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Treatment should aim to help you understand yourself and your OCD patterns better over time. The goal is not to eliminate triggers or discomfort entirely, but to equip you to respond skillfully when challenges inevitably arise.
There are several treatment options for OCD, including cognitive behavioral therapy (CBT) with exposure response prevention (ERP), cognitive restructuring and inference-based therapy, acceptance commitment therapy (ACT) with mindfulness, self-help, and medication.
Complicating matters, there are many treatments, and the practitioners offering these interventions claim effectiveness, even when there is little research to support these claims. Be very cautious of self-help advice for OCD, and make sure it is supported with scientific evidence.
Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by repeated unwanted
thoughts (obsessions) and repetitive behaviors (compulsions) that are difficult to control.
OCD is a self-maintaining disorder, as the person with it naturally searches for ways to reduce anxiety as quickly as possible to minimize the chances of the perceived threat becoming a reality.
According to the National Institute for Health and Care Excellence, the main treatment recommended for OCD is a type of therapy called cognitive behavioral therapy (CBT) (NICE, 2005). This includes three parts:
Ask Questions When seeking a provider who says they offer CBT, ask them how they will addresses OCD using exposure and response prevention (ERP). If they seem unwilling or unable to describe expertise with current gold-standard techniques, seek another provider to avoid the greater frustration of failed treatment. If not done correctly, exposure therapy for OCD can make symptoms worse.
Exposure and Response Prevention (ERP) Therapy is a type of Cognitive Behavioral Therapy (CBT).
The idea behind ERP is to trigger your obsessive fears intentionally but not allow yourself to complete the usual compulsive behavior you would do to reduce anxiety. So you “expose” yourself to the scary situation but “prevent” the response or ritual.
ERP breaks the OCD cycle by deliberately triggering obsessive thoughts and anxiety through planned exposure. It allows anxiety to fully peak without escaping or neutralizing with compulsions. ERP shows that feared consequences don’t actually happen even without performing rituals. It teaches your brain that intrusive thoughts are not dangerous, so compulsions become unnecessary.
The goal is to learn that even if you don’t do the compulsion, the bad thing you fear does not actually happen.
By not doing the handwashing ritual, you learn that even though it makes your anxiety sky-high at first, nothing terrible actually happens – your anxiety will peak and then start coming down naturally.
Over many repetitions, your brain learns not to fear door handles anymore.
The therapist helps you develop a fear hierarchy and graded exposure plan. They will guide you through initial ERP exercises in sessions, helping you stay with the exposure until your anxiety starts to decrease within each one.
It’s very tough at first, but gets easier in a belief-challenging way. Research shows ERP creates long-term improvement by targeting the underlying faulty associations between triggers, feared consequences and compulsions ((Antony & Swinson, 2000).
With OCD, it’s the ‘perceived threat’ that’s generating most of the anxiety. People cannot maintain an anxious state for a long period in the absence of a threat.
The length of treatment can vary based on the severity of symptoms and your therapy process.
Some people experience benefits and changes in just a few weeks after starting ERP, whereas for others, it can take months to see an impact.
On average, ERP will require around 12-16 weeks of treatment. Each session typically lasts from 90 to 120 min and they are typically carried out weekly.
You will know you’re getting close to the end of ERP therapy when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.
During ERP, you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. However, this increase in symptoms is only short-term.
Overtime, you will learn that while these feelings and thoughts are distressing, they can’t hurt you.
Eventually, you will find that when you stop fighting the obsessions and anxiety, these feelings will begin to subside.
Over the last 30 years, several investigations of ERP for treating OCD have been conducted worldwide. These studies, with over 500 patients and numerous therapists, have affirmed the success and generalizability of ERP’s beneficial effects on OCD treatment (Abramowitz, 2006).
Rather than worrying about “preparing” for ERP, ask yourself – how badly is my OCD impacting my life right now, and am I willing to feel some discomfort to live a more meaningful life?
You will face anxiety by going after your goals and living intentionally. ERP has been shown to help OCD through research over time. Be willing to feel discomfort to get your life back rather than waiting until your OCD gets severe.
ERP is considered the gold standard treatment, but it can also become a compulsion if not practiced carefully. Any treatment approach may potentially be used compulsively.
In CBT, cognitive restructuring involves looking at how you interpret intrusive thoughts, questioning whether your thoughts are realistic, and challenging your beliefs about responsibility, threat, importance of thoughts, need for control, etc.
Cognitive restructuring uses techniques like examining the evidence for and against the dysfunctional thought, weighing up the odds of feared outcomes actually happening, and putting things in perspective (Salkovskis, 1999).
For example, if you think, “If I don’t check the stove five times, the house will burn down,” you can challenge this by checking just once and seeing that the house does not actually burn down. Over time, this changes how you think about your obsessions.
Over time, building up these new balanced thought patterns helps reduce distress around intrusions and reliance on compulsions. Cognitive work can be combined with ERP for best results.
