OCD Treatment Challenges and Solutions

Dr. Moses Appel (Edited by Matthew Shields)

Here are ten common challenges people encounter when undertaking Exposure and Response Prevention (E/RP) therapy for OCD, along with solutions we employ here at ADO Psychology Center. I hope readers relate to how I give voice to their challenges while finding solace and comfort in the solutions provided. I similarly hope that therapists find these tips valuable for guiding their patients through the turbulent waters of E/RP. 

1.   Challenge: How to differentiate ‘OCD doubt’ from ‘regular doubt.’

Life is full of doubts. From small uncertainties –like whether to choose a strawberry or vanilla milkshake– all the way to big questions like ‘in which community should we buy our home?’ Doubts are a persistent part of what makes us human. For a lot of people, delving into pros and cons reveals the proper solution to whatever they’re pondering.

People with OCD have the opposite problem. For them, the uncertainty only grows as they engage with it, eventually leading to unhealthy compulsions to try and satisfy their ever-strengthening doubts. That isn’t to say that people with OCD experience every type of doubt as OCD doubt; indeed, all of life’s regular doubts apply to them as well. So, if you do have OCD, how do you differentiate between regular doubts (which require regular decision-making skills) and OCD doubts (which require a different approach entirely)?

Treatment Solutions:

• “Gun to the head” approach. Imagine putting a gun to the head where you need to answer immediately whether this doubt feels like OCD or a legitimate concern. The quicker you answer this question, the more accurate it will be.

• Ask: ‘Would I have this doubt pre-OCD?’ If it’s not a doubt you would have experienced before your diagnosis, then it’s likely an OCD doubt.

• ‘Would others in my community/culture/friend group have this doubt?’ If the answer is yes, then it’s likely a regular doubt and worth solving. If not, it’s best to label it as an OCD doubt and move on with your day!

• Recognize that OCD doubts are usually triggered by hypothetical statements like “what if,” “maybe,” or “how do I know for sure,” and not by concrete information from the here and now.

2.   Challenge: “Do I really have OCD? Even if I do, how do I know that this trigger is just OCD and not ‘real’?”

As we can see, people question the validity of their OCD in two ways. Some people wonder if they have OCD at all; others know they have OCD, but now, when they’re triggered, they question whether they’re triggered because of OCD or because what they fear might actually be true. Let’s look at a few examples.

Aaron is a religious man, but because of frequent OCD triggers, he often questions God’s existence. Aaron regularly thinks that maybe he doesn't truly believe in God during these moments. When Aaron isn't triggered, he does not have these concerns and he lives life as if he believes in God; he only questions God's existence when OCD triggers him. He notices the inconsistencies in his thoughts– between firmly believing in God and questioning God’s existence– and can’t quite shake the feeling that maybe he doesn’t have OCD at all.

         Consider another example. Beth has Pedophilia OCD; there are times when she sees a cute child and questions if she’s attracted to children. We, as outside observers, know her internal interrogations come from OCD because she doesn’t gain sexual pleasure from seeing children, and she never has. Still, in her mind, she can’t pin down where her thoughts are coming from. Additionally, when she’s triggered, sometimes she recognizes that she has OCD but can’t shake the feeling that maybe this time, what she’s feeling might actually mean she’s attracted to children.

         Cases like Aaron and Beth are extremely prevalent. Here are some of the messages and strategies I recommend to people in similar circumstances.      

Treatment Solutions:

• If someone wonders whether they have OCD at all, the first thing I’d tell them is, “Yes, you do! You have OCD; you’ve been diagnosed, and you’re here doing ERP for a reason. To practice this on one’s own, utilize the “gun to the head” approach from the previous challenge.

• It should be noted that this type of questioning normally reflects one’s general OCD themes. If it’s known that these doubts are typical of how their OCD presents, I advise them to assume that the above line of questioning is also OCD.

• Like the last treatment challenge and solution, clients often find it helpful to ask themselves what others are likely to think in this situation; the key here is focusing on what's likely, rather than trying to scientifically deduce what others might answer. This connects to the next point, where we proactively embrace uncertainty.

• People with OCD must understand that when it comes to any OCD, gaining absolute certainty is out of the question. Sure, it's possible that this time, whatever thoughts we have might be accurate, but anything in life is possible. The goal isn’t to disprove OCD thoughts but to accept that uncertainty comes from anxiety. Therefore, we should address the OCD demand for certainty as irrelevant.

