The Foolproof Guide to Treating Complications in OCD

Over the years, I’ve identified the major reasons OCD treatment fails in the hands of non-experts (and even experts themselves). Below is a list of the most common complications in the treatment of OCD and how to account for them.

Is your client experiencing distress during exposures that  you find difficult to manage?

• Does the client get depressed during exposures? Treat the depressive compulsion (see here).

• Is the client too scared to do an initial exposure? Use mindfulness as an initial exposure (see here).

• Did the exposure trigger too much distress? Pull back by focusing on the physical, not mental, by doing an expansion exercise (see here).

• Does the client get triggered by PTSD when you do an exposure? If so, treat the PTSD first (see here).

• Is the client experiencing guilt and shame? If the feelings are egosyntonic, explore psychodynamically. If they’re dystonic, fold them into the exposure, perhaps through an expansion exercise.

Are you treating a theme that requires a unique treatment consideration?

• Is it Relationship OCD? Make sure you work on emotional identification (see here) 

• Is it Just Right or Metaphysical Contamination OCD? Oftentimes there is no “feared consequence” in the term of a concrete outcome. Instead,conduct exposures about tolerating discomfort.

• Is the client obsessing about an aspect of treatment itself (e.g. fears that they can’t understand or do exposures correctly, fears that they are untreatable?) Treat the Meta OCD (see here). Also consider using the Inhibitory Learning Theory approach (see here) 

• Is the theme frequently switching? Help the client understand that we are only treating one thing: their intolerance of uncertainty (see here). Structure exposures to focus on that base skill rather than overly focusing on the costume the OCD is wearing this week.