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Treating obsessive-compulsive disorder with exposure and response prevention.

Exposure and Response (ritual) Prevention (EX/RP) for obsessive-compulsive disorder (OCD) is a behaviorally based treatment that is the most effective treatment available for most patients with OCD. In this paper, we will provide a brief description of OCD and outcome data on EX/RP, followed by discussion of the procedures and techniques involved in EX/RP which include imaginal exposure, in vivo exposure, and ritual prevention.



Obsessions are intrusive thoughts, images, or impulses that keep coming back to people and that do not make sense. Some common obsessions include fear of contamination, fear of harm to self or others, fear of sin or immorality (also known as scrupulosity), intrusive sexual thoughts, a need for symmetry or exactness, and fear of losing things or throwing things away. Compulsions are behaviors or "mental acts" which people feel driven to perform and have difficulty resisting. Common compulsions include washing, checking, reviewing, hoarding, reassurance seeking, and mental neutralizing. Compulsions, whether overt behaviors or "mental rituals," are meant to alleviate the distress brought on by obsessional thoughts and/or to prevent bad things from happening (e.g., patients with contamination obsessions wash their hands to prevent themselves from getting ill). Most patients tend to have more than one type of obsession or compulsion. When patients engage in an hour or more of obsessions or compulsions in a day, or if they are distressed or impaired due to these symptoms, then the patient is considered to have OCD.


Effective treatment for OCD must involve both exposure and ritual prevention. Exposure involves confronting situations, objects, and thoughts that evoke anxiety or distress because they are unrealistically associated with danger. Response (ritual) prevention is conceptualized as blocking avoidance or escape from feared situations. By encouraging the individual to remain in the feared situation without any avoidance behaviors, EX/RP affords patients the opportunity to learn that their fears are unrealistic.

It is essential that clinicians and patients understand why it is so important to do exposure and ritual prevention together. Many patients would not mind confronting a feared stimulus (e.g., touching something contaminated) if they could then engage in rituals (e.g., handwashing). Rachman and his colleagues (see Rachman & Hodgson, 1980) showed that exposure to cues that trigger obsessions increase anxiety and discomfort and that ritualistic behavior led to a decrease in anxiety and discomfort. When patients were exposed to obsessional cues, but were prevented from engaging in rituals, anxiety and discomfort decreased over time. When patients were then exposed to their obsessional cues again, the urge to ritualize had decreased as compared to the previous trial. This decrease in urge to ritualize did not occur if patients continued to engage in rituals in response to obsessional cues.

Foa and colleagues (1984) showed further evidence for the importance of using

both exposure and ritual prevention in the treatment of OCD. In this study, patients with OCD were randomly assigned to receive either exposure alone, ritual prevention alone, or combined EX/RP. The component treatments seemed to have unique effects on OCD symptoms--ritual prevention led to reduction in compulsions and exposure led to reduction in the anxiety response to feared stimuli. Not surprisingly then, the combined treatment was found to be superior to the component treatments, with patients in this group showing the greatest reductions in both anxiety and compulsions.

EX/RP treatment programs have gained empirical support, with both adults (Foa, Liebowitz, & colleagues, in preparation) and children (deHaan et al., 1998) treated with EX/RP showing more improvement in OCD symptoms than those treated with medication. Currently, many researchers are interested in whether combined treatments (medication and therapy) confer a greater advantage than monotherapies. The study done by Foa, Liebowitz, and colleagues suggests that there is not an advantage to using combined medication and EX/RP in the treatment of OCD over EX/RP monotherapy (see also Foa, Franklin, & Moser, in press).

Information Gathering

Most frequently, we conduct EX/RP two to five times a week, in two hour sessions, for a total of 17 sessions and include extensive homework assignments. Typically, the first two sessions of treatment involve information gathering; the remaining sessions are spent doing exposures and ritual prevention.

The first step in implementing EX/RP is for the clinician and the patient to get a clear sense of the functional relationship between obsessions and compulsions. While the distinction between obsessions and compulsions might be clear to clinicians, it is likely less clear for patients and perhaps not even something they have thought about. Clinicians should provide patients with clear definitions for obsessions and compulsions, using examples that are relevant to the patient's unique OCD symptoms. In addition to identifying compulsions as behaviors which function to reduce discomfort, non-ritualized avoidance behaviors need to be identified. For example, a person who fears getting contaminated by food might never eat outside their own home and a person who is worried about catching their house on fire by leaving the stove on might avoid ever turning the stove on in the first place. Getting a clear picture of avoidance patterns is also crucial to good treatment planning since EX/RP will include exposure to cues that are being avoided and subsequent ritual prevention. Starting after the first session, the patient is assigned self-monitoring homework which then continues throughout treatment in order to facilitate a continuous assessment process.

