Exposure and Response (Ritual) Prevention for Obsessive

Compulsive Disorder Therapist Guide, 2nd Edition

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About TreatmentsThatWork™

Stunning developments in healthcare have taken place over the past sev-
eral years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into ques-
tion by research evidence as not only lacking benefit, but perhaps induc-
ing harm. Other strategies have been proven effective using the best
current standards of evidence, resulting in broad-based recommenda-
tions to make these practices more available to the public. Several recent
developments are behind this revolution. First, we have arrived at a
much deeper understanding of pathology, both psychological and phys-
ical, which has led to the development of new, more precisely targeted
interventions. Second, our research methodologies have improved sub-
stantially, such that we have reduced threats to internal and external
validity, making the outcomes more directly applicable to clinical situa-
tions. Third, governments around the world and healthcare systems and
policymakers have decided that the quality of care should improve, that
it should be evidence-based, and that it is in the public’s interest to
ensure that this happens (Barlow, 2004; Institute of Medicine, 2001).
Of course, the major stumbling block for clinicians everywhere is the
accessibility of newly developed evidence-based psychological interven-
tions. Workshops and books can go only so far in acquainting respon-
sible and conscientious practitioners with the latest behavioral healthcare
practices and their applicability to individual patients. This new series,
TreatmentsThatWork™, is devoted to communicating these exciting
new interventions to clinicians on the front lines of practice.
The manuals and workbooks in this series contain step-by-step detailed
procedures for assessing and treating specific problems and diagnoses. But
this series also goes beyond the books and manuals by providing ancillary
materials that will approximate the supervisory process in assisting practi-
tioners in the implementation of these procedures in their practice.

v
 In our emerging healthcare system, the growing consensus is that evidence-
based practice offers the most responsible course of action for the mental
health professional. All behavioral healthcare clinicians deeply desire to
provide the best possible care for their patients. In this series, our aim is to
close the dissemination and information gap and make that possible.

This newly revised and updated therapist guide outlines a cognitive-behav-

ioral treatment (CBT) program for obsessive-compulsive disorder (OCD)
called Exposure and Response (Ritual) Prevention (EX/RP). EX/RP
includes five main components: in vivo exposure, imaginal exposure,
response (ritual) prevention, processing, and home visits. Over the course
of 17 to 20 biweekly treatment sessions, OCD patients are exposed to stim-
uli (in real life or imaginally) that trigger their obsessional distress and their
urge to ritualize. These exposures are designed to be gradual so that over
time patients come to realize that the things they fear will not necessarily
occur if they don’t perform their rituals. Treatment includes both therapist-
supervised exposures and ritual prevention, and self-monitored exposure
and ritual prevention at home. To successfully implement treatment, mental
health professionals should be familiar with CBT or have participated in
intensive workshops for EX/RP given by experts in this therapy.

EX/RP is a brief CBT-based treatment that has proven scientifically effi-

cacious in numerous studies. In OCD, a severe and often intractable
disorder, skillful application of this treatment, and this treatment alone,
offers the best hope for recovery. (Patients who are sufficiently moti-
vated and engaged in treatment will no doubt experience a decrease in
symptoms and potential mastery over their OCD.)

David H. Barlow, Editor-in-Chief,

TreatmentsThatWork™
Boston, MA

References

Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59,

869–878.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system
for the 21st century. Washington, D.C.: National Academy Press.

vi
Acknowledgments

I want to acknowledge the contribution of Dr. Michael Kozak to my

conceptualization of the psychopathology that underlies OCD and the
mechanisms that underlie exposure and ritual prevention, which are
explicated in the manual. Indeed, the present manual is an update and
expansion of a previous manual, “Mastery of Your Obsessions and
Compulsions,” coauthored by Dr. Kozak and myself. I also want to
thank Drs. Michael Leibowitz and Blair Simpson for the insight they
provided into my view of OCD through many years of collaborations.
My thanks are extended to my collaborators at the Center for the
Treatment and Study of Anxiety over the past 30 years. Lastly, I want to
thank the patients who taught me so much about how to help them.

- Edna B. Foa

To my dear family and friends who taught me about loyalty and gener-
osity; to my colleagues, past and present, whose work is incorporated in
this book; and last, but not least, to our patients, together with whom
we have learned about struggle, compassion, and triumph.

- Elna Yadin

To my wonderful, vibrant sisters—you keep alive the determined spirit

of our parents, and your love, encouragement, and friendship mean the
world to me.

