The patient should first have a diagnostic interview to establish the diagnosis of OCD and any other co-morbid diagnoses. The symptom severity should be evaluated using the Y-BOCS and the CAC. Such scales also list a wide range of obsessional thoughts and compulsions, thus opening the way for patients to disclose thoughts and behaviours they find embarrassing. The history of the course of OCD symptoms, engagement with and response to previous treatments, patient's treatment goals, social functioning, mood, treatment preference and availability, will affect decision making about treatment. Severe depression may require drug treatment before ERP or concurrently. Sessions should probably take place at least weekly initially, to ensure exposure work is being carried out between sessions and to help the patient get the support and challenging he needs to build on success experiences.

Behavioural Treatment with ERP

Foa & Franklin (2001) provide a detailed description of their exposure and intensive response-prevention treatment programme.

Stage 1: Information Gathering

Throughout treatment the therapist tries to develop good rapport. The therapist must initially gather information about the current obsessions, avoidance patterns and the relationship between the two. This includes information about the external cues (for example, objects or situations) and internal cues (for example, thoughts or images) that provoke anxiety; the believed consequences of exposure to these cues and the strength of belief that these feared consequences will happen. It is important to access the patient's beliefs about thoughts (for example, 'if I tell someone my thoughts something bad will happen'), in order to access all thoughts. Avoidance can be passive (such as avoiding certain places) or can occur through rituals. Rituals can be overt observable behaviours or covert mental activities (for example, praying). Although treatment principles are the same, it is more difficult to monitor covert behaviours and ensure response prevention. In treatment it is essential the patient can distinguish between obsessions (involuntary thoughts that produce anxiety) and neutralising thoughts (voluntary thoughts that are intended to reduce anxiety). The patient should be advised to tell the therapist about any mental compulsions occurring during exposure.

The therapist should also gather information about interaction around the OCD by others, such as relatives, who may have accommodated their behaviour substantially because of the patient's OCD symptoms. Studies have found conflicting results about the outcome of using a family member as a co-therapist but it is generally useful to provide the family with information about OCD and advice about how to manage the patient's behaviour and requests for reassurance. Part of the exposure work may involve advising that other family members normalise their behaviours to ensure that the patient is not avoiding exposure at home - for example, family members may be advised to stop any excessive cleaning that they do at the insistence of the patient.

Stage 2: Devising and Explaining the Treatment Programme

It is very important to explain the treatment rationale and to instil hope by giving information about the evidence base for ERP. Unless patients understand this and agree to proceed they are unlikely to engage in treatment or continue to use the techniques outside the therapy sessions. Explain that the patient needs to maintain engagement with the feared stimulus rather than using distraction during exposure. Emphasise the importance of complete ritual prevention. Explain that patients who become actively involved in planning exposure tasks and those who face the items at the top of their hierarchy have most success. In the past patients were physically prevented from carrying out the rituals. However it is now recognised that this is both excessively coercive and will not promote generalisability to situations when the individual is alone. Therefore the individual is encouraged by being given support, education about the rationale, and suggestions about alternatives to carrying out rituals. Explain that the therapist will not use force or do anything without prior consent from the patient. Also explain that the therapist will not give reassurance. The therapist should be encouraging and understanding but also needs to be challenging and to make judgements about when the patient will tolerate and benefit from being pushed.

Introduce a subjective units of discomfort scale (SUDS) ranging from 0 (no distress) to 100 (maximum distress). Arrange exposure items in a hierarchy according to the SUDS. The programme should be adapted to include ERP for any substitute rituals appearing as treatment progresses. With time the patient should gradually take on responsibility for planning the exposure tasks.

Stage 3: Exposure and Response Prevention

After the initial session each session should start with a review of homework and ritual monitoring since the previous session. In vivo and imaginal exposure exercises are designed to gradually increase exposure to obsessional distress. Through prolonged and repeated exposure to the feared stimulus the individual accesses information disconfirming unhelpful evaluations and the exposure promotes habituation. Imaginal exposure can be used before in vivo exposure or in situations where it is impossible to do in vivo exposure.

