates her anxiety by creating lists – both written and mental – of reasons to justify her behavior. Occasionally, Dana encounters difficulty in finding enough support for her behavior or believes that the consequences of what she did are so severe that her behavior is indefensible. In such situations, Dana feels panicked, and often goes to great lengths to apologize or to correct the perceived slight. Her attempts to apologize are so extreme that, at times, the “victims” of her behavior have asked her to stop calling and have gone out of their way to avoid contact with her. Dana feels that her behavior is embarrassing and wishes that she could stop, but she also feels compelled to pursue the relief that a person’s forgiveness grants her.
For individuals with this particular kind of OCD, life – and particularly the social part of it – presents numerous challenges. Sources of sin and offense are without limit, and the person typically finds that the range of acceptable behavior becomes increasingly narrow over time. For some, like Dana, recovery is easier because they recognize that their behavior is much more extreme than is merited and is onerous for other people. Others, like Sam, have difficulty gaining perspective on their rituals and feel that, if they were to not do them, they would damn themselves or their families for eternity.
Evidence-Based Treatment
Exposure and Ritual Prevention (ERP) for this type of obsession involves setting up a hierarchy of feared and avoided situations and behaviors. The person then works with their therapist in order to confront matters that are morally or spiritually ambiguous, while stopping their compulsions. By doing this over time, they learn to manage scrupulosity and to thus distinguish between obsessive doubts and issues of morality and spiritual welfare.
Fear of Being Ill (Hypochondriasis)
Most people have some fear of illness. Health-related anxiety, in fact, motivates people to engage in behaviors such as exercise, eating lower fat foods, and having regular visits with doctors and dentists. These behaviors prolong and improve people’s lives.
However, when this fear becomes part of an Obsessive-Compulsive Disorder (OCD) obsession, the fevered pursuit of health or fear about having a specific illness can damage the lives of the person and their loved ones.
Each person with OCD fears that are health related will experience this in a slightly different way. A person with OCD may have a fair amount of insight into the irrationality of their fears, and, indeed, have a history of handling serious health problems in an adaptive way. Others may have very little insight about the mismatch between the degree of fear they experience and the probabilities of adverse health outcomes; they may feel, as a result, that their rituals for preserving health are – quite literally – a matter of life and death. People also vary widely in the type of health problems they obsess about and the rituals and avoidance they use to cope with their fears. Some, for example, may overuse the medical system, asking for repeated scans and consult with an excessive number of specialists. Others may avoid medical services for years, unable to face the possibility that an illness will be discovered.
Example 1
Kate checks her body regularly for signs of ill-health. In the shower, she runs over her torso and breasts, especially, to discover any possible new lumps. Afterward, she looks at them in the mirror with her arms raised to ensure they are still perfectly symmetrical. This habit makes it difficult to get to work on time, because inevitably she cannot feel 100% certain that her breasts are the same as they were the day before.
During her waking hours, Kate is repeatedly distracted by physical sensations: she wonders whether a dull ache in her abdominal cavity might be ovarian cancer or a twinge in her chest indicates lung or breast cancer. Sometimes the anxiety about these symptoms can cause her to spend much of her day in a near-panic, and she researches symptoms on the Internet and puts in calls to her gynecologist to seek reassurance when she can no longer tolerate how she’s feeling. When she visits the doctor, Kate writes up a list of questions and things to talk about beforehand, knowing that her anxiety during the appointment usually makes it difficult to remember everything. As the doctor or nurse reviews the matter with her, Kate tries to write down what they say, verbatim, so that later on she can go over what they told her and reassure herself that everything is OK.
Even when her body feels comfortable, Kate feels anxious if she hears songs performed by celebrities who are known to have contracted cancer or if a coworker discusses the illness of a family member or a friend. She feels bad that she can’t be a “good friend,” but she finds that she simply cannot be supportive to people who are going through health problems because of her overwhelming anxiety. Kate withdraws from individuals who are dealing with health issues and has lost friendships and has problems with family members as a result.