In Vivo Exposure

In vivo exposure is probably the most commonly known type of exposure used as part of EX/RP. After creating a hierarchy of situations related to the patient's specific OCD symptoms, the therapist works with the patient to select a situation on the hierarchy that is moderately anxiety provoking (around a 50 on a I to 100 scale). The first exposure that is chosen is one that the therapist is relatively confident that the patient will be successful at staying in without ritualizing in order to habituate. After this, the therapist works with the patient to quickly move up the hierarchy, with the goal of accomplishing the highest item by the 6th session. While this may sound overly ambitious, we find that most of the time it can be accomplished. After the 6th session, most of the sessions are spent working on generalizing the gains to other contexts and finding variations that are more difficult for the patient. Thus, while we reach the top of the hierarchy, anxiety usually does not decrease to consistently low levels without repetition.

During exposure exercises, the therapist should not engage in distraction by constantly discussing other topics. Rather, focus should be placed on processing the activity that the patient is engaged in through discussing what they are doing and why they are doing it. For some patients, this may take the form of discussing the likelihood of the feared consequence occurring and for others it may be discussing the realistic consequences. One of the most important concepts to teach the patient during in vivo exposure is that the idea of exposure is to expose oneself to anxiety and to learn that it will naturally decline over time even if nothing is done to reduce it. Any time one tries to suppress the anxiety through some form of escape or avoidance, it is likely to recur again without having learned anything. The art of using exposure is to determine what is the best way to expose patients to situations/stimuli that will elicit the core fear and help them to stay in situations long enough to allow the anxiety to decline and learning to occur.

Imaginal Exposure

Another component of EX/RP is imaginal exposure. While unnecessary for some patients, imaginal exposure can be an important component of treatment for others. There are a number of feared consequences that one is not able to expose the patient to directly, thus making in vivo exposure impossible. In imaginal exposure, patients must habituate to the idea of their feared consequences were they to actually occur.

Another important principle that is addressed in imaginal exposure is that thoughts are not the equivalent of actions, a problem called thought-action fusion, which is one of the major cognitive errors made by patients with OCD (Coles, Mennin, & Heimberg, 2001). As an example, a patient might fear killing his family with a knife. In imaginal exposure, the patient would be asked to repeatedly imagine himself doing so in detail. While the patient will be extremely anxious initially, after repeated trials he will habituate to this scene and no longer find it as anxiety provoking. Over time, the patient will also realize that thinking such thoughts does not mean he actually will kill his family and he will learn to accept the temporary presence of the thought when it intrudes. Once the patient stops suppressing the thought, it is likely that it will return less frequently and with less intensity (see Abramowitz, Tolin, & Street, 2001).

There are a few important guidelines to keep in mind before embarking on imaginal exposure with patients. First, exposures of any sort should not be conducted until a careful assessment has been completed. One goal of the assessment process is determine the functional relationship between obsessions and compulsions. By definition, obsessions are experienced as intrusive, unwanted, and anxiety provoking; rituals are meant to alleviate the discomfort brought on by obsessions. Imaginal exposure should not be used if patients present with thoughts that are not experienced as intrusive and unwanted (e.g., when a patient thinks about sexual relations with a child and experiences these thoughts as arousing). People with OCD who have sexual and aggressive obsessions experience these thoughts as intrusive, terribly frightening, and completely incongruent with their beliefs and desires.

Secondly, imaginal exposures need to be conducted through a collaboration of the therapist and the patient in order to tailor the scene to the patient's core fears. For example, if a patient presents with fear of becoming ill, it is important to get a clear sense of the nature of this fear. One patient might fear contracting a specific illness and has a clear picture of how this would happen. Another patient might believe that she will just start to feel a general malaise and might be most frightened by not knowing the nature and cause of the illness. Imaginal exposures must take into account these subtle differences that underlie very similar core obsessions (e.g., "I am going to get sick and die").

The basic procedure for imaginal exposure begins with getting sufficient details to help the patient create a vivid scene that taps the core fears. The first time through the exposure, the therapist describes a scene for the patient, using details and the present tense. After this, the patient is encouraged to develop future scenarios under the therapist's guidance until they can do so without guidance. Each time the scene is tape recorded and listened to repeatedly, for 45 minutes or until habituation occurs (whichever comes first). It is important that the patient continues to listen to the same scene for a number of days without altering it in order to facilitate habituation. Generalization to similar scenarios typically occurs after between-session habituation has been demonstrated. The duration of each imaginal exposure really depends on how much context the patient needs to become engaged in the scene.

Ritual Prevention

In our treatment protocol, the first exposure is completed during Session Three, and at this time, ritual prevention is also introduced to patients. It is unrealistic to tell patients to simply stop engaging in rituals--if it were that simple, they would have stopped on their own. The best way to explain the need for ritual prevention (RP) is to return to the model of OCD and emphasize that only through exposure and ritual prevention will patients learn that anxiety decreases on its own without having to resort to rituals and that feared consequences are unlikely to happen. It is important to make clear that as long as patients acquiesce to that urge, the obsessional thoughts will be maintained over time. Given that obsessive thoughts are a source of distress, knowing that the thoughts should become less frequent and intense can be very motivating for patients. Of course, most patients also relish the idea of not having to engage in compulsions--even though this idea can be quite frightening. It can be very useful to spend some time with patients picturing a life without OCD. Many will voice a desire to spend more time doing pleasurable things and less time doing rituals.

