A Preface to the Blog

I want to start these articles with an important question think is essential for a reader to ask themselves: “Why am I reading this?”

So often we can fall into traps of overutilizing online resources. In the OCD world, an action alone is not necessarily skillful nor compulsive; it is the intent behind the action that determines whether or not it is healthy and useful. If you determine that reading through this blog is likely going to provide you new and useful information, it is likely a skillful action. If, however, this is the umpteenth time that you have been combing through blogs, Reddit threads, Facebook groups, and publications, it is worth considering whether you are compulsively trying to answer an OCD question in your mind.

Ask yourself if you are obsessing about a topic

• How do I know if I have OCD?

• How do I know I don’t want to hurt someone?

• How do I know I’m not racist?

• How do I know what’s safe?

• How do I know if I’m gay?

• How do I know if I’m straight?

• How do I know if I’m a pedophile?

• How do I know if God exists?

• How do I know I’m in the right relationship?

• What are signs of being a murderer?

• What if my OCD is different from others?

• How do I know if my OCD is treatable?

Choose your next step

One way to help decide if you are compulsively searching for information is to ask yourself if you’re past the point of diminishing returns. Are you no longer getting a good return on investment from the information you’re consuming? Do you find yourself reading similar information over and over? Are you no longer frequently learning new and useful information that is likely to lead you to treat your OCD?

If the answer to these questions are yes, it may be time to reach out to us to guide you down the next steps, as more info alone may not provide an impact. If however you think this information can be useful for you, read on! I hope these posts can help you in your journey towards your goals.

What is OCD?

Obsessive Compulsive Disorder (OCD) is a broken alarm system that can sound both frequently and intensely. Those with OCD frequently experience thoughts or feelings that something in their lives needs attending to and that ignoring the target of their obsessive thoughts may lead to a terrible result.

Even though one may rationally know that the alarm is nonsensical, the challenge is that it feels completely real. The broken alarm often comes along with a “gut feeling” that there is danger and if nothing is done about it one’s life will be ruined forever. (This is why the phrase “trust your gut/intuition” can be a terribly toxic phrase for anyone with OCD). As the name of the diagnosis suggests, someone with OCD responds to this threat with obsessions and compulsions. 

Obsessions

Naturally, someone with OCD experiences an urge to deal with this supposed threat. While the “threat” varies from person to person, one axiom is that a person with OCD has difficulty tolerating the uncertainty that this threat will manifest, and therefore obsessively worries about this topic. 

Compulsions

In addition to constantly attending to this topic, a person with OCD also try to get rid of the uncertainty by engaging in what are called “compulsions”. A compulsion is any action or thought that is done intentionally to try to figure out or fix the threat that the broken alarm system is warning about.

Is it Working?

The problem is this “solution” not only doesn’t work but instead makes things worse! Like paying attention to a child throwing a temper tantrum, the more one pays attention to or tries to fix the “problem”, the worse the experience gets and the more likely it is to repeat (if that metaphor doesn’t work for you, think of scratching a mosquito bite or pouring gasoline on fire. I’ve got a million more).

By responding to this broken alarm, the brain gets that signal that the alarm was useful and should be sent again. Therefore, therapy for OCD centers around learning how to abstain from reinforcing that signal so that it has less control over our lives.

OCD Themes

There are certain ways the OCD community categorizes the themes that people obsess over. It’s important to note that treatment-wise and clinically speaking these variations are completely irrelevant. All OCD topics are treated in nearly the same way and respond to treatment equally well. The reason that these themes are useful to mention is that they can help us recognize and label our OCD and provide a shorthand in discussing the specifics of our experience. For a more in depth look at various OCD Themes, click here.

What are common themes of OCD?

A number of these themes and the compulsive questions related to them are as follows:

• Existential OCD: Concerns about the meaning of life and existence, and sometimes the psychological implications of these concerns. What if I’m not living my life the way I should?  What if I go crazy from these ideas?

• Sexuality/Gender OCD (formerly called HOCD): What if my sexuality or gender isn’t what I’ve thought it is? What if I’m making the wrong choice?

• Harm OCD: What if I snap and harm or kill someone?

• Cancelled OCD: The fastest rising OCD subtype as of this posting in 2021. What if I say/said do/did something racist, sexist, homophobic or otherwise inappropriate that gets me “cancelled” or rejected by everyone around me?

• Pedophile OCD (POCD): What if I’m a pedophile?

• Relationship OCD (ROCD) : What if I’ve chosen the wrong partner, or what if my partner wants to break up with me?

• Past experience OCD: A compulsive desire to revisit past experiences. What if I harmed, cheated on, or sexually harassed someone? 

• Back-door OCD: OCD about OCD. What if my OCD is untreatable? What if I’m not doing therapy right? What if I’ll have OCD forever? What if I don’t actually have OCD?

• Contamination OCD: What if I get sick or harm someone by getting them sick?

• Metaphysical contamination: Disgust or anxiety around touching or spreading something that is contaminated by an idea or concept.

• Hyperawareness: An obsessive awareness of natural processes in the body such as blinking, breathing, or swallowing.

• Just right OCD: A compulsive urge to repeat actions or do them in a certain way until there is an internal feeling of “correctness”.

• Scrupulosity OCD: Fear of committing a sin that results in a punishment towards you or others.

• Suicidal/ Self Harm OCD: Fear of impulsively comitting suicide, sometimes due to “going crazy”, or becoming depressed.

• Pure O: A category of OCD that can include any of the above, with compulsions that are mostly internal such as reviewing evidence or repeating a mantra.

Are certain OCD themes harder to treat?

While the subtypes above are unrelated to treatment course and outcome, there is one variable that is: the degree of insight the client has over their OCD. In other words, it is the amount of healthy skepticism a client has in regards to their broken alarm system.  If a client refuses to engage in exposures because they are convinced there is a significant risk to challenging their OCD, therapy in turn can be more challenging. 

On the other hand, when a client describes their OCD theme to me with a “I know this sounds crazy, but...”, it is often a sign that they are willing to learn how to deal with their thoughts in a healthier way. In these situations there is a great chance of a quicker recovery.

Why your OCD Therapy Didn’t Work

If you’re motivated to work on your OCD and willing to face challenges, your OCD is treatable. If you’ve gone to therapy and it didn’t work, there’s a reason for that which can be fixed. The most common reason for a lack of results is the use of a treatment modality that doesn’t work on OCD.