Kate’s obsessions about health have spread to people who are closest to her, as well. She sometimes feels an overwhelming need to ask her boyfriend repeatedly about physical discomfort that he might talk about in an off-handed way. When he brushes aside her concerns, Kate feels ignored and worries that he is hiding something from her. As a result, she asks more questions, and this sometimes results in a heated argument.
Kate also reports that her obsession about cancer keeps her from enjoying sex as much as she used to. She notes that she cannot bear to have certain parts of her body touched because then she has an intrusive thought about cancer. She has asked her boyfriend to avoid these parts of her body, and this has caused more tension between them.
Evidence-Based Treatment
Exposure and Response Prevention (ERP) is the type of cognitive-behavioral therapy considered the front-line treatment for OCD, with or without medications. ERP targets the insidious cycle of intrusive obsessive thoughts/fears, associated distress/anxiety, and subsequent threat reducing behaviors (e.g. compulsive checking for signs of illness or disease, repeated trips to doctors and specialists, reassurance seeking from loved ones or friends, hours of research on the Internet, etc.) Through gradual exposure to the feared thoughts, situations, and uncertainties, without engaging in the threat-reducing behavior, the threat-reaction (and associated distress and anxiety) is significantly diminished, allowing the person to emerge from the shackles of his/her OCD and regain and live the life they value.
Fear of Harming Others or One’s Self
Most people have occasional violent or sexual thoughts or images that flash through their minds, but tend to have little trouble dismissing them. For people with Obsessive-Compulsive Disorder (OCD), however, these thoughts or images may trigger panic and great distress.
While changing her son’s diaper, for example, a new mother might suddenly realize that there is nothing to prevent her from molesting him. She might immediately recoil, with panicked fears racing through her brain: “Could I really do that? Why would I think that? Am I a pedophile? Would I harm my child?” Naturally, she would seek to qualm her terror by reassuring herself: “No! I’d never do such a thing! I could never harm my child!” At first, the distress might abate, but kernels of doubt would remain: she could struggle with questions about why she thought about this act in the first place, or she could find herself unable to know for certain that she would be able to resist this kind of impulse.
Such doubts would generate more attempts at reassurance, perhaps including lengthy research into the lives and thoughts of pedophiles. Any relief these efforts might bring would be temporary, however; the mother with this kind of obsession would, over time, experience increasing distress caused by her inability to eliminate all possibility of harm. Terrified, she might start avoiding her child and spend increasing amounts of time on rituals to assure her son’s safety.
Intrusive thoughts, images, or impulses about harming others (loved ones or strangers), either sexually or violently, are common obsessions. To individuals experiencing them, the harmful behavior may seem completely foreign and antithetical to their values. Despite this rational understanding, the person’s feelings about these obsessions make them nearly impossible to ignore. For many with OCD, it is the remote — but ever-present — possibility that they might commit such an act that gives rise to hours spent ruminating and reassurance seeking. People with this type of OCD tend to feel always on the verge of conclusively determining that they could not commit the acts they abhor, but this feeling simply draws them into increasingly frantic compulsions.
These can include seeking reassurance from others, repetitive checking and reviewing of past events, and making extensive lists of their moral and amoral behaviors. The person can also find him/herself avoiding increasing numbers of people, places, and activities to avoid triggering the distressing thoughts or images, or to ensure that s/he will commit no harm. These strategies can provide brief respite, but inevitably the person finds him or herself in an ever expanding, all consuming battle with a beast that grows more fierce with every round of fighting.
