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Behavioral Treatment of Obsessive-Compulsive Disorder
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In the last section, we discussed effective behavioral strategy number six: "Imagined Exposure" through four key concepts that I ask my clients to keep in mind. These four concepts included: sensory experiences; emotional responses; internal physiological reactions; and thoughts and ideas.
In this section, we will examine effective cognitive behavioral therapy strategy number seven: "Reducing Rituals." For this strategy, I use three different smaller CBT techniques. These three smaller techniques include: Ritual Restriction; Gradual Selective Ritual Prevention; and Response Delay.
4 CBT Techniques for Reducing Rituals
♦ Technique #1 - Ritual Restriction
The first technique is Ritual Restriction. This technique requires the client to reduce his or her ritual time by a specific period of time each occasion.
Dustin, age 36, took extremely long showers, sometimes reaching several hours. I asked Dustin what, for him, would be a short shower. Dustin stated, "About an hour and a half, maybe more."
I asked him to reduce this time to an hour in three weeks. After those three weeks had passed, he still hadn’t been able to reduce his shower habits. Dustin stated, "I do everything three times and that can take up quite a few hours."
I realized that Dustin had not cut out certain rituals, but only tried to do them faster, which only diminished the minutes by a few. When a client like Dustin cannot reduce his ritual time on his or her own, I find it useful to then limit the actions that he or she is allowed to do. To develop an idea of his shower habits, I asked Dustin to write out his routine in his journal and show it to me.
I noticed that instead of washing his body collectively, Dustin washed each arm, leg, and hand individually and methodically three times before moving on to the next one. I stated to Dustin, "From now on, I want you to wash each part only twice, and then move on." By gradually reducing the actions he was allowed to do, Dustin also reduced his shower time. After a few months, his showers had been reduce to twenty minutes.
Think of your Dustin. Could he or she benefit from Ritual Restriction? How could you help him or her reduce ritual time?
♦ Technique #2 - Gradual Selective Ritual Prevention
The second CBT technique is Gradual Selective Ritual Prevention. This technique allows clients to ritualize in situations high on the anxiety hierarchy, but to eliminate rituals entirely following exposure to easier obsessive situations.
Luke, age 47, feared others coming to harm. Whenever he felt a disaster approaching, he turned around in circles.
His anxiety hierarchy ranked the following situations with a discomfort level of zero to one hundred:
An older coworker dying of a heart attack ranked at 50
Wife being diagnosed with early breast cancer ranked at 70
Wife dying of cancer ranked at 95
Slowly, we began to organize imagined exposure sessions. First, we started with the older coworker dying. Once that session had been completed, Luke was no longer permitted to turn around in circles. However, if the thought of his wife being diagnosed or dying appeared, he was allowed to perform the ritual.
The next session, we exposed him to his wife being diagnosed with breast cancer. After that session, he was no longer permitted to perform that ritual if the thought popped up. Once we had exposed him to his wife dying, Luke was prohibited from completing the ritual.
Think of your Luke. Would playing this section for him or her be beneficial?
♦ Technique #3 - Response Delay
In addition to Ritual Restriction and Gradual Selective Ritual Prevention, the third CBT technique is Response Delay. During this exercise, the client is asked to refrain from performing their ritual for a certain period of time. This period of time becomes longer and longer. I find this technique useful for clients who cannot perform the previously described and more stringent techniques.
Sometimes I give my clients a specific amount of time, such as ten or thirty minutes. In less serious cases, I tell them to refrain from performing the ritual for as long as possible.
Jackie, age 28, obsessed about snakes. Whenever she thought of them, she repeated a litany seven times in her head that went,
Fire and flame
Singe or burn and simmer
Scorch and burn
She ardently believed that this litany drove off any snakes that could attack her. During our sessions, she would often times fall silent and I knew that she was repeating the litany in her mind. I asked Jackie to look at a picture of a snake bracelet during one of our sessions and to refrain from repeating her litany for at least ten minutes. To ensure that she could not repeat the phrases, I asked her to talk out loud for ten minutes straight, describing the bracelet and, if she ran out of descriptions, to talk about the objects in the room.
Of course, she could not accomplish the first, or even eighth time she saw the picture, but each exposure was accompanied with a longer and longer delay time until she had finally reached her goal of ten minutes. Eventually, we moved on to pictures of actual snakes and longer and longer delay times. Ultimately, the goal of this exercise is to allow Jackie to become more accustomed to her panic and to reduce that panic.
Think of your Jackie. Could he or she benefit from Response Delay?
♦ Technique #4 - Taking Control
Because Luke’s OCD was not magically cured by gradual selective ritual prevention, I asked him to try the "Take Control" exercise the next time he felt himself resorting to unnecessary rituals. This exercise entailed Luke writing out a list of chores and duties that he could do when he felt himself become overwhelmed with thoughts of sickness and death. All these chores took place outside of the house. By removing himself from the triggering environment, Luke could reduce his worrying thoughts.
Some of these chores included, "Going to the library", "taking a walk in the park", and "picking up groceries." Most of these chores were low stress ones which did not cause a great deal of anxiety or heighten Luke’s need for performing rituals.
Luke stated, "Last week I started thinking about all the germs and how they could be making my wife sick. The entire morning, from 6 am to noon I was cleaning and worrying. Finally, I decided to take control of the situation and get out of the house. So I picked up my list. The first thing I did was go to the library and pick up a bunch of books. As soon as I began to concentrate on the books I wanted to check out, my anxiety started to slow down. Although it didn’t stop completely, it did subside a little, and when I’m out of the house, I’m not cleaning. So ideally, it did work."
Think of your Luke. Could they reduce their tendency to ritualize by "taking control"?
In this section, we examined effective behavioral strategy number seven: "Reducing Rituals." For this strategy, I use three different smaller techniques. These three smaller techniques included: Ritual Restriction; Gradual Selective Ritual Prevention; and Response Delay.
Peer-Reviewed Journal Article References:
Arco, L. (2015). A case study in treating chronic comorbid obsessive–compulsive disorder and depression with behavioral activation and pharmacotherapy. Psychotherapy, 52(2), 278–286.
Benito, K. G., Machan, J., Freeman, J. B., Garcia, A. M., Walther, M., Frank, H., Wellen, B., Stewart, E., Edmunds, J., Kemp, J., Sapyta, J., & Franklin, M. (2018). Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD. Journal of Consulting and Clinical Psychology, 86(7), 615–630.
Conrad, R., Bousleiman, S., Isberg, R., Hauptman, A., & Cardeli, E. (2020). Uncontrolled experiments: Treatment of contamination OCD during a pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S67–S68.
Curling, L., Kellett, S., & Totterdell, P. (2018). Cognitive analytic therapy for obsessive morbid jealousy: A case series. Journal of Psychotherapy Integration, 28(4), 537–555.
Najmi, S., & Amir, N. (2010). The effect of attention training on a behavioral test of contamination fears in individuals with subclinical obsessive-compulsive symptoms. Journal of Abnormal Psychology, 119(1), 136–142.
Olatunji, B. O., Rosenfield, D., Tart, C. D., Cottraux, J., Powers, M. B., & Smits, J. A. J. (2013). Behavioral versus cognitive treatment of obsessive-compulsive disorder: An examination of outcome and mediators of change. Journal of Consulting and Clinical Psychology, 81(3), 415–428.
What are three CBT techniques that aid OCD clients in reducing the frequency of their rituals? To select and enter your answer go to .