Why didn’t therapy work for me?

• Talk Therapy: This is the most common reason for the failure of treatment that I’ve seen. Talk therapy is perhaps the most common form of therapy out there, and as the name suggests, it’s all talk. Sessions are mostly about a patient venting and receiving empathy from their clinician. Because venting can be cathartic and talk therapists provide tons of reassurance, the sessions can feel relieving but do not provide any long term change. In fact, because reassurance is such a huge component of talk therapy, it can often exacerbate the problem.

• Psychodynamic/Psychoanalytic Therapy: A large part of this group of therapies focuses on exploring issues on a “deeper” level by analyzing the meaning behind a patient’s thoughts. As anyone with OCD has experienced, trying to “figure out” the thoughts often makes them more intense and harder to deal with.

• Cognitive Therapy (Cognitive Behavioral Therapy/CBT): I included CBT in parenthesis because while the Behavior Therapy part of CBT is effective, many CBT clinicians just apply the Cognitive Therapy side of this treatment modality. Cognitive Therapy involves identifying illogical thinking patterns in your mind and challenging them. However, this often misused to try to prove that the thoughts are illogical and the fears won’t happen, which is just another form of compulsing.

Did my clinician treat me with an effective therapy in an ineffective way?

Did you undergo a gold standard treatment such as Exposure and Response Prevention (ERP) or Acceptance and Commitment Therapy (ACT) and not get the results you were looking for? The reason your treatment may have been ineffective is a more complex topic and will require an explanation of what effective therapy looks like. Let’s take a deeper dive in the next article.

Does ERP work for OCD?

Exposure and Response Prevention (ERP) is often the first treatment modality for OCD that is suggested, and for good reason. It has decades of strong research behind it and is considered to be one of the most effective treatments for a disorder ever created within the field of psychology. ERP falls under the umbrella of Cognitive Behavioral Therapy (CBT), which are treatments and techniques that target how the client is thinking and/or acting. As the name suggests, ERP has two components: exposure and response prevention. 

Exposures

During exposures, a therapist works with a patient to practice staying with a distressing situation or thought without ritualizing or avoiding. This can sound intimidating, but it’s important to note that the level of challenge is always chosen by the patient. Additionally, the process quickly starts to feel empowering and relieving as the patient learns that they can survive what they thought would overwhelm them. 

Exposures can be in vivo, wherein a patient will be tasked to sit with an observable discomfort such as touching a contaminated object or looking at an image they fear being attracted to, or imaginal, wherein a patient will be tasked to sit with a thought or premise such as “maybe I will harm someone” or “maybe I’ll go insane.” 

With the clinician’s guidance and support, the patient learns to navigate through the distress the OCD brings up, rather than having that distress control their lives. 

Response Prevention

Sitting with exposures helps the patient practice how to engage in response prevention. Response prevention is the practice of preventing ourselves from choosing a compulsive response to the OCD theme when it pops up. Because during exposures we practice resisting the urge to compulse, in our day to day lives it gets easier to apply that same skill. 

Through a combination of exposure and response prevention, we hone our skills to disempower our broken alarm system, robbing its signals of any relevance to our lives. With practice, these signals become weaker and weaker and quality of life improves considerably!

That said, even the gold standard of treatment could use a little polish. In my next post I’ll discuss why sometimes even ERP does not generate results and how that can be remediated.

Why your Exposure Therapy Didn’t Work

I treat many patients who report they’ve been to an Obsessive Compulsive Disorder (OCD) specialist who used exposure and response prevention (ERP), diligently completed all therapy homework assigned by their clinician, and received no results, dissatisfying results or rebounded to their previous level of OCD within a short period of time following termination. 

Rest assured, this is a pattern outside of my personal experience. While the non-response rate to ERP is great compared to other treatments, it remains that 14-31% of clients do not respond to treatment. Even more alarming than this statistic is that 50-60 percent of clients report undergoing at least a partial relapse after treatment!

Over my years of treating hundreds of patients, reviewing well established research of the past 15 years, and receiving guidance from some of the most brilliant OCD specialists of our time, I am confident as to why there are so many cases where exposure therapy didn’t work and what can be done to remediate this pattern. OCD treatment is so effective because we’ve created a brilliant form of therapy for it. OCD treatment is falling short because we are implementing the treatment in not just an unoptimized, but a problematic way. 

Emotional processing theory: Well intentioned and outdated

This happens a lot in the field of healthcare. Famously, many medications were developed not because scientists knew exactly how or why they worked, but rather discovered that they do work, and afterwards developed theories as to why. Sometimes the initial theories are correct and sometimes they are not. The research for years now has frequently shown that the model that was developed to explain why ERP is effective has many holes in it.

If you’ve gone through unsuccessful ERP based treatment, you were probably taught how it works along the following lines: The root of OCD is that a broken alarm plays in the brain, warning against a proposed danger, and the OCD sufferer responds to that signal with distressed reaction (compulsing). This is treated through exposures, where the client resists the urge to compulse when they are triggered. As a result of doing so, the client unpairs the brain’s connection between the OCD theme and distress and the distress goes away.

The problem is, this rationale has long been disproven. A number of studies show that:

• Habituation is not related to treatment outcome

• Complete habituation is not often possible

• If the patient’s OCD theme switches, the client will have to start from square one as habituation to a former theme would not apply to the new one. (This point in particular may be why relapse after OCD treatment is so high).

Along with these fallacies comes another issue. Placing pressure on the exposures to reduce distress makes them more likely to become targets of obsessions. Clients become more likely to obsess that they are doing exposures incorrectly and that their distress will never die down, and develop compulsions around their exposures, such as doing them more frequently, to try to assuage that fear. Of course as all compulsions do, this only makes the OCD worse.

Lastly, the ERP model reinforces the maladaptive concept that anxiety is bad and undesirable. As with many thoughts and feelings, the more power we lend a concept by dreading it, the more likely it will be to pop up. 

So all hope is lost: ERP has a huge relapse rate and the theory used to explain it is built on a flimsy premise, right? But wait a minute! ERP still works- it has amazing success rates- even though EPT clearly doesn’t explain why. If we can figure out what is really fueling the effectiveness of therapy and focus on that, we can take a great treatment and enhance it even further.