Example 1
During an argument with her husband, Meryl had an intrusive image pop into her head of stabbing him with a kitchen knife. She had a momentary spike of anxiety and started thinking: “Why did I have that image? Could I actually do this to him?” “Is this repressed anger, or am I going crazy?” She was able to reassure herself of the absurdity of the fear… after all, she’d never physically harmed anyone or anything her whole life. She reminded herself of how much she loved her husband. But she couldn’t quite shake the memory of the image, and the more she tried to forget about it, or exorcize the obsession from her mind, the more the image came back. She became increasingly panicky and upset that such horrible images were occupying her thoughts, after all, “What kind of person thinks such horrible things!” She began avoiding the kitchen when her husband was near and wouldn’t pick up a knife anywhere near him. She started worrying that she might harm him during the night when she was deep in sleep, so she slept as far away from him as possible. She started avoiding watching movies with violence, and then even news programs (the stories seemed to all be about harm and crime), as they triggered the “bad” thoughts and panic. Meryl found herself spending more and more time on the Internet researching information about “killers” and violent people to reassure herself that she wasn’t like them. More and more of her life was consumed by avoiding situations that might trigger the obsessions or where she might have the possibility of harming someone. She dared not tell her husband about the thoughts when he asked what was wrong; and their relationship started suffering as she was avoiding being alone with him or doing the activities with him that they used to share and enjoy. The fear started to spread, and Meryl starting worrying about harming close friends and co-workers. She feared she was losing her mind or becoming “psychotic.”
Evidence-Based Treatment
As with other forms of OCD, a person’s efforts to eliminate or neutralize harm obsessions ultimately strengthen the brain’s sense that the images are, in fact, dangerous. This process generates stronger impulses for the person to avoid or escape the “danger” that the obsessions present. In an ever worsening and self-perpetuating cycle, the person’s compulsions generate more frequent and stronger obsessions, to the extent that they cause significant distress and impairment.
The goal of Exposure and Response Prevention (ERP) is to gradually and repeatedly show a person’s fear system that the intrusive thoughts and/or images do not need to generate anxiety. When a person deliberately engages with the feared thoughts/images and associated uncertainties without engaging in neutralizing behaviors (i.e., the compulsions or rituals), the brain learns that obsessions are not dangerous. As the person’s fear system becomes used to these kinds of thoughts, the brain spends less energy looking for them. As a result, a person’s anxiety and distress decrease greatly: not only do they feel less fear when they have an obsession, but the frequency of the images and thoughts decreases over time.
Evidence-Based Treatment of OCD
Exposure and Response Prevention (ERP) is a type of Cognitive Behavioral Therapy (CBT) considered most effective for treating OCD (with or without medication) based on extensive clinical research over the past 30 years.
What makes exposure and response prevention so powerful is that it corrects mistaken beliefs about danger and threat at both the rational level and emotional level, allowing people to experience a significant reduction in anxiety in the face of an obsession. Clinicians at The Reeds Center are diligently trained in ERP methodology, supporting clients to learn a set of skills they can apply regularly to live a healthier and fuller life in which intrusive thoughts, avoidance, and compulsions no longer get in the way.
Breaking Down ERP
Exposure
Exposure therapy involves gradually confronting feared situations and thoughts repeatedly in order to get used to them and the anxiety they generate. By getting used to intrusive thoughts and the situations or activities that trigger them, people with OCD are much less bothered (or not at all bothered) when their obsessions arise, experience fewer urges to do compulsions, and over time experience significantly fewer intrusive thoughts.
Response Prevention
Response prevention involves learning to stop engaging in compulsions both during exposure and in daily life. When compulsions are done, they reinforce the belief and feeling that intrusive fears are dangerous and likely to occur, thus strengthening the OCD fear. Therefore, response prevention is an essential part of treatment since it teaches that feared outcomes are unlikely to occur and that anxiety will go down on its own without having to do compulsions.
FAQs
Medication can be a helpful component in the treatment of OCD. While ERP is the gold standard psychological treatment for OCD, medication can be prescribed alongside therapy to enhance symptom management and overall well-being. Research suggests that the combination of medication and CBT can produce the most favorable outcomes for individuals with OCD. The decision to include medication as part of your treatment plan is a collaborative one, made between you, your therapist, and your prescribing healthcare provider.
Selective Serotonin Reuptake Inhibitors (SSRIs) are the most commonly prescribed medications for OCD. These medications work by increasing the levels of serotonin, a neurotransmitter that plays a role in mood regulation, in the brain. SSRIs have been found to be effective in reducing the frequency and intensity of obsessive thoughts and compulsive behaviors in many individuals with OCD.
