CBT for OCD

Obsessive-compulsive disorder (OCD) is essentially a condition manifesting as excessive carefulness accompanied by an exaggeration of possible danger. Having treated it for years, what never ceases to amaze me is how many diverse manifestations present to my office. However, if you’re not that familiar with this disorder or tend not to treat it, it centers on obsessive and compulsive clusters. Common things that affected people obsess about are safety, contamination and orderliness. These obsessions are then typically joined at the hip with corresponding compulsions such as checking, handwashing and arranging – all of which become very ritualistic.

Expert consensus, with which I agree, continues to confirm that the most effective method for treating OCD is a modification of CBT (cognitive-behavioral therapy) that incorporates exposure to the issue(s) at hand, accompanied by ritual prevention. This is commonly referred to as ERP.

The central theme of utilizing ERP as a treatment method is that OCD behaviors are counterproductive, time consuming efforts to allay anxiety and accompanying fears about something the individual finds threatening – possibly leading to calamity of some sort. I consistently find that three themes emerge to fend off thoughts and feelings of overwhelm, depending on the circumstances:

  1. Avoid, if at all possible. This is simple; it means not exposing oneself to the troublesome situation. For example, not touching objects where contamination is possible- such as doorknobs, toilet bowls or the rims of trash cans.
  2. Using the example above, if the person exposed himself to the toilet bowl he would attempt to neutralize the anxiety by immediately washing his hands.
  3. A need for reassurance. In this instance, an individual with a safety issue would drive home from work to check on whether doors and windows are locked and the stove is off. Or they might call a neighbor or friend to do so.

ERP then, encourages and directs OCD sufferers to expose themselves to the triggers plaguing them, and then confront them, and in doing so, learn how to curb the threat potential without resorting to rituals. Here’s an example:

Say an individual is coming to you for contamination fears. A key step that I strongly support and would use myself would be to model desirable responses for the patient by touching something the person would ordinarily avoid (doorknobs, toilet handle), and then not washing or using disinfectant wipes. Some patients will ask me why I’m not washing up immediately, to which I respond, “I’ve touched these objects repeatedly without consequences.”

After this exercise, the patient would be encouraged to perform it. When the patient reports feeling “unclean” (which will more than likely happen at first), their “distress temperature” should be assessed via a 10-point SUDS (subjective units of distress scale). Then, strongly encourage reassessment of the SUDS score as the patient continues to expose himself to ostensibly contaminated objects. Continued exposure will eventually result in anxiety and threat reduction.

As effective as ERP can be as a desensitizing strategy for diminishing OCD’s power over affected people, I find that in most instances, it’s not enough from a long-term symptom maintenance perspective. This is because OCD is truly a con artist, in that the disorder talks back to people, attempting to trick them into believing that their fears of contamination and safety for example, are real. Telling oneself to just ignore these false messages requires strong resolve, which many OCD-affected folks just don’t have.

To complement ERP, I use a strategy I refer to as: audio and visual confirmation. Here’s how it works:

In the example above, I would ask the individual with contamination fears to use a smartphone to take a photo of his hands and upper arms if necessary, after exposing himself to a feared object. He would then save these photos to the phone and view them several times per day as necessary to serve as back up confirmation to practicing ERP. He would be instructed to take as many photos as he chooses day-by-day to actually see that not washing after contact isn’t leading to undesirable, possibly dangerous consequences. I’d also ask him to record on his phone exactly what he sees: “There are no signs of infection or rash on my hands and arms in spite of not washing.” “This has me feeling very confident.” Auditory and visual reinforcements are critical to success with OCD.

Seeing and hearing informs rational beliefs.


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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.