Program 18



  1. What is Obsessive Compulsive Disorder?
  2. What is the Cause of Obsessive Compulsive Disorder?
  3. Treatment for OCD
  4. Dealing with Safety Behaviours
  5. Dealing with Anxious Thoughts
  6. Preparing to Change
  7. Dealing with Obsessions and Compulsions

Contamination Fears


Repeating Actions


Demanding Symmetry

  1. Obstacles to Change  
  2. Cost-Benefit Analysis
  3. TIC-TOC Technique
  4. Big I, Little i
  5. Improving Your Self-Confidence
  6. Proceeding in Steps
  7. Conclusion

       1. What is Obsessive Compulsive Disorder?

Obsessions or compulsions (usually both) are symptoms of OCD. Obsessions (thoughts, images, urges) cause anxiety. Compulsions, mental rituals and safety behaviour, relieve anxiety. The main difference between OCD and other impulse control behaviours (e.g. alcoholism, overeating) is that pleasure seeking is entirely absent in compulsions.

Morbid preoccupations are similar to obsessions but usually more realistic and can be compared to extreme worry.

OCD is maintained by compulsive rituals, reassurance seeking, neutralization, thought control and avoidance/escape behaviour.

‘Obsessions’ can be described as ‘preoccupations’ but in OCD obsessions are thoughts, images or urges which enter the mind frequently and persist, causing distress (e.g. fear of contamination).

The OCD sufferer believes they are responsible through their actions to cause or prevent harm to themselves or others. Normal intrusive thoughts, images and urges are misinterpreted as abnormal or dangerous in the case of OCD.

‘Compulsions’ can be described as ‘rituals’ although the former refers to actions and mental acts while the latter refers to only actions.

In OCD compulsions are acts that are repeated many times until the OCD sufferer feels ‘comfortable’ (e.g. rather than finishing washing hands when they are clean, OCD sufferers continue until they feel ‘just right’). Compulsions are often linked to obsessions (e.g. fear of contamination is usually associated with compulsive washing).

Compulsions reduce stress and anxiety briefly but increase the frequency of the obsession and subsequent compulsive act in the long term. Hence, a vicious cycle is set up. You may avoid situations or restrict normal activities to prevent causing anxiety and compulsions.

Safety-seeking behaviours are aimed to reduce anxiety when in a threatening situation. They maintain obsessions by preventing you from testing the validity of your fears.

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2. What is the Cause of Obsessive Compulsive Disorder?

The cause of OCD is not fully understood yet but it is thought that it results from a range of risk factors – biological, psychological, social and life experiences. It is not always possible to find a trigger for OCD but events such as the birth of a baby, trauma such as rape, bullying or the use of drugs such as cocaine can aggravate OCD. There is a slight (5%) chance that the close family of an OCD sufferer will also develop OCD.

Abnormal brain activity or changes in size of parts of the brain are usually the consequences rather than the causes of OCD. In OCD the brain is desperately trying to switch off behaviour such as washing or checking which has been activated by stress.

Changes in the nerves that contain serotonin are likely to be a result of OCD. Medication may help by enhancing the brain’s use of serotonin. OCD does not seem to be related to a poor memory but it may be that OCD sufferers have a low confidence in their memory (e.g. for checking).

Psychologically the brain is trying to re-stabilize and reduce anxiety caused by system overload in which the brain is trying to deal with every catastrophe that could occur that you feel responsible for preventing.

Avoidance, compulsions and safety-seeking behaviours provide short-term reduction in anxiety but reinforce the behaviour and increase your anxiety in the long-term – they prevent you from experiencing the anxiety of a situation and seeing that it does not result in the negative prediction of harm.

Perhaps you think that you have the power to prevent a bad event and feel responsible for preventing harm in the situation, resulting in behaviour such as checking. You need to think anti-superstitiously and rationally to overcome OCD. We all have intrusive thoughts, images or urges that are absurd. However, for OCD sufferers these intrusions are more frequent and complex. In OCD distress occurs due to the meaning attached to the intrusions.


You may believe:

Thinking about something makes it more likely to happen.

Thinking about something is morally equivalent to doing it.

Because a thought has occurred this reflects a person’s true wishes.

Also, you may believe that: ‘Any influence over outcome = Responsibility for outcome’.

It is likely that you overestimate danger and underestimate your ability to cope in the situation.

People with OCD are intolerant of uncertainty and want a guarantee that things will not go wrong. To obtain peace of mind they perform compulsions at the cost of time and productivity. The end result of this behaviour is increased anxiety.

See Program 8: Overcoming Anxiety.

When the individual with OCD tries to reduce or eliminate their obsessive thought, image or urge, by increasing mental control strategies (e.g. neutralization, thought suppression), the results are counterproductive; the solution is to view the obsession as irrelevant and to dismiss it without trying to exercise control.