Some sufferers of OCD have read or been told that ERP isn’t effective if you don’t have any (or very few) behavioral rituals (such as excessive hand washing, checking locks or stoves, touching/tapping/rubbing, etc.). Some clients report having no compulsions, defining themselves as “Pure Obsessional” or “Pure O.” Others report only mental compulsions, such as mentally reassuring oneself, rationalizing, mental counting, mentally repeating calming words, or mentally reviewing conversations or things to do, etc.
The evidence from research as well as our own extensive experience treating OCD is that ERP is just as effective for those with primarily mental compulsions as it is for those with behavioral rituals. The same treatment model, rationale, and principles apply. At The Reeds Center we help clients identify their mental compulsions and teach them effective and proven strategies to stop them while designing exposures to help clients get used to their fears.
ERP, like most Cognitive-behavioral treatments, is a time-limited therapy. The objectives of the treatment are to reduce people’s OCD symptoms and get their lives back on track, and also for them to gain the knowledge and learn the skills needed to maintain gains without a therapist.
In treatment sessions, clients learn and practice new techniques and skills with the therapist, and then between sessions continue to practice what they have learned on their own. How quickly people feel better often depends a lot on how much time they are able to devote to this practice between sessions.
Another factor is how intensively people are getting the therapy. Research has shown that symptom reduction is most rapid when sessions occur from two to five times per week for up to two hours per session. But again, the more a person is invested in practicing between sessions, the better and quicker their results.
Evidence has shown that when exposure and response prevention is done correctly, it has a very high success rate in treating OCD. Unfortunately, there are several common reasons why exposure may have suboptimal effects. These include:
Response prevention strategies are not being emphasized. This occurs in cases where mental compulsions have not been clearly identified or targeted or when treatment just focuses on exposure without emphasizing response prevention. At The Reeds Center, we take great care to ensure that response prevention strategies are well explained and practiced.
Exposure is not being practiced in-session with the therapist. This is why early and difficult exposures are first practiced with one of our experienced therapists at The Reeds Center, who can guide the client and ensure they are not engaging in any compulsions or safety behaviors that can interfere with getting used to obsessions and the situations that trigger them.
Exposures are not being practiced in the environment where obsessions or compulsions usually occur. It is important that exposures are practiced in situations in which obsessions or compulsions are triggered. If therapy is limited to the therapist’s office, some clients will be unable to confront the situations and activities that trigger their fears and they will be unable to get used to these fears in their daily life. This is why we make every effort to practice exposures with our clients in the places and situations where they are triggered.
Practice of exposures between-sessions is not being emphasized or practiced. Evidence demonstrates that practicing exposure regularly between sessions is critical for therapy to be effective. This is why our therapists at The Reeds Center emphasize homework practice and follow guidelines to ensure that homework is clear and that it is reviewed at the beginning and end of each session. Moreover, clients need to adhere to homework instructions to be able to effectively manage their OCD, which is why we work with clients to help them effectively practice between-session assignments when they are having trouble.
Medication can be a helpful component in the treatment of OCD. While ERP is the gold standard psychological treatment for OCD, medication can be prescribed alongside therapy to enhance symptom management and overall well-being. Research suggests that the combination of medication and CBT can produce the most favorable outcomes for individuals with OCD. The decision to include medication as part of your treatment plan is a collaborative one, made between you, your therapist, and your prescribing healthcare provider.
Selective Serotonin Reuptake Inhibitors (SSRIs) are the most commonly prescribed medications for OCD. These medications work by increasing the levels of serotonin, a neurotransmitter that plays a role in mood regulation, in the brain. SSRIs have been found to be effective in reducing the frequency and intensity of obsessive thoughts and compulsive behaviors in many individuals with OCD.
Some sufferers of OCD have read or been told that ERP isn’t effective if you don’t have any (or very few) behavioral rituals (such as excessive hand washing, checking locks or stoves, touching/tapping/rubbing, etc.). Some clients report having no compulsions, defining themselves as “Pure Obsessional” or “Pure O.” Others report only mental compulsions, such as mentally reassuring oneself, rationalizing, mental counting, mentally repeating calming words, or mentally reviewing conversations or things to do, etc.
