Seven Ways Therapists Can Mess Up the Best OCD Treatment

Avoiding these common mistakes can maximize treatment success.

Posted Jan 17, 2015

My first job after I got my PhD was at an academic center that specialized in developing and testing treatments for obsessive-compulsive disorder, or OCD. Every week we’d meet to discuss the clinical work we were doing using exposure and response prevention (ERP), the best-tested psychological treatment for OCD. The meetings were an opportunity especially for the newer therapists to make sure they were doing the treatment the right way.

After sitting in these meetings for several years it struck me that we kept hearing about the same set of mistakes from new ERP therapists—the same ones I’d made when I was starting out. I decided to compile a list of these mistakes and how to avoid them, and worked with several of my fellow psychologists on turning the list into a piece that appeared in an OCD journal in 2012.  

We’ve gotten some nice feedback on the article from therapists and individuals with OCD and their family members who’ve said the article is helpful in understanding how to do ERP well. My plan is to present the material from the article in a way that’s easily accessible and that allows readers to comment on and discuss the issues.

My hope is that this series of entries will remove a final barrier from receiving effective OCD treatment. In order to get good ERP a person must 1) know s/he has OCD; 2) know that ERP is the psychological treatment that’s needed; 3) find a therapist who uses ERP; 4) be able to afford the therapist’s fees; and 5) actually receive effective ERP. It’s a shame to get all the way to number 5—which most people with OCD don’t do—and then get suboptimal care.

Much has been written about what ERP is; I’ll briefly review the treatment here. ERP has two parts, as the name implies: Exposure, which is deliberately doing the things that provoke obsessions, the repetitive terrifying thoughts about bad things that might happen (like getting sick from touching certain things); and response (or ritual) prevention, which means not doing the compulsive behaviors (like excessive hand washing) that define OCD.

Repeatedly doing exposures without compulsions lessens the fear tied to the triggers, and also reduces the person’s drive to do compulsions. Many research studies have found that ERP is extremely effective at treating OCD, and is at least as effective as the best medications.

How does ERP work? Exposure without doing rituals helps a person with OCD to better tolerate the fear and anxiety that the obsessions cause, and allows the person to learn that anxiety doesn’t last forever. ERP can also provide disconfirmation of the feared consequences—for example, learning that wearing a certain shirt doesn’t cause a family member to die.

It can’t be overstated how important the ritual prevention is. If a person with OCD does an exposure—say, drives a car in areas with lots of pedestrians—and then completes compulsions—circles over and over to be sure he didn’t hit someone—then no new learning will take place. Exposure without ritual prevention is just turning up the volume on OCD.

If ERP seems pretty simple, it is—at least in principle: Do exposures, don’t do compulsions. Nevertheless, therapists can go astray in any number of ways. In our article we identified the following seven common therapist mistakes in ERP:

1)      Stopping shy of the most difficult exposure items—the ones that really hold the key for unlocking the OCD

2)     Having the person with OCD only imagine the scary scenarios without actually doing them in real life. For example, the therapist might have a person imagine using a dirty public restroom (called imaginal exposure) rather than actually using such a restroom (called in vivo exposure).

3)     Encouraging distraction during exposure, which can make the exposure exercises less effective

4)     Giving the person with OCD reassurance that their fears aren’t realistic. For example, the therapist might try to convince the person that she would never, never, ever hurt her children in the ways her OCD tells her she will. As we’ll see, these reassurances backfire and reinforce the OCD.

5)     Not addressing the “core fear”—the thing that the person is most afraid of happening, and that often drives all the specific manifestations of the OCD

6)     Not knowing how to handle mental compulsions—things like saying silent prayers to neutralize “bad thoughts” or checking one’s memory to be sure the stove was off. Therapists often mistake these mental compulsions for obsessions, and will tell the person he or she has “pure obsessional OCD” or “Pure O.”

7)     Not working effectively with the family members of the person in treatment.

In future posts I’ll be expanding on each of these topics. By avoiding these pitfalls, the therapist can help the treatment seeker to get the most out of treatment. I look forward to hearing your thoughts.

The full journal article is available here.