- Tracey K. Lichner

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Contents

Chapter 1 Introductory Information for Therapists 1

Chapter 2 Assessment 35

Chapter 3 Treatment Components of Exposure and Ritual

Prevention 49

Chapter 4 Session 1: Treatment Planning Part I 67

Chapter 5 Session 2: Treatment Planning Part II 79

Chapter 6 Session 3: Exposure and Ritual Prevention—Introducing

In Vivo Exposure 93

Chapter 7 Session 4: Exposure and Ritual Prevention—Introducing

Imaginal Exposure 103

Chapter 8 Intermediate Sessions: Continuing Exposure and Ritual

Prevention 111

Chapter 9 Final Session 117

Chapter 10 Problems Commonly Encountered during Exposure and

Ritual Prevention 121

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 Appendices Information-Gathering Form 132

Obsessive-Compulsive Disorder: Some Facts 137

Sample Self-Monitoring Form 139

Self-Monitoring Form 140

Appointment Schedule 142

Telephone Tips and Reminders 143

Telephone Contact Notes 144

Treatment Planning Form 145

Understanding Exposure and Ritual Prevention

(EX/RP) Therapy for OCD 149

Hierarchy Form 155

Therapist Exposure Recording Form 156

Patient Rules for Ritual Prevention 158

Exposure Homework Recording Form 160

Imaginal Exposure Script Worksheet 162

Imaginal Exposure Homework Recording Form 163

Guidelines for “Normal Behavior” 165

References 167

About the Authors 181

x
Chapter 1 Introductory Information for Therapists

This therapist guide Exposure and Response (Ritual) Prevention Therapy

for OCD is accompanied by a client workbook Treating Your OCD with
Exposure and Response (Ritual) Prevention Therapy. The manuals and
treatment are designed for use by therapists who are familiar with
cognitive-behavioral therapy (CBT) or who have participated in inten-
sive workshops for exposure and ritual prevention (EX/RP) by experts
in this therapy. The manual aims to guide therapists in implementing
this brief CBT program that targets symptoms of obsessive-compulsive
disorder (OCD). Note: In the field of OCD, the terms “response-
prevention” and “ritual-prevention” are used interchangeably. The
abbreviations EX/RP and ERP are also used interchangeably when refer-
ring to exposure and response (ritual) prevention therapy. Throughout
this manual, we will be using the term “ritual prevention” and the EX/
RP abbreviation.

Background Information about EX/RP Treatment

This manual describes a CBT program for OCD that includes between
17 and 20 treatment sessions. The first two sessions involve presentation
of the cognitive-behavioral model of OCD, a description of the treat-
ment program, and collecting information about the specific clinical pic-
ture of the patient. This information includes the patient’s history of
OCD, exploring the onset and course of the disorder, identifying triggers
for the patient’s various intrusive, obsessional thoughts as well as delineat-
ing the compulsions (rituals) and avoidance patterns. In these two ses-
sions, the therapist also teaches the patient self-monitoring of symptoms,
and together with the patient creates a hierarchy of EX/RP exercises.

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 EX/RP treatment includes the following procedures:

■ Exposure in vivo (i.e., exposure in real life) involves helping the

patient confront cues that trigger obsessive thoughts. Cues include
objects, words, images, or situations. For example, touching water
faucets in a public restroom might trigger germ obsessions (for a
detailed discussion see Chapter 3).

■ Imaginal exposure involves asking the patient to imagine in detail

the distressing thoughts or situations. It is used primarily to help
patients confront the disastrous consequences that they fear will
occur if they do not perform the rituals. For example, imaginal
exposure may involve a patient imagining contracting a sexually
transmitted disease because he did not wash his hands sufficiently
after using a public bathroom and consequently being shunned by
friends and family (for a detailed discussion see Chapter 3).

■ Ritual prevention involves instructing the patient to abstain from

the ritualizing that he or she believes prevents the feared disaster
or reduces the distress produced by the obsession (e.g., washing
hands after touching the floor and fearing contracting a disease).
By practicing ritual prevention the patient learns that the anxiety
and distress decrease without ritualizing and that the feared
consequences do not occur (for a detailed discussion see
Chapter 3).

■ Processing involves discussing with the patient what happened

during the exposure as it relates to experiencing changes in anxiety
levels, as well as to gaining insights about feared consequences (for
a detailed discussion see Chapter 3).

■ Home visits involve planning and executing visits to the patient’s

home environment, both to help collect important information
about the patient’s OCD symptoms and to aid in transferring and
implementing treatment gains (for a detailed discussion see
Chapter 3).