Along comes Inhibitory Learning Theory

ILT is by no means a new and untested theory. A landmark paper on ILT for OCD was written back in 2008 and since then this approach has gained more and more support, with some of the most reputed OCD researchers of our time contributing to its development.  A quick academic search of OCD treatment articles written in the last ten years will find a trend of enthusiastic support for this theory. Sadly, as with much of the healthcare world, there is a sizeable gap between research and practice. As a result many modern practitioners have not even heard of this years old shift in theory. 

The premise of ILT is built around fundamental truths in psychology. New learning does not replace past learning. When we learn new ways of relating to our OCD themes through ERP, we don’t erase our previous associations with it.

Here’s a metaphor: I used to have a contentious view of my dad, but now we have a great relationship. Our present relationship doesn’t make me forget the difficulties we had in the past: occasionally my dad will say or do something that elicits difficult feelings in me that used to be more frequent in our relationship, but this distress is no longer the default response. Instead, the closeness I have with him today is the louder of those two voices. 

The same goes for treatment of OCD. Because someone with OCD has a broken alarm system in their brain, they may always have a predilection to experience a false alarm that something is wrong. However, through exposures they can learn a new way of relating to those signals that becomes the default response they naturally turn to. 

By structuring the ERP to work in this way, we can expect much more consistent results. No longer do we view the results of therapy as dependent to a variable that we are not in direct control over (our emotions). Instead, the goal of therapy is very logically within our grasp: it is about establishing a healthier relationship to anxiety by learning how to relate to it in a different way. When we learn to ascribe irrelevance to the brain’s broken signals by not responding to them, we rob those signals of any power or influence they have over our lives. The end result is practicality the same as if the distress was abolished: a patient’s life goes on unaffected and untarnished by the OCD signals. They become empowered to navigate throughout life as if the signals never existed. 

So there you have it: the theoretical underpinnings as to why EPT is maladaptive and how ILT fixes those holes. Next I will discuss what concrete changes can be done to the implementation of ERP to reflect this more effective theoretical underpinning.

How to Treat OCD Effectively

A clinical tool for treating OCD

In my previous post I discussed the differences between two ways of conducting ERP: The outdated and disproven Emotion Processing Theory (EPT) and the more contemporary and in my experience successful model called Inhibitory Learning Theory (ILT). In this post, I break down some of the most important differences between how ERP is conducted based on either of these models, and the rationales that each model uses to justify the techniques used. This is a lot of nuanced information, so if you find yourself confused please refer to earlier posts on this blog for more fundamental information before returning to this chart.

“Cancelled” or “#MeToo” OCD

OCD and MeToo: the Fastest Rising Theme of our Time

At some point in your life you’ve probably had some misconceptions about OCD. One idea you might have been that having OCD means being obsessed with cleanliness and handwashing. Interestingly, there’s a reason behind this stereotype. Folks with OCD often struggle with tolerating uncertainty, so when they become aware of a nebulous threat, their OCD theme will sometimes latch on to it. Folks began to gain more awareness about OCD in the 80’s just around the time of the HIV/AIDS crisis. For years, knowledge on how the virus was contracted and spread was unknown and the concept was replete with rumors and misinformation. For many of those with OCD, their themes latched on to this fear and they developed contamination themed OCD. It’s my hypothesis that around the time that society developed an increased awareness of OCD, contamination themed OCD was the most prevalent theme.

I’ve noticed a similar trend amongst the patients I’ve treated in the past five years. One of the most impactful movements on our collective conscious in the past decade has been the #metoo movement. This movement calls upon society to legitimize survivors of sexual assault and hold those who commit these assaults accountable. As a result of this movement, some prominent figures have been “cancelled”, which is to say that as actions that they have taken to infringe upon the rights, comfort, and safety of others were revealed, there was a collective move to reject these figures and their work. When a person becomes cancelled they often lose their job, their friends, and sometimes even their family.

While the movement has garnered widespread support, many folks with OCD have noticed their fears latching on to the threat of being cancelled. The specifics of this theme have changed a bit over time. Around the time of #metoo many of my clients had obsessive fears that they had or would sexually harass another individual and become rejected by everyone around them. Some of these clients would obsessively review past experiences, such as parties or dates, to try to ensure that they hadn’t violated other’s boundaries. Others would hold their hands by their sides when around peers to ensure they wouldn’t impulsively reach out and harass someone. Yet others would try to block out, prevent, or obsessively analyze their intrusive thoughts around harassing people.

Since then, I have noticed more variations of this theme, with subsequent rises in fears of saying, thinking or doing something racist, sexist, transphobic, or homophobic. Clients may fear that they will commit an impulsive inappropriate action, that they have posted something on social media that will be (mis)construed as inappropriate, or that they have an opinion that is “known” to be unacceptable to everyone except for themselves. They will often review past, present, and future for signs that they will be rejected by those around them. 

How is this treated?

Trick question! If you’ve read my article about OCD themes, you’ve already learned that all OCD themes are treated with the same principles, and this theme is no different. The goal of therapy is to help the client learn how to make decisions based on their own goals and values, rather than being controlled by an obsessive fear. In this case, the client learns how to tolerate the uncertainty that they may have or will do something that will result in them being rejected by everyone around them. Behavioral exposures include posting on social media, having conversations, and attending events to the degree that the client determines they would normally do if they didn’t have OCD. Imaginal exposures include tolerating the uncertainty that there will always be a possibility the client has or will do something that will get themselves cancelled.

I have found those with this theme to be just as treatable as any other, but there is one barrier to treatment that is common to this theme and worth mentioning. Sometimes prospective clients will delay seeking treatment for fear of revealing the content of their thoughts or actions to a clinician. The fear of getting confirmation that they are a terrible person keeps them away from therapy and stuck in the vortex of anxious thoughts in their mind. Of course once the client commits to bringing up their concerns in treatment the OCD can finally be worked on and they can start to live more peaceful and healthier lives. If you see yourself within this text I urge you to delay no further in getting the therapy you deserve. 

Pornography Addiction and OCD

It is very common for those who struggle with high amounts of distress to utilize drugs or alcohol as coping mechanisms. Although an overutilization of these substance comes with its own set of problems, the temporary numbing the substances provide can be very tempting to indulge in. But what about when these substances exacerbate distress rather than provide relief? With OCD, this is often the case. For many folks with OCD, marijuana and alcohol increase the frequency and intensity of intrusive thoughts.