The evidence from research as well as our own extensive experience treating OCD is that ERP is just as effective for those with primarily mental compulsions as it is for those with behavioral rituals. The same treatment model, rationale, and principles apply. At The Reeds Center we help clients identify their mental compulsions and teach them effective and proven strategies to stop them while designing exposures to help clients get used to their fears.
ERP, like most Cognitive-behavioral treatments, is a time-limited therapy. The objectives of the treatment are to reduce people’s OCD symptoms and get their lives back on track, and also for them to gain the knowledge and learn the skills needed to maintain gains without a therapist.
In treatment sessions, clients learn and practice new techniques and skills with the therapist, and then between sessions continue to practice what they have learned on their own. How quickly people feel better often depends a lot on how much time they are able to devote to this practice between sessions.
Another factor is how intensively people are getting the therapy. Research has shown that symptom reduction is most rapid when sessions occur from two to five times per week for up to two hours per session. But again, the more a person is invested in practicing between sessions, the better and quicker their results.
Evidence has shown that when exposure and response prevention is done correctly, it has a very high success rate in treating OCD. Unfortunately, there are several common reasons why exposure may have suboptimal effects. These include:
Response prevention strategies are not being emphasized. This occurs in cases where mental compulsions have not been clearly identified or targeted or when treatment just focuses on exposure without emphasizing response prevention. At The Reeds Center, we take great care to ensure that response prevention strategies are well explained and practiced.
Exposure is not being practiced in-session with the therapist. This is why early and difficult exposures are first practiced with one of our experienced therapists at The Reeds Center, who can guide the client and ensure they are not engaging in any compulsions or safety behaviors that can interfere with getting used to obsessions and the situations that trigger them.
Exposures are not being practiced in the environment where obsessions or compulsions usually occur. It is important that exposures are practiced in situations in which obsessions or compulsions are triggered. If therapy is limited to the therapist’s office, some clients will be unable to confront the situations and activities that trigger their fears and they will be unable to get used to these fears in their daily life. This is why we make every effort to practice exposures with our clients in the places and situations where they are triggered.
Practice of exposures between-sessions is not being emphasized or practiced. Evidence demonstrates that practicing exposure regularly between sessions is critical for therapy to be effective. This is why our therapists at The Reeds Center emphasize homework practice and follow guidelines to ensure that homework is clear and that it is reviewed at the beginning and end of each session. Moreover, clients need to adhere to homework instructions to be able to effectively manage their OCD, which is why we work with clients to help them effectively practice between-session assignments when they are having trouble.
ERP is considered the most effective treatment for OCD and is a specific type of Cognitive Behavioral Therapy (CBT). Standard CBT consists of a number of evidence-based strategies designed to help specific types of symptoms. However, some of these strategies (e.g., relaxation or trying to rationalize/challenge intrusive fears) are not effective for OCD, even though they may help with other problems. When seeking treatment, it is important for people to ensure their therapist has experience treating OCD with ERP, not just CBT.
It is essential that treatment for OCD follows the evidence-based principles practiced at The Reeds Center. When psychotherapy focuses on understanding the past to explain OCD, it is unlikely that it will help reduce or manage the symptoms effectively. Additionally, when therapy becomes about reassuring and reasoning away intrusive fears and compulsions, it is also unlikely to help.
This is because intrusive fears are not just based on a misunderstanding about what is dangerous (many sufferers of OCD know rationally that their fears are unlikely but they still have them). Rather, OCD affects parts of the emotional system involved in managing danger so that when a person’s fears are triggered their emotional system experiences distress to the point that a rational understanding is not sufficient. That’s why ERP is needed– it helps to activate and desensitize intrusive thoughts at the emotional level so these thoughts and their triggers are no longer experienced as highly distressing.
