Treating OCD in Therapy 

Treating OCD in Therapy 

What is OCD?

Obsessive Compulsive Disorder is a common mental health disorder in which people have unwanted, reoccurring thoughts, fears, worries, ideas, sensations, or urges (obsessions) that lead them to engage in repetitive thoughts or behaviors. The resulting behaviors will temporarily relieve the anxiety an individual feels, however, the obsessions and anxiety quickly return, reactivating the cycle. These frequent thoughts can be disturbing to individuals experiencing OCD, and are different for everyone. To be diagnosed with OCD, someone needs to be experiencing both obsessive thoughts and compulsions. (1,2)

Common Symptoms of OCD

Obsessions: recurring thoughts, urges, or mental images that feel intrusive, unwanted, and distressing. People with OCD will often try to ignore or suppress obsessions and avoid triggers, or they may take action to neutralize them. (2,3)

  • Examples of obsessions commonly center around themes such as fear of contamination, the need for objects to be arranged specifically or orderly, unwanted, aggressive thoughts about losing control and harming yourself or others, sexual or religious acts and images, morality concerns, fears of acting inappropriately in public and much more. 

Emotions: The obsession then causes a feeling of intense anxiety or stress which the person looks to alleviate

Compulsions are repetitive behaviors or mental acts that someone with OCD feels driven to perform. Someone with OCD engages in compulsion as a way to alleviate distress or prevent something negative they believe will occur. Sometimes, compulsions might happen according to a set of self-imposed rules. (3) 

  • Examples of compulsions may include themes such as washing, checking, counting, orderliness, rigid routine, repetition, the need to confess, reassurance seeking from others, repeating prayers or phrases, etc.

Additional OCD spectrum disorders include a presentation with concerns related to body preoccupation, hypochondriasis, skin picking, hair pulling, and impulse control challenges. (​​4) 

OCD symptoms will usually present in childhood or early adolescence and are most commonly first experienced before age 25. Symptoms usually begin gradually and adapt or vary throughout life. It is common for a person with OCD to have good insight and understanding that their behaviors are unreasonable or extreme, yet think they are unable to stop. (5)

Thought Action Fusion

Thought action fusion is a main characteristic of OCD. This is the belief that thoughts are equivalent to actions. For example, if someone with OCD has obsessive thoughts about harming someone else, this is equally as bad and distressing to them as if they had actually engaged in that behavior.

The person’s anxiety in this situation is so intense it prevents them from making informed, rational decisions and judgments about the risk of the situation, and to remain on the safe side they will often avoid or create compulsive rituals to prevent any possibility of harm to themselves or others regarding the feared outcome. (6)

What if I Suppress My OCD Thoughts?

Often individuals with OCD tend to engage in thought suppression by trying to ignore or control distressing intrusive thoughts. Although doing so may feel adequate at the moment, pushing away intrusive thoughts will actually worsen and strengthen the obsessions. Without an understanding of how to adequately manage obsessions and thoughts, continuing to engage in thought suppression will continue to worsen obsessions and contribute to the OCD cycle. (7)

How & Why does it get worse?- Trying to suppress an intrusive, unwanted thought can cause it to rebound, or reoccur. While the initial thought likely happened automatically and without mental effort, suppressing that thought is a controlled, purposeful action. The suppression is a conscious effort that requires your mental resources and brings the thought to the forefront of your brain even more. In addition, in doing so you lower mental resources, and the ability to cope,  which may already be depleted if you are feeling stressed, tired, or overwhelmed.

How do I stop engaging in thought suppression?- A mental health professional can increase your ability to notice when intrusive thoughts are occurring, manage feelings of anxiety and challenge the thoughts without acting on compulsions. 

How is OCD Treated?

If you or someone you know is struggling with OCD, it may be helpful to consult with a mental health professional in psychotherapy to learn effective strategies to deal with intrusive thoughts and obsessions. In some cases, medication will be recommended in combination with therapy. 