In comes pornography addiction, which is a noticeable trend amongst patients that I’ve seen for OCD. These clients turn to pornography to “numb out” from their obsessions. Because pornography is very engaging, it can distract folks for hours. However, trying to suppress intrusive thoughts is a compulsive behavior that ultimately exacerbates OCD symptoms.

An overutilization of pornography

• can lead to increased isolation,

• can deny the user opportunities to strengthen their ability to tolerate distress, and

• empowers the intrusive thoughts by ascribing relevance to them.

One other reason for the overutilization of pornography is mostly unique to folks with sexuality themed OCD. These folks may turn to pornography to try to reassure themselves about their sexual preferences by testing how their mind or body react to certain images or videos. 

Pornography addiction in these cases is treated by focusing on the distress that porn usage is trying to “solve”. By learning how to deal with the OCD signals in a healthier way (through Cognitive Behavioral Therapy), the client no longer experiences as strong of an urge to numb out. Additionally the client learns to proactively schedule in more value-centric activities to both decrease the time they have to compulse and increase the satisfaction they get from their life. This leaves the client with less time, urge, and need to over utilize porn. 

Pornography addiction can also comes with fear and shame attached to it. For example, some clients may have a version of “past event” OCD, where they fear they may have seen unethical pornography and that this implies something about their character or future. In general, pornography usage can feel like a challenging thing to talk to a professional about. If you have identified with any of the above and are looking to work with a professional who has experience treating these topics compassionately, nonjudgmentally, and effectively, please reach out here for a free consultation.

How Effective is OCD Therapy?

Clients are often hesitant to begin therapy because it can feel like a gamble: it requires an investment of time, money, and energy in the hopes of the reward of a better quality of life with no guarantees that it will work.

Luckily, there are ways of reducing the risk of investing in therapy that doesn’t work. One way to determine how successful therapy is likely to be is by looking into overall effectiveness rates of different types of therapy. For example, a brief search into Exposure and Response Prevention (ERP) will find that it is considered the gold standard treatment for OCD and has high rates of success. 

The challenge remains, however, in finding a clinician that is competent at delivering therapy effectively. I’ve heard many disheartening stories of clients who had gone to clinicians who claimed to be proficient at treating OCD using ERP but failed to deliver the treatment effectively.

Does ERP work?

To aid prospective clients in making a rational decision, I’ve presented below my effectiveness rates in treating OCD compared to other clinicians. For information on how I calculated these numbers, you can continue to read below the table.

Good ERP for OCD, done by an expert, should have clear and measurable results on your life. If you are working with a clinician, even myself, who is not clearly having an effect on your life, I encourage you to have a conversation about whether the treatment is worth it to you. For insight as to why my work may be more effective than the work analyzed in these published studies, you can refer to this link.

How were these numbers calculated?

This data is drawn from the 51 patients that I treated for OCD who completed treatment within the past two years. All patients included had a primary diagnosis of OCD and did not have any organic disorders such as significant brain damage. The numbers for “Other Clinicians” are drawn from this large study of the effectiveness of OCD treatment as practiced in multiple different settings, which can be found here.

OCD and Depression

Depression can serve as a complicating factor to OCD treatment. Luckily, with a few extra steps depression can be treated which frees up the OCD to be treated as well. There are two main ways that depression interacts with OCD.

What if I have depression and OCD?

Sometimes people with OCD will have episodes of depression that follow intense episodes of OCD. Unmanaged OCD can take a lot from our lives and distance us from the things we hold most important to us. During challenging bouts of OCD, it can be hard to connect to others, devote time to our goals, and participate in pleasurable activities. In the wake of these episodes, it is not uncommon to feel hopeless, fatigued, and depressed. Even worse, this can create a vicious cycle, where depression decreases the client’s drive to challenge their OCD, which in turn lets the OCD become more severe.

Thankfully, treating depression can be folded into OCD treatment fairly easily. In therapy for OCD, we learn that much of the content that our brain produces is not useful to listen to. We practice experiencing these signals without responding to them.  By choosing to not respond to these signals as if they have any important meaning, we rob them of their power and turn them into harmless occasional background noise. 

The same pattern of treatment works for depression. Just as OCD asks us to devote time to its demands (by checking, reviewing, and avoiding fears, etc), depression also asks us to cater to its will (by sleeping more, bingeing TV, avoiding friends, etc). When we choose not to respond to these unhelpful signals sent by the brain, we free ourselves up to instead spend our time and energy pursuing our goals and values, which in turn helps the depressive signals fade. The great part about this is that because depression and OCD can be treated using the same set of skills, once a patient learns to treat one condition they’re well on their way to mastering the other!

What if I become depressed when I do an exposure?

Another way that depression can interfere with OCD is when a client begins to feel depressed in reaction to an exposure. An exposure is an activity where we intentionally face distress and uncertainty in order to practice how to sit with it without compulsing. (As a refresher, the term compulse means engaging in an action or thought that is meant to reduce uncertainty or distress in regards to an OCD theme).  There are many different ways that a client may be tempted to compulse: they may try to push a thought out of their head, review whether or not their fear is likely to occur, reassure themselves that their fear will not happen, or try to calm themselves down with a mantra or relaxation exercise. 

One sneaky way the brain tries to compulse is to generate depression. Think about it this way: when we are depressed we feel like we’ve reached a conclusion (usually that everything is terrible and our worst fears are true). Depression can be a protective mechanism that the brain generates when it decides that dealing with uncertainty is too challenging. Instead of sitting with the distress of “I don’t know if X is true or not”, for some people with OCD it’s easier and more desirable in that moment to instead endorse the distress of “I bet X is true.” If a client chooses to endorse a depressive stance during an exposure, they don’t have to sit with the uncertainty and the intense distress that comes with it: instead they get depression, which although uncomfortable, can be less challenging than OCD. In this way, leaning into depression during an exposure is a compulsion: it is a sneaky tactic of the brain to avoid the discomfort of uncertainty. 

So how do we deal with this? We learn to respond to depressive thoughts during an exposure the same way we respond to any other thoughts that promise certainty. If my client had health OCD and during an exposure experienced the thought “I definitely don’t have cancer”, I would encourage them to respond to that thought by saying “well, I can never know for sure”, so that they could practice sitting with the distress of not knowing the answer. Similarly, if during the same exposure they noticed feelings of depression and their brain saying “I just know it: I’m doomed and definitely have cancer.”, I would advise them to do the same thing: tell their mind “well I can never know either way, and I’ll have to sit with that uncertainty forever”. When the client learns to see the depression as just another compulsion, they can identify it and work around it the same way they would with any other compulsive thought. This frees them up to fully participate in their OCD treatment in order to get the results they are looking for.