“Pure-O” or “Pure Obsessional” is a term often found on the web and in parlance with some health care professionals. Historically it was a term that emerged to describe a subset of OCD sufferers who seemed on evaluation to have obsessions (intrusive thoughts, images, and impulses causing distress) but no compulsions/rituals (mental or behavioral actions performed to reduce the distress caused by obsessions). We often get calls from people with OCD self-designating themselves as suffering from “Pure-O.”
More recently, the term has evolved to describe those who do not seem to have overt behavioral compulsions (like hand-washing, checking, etc.), but primarily engage in mental rituals. In fact, the most recent research tends to suggest that having only obsessions with no rituals is quite rare. Inevitably we find that somehow, a person having obsessions and associated distress is doing something to get rid of it (or at least to lower the distress to “manageable” levels). Mental compulsions can include rationalizing self-talk, reassuring oneself, special words or phrases repeated mentally (e.g. “I’m okay, I’m okay”), mental reviewing (of conversations, events, etc. to ensure nothing “bad” happened), and mental counting (counting to prevent something bad from happening).
Exposure and Response Prevention (ERP) has been shown to be just as successful treating “Pure-O” as other manifestations of OCD. A critical component of successful treatment is for a client and their therapist to identify anything they might be doing (or not doing) either in behaviors or in their head to try and respond to the intrusive obsessional fears and reduce the associated distress/anxiety. These rituals, along with obsessions, will be specific targets of treatment.
ERP is considered the most effective treatment for OCD and is a specific type of Cognitive Behavioral Therapy (CBT). Standard CBT consists of a number of evidence-based strategies designed to help specific types of symptoms. However, some of these strategies (e.g., relaxation or trying to rationalize/challenge intrusive fears) are not effective for OCD, even though they may help with other problems. When seeking treatment, it is important for people to ensure their therapist has experience treating OCD with ERP, not just CBT.
It is essential that treatment for OCD follows the evidence-based principles practiced at The Reeds Center. When psychotherapy focuses on understanding the past to explain OCD, it is unlikely that it will help reduce or manage the symptoms effectively. Additionally, when therapy becomes about reassuring and reasoning away intrusive fears and compulsions, it is also unlikely to help.
This is because intrusive fears are not just based on a misunderstanding about what is dangerous (many sufferers of OCD know rationally that their fears are unlikely but they still have them). Rather, OCD affects parts of the emotional system involved in managing danger so that when a person’s fears are triggered their emotional system experiences distress to the point that a rational understanding is not sufficient. That’s why ERP is needed– it helps to activate and desensitize intrusive thoughts at the emotional level so these thoughts and their triggers are no longer experienced as highly distressing.
“Pure-O” or “Pure Obsessional” is a term often found on the web and in parlance with some health care professionals. Historically it was a term that emerged to describe a subset of OCD sufferers who seemed on evaluation to have obsessions (intrusive thoughts, images, and impulses causing distress) but no compulsions/rituals (mental or behavioral actions performed to reduce the distress caused by obsessions). We often get calls from people with OCD self-designating themselves as suffering from “Pure-O.”
More recently, the term has evolved to describe those who do not seem to have overt behavioral compulsions (like hand-washing, checking, etc.), but primarily engage in mental rituals. In fact, the most recent research tends to suggest that having only obsessions with no rituals is quite rare. Inevitably we find that somehow, a person having obsessions and associated distress is doing something to get rid of it (or at least to lower the distress to “manageable” levels). Mental compulsions can include rationalizing self-talk, reassuring oneself, special words or phrases repeated mentally (e.g. “I’m okay, I’m okay”), mental reviewing (of conversations, events, etc. to ensure nothing “bad” happened), and mental counting (counting to prevent something bad from happening).
Exposure and Response Prevention (ERP) has been shown to be just as successful treating “Pure-O” as other manifestations of OCD. A critical component of successful treatment is for a client and their therapist to identify anything they might be doing (or not doing) either in behaviors or in their head to try and respond to the intrusive obsessional fears and reduce the associated distress/anxiety. These rituals, along with obsessions, will be specific targets of treatment.
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