• It is important to recognize that you are “innocent until proven guilty,” not “guilty until proven innocent.” So, if Aaron believed in God his whole life, and Beth never engaged in any pedophilic behaviors, Aaron can safely assume that he is a true “believer” and Beth can safely assume she is not a pedophile. There is no need to “prove” it, because after all, you are innocent until proven guilty, not the other way around.

• If all else fails, and the person with OCD still can't shake the thoughts that maybe they don't have OCD, or that whatever triggering moment was genuine and not a product of OCD, I would recommend they set an alarm for a month from now to reevaluate. Don’t give in to the false sense of urgency which is convincing you that you must solve it in the moment you are triggered.

  
  

3.   Challenge: Double bind: when treatment itself becomes a trigger.

Here is a situation where someone constantly goes back and forth trying to do the “right” exposure. The best example of this is someone who thinks that if they enter a room with their left foot, bad things will happen. Here, the therapeutic response would be for them to enter with their left foot. The problem is that they then associate their right foot with the problem foot, so the therapeutic response would become for them to enter with their right foot. They’re playing a never-ending game of Hokey Pokey, where no matter what they do, they’re still triggered. Here are the ways of dealing with a situation like this.

Treatment Solutions:

• Engage in any behavior (for example, walking into the room with either foot) while accepting that perhaps it was the wrong one.

• Come up with a phrase that conveys irrelevance. This can be any phrase that’s easy to connect to, and some people find it especially helpful to use a nonsensical phrase. For example, say ‘oogly boogly’ and just walk into the room without choosing a specific foot to enter with.

• Don’t ruminate about it after the fact. It can be easy to fall into the trap of figuring out which response was the "right" one, but this is ultimately detrimental. It's much better to avoid ruminating after the fact and just move on with your life.

4.   Challenge: When Exposures Turn into Compulsions

This Challenge happens in two forms: 

• 1st form: Repeating exposures again and again until it’s done correctly. An example would be someone who has OCD, where they avoid walking into a room with a bad image. So, the exposure for them is deliberately walking into a room with a bad image in their mind. Unfortunately, when they perform this exposure, they feel as though it wasn’t intense enough, so they do it repeatedly to try to feel the level of discomfort they associate with a successful exposure. In essence, their exposure is now a compulsion.

• 2nd form: Checking/testing compulsions: I’ll illustrate this challenge with the example above of someone with Pedophilia OCD. Their homework is to go to the park and sit on a bench while kids are playing to combat the narrative that they're attracted to children. The problem becomes that they start doing this exposure to test how their OCD is doing overall instead of doing it to trigger themselves. They sit on the bench and hope for their Pedophilia OCD to evaporate, constantly testing how much they’re triggered. This is problematic because it defeats the whole purpose of exposure therapy, which is to endure triggering situations. Additionally, it runs the risk of having their checking turn into a compulsion in it of itself.

Treatment Solutions:

As discussed, this can take two forms:

• For repeating exposures, I recommend only doing the exposure once, even if it isn't perfect. We're not trying to do "perfect" exposures; we're trying to cope with OCD.

• For checking/testing compulsions, it’s critical to only do the exposure as prescribed in therapy. Set out a time and place each week to do the exposure so that when the exposure is engaged, it’s exclusively for the sake of the treatment, and not as a testing compulsion. Therefore, if one finds themselves doing it outside of that demarcated session, it’s easy for them to recognize that what they’re doing isn’t exposure work, it is checking and testing if their OCD is still around.

5.  Challenge: “I Understand ERP, but when triggered, I feel stuck. I feel like I’m in ‘OCD land’ when I am triggered.”

We hear variations on this line all the time at ADO Psychology Center. The challenge here is that when an OCD sufferer experiences the distress caused by their trigger, it feels insurmountable, which causes them to feel unable to apply the therapeutic skills that they have learned, even though when they’re outside of the triggering situation, they understand the therapeutic response perfectly well.