Research shows that ERP on its own or combined with cognitive restructuring therapy is the most effective psychological treatment for OCD (Öst et al., 2015). Doing ERP every day between sessions boosts improvement, too (Antony & Swinson, 2000). Sometimes, medication is combined with CBT as well.
Traditional CBT for OCD focuses on identifying irrational or exaggerated thoughts and beliefs related to your obsessions, like “If I don’t wash my hands repeatedly, I’ll get sick.”
It then uses tools like logical disputation to challenge those thoughts, replace them with more rational ones, and gradually face feared situations to show that the feared outcome doesn’t happen.
Inference-Based Cognitive-Behavioral Therapy (I-CBT) takes a different approach. It sees OCD not as an anxiety disorder driven by exaggerated fears, but primarily as a “doubting disorder.”
The key idea is that OCD doesn’t come out of the blue. It starts with an intense feeling of doubt popping into someone’s head – doubt that something bad might happen or that something is dangerously contaminated.
This doubt feels real and urgent even though there is no actual evidence for it. The person can’t just ignore it. Where does this feeling come from then?
The Inference-Based Approach says it comes from a glitch in how someone is thinking. Their brain tricks itself by overvaluing “what if” possibilities compared to what they are actually seeing or experiencing in that moment.
The treatment then identifies these reasoning tricks underlying patients’ obsessive doubts. It helps them recognize when their brain is favoring remote “maybes” instead of realistic information.
Rather than only saying “Tolerate the uncertainty,” it shows how the doubt itself was unreasonable to begin with. The goal is to prevent the obsessive doubt from arising, rather than mainly managing anxiety after it arises.
Once these doubt thought patterns are corrected, the extreme anxiety, repetitive rituals and other OCD symptoms should improve or even go away. The key is catching that initial spark of obsessional doubt where something feels dangerously uncertain or contaminated. By changing reasoning here, the later fire of full-blown OCD can be prevented.
Acceptance and Commitment Therapy (ACT) takes a different approach to treating obsessive-compulsive disorder (OCD) than traditional methods. Accepting means not judging the thoughts as good or bad, and understanding that we cannot control thoughts that arise. Here’s a basic explanation of what happens:
The ultimate goal of ACT for OCD is to live a meaningful life even with obsessions continuing to arise at times. It’s about accepting what is out of one’s control, and focusing energy on what can be controlled – chosen values and actions.
Mindfulness interventions emphasize present-moment awareness with an attitude of non-judgment. They have shown promise for improving both physical and mental health across disorders.
The mindfulness skill of non-reactivity, or allowing thoughts and feelings to come and go without reacting, may be particularly helpful for managing intrusive thoughts in OCD.
One mindfulness skill that could be especially useful for managing intrusive thoughts in OCD is called non-reactivity. This means noticing intrusive thoughts and urges come into your mind, but allowing them to pass by again without reacting, engaging with them, or being critical of yourself.
So rather than doing compulsions when obsessions occur, non-reactivity mindfulness teaches people to observe their thoughts non-judgmentally and let them fade away naturally.
This calmer, more detached response style may reduce OCD symptoms over time.
Mindfulness is a core component of Acceptance and Commitment Therapy (ACT). Here are some of the key ways mindfulness is incorporated into ACT:
Medications that increase serotonin, a brain chemical that helps regulate mood, are usually the first treatment doctors try for OCD.
Antidepressants, specifically SSRIs, which are considered the most tolerable and are, therefore, the most prescribed, are generally safe to take long-term.
The most commonly prescribed drugs are antidepressants like Prozac, Zoloft, and Luvox. Another medication called clomipramine also helps control OCD symptoms.
These medicines ease OCD symptoms in many patients. Treatment response is dose-related, with
better clinical responses associated with higher dosages, although lower doses.
The choice of medication regimen is still based on trial and error. In the future, genetic testing may allow doctors to predict the best drug for each patient. But those personalized tests aren’t ready for routine medical use yet.
But 40-60% of people don’t respond well enough to the medications alone. In these cases, doctors might add other drugs like risperidone or aripiprazole, which are normally used to treat schizophrenia. Adding these medications often helps control OCD when the antidepressant drugs haven’t worked.
Family and friends often shape our views about our mental health difficulties and whether we should pursue treatment.
Family members who criticize you or your symptoms may unintentionally be making your OCD worse. Criticism is linked to more severe OCD symptoms.
Critical family members often think you have more control over your obsessions and compulsions than you do. They may believe you could stop the OCD if you tried harder. This could lead them to have more negative attitudes about you seeking treatment.
It’s also common for family members to accommodate your OCD symptoms, like participating in compulsions or modifying family routines. They may do this to reduce your distress or their own anxiety. However, high levels of accommodation can increase family stress.
Family members who accommodate a lot may think exposure therapy will be too hard for you. The high stress may also motivate them to encourage you to get treatment.
The critical and accommodating behaviors that family members show, while often well-intentioned, can fuel OCD and create concerns about treatment.
If you choose to include family in your treatment, addressing these behaviors and treatment worries early on will be important. This can create a more supportive environment and improve your treatment success.
Here’s a quick summary of what can happen if OCD goes untreated:
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