Does NOCD Work?

NOCD is an online platform through which people can receive live exposure and response prevention (ERP) teletherapy from a licensed therapist. This platform has become increasingly popular and a number of patients have asked about my opinion on it. While I cannot give firm conclusions about this program’s delivery of treatment, I can provide my impressions based on conversations with clients who have undergone NOCD treatment and clinicians who have been a part of their training program as well as results published by NOCD. 

How effective is NOCD?

Results published by NOCD suggest that its treatment is as effective as traditional ERP. In both NOCD and traditional ERP, an average of 70% of patients experienced a significant effect from treatment (at least a 35% reduction in OCD symptoms). Furthermore the study on NOCD reports that these results were reached in “less than half of the total therapist time compared to traditional outpatient ERP (Fuesner et al., 2020)”

The content within NOCD treatment seems to be very similar to traditional ERP as well. Clients that I’ve treated who previously tried NOCD report that they were guided through traditional ERP processes such as making a hierarchy and doing exposures in an attempt to habituate to their OCD themes. Therefore, if you haven't tried therapy before, NOCD has potential to be a useful option.

“NOCD Didn’t Work”

Is NOCD not working? While offering traditional ERP can be a strength of NOCD, it can also be a weakness. Traditional ERP is garnering more and more evidence that it has several shortcomings, including a high relapse rate and failing to be effective for a significant amount of people with OCD. Therefore, if you already tried traditional ERP treatment and did not get the results you were looking for, I would not be confident that NOCD would be any different. Instead, you may benefit from what I would consider to be the more up to date and effective treatment approach: the Inhibitory Learning model of ERP. To learn more about the differences between this model and the traditional model of ERP, read more here. 

OCD and Grief, Identity, and Education

OCD does not exist in a vacuum. Too often OCD treatment exclusively targets obsessions and compulsions. Severe and/or lengthy OCD can have a number of “side effects” on a person’s development that are important to address. In this article I discuss important the ancillary issues often generated by OCD that good treatment can target.

Grief and acceptance of OCD:

Here’s a story about my relationship focused OCD (ROCD): For most of my adolescence and young adult life, I had a “I’ll be happy when…” mentality. I believed that all of my distress was because I wasn’t with the right romantic partner yet: that one day I’d find someone I would be sure is “the one” and would live happily ever after. Imagine how much pressure I had built up for my relationship to perfect my life! Even though I chose a wonderful person to marry, when I realized this choice wasn’t the fix to my anxiety I was counting on, I started to feel even more anxious! I was instead faced with the challenge of accepting that my anxiety was not because of my external circumstances, but rather was an indelible part of my brain. I had to come to terms with the fact that I would likely experience some form of anxiety for the rest of my life, regardless of the choices I made. After months of hard work and effort, I can gladly say that I’ve made great strides in accepting that my fantasy of a completely anxiety free life was never going to happen, and as a result I am more in control and able to enjoy my marriage.

As a part of the therapeutic journey with OCD, we need to grieve the loss of the fantasy that a) we can achieve certainty and b) once we do we will live happily ever after. Skillfully living with OCD means accepting that we have brains that will highlight the uncertainty around things and occasionally produce challenging emotions. However, once we are able to accept that the solution to improving our lives comes from relating to our minds in a healthier way rather than pursuing a perfect answer to our obsessive question, we can begin to invest in strategies that work much better.

OCD and Identity:

When folks learn to stop obsessing and compulsing, they often free up enormous amounts of time and energy. Clients may either be unsure of how they’d like to devote these newly free resources, or have a long history of avoiding certain choices that are important to them, such as dating or applying to a certain job. OCD can gaslight us into thinking that we are less capable of taking on challenges than we actually are: a concept one client coined as “perceived fragility.” Through treatment for OCD, we learn that we are far more capable than we previously thought. We identify our goals and values and structure their lives accordingly, rather than in a way that tries to protect us from our fears.

Psychoeducation and Skill Building

Some folks with OCD obsess around their theme so much, they miss out on the opportunity to understand what the generally accepted reality is regarding those themes. Good treatment may sometimes need to provide education around a client’s OCD topic, such as reviewing what “is” a healthy relationship, what does a “good” sexual experience feel like, or how people without health themed OCD decide when to see a doctor. Additionally, the client may need to learn certain skills, such as how to communicate to a partner or set boundaries with a boss in a non-obsessive way. Of course, it is important to provide this information in a manner that does not provide reassurance, so it is often done after a client has developed skills to tolerate uncertainty. 

OCD and Trauma

Folks with OCD occasionally develop an intense fear of experiencing severe OCD again. Often this is due to an intersection of trauma and OCD. However, there are a few  different ways that trauma and OCD can interact. The differences between each scenario are important to assess because they indicate different treatment paths to help the client. There are three main ways I have identified that trauma and OCD can interact. 

Situation A: OCD about OCD (Meta-OCD).

Some folks develop an OCD theme about a fear of experiencing severe OCD again, a theme I call meta-OCD. People with this theme may obsess about the intensity, duration, content, and/or frequency of their intrusive thoughts as well as the extent to which they are following treatment correctly. They may find themselves frequently asking themselves, clinicians, or the internet:

• Am I doing therapy right? How do I know if I’m doing therapy right?

• What’s the difference between an intrusive thought and a compulsion?

• Is my OCD getting worse?

• Am I developing a new OCD theme, or is an old theme coming back?

• Can you explain [insert therapeutic concept] again? I need to be sure I understand it perfectly.

Meta-OCD can be treated like any other variation of OCD.  Exposure and response prevention along with ACT skills are applied to the fear of experiencing severe OCD again. The client learns to tolerate the urge to seek answers to their obsessive questions and to instead sit with uncertainty. As with other OCD themes, when a client learns to sit with uncertainty, the intensity of the theme will often die down and they will gain a sense of clarity and increased calm.

Situation B: Trauma reactions to OCD.