 Treatment Solutions:

• The best way to deal with this challenge is to pre-commit to a specific response for triggering moments. The more deliberate and explicit the plan, the more likely you are to follow through with it in a healthy, therapeutic way. There are many directions to take here, so feel free to incorporate what feels effective:

• Say “thank you, mind” to the distressing thoughts. This can help extract you from ‘OCD land’ and back into reality, recognizing that just because your mind sent you a triggering thought, it does not mean that you must respond to it. You can just acknowledge the thought and move on.

• Recognize that the doubt was triggered by a “what if” and not from concrete evidence to ponder over.

• Choose irreverence. Commit to making a joke about the OCD thought when triggered. ‘I’m afraid that I’m going to stab someone when I hold a knife. I’ll probably stab everyone, including every single person in the whole world’ Exaggerate it to the point where it’s nonsense.

• Alternatively, transform content-specific distress into general distress. Instead of hyper-focusing on the OCD content, recognize the general distress that is being experienced. Then, treat the distress the way one would treat any distress. Maybe the answer is going for a run; maybe it’s listening to podcasts while painting. Whatever it is, it becomes much more approachable if we frame it as just another generally distressing moment instead of as a debilitating OCD specific doubt that must be addressed.

• One tactic I love is shifting goals, from engaging in anxiety-reducing behavior to practicing value-driven behaviors. If our direct objective is to reduce anxiety, that’s not going to work. If our end is to live according to our values, we have a much greater chance at success. Shift attention back to whatever values-driven activity was being pursued before the onset of the OCD trigger. Again, it’s about living by our values, not getting rid of nonsense OCD content.

6.   Challenge: “How do I make decisions when I keep going down rabbit holes trying to find the “right/correct” answer?”

This is where a person has real decisions to make, but whenever they try to weigh their options, they spiral into unhelpful OCD rabbit holes. This typically happens when people need to make big decisions in life. ‘Do I want to propose to my partner, or do I feel like I’m forcing this relationship and should walk away?’ 'Do I want to stay religiously involved or live a more secular lifestyle?' These are tough questions for anyone, but for people with OCD, it’s often the case that they explore every possible answer and repercussion to the point of not being able to decide at all. OCD challenges them constantly, making them ask: 'How do I really know what I'm feeling here? What if I choose the wrong option and my life becomes ruined forever? How do I know what I truly believe?'

Treatment Solutions:

• Recognize that in life, there is no such thing as a right/correct decision, and whatever decision we end up choosing, we cannot and will not be 100% certain about how it will turn out. This is part of being human.

• Recognize how your current (obsessive) methods of trying to find an answer haven’t been working. So, instead, commit to going down a different (more helpful) path. Instead of endlessly obsessing and ruminating, talk to a mentor or a trusted friend and glean how they would approach it. Use their methodology as a guide for you to work through your options and make a decision, and once you do, don’t look back.

• Think about other scenarios where the question/dilemma would be more appropriate and contrast those scenarios with this one to gain insight into whether your current circumstances warrant the decision making process you are about to delve into.

• If you are still feeling stuck, put off committing to deciding for a week and make sure not to engage thoughts about it during that time. Things tend to become clearer when we stop ruminating about them, thus making it easier to decide.

7.   Challenge: “I can’t seem to stay motivated throughout the week to stay committed to the therapy homework!”

Unfortunately, people still think that all that goes on in therapy is a weekly conversation about all the ways your parents came up short. In truth, therapy is a difficult process where progress happens as much outside the confines of the 45-minute session as in it. For treating OCD, this is especially the case. Exposures and response prevention are not easy, and it makes sense why people have trouble putting in the day-in-day-out grind that it requires. Nevertheless, tackling OCD requires commitment from the patient to what they and their therapist decide to do that week. Here are some recommendations to help stay on track during those weeks where all you want to do is quit.

Treatment Solutions:

• Create a timeline with a final goal in mind, and then map out smaller goals that need to be accomplished along the way. Keeping the final goal in mind can help you stay motivated to accomplish the smaller goals. It’s hard to do an exposure when it seems like there is no point. Therefore, it’s important to remember the larger goal that you are heading towards.  

• Alternatively, write a motivating statement and find reasons to stay committed. Picture what life might be like if OCD wasn’t a factor. ‘What could I accomplish? How would it feel like not to have to deal with the burden of OCD?’ Review this a few times daily and consider setting reminder alarms to keep on track.

