Department of Psychiatry
Penn Behavioral Health

Center for the Treatment and Study of Anxiety

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Understanding CBT for OCD



Understanding Cognitive-Behavior Therapy for OCD

Cognitive-behavior therapy is a type of treatment that helps individuals cope with and change problematic thoughts, behaviors, and emotions. The treatment you are beginning is a specialized type of cognitive-behavior therapy for obsessive-compulsive disorder (OCD) called Exposure and Ritual Prevention. This treatment is designed to break two types of associations that occur in OCD. The first one is the association between sensations of distress and the objects, situations, or thoughts that produce this distress. The second association is that between carrying out ritualistic behavior and decreasing the distress. The treatment we offer will break the automatic bond between feelings of anxiety and ritual behaviors. It will also train you not to ritualize when you are anxious. This treatment program includes three components that we call in vivo exposure, imaginal exposure, and ritual prevention.

In Vivo Exposure: Also known as "real-life" or "actual" exposure. Staying for longer periods of time in the presence of a feared object or situation that evokes anxiety and distress (for example, actual contact with contaminants)

Imaginal Exposure: Mentally visualizing oneself in the feared situations or visualizing the consequences of the feared situations (for example, visualizing driving on the road and hitting a pedestrian)

Ritual Prevention: Refraining from ritualistic behavior (for example, leaving the kitchen without checking the stove, or touching the floor without washing one’s hands)

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What is Exposure?

Exposure is a procedure in which you purposely confront objects or situations that prompt distress and stay in those situations long enough for your anxiety to decrease by itself. In vivo exposure is a type of exposure that involves confronting feared objects and situations in "real life". For example, a person who feels contaminated by public restrooms would visit a public restroom and stay there long enough for their anxiety to decrease. If you feel contaminated by contact with the floor, you must sit on the floor for an extended period of time. You may believe that your discomfort will last forever unless you avoid or escape such situations. You may feel as if you couldn’t handle such a situation. As you will find out, this is not true. At first, you can expect to feel anxiety or discomfort. After exposure practice, though, such situations will no longer make you feel as uncomfortable as they once did. This process is called habituation.

If habituation works, you may wonder why you haven't relieved your distress already through many encounters with situations that provoked obsessions and anxiety. Simply provoking an obsession is not enough. Exposure to the obsession and the resultant distress must be done for a long enough time for the distress to diminish on its own. In addition, exposure must be done repeatedly to really help with OCD.

Sometimes you will not be able to actually confront your feared situation and its perceived consequences through in vivo exposure. For example, a person may fear that their house will burn down if they do not check to ensure that the iron is turned off. We could not burn their house down to allow them to confront their fear. Instead, the person can confront the harm by visualizing it in their mind. In imaginal exposure, you create in your mind detailed images of the disaster you feel will occur if you do not avoid or ritualize. As in actual exposure, the obsessional distress gradually decreases during imaginal exposure.

Imaginal exposure is also helpful for individuals whose obsessions occur simultaneously and are not triggered by any identifiable situations. For example, a person might have a blasphemous thought at any time or place. This thought may cause them distress. In this case, there is no particular situation for the person to confront and the person can’t practice remaining in the exposure situation for a prolonged period of time. With imaginal exposure, the blasphemy can be imagined repeatedly, without trying to eliminate it or neutralize it with a ritual.

Imaginal exposure may also be used to make subsequent in vivo exposure practices easier for you. If you are extremely distressed about the idea of confronting a situation or object that provokes your obsession, you might find it helpful to imagine confronting if first. The decrease in your distress during imagery will carry over to the actual exposure.

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What is Ritual Prevention?

When people with OCD encounter their feared situations or have obsessional thoughts, they become anxious and feel compelled to perform ritualistic behaviors to reduce the distress. Exposure practices can cause this same distress and the same urges to ritualize. Therefore, in treatment, ritual prevention is practiced to break the habit of ritualizing. Ritual prevention requires that you stop ritualizing, even though you are still having urges to do so. In short, rituals are difficult to stop because they bring relief from anxiety or discomfort. However, you are receiving treatment because these rituals are interfering with your ability to function. Through ritual prevention, your therapist will teach you how to stop rituals and you will learn more effective ways of coping with and managing your discomfort.

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Why should I do Exposure and Ritual Prevention?

Perhaps you are asking yourself, "Why should I suffer the distress of confronting feared situations on purpose without doing some rituals to get relief?" Remember that this treatment program is designed to weaken two types of connections that people with OCD have. The first is the connection between distress and the objects, situations, or thoughts that trigger distress. The second connection is between ritualizing and relief from distress. In other words, after you carry out a ritual you temporarily feel less distress, so you continue to engage in the ritual. By not doing rituals, you help to weaken the connection between rituals and feeling better.

In addition to weakening connections, this treatment program is designed to help correct mistaken ideas that are common in OCD and cause considerable distress. The first mistaken idea commonly seen in OCD is that it is necessary to avoid or ritualize in order to prevent harm. Most people can think of potential disasters that might happen to them or others when they carry out necessary daily activities such as driving a car. However, because they can think about the risk without disabling distress, they can see that the actual risk is so low that it should be ignored. Many people with OCD become overwhelmed with distress when they think about certain potential disasters that might happen to them or others. For example, individuals with OCD might become intensely anxious about the thought of their house catching fire, being possessed by the devil, or contracting AIDS. The intense anxiety prevents them from making rational and informed judgments about how risky a situation really is and what they can do to protect themselves or others. To be on the safe side, the person with OCD will avoid or ritualize to prevent even the most remote possibility of harm. Consequently, the individual does not have the opportunity to learn that the feared situation is actually quite safe.