The loss of control and helplessness that one experiences with OCD can have a strong impact on an individual. Although this may not meet criteria for Post-traumatic Stress Disorder (PTSD), which according to the DSM must be in reaction to “actual or threatened death, serious injury, or sexual violation”, the loss of control and helplessness that one experiences with severe OCD can produce a similar experience. In these cases, clients may benefit from processing their experience with OCD. Understanding what about the OCD was so impactful and challenging, identifying the conclusions that one has made in response to their experience (e.g; OCD can get so bad that I lose all agency, I am sometimes unable to do anything to make my experience of OCD easier) and helping the client challenge those conclusions can help relieve the impact of that experience. 

Situation C: PTSD and OCD.

In some situations, clients may meet clinical criteria for both OCD and PTSD.  These are cases where the client both meets full criteria for OCD and has undergone an experience that generated clinical criteria for PTSD, such as a near-death experience or sexual assault. In these cases, OCD and PTSD are often tied to similar themes. In general, the PTSD should be treated first. Otherwise, a client can have PTSD reactions to OCD exposures. The full treatment of PTSD is beyond the scope of this article, but it is important to note that there are many similarities between treatments for the two disorders, so after treating one, a client will have skills that can be applied to the other.

Queer Themes in OCD

While OCD has as many manifestations as there are colors in the rainbow, some OCD themes may present more frequently in the LGBTQIA+ community as well as the polyamorous, kink, and other non-traditional relationship communities. The purpose of this article is to identify some interesting trends and unique OCD themes I have noticed in working with these populations.

In my experience, folks in these communities have a greatly increased chance of their OCD latching on to themes involving sexual orientation, gender, and/or relationships. This may be because folks in these communities have an increased awareness of the role that sexuality, gender, and relationships play in their lives, as they may have had to fight for, accept, process, and wrestle with these concepts more than others. Therefore, when the broken alarm system that is OCD creates an urge to scan one’s life for potential problems, folks in these populations may be more predisposed to obsess around these themes.

A little precursor before we jump into some examples: it is completely healthy and even expected for a given individual to struggle at some point in their lives with many of these concepts. When I talk about OCD however, I am describing a situation where an individual finds it so difficult to tolerate fears that they may be concluding something incorrectly that they spend an excessive amount of time and energy trying to achieve certainty, which significantly impacts their daily functioning. This search can include observable actions such as googling, asking friends, or testing if one’s genitals respond to different images, as well as covert compulsions such as mentally reviewing information and engaging in an endless internal debate. If an individual has OCD, the therapeutic goal is to build an ability to identify their best guess and tolerate the uncertainty that it is wrong. For more about the nuances of treatment, check out this and this article.

The following are some themes that folks with OCD that I worked with or know have obsessed over:

Relationship OCD (ROCD): 

Many queer folks face rejection and descrimination from others, including their biological family. Therefore, the people they choose to bring into their lives can carry an extra special importance to them. Sometimes, this can lead to folks feeling extra pressure to choose the right person to be in a relationship with or especially fear losing the person they’ve chosen.

Some folks in queer communities may compulsively respond to this pressure through avoiding intimacy. For example, one trend amongst gay and bi men seems to be an increased likelihood of engaging in flippant sexual encounters either to avoid the risk of intimacy or to compulsively check elements about their sexual orientation. 

Queer folks with ROCD may obsessively ask:

• How do I know if I’ve found the one?

• How do I know if my partner will leave me?

• Is our relationship passionate enough?

• Am I sexually attracted to my partner enough?

• How do I know if I’m gay enough, masculine enough, feminine enough, or queer enough for my partner?

• How do I know if my partner is gay enough, masculine enough, feminine enough, or queer enough for me?

Sexual Orientation OCD

At first, sexuality and gender themed OCDs colloquially fell under a category (not created by psychologists, but by those within the OCD community) called Homosexual OCD (HOCD). Nowadays we understand sexuality to be far more complex than a gay-straight binary and likewise understand that OCD themes can be more nuanced as well. The umbrella these themes fall under is now usually referred to as Sexual Orientation OCD (SO-OCD).  Folks struggling with SO-OCD may obsessively ask:

• I identify as straight but what if I’m wrong? How do I know if I’m really straight?

• I identify as gay but what if I’m wrong. How do I know if I’m really gay?

• I identify as bisexual/pansexual but mostly pursue X gender. What if I’m wrong in determining the “ratio” of my bisexuality/ pansexuality? What if I’m not actually bisexual or pansexual? How do I know if I’m bisexual or pansexual?

• I identify as (any sexual orientation) but what if I’m wrong. How do I know what to identify as? Which labels describe me best?

Gender OCD (GOCD)

This theme has had somewhat of a rising trend the last few years as more folks learn that one’s gender identity is a choice, which can evoke distress that one’s choice could be “wrong”. While GOCD can come up in someone who has no innate desire to transition or alter their gender but fears that they could be wrong, it can also come up in those who genuinely want to transition and fear that they may make the wrong choice. Folks struggling with GOCD may obsessively ask:

• I identify as cis-gender, but what if I’m wrong?

• I identify as transgender, but what if I’m wrong? How do I *know* if I’m trans?

• Should I take hormones? Should I get surgery?

• How do I know how much transitioning I want to do? When should I stop transitioning? 

• How do I know what to identify as? What pronouns should I use?

Pedophilia OCD (POCD)

One harmful and baseless stereotype about queer folks, especially gay men, is that they are malevolent pedophiles. Growing up with these stereotypes can lead to internalized homophobia, which in turn can inspire OCD to manifest around the theme of pedophilia. Folks with POCD may ask:

• How do I know if I’m a pedophile?

• What are signs that I’m a pedophile?

• What if I get arrested under suspicion that I’m a pedophile because of XYZ?

Polyamory, Kink, and other Non-traditional Relationship Styles

Folks with OCD who identify as polyamorous or engage in other non-traditional relationship styles sometimes struggle with the freedom of choice and lack of imposed structure inherent in these relationship styles. They may obsessively ask:

• How open or closed should my relationship be? 

• Do I really want to be poly? What if it’s just avoidance of intimacy? 

• How do I know what labels to use for my partners?

• What if I’m making the wrong choice? Will polyamory ruin my relationship?

• For kink-centric relationships: 

  • Am I giving too much power to my partner? 

  • What if I’m too kinky or not kinky enough for my partner?

  •  What if asking to include my kink more in the relationship will ruin it?