The bulk of the treatment program involves the practice of EX/RP exer-
cises, both in session and as homework assignments, working through
more difficult exposures as treatment progresses. These sessions can be
conducted once a week, twice a week, or daily in an intensive treatment

2
 program, depending on symptom severity and logistical considerations
(see Chapter 3). Treatment includes both therapist-supervised EX/RP
and self-monitored EX/RP at home. During the last couple of sessions,
an emphasis is placed on relapse prevention and maintenance of gains.
The corresponding workbook includes readings and homework assign-
ment forms.

In the first session, the cognitive-behavioral model of OCD is presented,

as well as an explanation of how EX/RP treatment relates to this model.
It is of utmost importance that the patient has a clear understanding of
how and why EX/RP works to reduce OCD symptom severity and
related symptoms. Understanding the rationale will motivate patients to
encounter the cues that trigger their obsessional distress and resist the
urges to ritualize that their obsessional distress generates. Understanding
the rationale is particularly important in encouraging patients to
complete their homework assignments, which they mostly do without
supervision.

Obsessive-Compulsive Disorder

Prevalence and Course of Treatment

Once thought to be a rare disorder, it was estimated that between 2 and

3 million people in the United States suffer from OCD (Karno, Golding,
Sorenson, & Burnam, 1988). According to the National Comorbidity
Survey Replication, approximately 1.6% of the U.S. population reported
experiencing OCD during their lifetime (Kessler, Berglund et al., 2005),
with 1% of the sample having the disorder within the past year (Kessler,
Chiu, Demler, Merikangas, & Walters, 2005). Age of onset typically
ranges from early adolescence to young adulthood, although cases have
been reported as young as 2 years old (Rapoport, Swedo, & Leonard,
1992). Males generally develop the disorder earlier in their lives, in the
teenage years around ages 13 to 15, while female onset is more likely to
occur in young adulthood, ages 20 to 24 (Rasmussen & Eisen, 1990).
Among adults the prevalence of OCD is equal for men and women
(Rasmussen & Tsuang, 1986). Development of OCD is usually gradual,
although acute-onset cases have been reported.

3
 In some cases of childhood OCD, patients experience a very sudden
onset following a strep infection. When the infection is treated, the chil-
dren experience a substantial reduction of symptoms; however, if the
infection recurs, the OCD symptoms again increase abruptly (Swedo,
Leonard, & Rapoport, 2004). This presentation of OCD is referred to
as pediatric autoimmune neuropsychiatric disorders associated with
streptococcal infections (PANDAS).

Typically, without treatment, the course of OCD is chronic, with waxing

and waning of symptoms over time (Antony et al., 1998; Eisen &
Steketee, 1998). However, a small percentage of patients report episodes
in which they have OCD interspaced with periods of remission. There
are cases where OCD symptoms consistently worsen across a lifetime
(Rasmussen & Eisen, 1989). Over time, most individuals continue to
meet full criteria for OCD or still show residual symptoms (Steketee,
Eisen, Dyck, Warshaw, & Rasmussen, 1999). Although effective treat-
ment significantly improves quality of life among individuals with OCD
(Bystritsky et al., 1999), many persons with OCD suffer for years before
seeking treatment. One research study found that on average, individu-
als with OCD wait over 7 years after the onset of significant symptoms
before they seek treatment (Rasmussen & Tsuang, 1986).

Impact of OCD

Untreated OCD has a significant negative impact on one’s life. Dealing

with obsessions and compulsions for hours each day causes severe per-
sonal distress and interferes with employment, relationships, and daily
activities of life. For those with severe OCD, between 80% and 100%
report significant impairment in home, work, relationships, and social
life (Ruscio, Stein, Chiu, & Kessler, 2008). Studies have found that
22% to 40% of OCD patients seeking treatment were unemployed
compared to a typical 6% unemployment rate for the U.S. general pop-
ulation (Koran, Thienemann, & Davenport, 1996; Steketee, Grayson,
& Foa, 1987). Not only do individuals with OCD frequently suffer
from job loss (Leon, Portera, & Weissman, 1995), but they also experi-
ence interpersonal relationship difficulties (Calvocoressi et al., 1995;
Emmelkamp, de Haan, & Hoogduin, 1990; Riggs, Hiss, & Foa, 1992).

4
 Marital distress is reported by about half of married individuals seeking
treatment for OCD (Emmelkamp et al., 1990; Riggs et al., 1992). Fifty
percent of OCD sufferers report losing friendships and 25% report
losing intimate relationships due to OCD symptoms (Gallup, 1990).
Celibacy rates are also elevated in OCD populations even relative to
other anxiety disorders (Steketee et al., 1987). Overall, OCD is consid-
ered one of the top ten causes of disability worldwide (Lopez & Murray,
1998).

