So you think you have OCD... Now what?

by Jacob Weissman, LPC, specialist in OCD, Anxiety, and Men’s Mental Health

Something has felt “off” for a while now. Maybe it’s felt “off” for as long as you can remember. You stumbled across a YouTube video, or maybe a Reddit post about something called obsessive compulsive disorder- aka OCD. Suddenly it all makes sense. All of the bizarre thoughts, the impulses, the feelings of “I have to do this… or else”. You’re now convinced you have OCD. The natural question is, of course, now what? What do you do about it? What does treatment look like? What’s the first step? The goal of this article is to serve as something of a reference for treatment and a how-to guide for what comes next.

Step 1: Double-check your understanding

The first step is to make sure your hypothesis is actually sound! Lots of things may seem like OCD that actually aren’t, and vice versa. I can’t tell you whether or not you have OCD (that’s where step 2 comes in), but I can tell you a little about what it tends to look like.

Let’s start by breaking down OCD into its constituent parts- obsessions and compulsions.

Obsessions:

Obsessions are intrusive, unwanted thoughts, feelings and/or urges that the individual experiences as distressing. Individuals with OCD often describe these thoughts/urges as “sticky” (they become easily “stuck” in their mind) and tend to experience these thoughts, urges, etc as urgently needing resolution.

Compulsions:

Compulsions are what individuals with OCD do to try and resolve their obsessions. Compulsions are mental or physical acts, and are almost always repeated. Individuals with OCD usually experience their compulsions as “urgently” needing to be done, and find only temporary relief from them.

The overall experience:

The obsessions and compulsions that make up OCD form a cycle. The cycle starts with an intrusive thought (the obsession). This obsession distresses the individual with OCD, who then desperately finds a way to make it go away. This is where the compulsion comes in. The individual experiences a little, short-term relief from the compulsion, but… then the obsession/distress comes raging back. So, they do the compulsion again. And again. And again. Often, both the obsessions and compulsions grow over time, as the individual makes their life smaller and smaller, in an attempt to avoid distress.

Example:

For example, an individual with religious-based OCD (religious scrupulosity) might have experienced an intrusive thought like, “What if I committed an unpardonable sin, and my soul will not be saved?” To resolve this, they then start doing extensive internet research, repeatedly asking their local faith leader questions, and engaging in elaborate, compulsive prayer. This causes them to worry about their relationship with faith more and more, as they begin focusing more and more on their potential “wrongness”. Nearly anyone in their religious community would recognize their concerns — and the extensive religious rituals they compulsively engage in — as beyond the pale. It is not a passing concern they are able to shrug off after a conversation with their pastor. It is a massive knot of distress, obsession, and compulsion centered around their faith.

Step 2: Find a Professional

The second, and perhaps important step, is to reach out to someone who treats OCD. If you’re in Houston, I’m happy to help. You can reach out to me for a free consultation using this link here. Otherwise, the best way to do this is by going to this site run by the IOCDF. The International OCD Foundation is the premier non-profit dedicated to helping people through their OCD journey. Here you’ll find a search bar where you can enter your zipcode. This will populate a list of OCD therapists in your area.

But, how do I know if my therapist is good?

Finding a therapist who says they treat OCD is relatively easy. Finding a therapist who treats OCD well- that’s the hard part. OCD treatment is highly specialized — meaning generalists, who tend to have lots of experience treating “run-of-the-mill” anxiety — may struggle to effectively treat OCD. The most popular, effective treatment modality for OCD is called ERP: Exposure and Response Prevention Therapy. There’s a comprehensive overview of ERP therapy on my blog here. My general advice is to look for a therapist who says they use ERP when seeking out OCD treatment. This is not a guarantee of a good therapist, but it’s a good sign at the very least.

Step 3: Treatment

Once you’ve found a therapist, then the real work begins. OCD treatment. Treatment looks different for everyone, but these broadstrokes will hopefully give you an idea of what it might look like (and whether you’re getting good therapy).

A good ERP therapist will start by walking you through a full OCD asessment. The Y-BOCs is the most popular OCD assessment. A full assessment is important, as this will help the therapist determine, first, whether or not you have OCD, and, second, what your specific obsessions/compulsions on. There are many different subtypes of OCD, and knowing yours is a very important part of making sure the proper symptoms are being treated.

After the assessment process, an ERP therapist will then build an exposure hierarchy with you based on your specific symptom profile. This usually looks like a rank-ordered list, from most to least distressing, of potential exposures based on your fears/obsessions. Clinicians generally rank an exposure hierarchy using a SUDs (Subjective Units of Distress) scale. SUDs are usually ranked on either a 1-10 or 1-100, with 1 being no distress and 10/100 being as much distress as you can imagine (think full on panic attack). I prefer using 1-10. In my experience, it feels more intuitive for people than 1-100. Your therapist will use this exposure hierarchy to pick a good “starter” exposure for you. I find it is often times most helpful to start with an exposure in the 4-5 range. This is something that elicits a good amount of distress, but doesn’t completely overpower the clients ability to think. This allows the client to mindfully watch their distress, without pushing it away. I spend about 15-20 minutes on an intro exposure, checking in with my client periodically about their level of distress. I’m looking to end the exposure once their distress is about 50% of their originally reported level (ie: 2 for 4/5 starting SUDs). After an exposure ends, a good ERP therapist should then spend time debriefing. It is especially important to compare expectations before the exposure to what actually happened. This helps to promote inhibitory learning- a process where the brain learns to have a new relationship with the obsessions that drive OCD.

Once you have this process down, the therapist will work with you to move through the treatment hiearchy. You’ll do harder and harder exposures, but, thanks to treatment, they won’t feel impossible. Your therapist will also assign you homework throughout the process. You’ll probably leave every week with some exposures to try at home. After 12-20 weeks of weekly sessions, you should feel signficantly better. At that point, your therapist will likely recommend terminating treatment- or moving down to a “maintenance schedule”. At this point, you will know the ins-and-outs of OCD, and will know how do much of the work of treatment on your own. Congratulations, you’ve taken back your life and become an OCD-expert!

I hope this is a helpful premier for those beginning their OCD journey. It can be daunting, but there is help available. Simply starting the journey is often the hardest part. If you have questions about OCD treatment or would like to work with me, you can contact me here. I am always happy to help.