• Create a reinforcement schedule for daily goals, weekly goals, and the ultimate goal of E/RP. This could include anything from treating oneself after accomplishing the exposure to having a friend to report to and receive positive feedback. Having a friend to report to can also create a sense of accountability that could be very helpful (see below).

• Likewise, some people find it helpful to send twice-daily emails to someone they trust, once in the morning and once at night. The email in the morning helps set their intention to do the exposure homework, while the email in the evening holds them accountable.

8.   Challenge: “I’m doing exposures, but the distress level remains the same throughout the exposure!”

Here, the patient bravely engages in their exposures–something we should laud– but continues feeling just as much pain as they did when they started this particular exposure. Aren’t exposures meant to make people with OCD feel better? When this happens, patients with OCD may wonder why they’re putting themselves through such an excruciating ordeal if it’s not even going to work for them.

Treatment Solutions:

• Feeling unwavering pain during exposures is an extremely common occurrence, particularly when the focus is on waiting for distress levels to subside. Here, we must change our intention from “decreasing stress levels” to instead emphasize “tolerating” them. The goal of exposures should NOT be focused on decreasing distress levels. Instead, the goal should be tolerance and acceptance. Fortunately, when we focus on tolerance/acceptance instead of distress mitigation, we usually feel decreased distress as well (But only if we don't focus on it!).

9.   Challenge: “I’m doing exposures, but my OCD is not getting better!”

This is very similar to the previous challenge, except that here, they feel that their cumulative exposures haven’t helped with their OCD. I empathize with people who feel this way because I know how disheartening it must be to perform exposures continually and still feel no relief. For these people, it’s going to take more introspection and hard work to feel better, but they have the ability and the right to live life without the chains of OCD.

Treatment Solutions:

• Here, the main approach is to investigate what’s behind the lack of improvement.

  • Maybe you’re using exposure homework as checking compulsion. If so, ensure that we’re only doing exposure homework as prescribed (see the solutions above by challenge #4).

  • If the reason is that you’re not committing to response prevention, then you must recognize that exposure is only one piece of the puzzle. Response prevention is a major component in successful treatment.

  • Bring any unidentified compulsions to the surface. Usually, these are mental compulsions, so once you figure out what they are, treat them as you would any other compulsion and refrain from engaging with them.

  • If the problem is that you’re ‘buying’ into the OCD content even when refraining from compulsions, or perhaps you are ruminating, then you must learn how to convey irrelevance to the OCD content instead, and make sure not to ruminate.

  • Perhaps the problem is continually giving in to minor compulsions, and the solution is to stamp out that behavior. Think of OCD as a fire, where the compulsions are sources of oxygen. Just like the fire will take oxygen from wherever it gets it, so too will OCD survive on even the slightest compulsions.

10. Challenge: “Even when I succeed in response prevention, I still feel like I have an unresolved itch!”

This scenario occurs when patients admirably achieve their goal of response prevention but still don’t feel 100% better. Let’s look at an example here. Daniella has Checking OCD, where she can’t go to sleep without continually checking that the oven’s off. She somehow musters up the strength to refrain from checking, but she realizes that she is still bothered by her obsessive doubt of whether the oven is on or not. Why hasn’t the feeling gone away?

Treatment Solutions:

• First, this makes sense! Resisting compulsive behaviors will be uncomfortable. When this feeling occurs, we want to focus on value-driven behaviors instead of living to scratch the proverbial itch. Ultimately, we feel best when we live life according to our values, and the itch tends to then dissipate on its own.

• It can also be super beneficial to separate the itch feeling from the specific OCD trigger and treat it as we would with any other unresolved itch. Forget about what's causing this itch and ask instead what can be done to deal with an itch in general, such as choosing to engage in fun/relaxing activities.

• Release energy in positive ways (exercise, socialization, engrossing oneself in chores or helping others).

Exposure and Response Prevention (ERP) therapy can be a powerful tool for overcoming anxiety, but it's not always a walk in the park. It's common to have doubts about whether it's working and to feel uncomfortable during the process. You might even find yourself wanting to fall back on old habits that used to help you cope. It's important to remember that this is normal. With consistent effort, patience, and the guidance of a skilled therapist, you can navigate these challenges and come out the other side with a stronger sense of control and a brighter outlook. Likewise, this list can be helpful for therapists in supporting their patients through the ERP process.

Disclaimer: All characters and scenarios in this post are entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.