What Is OCD?
Obsessive-compulsive disorder or OCD is a psychological condition involving—no surprise—obsessions and compulsions. We use these words in a lot of different contexts, so it’s important to understand their meaning in OCD.
An obsession is a repetitive fear about something bad that might happen. Ones you may be the most familiar with include starting a fire by leaving the stove on and getting sick from not washing one’s hands well enough. However, an obsession can be about pretty much anything. For example, OCD might lead to fear of:
- becoming like someone else.
- losing one’s mind.
- causing a car accident.
- making a plane crash.
- marrying the wrong person.
- doing forbidden sexual acts.
- impulsively harming another person.
- always being aware of one’s bodily sensations.
- causing harm with one’s thoughts.
… and countless other possibilities. These fears come back over and over, and aren’t eliminated by being told how unlikely they are. Uncertainty is unavoidable, and OCD wants absolute certainty.
Given the tremendous—even paralyzing—anxiety that comes with these preoccupying concerns, a person with OCD will do things to try to prevent the scary outcome from happening. A compulsion (also called a “ritual”) is an action or a thought that is meant to prevent the feared outcome.
[Mental Rituals in OCD on Psychology Today blog]
For example, if I’m afraid I might have left the stove on, I’ll check it to make sure it’s off. If I’m afraid of being in a romantic relationship with the wrong person, I might do research into how one knows if this person is “the one.” None of these behaviors by itself would be a compulsion, which must be repetitive and either excessive or not connected in a realistic way to the obsession.
With the example of the stove, I might check the stove, and then check it a second time, and then continue to check it for an hour, all the time feeling less and less confident and more and more frustrated. If I’m afraid I might bring down a plane by wishing it to crash, I might tap my fingers together twice to signify “No, no,” meaning I do not wish the plane to crash.
[The More I Check, the Less Confident I Feel on Psychology Today blog]
OCD can cause us to doubt even what is patently obvious. I might doubt that what just came out of the tap is actually water, or think I stepped on something that looks contaminated even though I avoided it by 6 feet, or question whether the person I’m talking to is actually the person I think she is.
The trick of OCD is that the compulsions often provide at least some measure of relief, a sense of “whew.” Unfortunately that feeling doesn’t last for long, and before you know it you’re repeating the ritual “just to be sure.” The only way to defeat OCD is to break out of this cycle of obsession-compulsion-obsession etc. That’s where exposure and response prevention comes in.
Exposure and Response Prevention (ERP or EX/RP)
ERP is the psychotherapy treatment of choice for OCD. It can be helpful for individuals who are thinking about starting ERP, or who have planned to begin the treatment, to get a sense of what it will actually be like. Knowing what ERP involves can help with the understandable anxiety that a lot of people feel as they prepare for the treatment. What I’ll describe are pretty standard ERP practices; please note that they may vary to some extent depending on the clinic and the therapist.
First, the nuts and bolts: ERP generally involves about 15 to 20 sessions that are 60 to 90 minutes long—you and your therapist will decide how long your sessions will be. In terms of how often you meet with your therapist, you could have sessions as often as 5 times per week—what’s known as “intensive ERP”—or you might meet less frequently, like once or twice a week. Again, your therapist will work with you to make a treatment plan that’s best for you.
In the first visit to an ERP therapist you’ll talk about what your OCD is like and how it’s getting in the way of things you care about in life. This initial evaluation or assessment may be done by the person who will provide the treatment—which is how it’s done in my practice—or it may be done by a different clinician who will pass along the information to the person who will be your therapist.
The assessment usually includes general questions about your background (education, family, relationships, etc.) as well as more specific questions about psychological symptoms (besides OCD) that you’re dealing with. During this visit you’ll answer questions about your specific type of OCD—for example, are you worried about germs? About accidentally hurting someone? About committing blasphemy? About your sexual orientation?—and about how severe your OCD symptoms are. Most likely the evaluator will use a scale called the Yale-Brown Obsessive-Compulsive Scale, or the “Y-BOCS.” Your score will provide an idea of how intense your OCD is. Scores on the scale range from 0 to 40, with higher scores meaning more severe OCD.
Your therapist will use the information from the Y-BOCS and the rest of your evaluation to figure out how best to address your OCD and help you get your life back. The following session outline gives a general idea of the kinds of things that will happen in each treatment session.
Session 1. The purpose of the first two visits is to develop a specific treatment plan that will guide the rest of your work with your therapist. (“Work” is the right word because the sessions definitely are work. Just remember that you won’t be doing it alone—your therapist will work closely with you, may be available between sessions to answer questions that come up, and has worked with many people dealing with very similar issues.) During the first treatment visit you’ll talk with your therapist more about the specifics of your OCD, and in particular the kinds of things that trigger your obsessions. What thoughts, situations, images, and so forth activate obsessive thoughts? For example, touching a doorknob might be a trigger for someone with obsessions about germs. You’ll also talk about what you’re worried will happen—what are the feared outcomes that upset you? For the doorknob example it might be the fear of getting some horrible disease. (Don’t worry if these examples don’t seem to fit for your own kind of OCD—your therapist will help you to tailor the treatment to exactly what you’re dealing with.)
Additionally, you’ll describe the kinds of compulsions or “rituals” you do—like washing one’s hands repeatedly—to prevent the feared outcome, as well as things you avoid in order to prevent bad things from happening. At the end of the first session you’ll be asked to keep track of your rituals between sessions and to read a handout about OCD that will give you some information about the condition.