Exposure works against this type of mistaken idea. When you actually confront a feared situation repeatedly and don’t ritualize, you realize that no harm follows. Thus, you recognize that the risk is remote and you learn to ignore it. For example, Stacy was afraid that her house would catch fire, so she refused to use her central heating even in cold weather. For therapy, she practiced starting the heater and leaving it on while she was away from home. After 24 hours, the house was comfortably warm inside, but did not catch fire and Stacy learned that her fear was unfounded.

The second mistaken idea people with OCD tend to have is the belief that they must avoid the distressing situation or they will be distressed forever. This leads them to avoid many situations or to ritualize if they can not avoid them. However, during prolonged exposure, intense anxiety gradually decreases. If someone confronts a distressing situation for a prolonged period of time (such as 1-2 hours), the individual will experience a gradual decrease in distress until the distress is gone. As the distress drops, it becomes easier to see whether or not a situation is actually dangerous. When the same or similar situation arises later, there will be far less distress than experienced previously.

A third mistaken belief in OCD is that, “if I don’t avoid or ritualize, the distress will get so bad that I’ll lose my mind.” For example, Ray was concerned that if things were not arranged neatly and in the right order, he would be so uncomfortable that he would not be able to stand it, he would lose his mind, and be committed to a psychiatric hospital. For his therapy, Ray purposely disordered his office and bedroom and did not put things back in order even though he became distressed. Instead, his discomfort eventually decreased and he did not lose his mind. He learned that anxiety did not produce insanity.

A program that involves prolonged exposure is designed to help you, whether you are afraid of contracting a disease from public bathrooms, causing automobile accidents, discarding something important, saying inappropriate things, or hurting someone with a knife. When you first confront a feared situation, you will become distressed. However, if you remain long enough in the situation, and do so repeatedly, the distress will diminish.

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How involved do I need to be in Exposure and Ritual Prevention?

For in vivo and imaginal exposure to be helpful, you must become emotionally involved during the exposure exercises. Specifically, the exposure situation must evoke the same kind of obsessional distress that you experience in your daily life. To promote emotional involvement, we will develop exposure exercises that are a good match to the real-life situations that provoke your obsessions and urges to ritualize. For example, if you are distressed by contamination related to cancer and you visit a hospital with no cancer ward, the exercise will not be helpful. The situation does not match your fear. Thus, it will be hard for you to become emotionally involved when your exercises are not matched to your obsessions.

During the exposure exercises that are matched to your obsessions, you must involve yourself emotionally. This means that you must pay attention to the distressing aspects of the exposure situation, rather than trying to ignore them. This is true for both imaginal and actual exposure. For example, if you pretend that a cancer ward is really a cardiac unit in order to reduce your distress, the exercise will be less effective. Therefore, during exposure you should think about the potential harm that concerns you. For example, you are afraid of using public restrooms and you go to a public restroom as an exposure exercise. To truly involve yourself emotionally, you must think about what concerns you have about the restroom, such as how dirty it might be or what disease you are afraid of catching. In turn, during imaginal exposure, you should include anticipated disasters and work at imagining them as vividly as you can.

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How can I get the most benefit out of Exposure and Ritual Prevention?

When people hear about exposure treatment, they often do not understand how it works. You might think that if you just decide to do things that you avoid and give up doing rituals, you really wouldn’t need treatment at all. Most people with OCD can temporarily stop their avoidance and rituals, but it is very uncomfortable and they don’t see why anyone would want to go through it. Not just any kind of exposure works. Certainly you have had occasions when you accidentally or purposely confronted feared situations, but your OCD habits persisted. You must do well-designed exercises, and do them correctly for exposure to work. In this treatment, exposure exercises will be designed specifically for your OCD symptoms and your therapist will coach you through them as you practice.

What you get out of exposure and ritual prevention depends heavily on what you put into it. It also depends on your therapist coming up with an exposure plan that fits your particular OCD habits. Sometimes exposure exercises may seem counterintuitive or even extreme, but it will be important for you to practice anyway. The goal of exposure is not to get you to do what other, "non-OCD" people do. Exposure exercises are specially designed to weaken your obsessions and compulsions.

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Summary

In summary, your treatment program will involve two procedures: exposure and ritual prevention. Exposure involves confronting objects or situations that prompt distress and urges to ritualize. Ritual prevention means resisting the urge to perform rituals. The exposure exercises are designed by you and your therapist to help you break associations between fear and the objects or situations that make you feel distressed. Exposure also helps you to learn that confronting these situations will not lead to intolerable anxiety. Ritual prevention is designed to help correct certain beliefs, such as the idea that doing rituals prevents disastrous things like harm to you or others. By purposely becoming anxious when doing exposure practice and resisting the urges to ritualize, you will learn that the anxiety and discomfort will dissipate on their own. In turn, the urges to ritualize will decrease.

Exposure and ritual prevention may be difficult at times. It takes hard work to confront the situations that you would usually avoid. However, in order to reduce OCD, you must practice exposure and find out that anxiety and distress will decrease without rituals. As you practice exposure, these exercises become easier and easier, and your urges to ritualize will decrease.

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