Of course the above are all just a sampling of the many ways that OCD can manifest. If you don’t see yourself reflected above but are still struggling with obsessions and compulsions, know that OCD is as unique and diverse as humanity itself. That said, it is my hopes that pointing out these trends can help some readers feel less alone in their struggles. As I always say, OCD is very treatable. If you’ve been struggling, don’t wait any longer to seek help!

What can Therapy Change?

When folks come to therapy it is often with the hopes that their clinician can “get rid of” their Obsessive Compulsive Disorder (OCD) and help them achieve certainty about their obsessive topic. For better or for worse, therapy cannot so radically change the automatic processes of a person’s mind, nor can certainty be provided around any topic*. However, this does not mean that someone with OCD must accept all the distress that they are experiencing, unbridled and unmitigated. Therapy can be expected to reduce overall distress, but it’s important to understand what types of distress therapy targets.

To understand what types of distress therapy seeks to reduce, we must first have a language for describing distress in different ways. In OCD treatment, we often draw from the Bhuddist distinctions of “pain” and “suffering”.

• Pain can be described as the inevitable, unavoidable challenges of life. These can include bigger life events such as losing a job, going through a breakup, or suffering an injury, as well as smaller everyday experiences such as experiencing stress from deadlines or experiencing unwanted intrusive thoughts.

• Suffering on the other hand is what we add to the pain due to our maladaptive relationships to those unavoidable experiences. Examples include avoiding, ruminating, drinking, numbing through media, beating ourselves up, obsessing, and compulsing.

Pain generally makes up a small minority of the overall distress in any given person’s life. Instead, it is our engagement with suffering that really degrades the quality of our lives. In therapy we learn how to accept the slim minority of distress (intrusive thoughts and emotions) in order to dramatically reduce that which is causing the majority of our distress (obsessing and compulsing). As a result, our overall level of distress dramatically reduces and the quality of our lives improve significantly. 

There is another pragmatic way to look at the types of distress we experience and how they can be affected by effective therapy. We can measure our intrusive thoughts through four categories: duration, frequency, content, and intensity. Therapy can be expected to affect each of these variables in different ways. 

• Duration: By engaging in skillful response prevention, one can have a direct effect on the duration of each experience with an intrusive thought. The logic here is simple: by resisting the urge to respond to the question or thought our brains produce, we speed up the time it takes for the experience to pass on its own.

• Intensity: This in turn decreases the likelihood of experiencing intense distress. Rarely do we experience out of the blue a ten out of ten level of distress from OCD. Intense distress most often comes from our obsessing and compulsing and trying to escape the distress. By acting unskillfully, we add fuel to the fire and end up feeling more uncertain and more concerned. By engaging in response prevention, we can starve that fire, preventing it from reaching certain intensities far more often. 

• Content: Interestingly, our work can often have an effect on the content of OCD, but not in the way you might think. When we engage in response prevention, we send our brains a signal that we’re not going to explore the topic that it has deemed a potential emergency. As a result, the brain may search for other “emergencies” to explain why it’s experiencing distress. In fact I often see theme switching as a positive (but not necessary) sign that one is being skillful with their OCD. Essentially it doesn’t matter at all if one’s theme switches or not, but understanding that it might can help one not become surprised or dismayed when it happens but instead see it as a result of their skillfulness. 

• Frequency: In my experience in working with clients, a moderate level of adherence to Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT) protocols can quickly have effects on the duration and intensity of intrusive thoughts, but the frequency of experiencing intrusive thoughts are more stubborn. What this means is that an individual may still experience intrusive thoughts a number of times each day, but they have the skills and ability to usually let those experiences last just a moment and remain at a low intensity. However, that is not to say that the frequency of intrusive thoughts can’t be affected at all by our work. It is my belief and personal experience that achieving a stellar level of response prevention, through self exploration and understanding the nuanced, subtle ways that we may still be compulsing, can reduce the frequency of intrusive thoughts. 
  

Knowing what change can be expected to take place through effective therapy help us invest our energy in changing what we can, accepting what is more change-resistant, and having the wisdom to identify the difference between the two. When we can skillfully balance change and acceptance, our overall level of distress plummets. It is the key to treatment success.

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*In sessions, to display this point I’ll raise my right hand and discuss how there can be no certainty that this in fact is my right hand. Maybe it’s a prosthetic, maybe the client is dreaming and I don’t exist, maybe their sense of right and left is inaccurate and they’ve never realized.

What Can Our “Gut” Tell Us?

In my early career, I often spoke ill of the phrase “gut feeling.” I would tell patients that having OCD challenged one’s ability to make decisions based on feelings because OCD creates powerful misleading emotional signals. Because much of the suffering from OCD comes from ascribing too much relevance to emotions such as a sense of dread or intense anxiety, I advised my patients to only make decisions based on their rational, logical side of their mind.

I was (sort of) wrong.

As an OCD specialist who has OCD, I am often informed not just by research in the field, but also by my personal experiences with OCD. The lesson I learned in regard to the role emotions play in decision making came from a challenge with relationship themed OCD that I experienced. In this relationship I experienced intense and frequent anxious and intrusive thoughts and feelings about whether or not it was the right relationship for me. I worked tirelessly to ascribe irrelevance to all of the signals I was experiencing because I had determined that staying in the relationship was logical and aligned with my values. However, I didn’t realize how disconnected my rational assessment was from the very real and legitimate emotions I was feeling. I had fallen into a state of mechanical logic. There were parts of the relationship that I could “feel” were not right, but I denied the validity of those feelings with lines such as “it’s against my values to judge this quality of my partner” or “rationally I understand a relationship takes work, so I need to pay this toll to be connected to someone in this way.”

My heart was sending me signals that this was not the right relationship to me, but I couldn’t tell that these were legitimate signals because at the same time, I truly was experiencing intense OCD. My relationship was a topic I could not stop thinking about, the consequences felt pressing and catastrophic, and I experienced intense anxiety for hours each day.

The most useful relationship with one’s “gut”, I finally learned through the guidance of wise clinicians, is more of a “both-and.” While it is incredibly important for anyone with OCD to learn and frequently use the skill of ascribing irrelevance to certain emotional signals, it is also integral that they be able to identify their more “authentic” or “true to self” feelings and understand what these feelings are trying to convey.

