Changing the Way You Think

One big reason you might find it difficult to begin practicing your particular exposure and response prevention treatment is that people who have OCD typically fear risks, even small ones. After all, for the great majority of sufferers, anxiety is what OCD is all about! However, it is important to keep in mind that ERP will almost certainly not expose you to genuine harm, and it has a very high rate of success.

Over time, you can get used to any situation, bad or good. That's exactly how ERP works (although the hope is that you'll ultimately find it good rather than bad). If you are practicing ERP as part of therapy, make sure to discuss your progress frequently with your therapist. And be honest. The old saying is true: If you report more improvement than you've actually made, you will, indeed, only be cheating yourself. Plus, you'll be depriving yourself of your therapist's support.


One of the earliest practitioners of ERP was Dr. Edna Foa of the University of Pennsylvania, who instructed germ-phobic patients to pass their hands over a toilet seat, then, without washing, pick up and eat a sandwich! In most cases, the crude technique worked: Patients got over their fears. Most ERP exercises, however, are not nearly that drastic.

Getting Started

In some cases, your cognitive behavioral therapist may accompany you while you take on your feared task. She might, for instance, go into a hospital with you if you're afraid of hospitals and germs, walking closely by those whose white coats might signal danger to you. Perhaps she will calmly “model” certain other desired behaviors, such as petting a dog or discarding a newspaper, before encouraging you to follow suit.

You may well have more than one fear; for example, you might be afraid of germs and saying blasphemous things. Perhaps several things cause you excessive worry. (The longer your OCD has gone on, the more likely you are to have multiple fears, as anxiety is known to “generalize.”) The good news is that as CBT begins to work, all fears tend to diminish. Just as the circle of anxiety gradually widened, so, with treatment, will it shrink over time.

Your Belief System

Another part of cognitive behavioral therapy for OCD is examining your belief system. Believe it or not, a big part of what's wrong is your thinking! Cognitive therapy is based on the notion that your thoughts drive your emotions. A psychologist would say that your “core beliefs” create your automatic (habitual) thinking, leading to a certain reflexive emotional response.

It may not seem so right away, but when you stop to consider this, you'll probably realize that your long- and firmly held beliefs have a lot to do with the way you feel. It's as if, over time, you've developed a “negative filter” that refracts the information you take in about the world around you in an anxious, worried direction.

Put a little more simply: You may worry, for example, that you are spreading germs to others, endangering their health or even their lives. A cognitive therapist can help you re-evaluate your thoughts and beliefs.


Maybe you avoid difficult situations on days when you feel especially stressed or fragile. Generally speaking, this is not a good idea. Avoidance is a hallmark of anxiety disorders (and OCD specifically). In all probability, if you give in to your impulses, you'll end up avoiding your feared situations more and more often. Don't let down your guard. Treating OCD requires daily vigilance.

For instance, your therapist may ask you how it is that other relatively healthy individuals seem to pass through their social and professional circles without spreading wholesale infection to the people they encounter. Depending on your answer, another question, or series of them, may follow as the therapist helps you to arrive at a more realistic evaluation of your risk to others. You may eventually concede, after all this Socratic interaction, that you do not, in fact, pose a serious danger.

Do You Believe in Magic?

People who have OCD sometimes engage in “magical thinking,” believing they can influence events that are actually beyond their control. Everyone probably does a little of this from time to time. You might pray that the people you care about do not come to harm. That is perfectly normal (even if several people who were close to you died in spite of your entreaties).

But let us say you've discovered another seeming correlation: If you refrain from eating before phoning your mother, she will be well. Otherwise, you believe, she'll get sick. You probably know, on the face of it, that that's untrue, that no real correlation exists, yet you persist in this belief. Why?

Well, that's simple, really: You've drawn an illogical conclusion. Your technique seems to have worked well in the past — that is, your mother has come to no harm yet — so, you reason, you must be doing something right. Of course, sadly, you are wrong. If life were that easy, so many more people would be alive and well that the planet would be overrun!

Thinking It Through

Your therapist can help you to redirect your thinking in a number of ways. Some of these might be painful, but only temporarily. For example, if you fear doing harm to your child, you might be encouraged to explore verbally and in depth exactly what you're afraid you might find yourself doing. In the huge majority of cases, a patient will realize after verbalizing her fears that she would not, in reality, act on any of them.

Getting from Point A to Point B in such a case might cause the patient a great deal of distress. However, the expected reward would be a tremendous reduction in anxiety and OC symptoms. Well worth it, you'd have to agree! Very often, people who have OCD overestimate risk to a huge degree. Cognitive behavioral therapists are trained to gently confront these false, if tightly held, beliefs and estimations of risk. It is said that people thrive on the familiar, so confronting even a positive change may be hard. That means you have to work at it.


Unlike medication, behavioral therapy requires effort on your part. You must be committed, at least to a degree, to change, and you have to be willing to work at it. Achieving any change, even good change, can be difficult.

Beyond Therapy

Therapy may not have helped you in the past, but that in itself is not a reason to believe that it can do you no good now. Traditional or “talk” therapy, while helpful in that it gives anxious persons someone with whom to talk through their fears, has not been shown to be very effective against OCD in particular.

Or you may have chosen a cognitive behavioral therapist, but found that she was simply not the right match for you. Therapy is a lot like employment: There are many potential jobs and many possible candidates to fill them; some matches will be almost perfect, others not so good.

One important thing to keep in mind about CBT is that, with the help of your therapist (and later, ideally, on your own), you will need to maintain your gains. Don't neglect to continue to practice your newly learned beneficial behaviors — every day, if possible.

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