Session 2. The second session builds on the first one by using the information that was collected to develop a treatment plan. As the name of the treatment suggests, there are two main parts of the treatment. The first is called “exposure.” It simply means approaching the things you’ve been avoiding because of your OCD. The second is “response prevention” (or “ritual prevention”), which means stopping the compulsions. Both of these elements of the treatment are essential for getting a good outcome. You’ll let your therapist know how hard you think it would be to do each exposure that you come up with—for example, touching a doorknob at work might be easier than touching the doorknob of a bathroom. Then the exposure exercises you’ll do are simply placed in order, from easiest to hardest. You’ll work with your therapist on a plan for when to complete each exposure exercise.
Exposure is done gradually, starting with things that are not too hard to imagine doing right now, and working up to things that are more difficult. It’s just like climbing a ladder: You don’t start climbing in the middle or at the top! You start at the bottom, right where you are. After this session you may be given a handout to read about how the treatment works and you’ll be asked to continue to keep track of what rituals you’re doing. At this point you won’t be asked to start the exposures and ritual prevention.
[Doing Less to Conquer Your Fear on Psychology Today blog]
Session 3. The third session will be the first time that you and your therapist work together on doing your exposures, without compulsions. You will be in charge of what you do in the session. While your therapist will encourage you to do what you’ve planned, you will not be forced to do anything you’re not willing to do. You can think of your therapist’s role as being like that of a coach—to help you get the most out of your treatment and to reach the goals you’ve set. A coach can encourage an athlete to do one more repetition while lifting weights, but obviously it won’t be helpful if the coach lifts the weight for the athlete! In the same way, ERP therapy is something that you do—it’s not done “to you.”
During the in-session exposures your therapist will ask you from time to time how distressed you’re feeling. Exposures get easier over time, so that what was hard at first becomes more and more manageable. At the end of the session you and your therapist will make a plan together for things that you’ll work on between sessions. Repeating the exposures on your own is an essential part of the treatment. You’ll be instructed not to do rituals between sessions, and will continue to keep track of times that you do give in to urges to do compulsions.
[“Extreme” Exposures in ERP for OCD on Psychology Today blog]
Session 4-15. The rest of the sessions will follow a pretty predictable outline. At the beginning of the session you’ll talk with your therapist briefly about how things went since your last session, and you’ll troubleshoot together any problems that might have come up. You’ll also talk about the things that are going well and the progress you’re making. Once you’ve gotten used to the less difficult items on your exposure hierarchy, you’ll move up to the next “rung”—the things that are a little more challenging. Gradually over the course of several sessions you’ll work up your hierarchy. You’ll keep working on exposures between sessions, tracking any rituals (which tend to become less and less frequent), and talking about your progress with your therapist.
So far what I’ve described are called “in vivo” exposures—that is, exposures in real life. You might also need to do what is called “imaginal exposure,” another technique that’s been shown to be really effective in treating OCD. During imaginal exposure you simply listen to a script that you develop with your therapist that talks in detail about your feared outcome. After listening to this script several times it tends to stop sounding so scary, which further helps to conquer your OCD fears.
[Thinking and Doing in ERP Therapy on Psychology Today blog]
Sessions 16-17. In the final sessions you and your therapist will take stock of how far you’ve come since the beginning of treatment and will discuss relapse prevention—in other words, how to hold on to the gains you’ve worked hard to achieve. You’ll talk about the strategies that you’ve found work for you, and how to continue to use these strategies. Your “homework” from this point on is to keep using your new skills to stay well and be able to enjoy life.
Does ERP Work? Many studies have shown that ERP is the most effective form of psychotherapy for OCD. For example, a large study by Dr. Edna Foa and colleagues found that 86% of people who completed ERP were rated as “much improved” (29%) to “very much improved” (57%). The average Y-BOCS score at the end of treatment for people who got ERP fell in the “mild” range. So while there are no guarantees in life, chances are that a person who commits to the treatment and does the work will be a lot better at the end of the treatment than before.
Download a pdf version: Exposure and Response Prevention for OCD: What to Expect
The IOCDF provides information about OCD and the best way to treat it; resources for the public and professionals; links to support groups; how to find an effective OCD therapist; and a searchable database of therapists who use exposure and response prevention (ERP) for OCD.
My co-author and OCD advocate Janet Singer blogs about all topics related to OCD and its treatment. The website also hosts OCD Network to Recovery, which “connects those who have suffered severely from OCD and have found their way back to good health with those who have yet to find the strength necessary to fight their disorder.”
Dr. Weg is an OCD expert in New Jersey and has made a series of free short videos (available on youtube.com) that provide tips for OCD treatment. Each video is about 2 minutes long and focuses on a single topic, such as exposure intensity or exposure duration in OCD treatment.
When I was on the faculty at Penn I was struck by how often therapists made certain mistakes when starting to learn ERP for OCD. I decided to summarize these mistakes in this article I wrote with some of my colleagues. We discuss how ERP works, common therapist mistakes that can weaken the treatment, and how therapists can avoid these pitfalls. For example, when is it harmful to use distraction during exposures? When is the right time to use imaginal exposure versus in vivo exposure? What if a person has mostly mental compulsions? How can family members help a person with OCD to get the most out of ERP treatment? The article may be of interest both to therapists and to individuals with OCD who are considering their treatment options.