A  large number of research studies suggest that two treatments are especially effective in the treatment of  obsessive-compulsive disorder: behavior therapy and medications.  Behavior therapy has the edge in outcome studies, markedly helping up to 80 percent of people who complete treatment compaired to medications’ 50 to 70 percent.  Behavior therapy is also less costly than medications, and it causes no side effects.  Behavior therapy is thus the premier treatment for OCD, indicated for all who suffer the disorder.

From a theoretical point of view, behavior therapy is extremely simple.  It requires no plumbing of the unconscious, exploring the distant past, or examining tangled motives.  Instead, it stands on a basic, physiological property of the nervous system that is found in all animals from mollusks to man: habituation.  If a snail’s head is lightly touched, it recoils quickly into its shell.  If it is touched fifteen times in a row, however, it stops withdrawing.  The snail, in effect, gets used to being touched: that’s habituation.  The same type of response occurs in the infinitely more complicated case of a human who is afraid of a certain situation.  Like the snail, if a person is presented with a noxious stimulus repeatedly, and neither escapes from it nor is harmed by it, then he or she will eventually get used to it.

Applying the law of habituation, behavior therapy has proven to be extremely effective in the treatment of simple phobias.  Take, for example, a man who is afraid to ride in elevators.  In order to get over his fear, he must first go into an elevator; this is called exposure to the anxiety producing situation.  Next, he must prevent himself from running off the elevator; this is called response prevention.  Research shows that if the man places himself in elevators a sufficient number of times, and each time stays on the elevator long enough for his anxiety to diminish (as a rule, not longer than an hour), then eventually he will habituate to fear of elevators.  He will overcome his phobia.

The same principles apply when behavior therapy is used to treat OCD.  A woman has obsessions that her hands are dirty and washes her hands compulsively.  What she must do is expose herself to the anxiety-producing thought of dirt (the equivalent of going into the elevator) while resisting the response of washing (preventing running off).  If she can do this often enough–twenty to thirty total hours of exposure and response prevention is usually sufficient–the idea of having dirty hands will no longer make her severely anxious, and she will no longer be driven to wash.  She will conquer her compulsions.

The gist of behavior therapy is found in an old adage that most people have heard all their lives, but too few OCDers have taken to heart: face up to your fears.  Behavior therapy simply takes this wise counsel and applies it systematically and scientifically.

A number of different procedures may be employed in implementing behavior therapy for OCD.  Usually, patients begin by recording in a diary the severity and duration of all obsessions and compulsions as they occur throughout the day.  Situations that are being avoided because of OCD are carefully noted, as well.  Obsessions and compulsions are then ranked according to the degree of discomfort and disruption they cause.  Specific symptoms are chosen for exposure and response prevention tasks.  Progress is recorded daily in a journal or log.

The meat of behavior therapy–the part of treatment where great gains are made–is in the tasks, or homework assignments, where patients must expose themselves to obsessional situations while preventing themselves from performing compulsions.  Most commonly, the situations targeted for exposure and response prevention are the every-day triggers of OCD.  A person with handwashing compulsions, for instance, may be asked to touch the toilet and refrain from washing her hands for two hours.  An exaggerated measure of exposure may be encouraged: touch the toilet then touch her clothes and furniture with her “contaminated” hands.  Such exaggerated exposure, or “flooding,” speeds up the process of habituation, as it keeps a fearful thought prominently and inescapably in the forefront of a person’s mind.  Sometimes, a therapist first models a task.  For example, a patient might be asked to bring a “dirty” object into a session, and the therapist could rub it all over himself, demonstrating that it is not dangerous. Occasionally it is helpful for a therapist to accompany a client home, and model an assignment in its natural setting.

Exposure and response prevention can also be carried out in the imagination.  Here, a patient is asked to bring to mind a fearful obsessional scene, and to keep it in vivid awareness until the anxiety it causes begins to fade.  For people who possess a strong capability in visual imagery (OCDers, it seems, usually do), this technique can be just as effective as exposure in real life. (Click here for an example of the use of exposure and response prevention in the imagination.)

In some cases, it is not even necessary to see a therapist. In this regard, behavior therapy for OCD is much like physical rehabilitation for a knee injury.  Both can be accomplished without external help.  More often than not, however, some assistance is essential.  In the first place, just as it is not obvious that one should exercise a painful joint, it is not intuitively obvious that one should expose oneself to frightening thoughts.  Secondly, exercising a knee, like preventing compulsions, is hard work.

Extending the analogy further: if one has a minor knee injury, it may be fairly easy to devise and implement an exercise rehabilitation program. If the injury is severe, however, almost certainly a professional must be consulted in order to prevent worsening the injury by exercising incorrectly.  Thus, in milder cases of OCD, for the self-motivated person who has learned the principles of behavior therapy, no therapist may be necessary.  Otherwise, however, it is wise to seek consultation. One thing can honestly be said about behavior therapy in the treatment of OCD: Significant improvement is the rule.