Comorbid Disorders

Individuals with OCD commonly present to treatment with other con-

cerns and symptoms, such as depression, phobias, anxiety, and worry
(Karno et al., 1988; Rasmussen & Tsuang, 1986; Tynes, White, &
Steketee, 1990). Recent findings indicate that over a lifetime, 86% to
90% of individuals with OCD meet criteria for at least one additional
DSM-IV disorder (Brown, Campbell, Lehman, Grisham, & Mancill,
2001; Ruscio et al., 2008). Other studies have found that between 50%
and 60% of patients with a current diagnosis of OCD also meet criteria
for at least one other Axis I disorder (Brown et al., 2001; Lucey, Butcher,
Clare, & Dinan, 1994; Rasmussen & Eisen, 1990; Ruscio et al., 2008).
Anxiety disorders such as social phobia, specific phobia, and panic dis-
order appear to be the most common additional diagnosis, with approx-
imately 76% of patients meeting lifetime criteria for these disorders
(Ruscio et al., 2008). Weissman et al. (1994) found that approximately
half of individuals with a current diagnosis of OCD also meet criteria
for another anxiety disorder. Mood disorders are also common for those
suffering from OCD. Lifetime occurrence for any mood disorder is
60%, with the most common being major depressive disorder (41%;
Ruscio et al., 2008). Other studies have found that approximately 30%
of patients with a current diagnosis of OCD also meet criteria for major
depression (Crino & Andrews, 1996; Karno et al., 1988; Weissman
et al., 1994). This is especially important because some research has sug-
gested that severe depression in particular is associated with poorer CBT
outcomes (Abramowitz, Franklin, Street, Kozak, & Foa, 2000; Foa,
Grayson, & Steketee, 1982). A relationship of OCD with eating

5
 disorders has also been reported in the research literature. About 10% of
women with OCD reported a history of anorexia (Kasvikis et al., 1986),
and 33% of women diagnosed with bulimia had a history of OCD
(Hudson & Pope, 1987; Hudson et al., 1987; Laessle et al., 1987). Tic
disorders also appear to be related to OCD. Between 20% and 30% of
individuals with OCD reported a current or past history of tics (Pauls,
1989). Comorbidity estimates of Tourette’s and OCD range from
approximately 35% to 50% (Leckman & Chittenden, 1990; Pauls et al.,
1986).

Diagnostic Criteria for OCD

Here are the American Psychiatric Association (DSM-IV-TR, 2000)

diagnostic criteria for OCD (p. 462):

A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):
(1) recurrent and persistent thoughts, impulses, or images
that are experienced, at some time during the distur-
bance, as intrusive and inappropriate and that cause
marked anxiety or distress

(2) the thoughts, impulses, or images are not simply

excessive worries about real-life problems

(3) the person attempts to ignore or suppress such

thoughts, impulses, or images, or to neutralize them
with some other thought or action

(4) the person recognizes that the obsessional thoughts,

impulses, or images are a product of his or her own mind
(not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

(1) repetitive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting,
repeating words silently) that the person feels driven to
perform in response to an obsession, or according to
rules that must be applied rigidly

6
 (2) the behaviors or mental acts are aimed at preventing or
reducing distress or preventing some dreaded event or
situation; however, these behaviors or mental acts
either are not connected in a realistic way with what
they are designed to neutralize or are clearly excessive

B. At some point during the course of the disorder, the person has
recognized that the obsessions or compulsions are excessive or
unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time

consuming (take more than 1 hour a day), or significantly
interfere with the person’s normal routine, occupational (or
academic) functioning, or usual social activities or
relationships.

D. If another Axis I disorder is present, the content of the

obsessions or compulsions is not restricted to it (e.g.,
preoccupation with food in the presence of an Eating Disorder;
hair pulling in the presence of Trichotillomania; concern with
appearance in the presence of Body Dysmorphic Disorder;
preoccupation with drugs in the presence of a Substance Use
Disorder; preoccupation with having a serious illness in the
presence of Hypochondriasis; preoccupation with sexual urges
or fantasies in the presence of a Paraphilia; or guilty
ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of

a substance (e.g., a drug of abuse, a medication) or a general
medical condition.

Specify if:

With Poor Insight: If, for most of the time during the current
episode, the person does not recognize that the obsessions and
compulsions are excessive or unreasonable.

Several issues emerging from these criteria are worth noting:

■ Obsessions always give rise to distress and anxiety; there are no

positive obsessions.