Cognitive Behavioral Therapy (CBT) is an effective form of therapy in reducing OCD which encourages you to notice your thought patterns so you can understand the effect that they have on your life (8). This form of therapy for OCD will often focus on learning to accept and challenge thoughts, rather than suppress or avoid them. CBT does so by challenging negative automatic thoughts, addressing cognitive distortions, and changing “unhelpful” thoughts to more rational ones. It also focuses on exposing yourself to situations that may trigger obsessions in a controlled manner, to learn to manage feelings of anxiety and response. Due to CBT being such a broad approach to therapy, it will often help with building skills to manage other areas in life OCD may have impacted through awareness, social support, positive reinforcement, challenging thoughts, and relaxation. 

Exposure and Response Prevention (ERP) is the most effective form of CBT used to treat OCD (9). This modality focuses on discouraging avoidance through exposure. A CBT therapist will first help you identify and understand your triggers, then work to safely confront them. Ideally, ERP helps an individual learn new ways to respond to triggers and cope with emotions. While engaging in ERP, with the support of the therapist, you will be exposed to a fearful stimulus, experience anxiety/discomfort, and work to refrain from engaging in compulsions which would typically be used to cope with the uncomfortable feelings. By not engaging in the compulsive ritual, you weaken the relationship between needing the ritual to feel better. This can be difficult, but is thoughtfully introduced in a hierarchical way and is effective in reducing symptoms of OCD and stopping the cycle long-term.

Exposure therapy focuses on three main areas, In Vivo (staying in the presence of a feared object or situation that evokes anxiety and distress), Imaginal (mentally visualizing oneself in the feared situations or visualizing the consequences of the feared situations), and Ritual Prevention (refraining from engaging in compulsive behavior) (10). 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 must be done repeatedly and be paired with relaxation to really help with OCD. Where a person may have initially felt that they could not handle the anxiety or perceived consequences of a particular situation, they will find out with ERP that they can. After exposure practice, such situations will no longer make them feel as uncomfortable as they once did. This process is called habituation. (11)

Acceptance and Commitment Therapy (ACT) is an empowering form of CBT that has become popular in working with OCD through its role of building flexibility in thinking (acceptance) rather than engaging in avoidance. ACT emphasizes the ability to control our actions and strive toward what matters most, while not attempting to control or waste resources on internal experience, obsessions, or compulsions. According to ACT, difficult thoughts and feelings are not to be perceived as problematic, but rather as part of life's unique experience. 

ACT proposes that frequent attempts to control our thoughts to avoid discomfort may help in the short term, however, it gets us stuck in our internal experiences and removes us from the present. In the case of an intrusive thought, that would mean accepting the presence of the thought without making an effort to suppress it or change it in any way. ACT teaches psychological flexibility, or approaching discomfort with self-compassion and curiosity, rather than responding in a rigid way. It emphasizes the freedom to choose how to respond at the moment. This form of therapy uses a variety of mindfulness techniques and perspective-enhancing exercises and has been shown to be helpful for people with OCD.(12)

Mindfulness may help with mental clarity and distance from thought-action fusion. This practice encourages you to notice your thoughts and emotions while maintaining a non-judgmental point of view. For example, when an intrusive thought arises, instead of suppressing it or reacting to it, you would acknowledge the thought non-judgmentally and remind yourself that it doesn't control you. For people with OCD, learning to accept thoughts without judging them may make intrusive thoughts happen less often and feel less distressing. (13)

When to Seek Help for OCD

OCD goes beyond the idea of being a perfectionist. If you or someone you know has symptoms of OCD that are becoming unmanageable or disruptive, understand that anyone with OCD can benefit from therapy and should seek treatment. It may be beneficial to ask the following questions: 

  • Are symptoms causing distress?

  • Is excessive time being spent preoccupied with symptoms? (i.e., intrusive thoughts, engaging in behaviors)

  • Do symptoms disrupt the course of the day or interfere with activities/relationships/work?

OCD treatment looks different for everyone, however intervening as early as possible with the general techniques previously mentioned is known to be effective. The right therapist can provide valuable techniques and help you regain control of your life as soon as possible. 

If OCD is negatively affecting the quality of life, it's time to seek additional help. Heritage Counseling has experienced therapists trained to treat a broad range of OCD spectrum disorders and design a treatment plan specific to a client's individual needs. Please reach out to Heritage Counseling & Consulting at 214-363-2345 for more information.