Generally patients prefer to work through a hierarchy of increasingly difficult situations, rather than confront their greatest fear first. However it is important that therapists do not collude with the patient in avoiding exposure to the more distressing situations. Begin with an item around the middle of the hierarchy. Continue the ERP until the SUDS is reduced by half, then repeat that item until it provokes no more than minimal anxiety. Standardised information sheets (for example about washing or checking) with rules for ritual prevention during treatment and guidelines for 'normal behaviour' after treatment can be useful (Foa & Franklin, 2001). During treatment the individual is expected to learn to tolerate a greater degree of exposure than normal, e.g. compulsive washers afraid of contamination should be exposed to purposeful contamination and be encouraged to avoid 'normal' cleaning.

It is very important that exposure work is continued by the individual between sessions. Home visits can provide additional useful information and treatment at home is necessary if the symptoms are confined to home.


If patients are non-compliant the therapist should use motivational techniques and repeat the treatment rationale. If they still do not engage, give them the option to stop.

It is important to question the patient directly about the emergence of new rituals as treatment progresses and to add these to the hierarchy. Usually these will appear connected or have the same underlying theme. Occasionally treatment has to be interrupted or postponed because of a personal crisis.

Cognitive Therapy

Three CT techniques have been described: challenging obsessional thoughts, thought stopping and challenging negative automatic thoughts. Patients can be taught to monitor the obsessional thoughts and then learn how to replace them with more helpful thoughts or learn to challenge the belief in the thoughts by employing rational counter claims. In thought stopping patients are taught to say a cue word, such as 'stop', to disrupt a chain of obsessional thoughts. The patients can also be instructed to picture a positive image after saying the cue word. The third technique uses Beckian principles to challenge the negative automatic thoughts that result from the obsessional intrusive thoughts, rather than targeting the obsessional thoughts. The patients are helped to consider alternative, less threatening explanations.

Cognitive Behavioural Therapy for Obsessions

Salkovskis, Forrester & Richards (1998) has devised a cognitive-behavioural treatment for obsessions. In assessment the therapist identifies the sequence of events in a recent episode, for example intrusion/interpretation/reactions, with emphasis on the interpretation of intrusions in terms of key responsibility assumptions and appraisals. Some patients show cognitive avoidance as they hold the belief that disclosing their thoughts will make the feared outcome more likely to happen. The impact of attempts to control intrusive thoughts is discussed. The occurrence of intrusive thoughts is normalised and the therapist helps the patient see their usefulness. The initial aims are to reach a shared understanding through formulation of an alternative and less threatening understanding of the patient's difficulties and to set the goals for therapy. If patients have understood the formulation they will agree that the therapy goals relate to dealing with the significance they attach to intrusions, not to getting rid of them completely. Patients therefore understand that they are individuals with worries about negative events, not individuals who are going to suffer negative events.

The next stage is engagement in treatment. A loop tape is used to record and play back the intrusions in the session. This allows the patient and therapist to deal with any difficulties with response prevention. The tape is repeated until the discomfort or urge to neutralise has reduced. Helping patients to challenge their appraisal of intrusions encourages them to do response prevention. They are encouraged to assess how new information fits with the two different formulations. Initially the therapist will play a major role in helping the patient plan behavioural experiments. In time patients should take on more of this planning, recording intrusions and the appraisals made during response prevention. Behavioural experiments should explicitly tests their beliefs and reinforce the alternative explanation. The belief that thoughts can influence events can be challenged by doing an experiment involving trying to cause a positive outcome by thinking. Behavioural experiments cannot falsify predicted negative outcomes that are vague or distant such as that something bad will happen to some relative at some time.

Through therapy the number of intrusions usually decreases as patients no longer seek to control their occurrence and as they lose their priority of processing as they are no longer considered important.

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