OCD CBT Treatment

Psychoeducation is the first step.  It is necessary to understand what OCD is and how it works before one can do behavioral experiments, let alone Exposure and Response Prevention (ERP).  Please read "Understanding OCD and Obsessive Worry" on the OCD Information page, as a start.

I have coined a term "Doing OCD Wrong" as a frequent starting point.  These ideas are borrowed from Reid Wilson, PhD and others.  What this means is doing a compulsion, but somewhat differently than what the OCD demands.  For example, if someone thinks even numbers are "good" and odd numbers are "bad," to do the compulsion an odd number of times.  Behavioral experiments are also a way of doing OCD wrong.  For example, if someone washes their hands for 3 minutes, the experiment might be to try to stop after 2 minutes.  I see this as generally a prelude to helping people before they are ready/willing to do ERP.

ERP is considered the "gold Standard" of OCD treatment.  This means exposing the individual to the feared situation, thought, image, and/or object and then preventing them from engaging in the compulsion.  For example, someone afraid of germs might take something out of the trash and then NOT wash their hands, as the OCD directs them to do.  This is admittedly difficult.  A hierarchy Is constructed from the least distressing obsessions to the most distressing obsessions.  The trick is starting at a point where the person can be successful, even though they initially feel that they cannot.  The presence of a therapist often is needed to begin the task.  Sometimes medications are needed in order to help a person begin ERP.

Many receive medications (primarily SSRI antidepressants) before seeking CBT.  Some may be surprised to learn that research shows CBT Treatment to be more powerful than medications.  There are not conclusive findings if a combination of these treatments is superior to either alone.  Clinically, they are often used together.  If you are currently taking medications and they are working - GREAT!  If you are taking them and they don't seem to be helpful, then speak with your psychiatrist.  DO NOT read this and decide on your own to stop your medications.  This would be a Very bad idea and can be dangerous.

To watch examples of ERP, check out the OCD Project that was broadcast on VH1 in 2010.  Noted psychologist David Tolin, PhD and colleagues treat six people with very severe OCD.  While there definitely is a lot of drama, there also is solid, effective treatment, as well as explaining how treatment works.

The Paradox of Exposure and Acceptance

Psychologist Reid Wilson, PhD also has two-day intensive programs (www.anxieties.com) which might be a more affordable and doable program for many.

In order to stop the anxiety from continuing to win, he suggests the following NEW RULES:

     1.  Don't pay attention to the "Content," i.e., the specific obsessions and fears.
     2.  Accept the obsession when it pops up - "It's fine that I just had that thought."
     3.  Tell yourself "I WANT to be anxious and STAY anxious. It's NOT about the content." It's
          purposefully choosing to feel the generic sense of uncertainty and anxiety.
     4.  If necessary, make rules and follow them, i.e., "Here is how I am going to wash my hands,
          check doors, etc."  This means what procedures and limits will be used, as opposed to doing 
          those things until they "feel right."

On first take, this is counter-intuitive - and sounds impossible to anyone struggling with significant anxiety. The natural response to this type of anxiety is to avoid and try to escape. Avoidance and escape is how anxiety maintains itself and gets stronger.

By this logic, if you have your fingers in a Chinese finger trap, you pull your fingers apart. The result is the finger trap becoming tighter on your fingers, making escape impossible. The only escape is pushing your fingers together, just as Dr. Wilson suggests accepting and inviting the anxiety.

What happens when you accept and stay with the anxiety is that over time, it diminishes. This is called habituation. I have often seen anxiety decrease (not totally go away) in a matter of minutes. It is important to note that this may take longer. It is routinely suggested to spend an hour for exposure practice. Habituation generally occurs most quickly when you perform exposure frequently, you accept a higher level of anxiety, and you stay with it for longer periods of time.

Here are some ways he suggests responding to various "content:"

     1.  When obsessive doubts occur, responding to them with statements like "I'm glad that I'm
          having these doubts."  "I'm not answering that question."   
     2.  "If I imagine something inappropriate, then it means I'm a bad person - AND I CAN handle
     3.  "If I imagine something inappropriate, then it means Ill feel uncertain and anxious - AND I CAN
          handle that."
     4.  "If I don't check the stove, it will be my fault that the house will burn down - AND I CAN handle
     5.  "If I have a "bad thought," it means that I really feel that way - AND I CAN handle that."
     6.  "If X does/not happen, something bad will happen and it will be my fault - AND I CAN handle

The more you "play" by the new rules, the weaker the anxiety will become. Maintaining the anxiety rules, maintains the anxiety and makes it stronger.  Several videos are available for viewing on Dr. Wilson's website (
www.anxieties.com) or Youtube.
Copyright 2011 - 2017.   Michael Miller.   All rights reserved.

Mike Miller, PhD, LICDC
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Cleveland OCD Treatment