Therapy for Obsessive-Compulsive Disorders (OCD)

Dr. Melissa Shepard Smiling in white lab coat

By Dr. Melissa Shepard

Obsessive-compulsive disorder (OCD) can be a challenging illness to live with and manage. If you haven’t already, click to read my previous blog post discussing the symptoms and different subtypes of OCD. Thankfully, many treatment options work well for most patients with OCD, including the therapeutic approaches we will talk about in this post.


When I work with someone with OCD, I typically take a three-pronged approach, with the exact structure of therapy dependant upon the patient’s level of anxiety, type of obsessions and compulsions, level of insight, and overall treatment preferences. The three parts of OCD treatment typically include exposure and response prevention (ERP), cognitive restructuring, and mindfulness with acceptance and commitment therapy (ACT).


While these interventions are typically most successful when done with a therapist who is an expert in OCD, unfortunately, many people do not have access to this kind of help. In this post, I’ll describe what the treatment process looks like and provide links to workbooks that can help guide you through these strategies if you have to go the self-help route.



Exposure and Response Prevention


The natural response to obsessions and intrusive thoughts is to try and get rid of them. After all, they are upsetting, and the natural reaction to anything unpleasant, painful, or anxiety-provoking is to try and get as far away as possible.


But this is precisely the fan that keeps the OCD flames burning. Why? Well, try and think of a purple giraffe for a moment.


After you’ve brought that to mind and tried to focus on it for a bit, I want you to stop. Yes, that’s right. Stop thinking about the purple giraffe. Set a timer for a few minutes and during that time, try your best not to allow a purple giraffe to enter your mind.


It should be simple, right? Purple giraffes don’t even exist! But if you are like most people, when you try to stop thinking of the purple giraffe, it just keeps popping up. This is because in attempting to STOP focusing on something, we are, by definition, focusing on that thing! We have a saying for this in therapy: “What you resist persists.” and this is undoubtedly true for OCD. ERP treats OCD by essentially doing the opposite.


The first goal of ERP is to help you “habituate” or get used to your obsessive thoughts. So instead of trying to push the thoughts away or engaging in compulsions (like checking, counting, etc.) to try and get rid of the thoughts, we have you sit with your obsessions until their mind gets bored and starts to tune them out naturally. It’s kind of like watching the same scary movie over and over again: you start to learn where the jump scares are and how they look, and you no longer have the same intense reaction as the first time you watched the movie.


The second goal of ERP is to eliminate the reinforcement we get by engaging in compulsions. Compulsions (whether mental, like counting or reassuring oneself or physical, like checking or washing) provide temporary relief from the obsessions. Unfortunately, this temporary relief prevents habituation, and, as anyone with OCD will tell you, the obsessions inevitably come back with more intensity. The “response prevention” piece of ERP refers to the process of “extinction,” where we prevent you from engaging in compulsions as we expose you to obsessive thoughts. Extinction allows you to learn that you don’t need to perform compulsions to be safe from your fears.


Of course, this type of therapy could quickly become overwhelming, so ERP is done by taking baby steps and very gradually exposing you to what you fear. We typically have you come up with an “exposure hierarchy,” where you rank different objects or situations from least to most anxiety-provoking. We rate these on a 100-point scale called the “Subjective Units of Distress Scale,” or SUDS, where 100 is the most anxiety-provoking scenario you can imagine, and 0 is the least. We then have you work your way up the hierarchy until each of the scenarios feels less scary. It is hard work and can be slow-going, but it can be incredibly effective.



Cognitive Restructuring


People with OCD have to contend with a lot of thinking errors. We call these thinking errors “cognitive distortions,” and we use cognitive restructuring to address and challenge the thinking errors that arise in response to OCD triggers. Some of the most common cognitive distortions in people with OCD include things like:

  1. Black-and-white thinking: seeing things in extremes and having difficulty finding the middle ground in situations. For example, “If I ever have a thought about harming someone, it means I’m a horrible person.”

  2. Catastrophizing: thinking of the worst possible outcome of a scenario while ignoring the more likely and less extreme possibilities. For example, “If I touch the door handle, I will get sick and die.”

  3. Magical Thinking: believing that there are connections between things that don’t make logical sense. For example, “If I don’t count to an even number while I’m washing my hair, something terrible will happen to my family.”

  4. Mental Filter: having a bias towards noticing negative or anxiety-producing things while not noticing the positive. For example, “I know most people never leave the stove on, but I heard a news story once of someone who accidentally left their stove on and burned their house down, so I have to check several times.”

  5. Emotional Reasoning: using your emotions to determine the likelihood of a particular outcome. For example, “I feel anxious when I don’t complete my routine in a certain way- that must mean something bad is going to happen.”

  6. Overvaluing Thoughts: believing that thoughts hold more power than they do or thinking about something is the same as taking action. For example, “I had imagined myself stabbing my loved one. That must mean I’m a violent or evil person.”

We work on helping you notice when these thinking errors are at play, challenge the erroneous beliefs, and practice replacing them with a more helpful way of thinking. It is important to note that identifying and replacing these negative thoughts may not make you feel better right away. Keep practicing, though. The goal is to teach yourself a new way of thinking, and that requires repetition and persistence.


Mindfulness and Acceptance and Commitment Therapy


Mindfulness is probably one of the most effective ways to gain some distance from your thoughts (called “cognitive defusion”). This distance is crucial for allowing you to engage in the exposure and response prevention and cognitive restructuring exercises we discussed earlier. After all, you can’t fix what you don’t notice, and you can’t challenge thoughts that you automatically interpret as truths.

Mindfulness can be practiced formally or informally. Formal mindfulness is what you probably think of when you hear about mindfulness. This involves sitting down for a set time (I recommend starting small- between 3-5 minutes each day) and bringing your attention to your breath or another similar anchor point. You will notice that your mind wanders off, and that is okay. Just gently return your focus to your breath when you notice that your mind has drifted.

Informal mindfulness practice can happen anytime, anywhere. To practice this, choose something to use as a reminder to return to the present moment. For example, some people set a phone reminder, some use a red stoplight as a reminder to return to the present, and others choose to post a note on their mirror or refrigerator. These different prompts remind you to check in with yourself, notice where your thoughts are, and bring your attention back to the present as needed.


With time, these mindfulness practices help strengthen your mindfulness muscle, which allows you to find space between yourself and your thoughts. You start to realize that you are not your thoughts. Instead, you can sit back and observe your thoughts rather than immediately react to them. This can be immensely helpful in allowing us to take back some of our power from our anxious and obsessive thoughts.


A Note on Medication for OCD


Medication treatment can also be necessary for many people. We typically use antidepressant/antianxiety medications like selective serotonin reuptake inhibitors (SSRIs like Zoloft/sertraline, Prozac/fluoxetine, Celexa/citalopram, and Lexapro/escitalopram), serotonin and norepinephrine reuptake inhibitors (SNRIs like Effexor/venlafaxine and Cymbalta/duloxetine), and sometimes others (like the tricyclic antidepressant, clomipramine). Although not the case for everyone, many people with OCD will require higher doses of these medications when compared to people with anxiety or depressive disorders. If you choose to use a medicine to treat your OCD, you will need to work closely with your doctor to determine the medication and dose that are right for you.

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