It is important to note that this should not be interpreted as me advising that every emotion should be directly listened to and dealt with, nor that they mean that acting on them is necessary. Some emotions may just be asking of us to be heard, others advise us that there is an issue that needs communication or problem solving (rather than the life or death extreme solutions OCD more often suggests).

In therapy, I still suggest that the first step is for a client to practice using response prevention ubiquitously. Prior to therapy, someone with untreated OCD has likely swung way too far in the direction of ascribing relevance to every thought and feeling. It is also easier to first focus just on learning the skill of response prevention before adding in the complex layer of when and where to apply it. However, once a client has mastered response prevention skills sufficiently, it is an important part of our work to introduce the concept of a “gut feeling” in a healthy and useful way. The client, in good therapy, learns how to distinguish what their OCD is trying to communicate versus what their true thoughts and feelings are on a given matter. In this way, the client learns how to more fully trust themselves and is able to draw from the whole spectrum of information their mind, heart, and body is seeking to convey.

An Update Model of OCD Treatment

If you or a loved one struggles with Obsessive Compulsive Disorder (OCD), you’ve likely heard of Exposure and Response Prevention (ERP). This treatment is known as the gold standard and has been shown through ample research to be a highly effective treatment (e.g. Song et al., 2022). What you may be unaware of, however, is that there has been an innovation in the application of ERP that may enhance its effectiveness. In this article we’ll compare this innovation, called the Inhibitory Learning Theory (ILT), to the older model of ERP, namely Emotion Processing Theory (EPT).

Is Habituation Central to ERP?

Initially, ERP was thought to work through a process called habituation. Habituation is a process in which repeated exposure to a stimulus decreases a subject’s responses to that stimulus.. A model called the Emotion Processing Theory (EPT) claimed that habituation is the central component to ERP: that repeatedly exposing a patient to their fear, while preventing the client from escaping that fear, would gradually reduce the patient’s physiological responses to said fear (Foa & Kozak, 1986). However, much research since then has questioned whether habituation is actually central to successful outcomes in exposure therapy. Many researchers have found no relationship between habituation within a given session and treatment outcomes (Baker et al., 2010, Jaycox, Foa, & Morral, 1998; Kozak, Foa, & Steketee, 1988; Meuret, Seidel, Rosenfield, Hofmann, & Rosenfield, 2012). Researchers have also discovered that treatment results can be gained in the absence of habituation (e.g., Rachman, Craske, Tallman, & Solyom, 1986; Rowe & Craske, 1998b; Tsao & Craske, 2000).

Introducing Inhibitory Learning Theory (ILT)

This leaves us with an important question. If habituation is not a central component of ERP, but ERP is still effective, what is actually causing the change? Inhibitory learning theory (ILT) offers a new and perhaps more accurate perspective on ERP. Rather than focusing solely on reducing anxiety during exposures, ILT emphasizes creating new learning experiences that override old fear-based associations. When a client has OCD, they often have expectations that facing their fear without protective measures such as reassurance or other compulsions will result in disaster: either literally or in the form of intolerable heightened anxiety. When we utilize an ILT approach, we challenge these expectations in a variety of ways, to help the client learn that they can handle their anxiety much better than they might have anticipated (Kim et al., 2020, Jacoby & Abramowitz, 2016).

What are the strengths of an ILT approach?

One central issue with the EPT ERP is that patients often relapse (e.g., Franklin & Foa, 1998). Researchers have begun to propose that ILT ERP may be more effective in providing lasting results. For example, a study by Elsner et al. (2022) found that habituation (reduction in fear during exposure) predicted short-term improvement, but something called “expectancy violation” (a key component of ILT) was more predictive of long-term success after treatment. Similarly, Bautista and Teng (2022) argue that an ILT approach utilizes tools that can prevent relapse more effectively than the traditional habituation method. This may be because through an ILT model, clients learn a generalizable set of skills to handle anxiety which can help them even if their OCD switches themes. Conversely, habituating to one OCD theme may not help clients to the same extent later on if their OCD takes on a different theme.

It is important to note, as can be seen from a quick glance at the dates of the studies referenced here, that this research is still very new. However, in our clinic at OCD and Anxiety Specialists, we can attest to a bevy of anecdotal data. We frequently treat folks who report having had been to therapy before or even seen an OCD specialist before and did not receive the results they were looking for. Perhaps during therapy, the client struggled to habituate to their theme, and each exposure was as challenging and unhelpful as the one before it. Perhaps the client developed “meta-OCD” and began obsessing about the treatment itself, which interfered with treatment results. Perhaps in the moment they felt that therapy was “working,” or the therapy helped them achieve relief from their current OCD theme, but the results did not last over time. Perhaps the client did achieve enduring results for their specific OCD theme, but when the theme switched after therapy was over, the client had no idea how to manage it. In these situations and more, we have frequently found the ILT approach to be helpful where the EPT approach fell short.

Conclusion

Whether you are just learning about OCD or have been in treatment for a while, understanding these different approaches can provide valuable insight into your treatment. Both the habituation model and ILT offer powerful tools for treating anxiety and OCD, and knowing how they work can help you feel more confident and engaged in your treatment journey. We believe that there are many advantages to undergoing treatment based on a more modern and updated understanding of the processes of ERP. If you agree, consider working with us at OCD and Anxiety Specialists to get the treatment outcomes you deserve.

References:

Adams, T. G., Cisler, J. M., Kelmendi, B., George, J. R., Kichuk, S. A., Averill, C. L., ... & Pittenger, C. (2021). Transcranial direct current stimulation (tDCS) targeting the medial prefrontal cortex (mPFC) modulates functional connectivity and enhances inhibitory safety learning in obsessive-compulsive disorder (OCD). medRxiv, 2021-02.

Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour research and therapy, 48(11), 1139-1143.

Bautista, C. L., & Teng, E. J. (2022). Merging our understanding of anxiety and exposure: Using inhibitory learning to target anxiety sensitivity in exposure therapy. Behavior Modification, 46(4), 819-833.Elsner, B., Jacobi, T., Kischkel, E., Schulze, D., & Reuter, B. (2022). Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy. BMC psychiatry, 22(1), 66.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological bulletin, 99(1), 20.

Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40.

Kim, J. W., Kang, H. J., Lee, J. Y., Kim, S. W., Shin, I. S., & Kim, J. M. (2020). Advanced cognitive-behavioral treatment model with exposure-response prevention for treating obsessive-compulsive disorder. Psychiatry Investigation, 17(11), 1060.