Have you ever had distressing thoughts and urges—like the thought that you might set the house on fire or the impulse to drive into oncoming traffic?
Such distressing thoughts, images, and urges are called obsessions. Obsessions are often accompanied by compulsions. Compulsions are repetitive mental or behavioral rituals intended to reduce distress or prevent the dreaded situation from occurring. For instance, checking the stove dozens of times before leaving the house may be considered a compulsion.
Obsessive-compulsive disorder (OCD) is a psychological disorder characterized by both obsessions and compulsions. Typical obsessional themes include contamination, symmetry, harm, and taboo thoughts (e.g., forbidden sexual thoughts). Typical compulsion categories include checking, cleaning, ordering, and mental rituals (e.g., praying too much).
In this article, we describe two effective psychological treatments for OCD: exposure and response prevention, and cognitive behavioral therapy.
Two Effective Psychological Treatments for OCD
1. Exposure and response prevention (ERP)
During ERP, patients are exposed to obsessional cues; however, they are prevented from performing compulsions. For instance, a patient with contamination obsessions is asked to touch a dirty object but then is prevented from washing her hands. Similarly, a patient with symmetry obsessions is prevented from arranging items in a specific way or putting things back in their “right” place.
It is recommended to begin with mildly distressing situations and, only after successful exposure, progress to more distressing ones. To illustrate, a person with checking compulsions may first attempt to, say, leave the house without checking the lights. Over time, she can move on to more difficult situations, like leaving the house without checking the stove or the door lock.
What does exposure therapy teach?
- That the anxiety one feels initially will not remain at the same intensity. The distress will eventually go down; and so will the urge to escape or do compulsions.
- That it is possible to live with doubt and uncertainty. Compulsions are not necessary and offer only the illusion of control. Genuine power and control come from learning to live with uncertainty.
2. Cognitive-behavioral therapy (CBT)
CBT, which sometimes also includes exposure therapy, focuses on identifying and modifying dysfunctional thoughts and behaviors.
To illustrate, suppose a patient with OCD experiences the following intrusive thought about a group of his friends who are on vacation: “My friends are going to die in a plane crash.” In response to the thought, the patient engages in compulsive behaviors, such as trying to convince his friends to cancel their flight and take the train instead.
In the above case, the individual attached a lot of importance to his intrusive thought and felt overly responsible for the welfare of his friends. Both of these are examples of dysfunctional beliefs. People with OCD have dysfunctional beliefs in several domains, as described below.
- Perfectionism: Believing that imperfections and errors are absolutely intolerable.
- Overestimating threats: The idea that negative outcomes are both highly probable and extremely bad.
- Excessive responsibility: Believing oneself to have a unique power to cause—or a special duty to prevent—terrible things from happening.
- Over-importance of thoughts: The assumption that all thoughts are significant. For example, they assume merely thinking about a disease increases the likelihood of the disease occurring.
- The need to control one’s thoughts: Believing it is possible and important to control thoughts.
- Intolerance of uncertainty: Assuming one can (and must) be absolutely certain that a dreaded event will not happen.
In therapy, patients learn how to identify such maladaptive thoughts (and maladaptive behaviors like avoidance and compulsions), challenge them, and replace them with more adaptive ones.