For some OCD patients, rituals occupy their entire day and it would be near impossible for them to simply stop engaging in all rituals from one day to the next. Even with less pervasive rituals, some patients will refuse to do complete RP even if they understand the rationale for it. Rather than lose patients, it is sometimes appropriate to implement RP more gradually. Early success experiences can then be used to encourage more complete RP as treatment continues.

Some patients who have rituals in many different areas (e.g., washing, symmetry, checking) might be able to handle doing widespread ritual prevention right away. Others might be less overwhelmed if they can start with one focused area. In making this decision early on in treatment, clinicians should be mindful of the importance of giving their patients success experiences. If an overwhelming assignment is given early on in treatment, patients might feel as if they have failed and might see the prospect of living life without OCD as impossible. It is certainly better to initially assign a manageable ritual prevention task and use the success of that experience as a motivator for working on more difficult OCD symptoms. As therapy continues, it is essential that patients understand the principle of generalization. Particularly for complicated cases, there will not be time in therapy to individually tackle each OC symptom. Rather, patients should see that the principles of exposure and ritual prevention can be applied to all OC symptoms and they must become comfortable working on difficult symptoms on their own. This is important in terms of long-term maintenance of gains since once therapy ends, since patients might experience recurrences of OC symptoms and might also develop new concerns. It is essential that they be able to apply the principles of EX/RP at these challenging times regardless of the nature of the symptoms.

Although clinicians should certainly be flexible about ritual prevention, they should clearly communicate to patients that complete ritual prevention is the goal of treatment and that they should develop a commitment to living life without OCD. It is important to recognize though that patients might violate ritual prevention rules and that they should see these violations as learning experiences, rather than as failures. This is particularly true early in treatment. When patients do engage in rituals, they should make a note of what happened and try to develop an awareness of what triggered the ritual. This knowledge can then be used to design subsequent exposures that specifically target these problematic areas.

As therapy progresses, ritual prevention violations should become less frequent and clinicians should be more firm about the importance of this progression. When patients do engage in rituals, they should know to immediately re-expose themselves to the cue that triggered the urge to ritualize. For example, when a person with contamination fears washes their hands after touching something they perceive to be contaminated, they should touch the object again and try again to resist the urge to ritualize.

Knowing When to Terminate EX/RP

Finally, clinicians need to consider when it is optimal to terminate OCD treatment. It is usually unrealistic to keep patients in treatment until they have no OCD symptoms. An important component of treatment is to help patients realize that they might continue to have some intrusive thoughts and urges to ritualize. The important issue is how patients handle these challenges. Patients will likely be ready to discontinue treatment when they recognize the importance of not suppressing obsessive thoughts and are able to refrain from ritualizing the great majority of the time. When they do slip, they should know to re-expose. Furthermore, as we mentioned earlier, it is important that patients know what to do if an old symptom starts to cause problems again or if a new concern arises. In short, we should feel confident sending patients away if they have the skills to be their own clinicians. As treatment progresses, it is essential to make patients comfortable in that role. Patients should take a more active role in designing exposures and if they come in to sessions with questions about how to deal with a challenging situation, they should be encouraged to try to devise strategies on their own first before the clinician offers suggestions.


Abramowitz, J.S., Tolin, D. F. & Street, G. P. (2001). Paradoxical effects of thought suppression: A meta-analysis of controlled studies. Clinical Psychology Review, 21 (5), 683-703.

Coles, M.E., Mamin, D. S., & Heimberg, R. G. (2001). Distinguishing obsessive features and worries: The role of thought-action fusion. Behavior Research & Therapy, 39, 947-959.

deHaan, E., Hoogduin, K.A.L., Buitelaar, J.K., & Keijsers, G.P.J. (1998). Behavior therapy versus clomipramine for the treatment obsessive-compulsive disorder in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 1022-1029.

Foa, E.B., Franklin, M. E, Moser, J. (In press). Context in the clinic: How well do CBT and medications work in combination Biological Psychiatry.

Foa, E.B., Liebowitz; M.R, Kozak M.K., Davies, S., Campeas, R., Franklin, M.D., Huppert J.E., Kjemisted, K., Rowan, W., Simpson, H.B., Schmidt, A., & Tu, X. (in preparation). Treatment of obsessive-compulsive disorder by exposure and ritual prevention, domipramine, and their combination: A randomized, placebo-controlled study.

Foa, E.B., Steketee, G., Grayson, J.B., Turner, R.M. & Latimer, P.R. (1984). Deliberate exposure and blocking of obsessive-compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15, 450-472.

Rachman, S.J. & Hodgson, R.J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall.

Jonathan D. Huppert and Deborah A. Roth

University of Pennsylvania

Please address correspondence to: Jonathan D. Huppert Ph.D. Center for the Treatment and Study of Anxiety, University of Pennsylvania, Department of Psychiatry. 3535 Market St., 6th Floor, Philadelphia, P.A., 19104. Phone: 215-746-3327. Fax: 215-746-3311. E-mail:

We would like to thank Edna Foa for her mentorship and guidance on the ideas presented in this manuscript.
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Author:Huppert, Jonathan D.; Roth, Deborah A.
Publication:The Behavior Analyst Today
Date:Jan 1, 2003
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