In OCD there is often a demand for perfection and not achieving this highest standard is viewed as being a complete failure. It is healthier to aim for high standards accepting that you are a fallible human being and do not need to succeed 100%.

See Program 1: Coping Strategies Counselling Advice – Competitiveness and Perfectionism, Frustration, Procrastination and Persistence.

Some OCD sufferers hoard items they are emotionally attached to and this can lead to a clutter. Such individuals identify themselves with these frequently overvalued possessions and feel they must protect them at all costs, perhaps even with their own lives.

It is likely that you concentrate on situations that are threatening – this magnifies the situation and you focus on it even more. You then have even less time to attend to normal activities. Excessive focusing on threat can make you scrutinize a situation that may be dangerous. As a result you will find it difficult to relax or concentrate on normal activities.

See Program 1: Coping Strategies Counselling Advice – Controlled Breathing and Relaxation Techniques, Problem-Solving, Program 22: Overcoming Stress and Program 23: Overcoming Stress At Work.

The more you try to not think about an intrusion, the more frequent and disturbing it becomes. When you sense an intrusion or anxiety, refocus by concentrating on external objects or activities. Try to live in present reality and oppose the way you feel.

You may feel anxious and your thinking can be biased.

To deal with negative thinking:

See Program 1: Coping Strategies Counselling Advice – Modifying Maladaptive Thinking.

Low Frustration Tolerance can lead you to believe that the anxiety you are feeling is ‘intolerable’. Replace these beliefs with coping statements such as ‘This distress is bearable’.

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                  3. Treatment for OCD

Note that you do not need to tolerate things the average person would not do in everyday life. Keep in mind that setbacks can occur and being prepared for them will enable you to get back on track.

It is necessary that you tackle your compulsions before any planned exposure. Keep a chart of the frequency of, for example, your checking/washing and work to reduce the frequency, intensity and duration of such compulsions.  

Compare increasing, for example, checking/washing with stopping these compulsions completely. You will find that your anxiety is worse when you increase the compulsion than when you resist it. In the latter case anxiety increases slightly initially but fades over time and the urges for reassurance decrease.

People with OCD do not have poor memories but rather they lack confidence in their memory.

Exposure (facing your fears until anxiety is reduced) and response prevention (ritual or safety behaviour prevention) ERP, are effective in treating OCD.

See Program 1: Coping Strategies Counselling Advice – Eye Movement Technique (EMT), Mood Induction Procedure, Rational Emotive Imagery (REI), Imago Graded Exposure and In Vivo Graded Exposure.

Paradoxical Intention is a cognitive intervention technique for obsessions based on prolonged exposure. It involves in vivo exposure to situations or objects that elicit the obsession; the OCD sufferer is instructed to deliberately exaggerate the consequences of their obsessional thinking.

The gradual reduction in anxiety following exposure and response prevention (ERP) is called ‘habituation’. When finishing a ritual/compulsion, focus on the external environment and not how you ‘feel’. Remember the more you try to avoid anxiety the more anxious you will get in the long-term.

Your exposure needs to be frequent, long enough and exclude safety behaviours to be effective in reducing your anxiety.

Examples of exposure and response prevention are:

Touching contaminated objects and not giving in to the urge/compulsion to wash until ‘comfortable’.

Deliberately creating disorder and tolerating the anxiety.

Tolerate leaving taps dripping and avoid checking if they are fully tightened.

Consider the following:

Buy a lottery ticket and think repetitively about winning – did you win?

Choose a reliable appliance (e.g. toaster). Think repetitively about it breaking – did it break?

Buy a goldfish in a fish bowl and take proper care of it. Think repetitively about it dying – did it die?

The above exercises can test the faulty beliefs that thoughts cause bad events to occur and that thoughts are the same as actions.

Write out the advantages and disadvantages of carrying on with OCD and then note the benefits and costs of overcoming OCD.

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                  4. Dealing with Safety Behaviours

If the aim of a behaviour is to reduce the risk of harm or anxiety, then it is a safety-seeking behaviour and will reinforce your beliefs about being responsible for preventing harm.

Avoidance is safety behaviour; reassurance seeking is also safety behaviour. By not being solely responsible, a reduction in discomfort and anxiety occurs but prevents ‘habituation’ (a natural decrease in anxiety with repeated exposure to distressing situations).

For effective exposure avoid distraction, alcohol, drugs, compulsions, reassuring phrases, or other safety-seeking behaviours and focus on the trigger allowing your obsession to enter your mind.

Tape aloud your intrusive thoughts which are anxiety provoking and exclude any response such as rituals. Listen to the recording repeatedly with headphones until your anxiety subsides. It may also help to draw or paint intrusive images.

Use Thought Management Procedures and Ritual Delay (gradually delaying safety behaviour until it is eliminated) to deal with your OCD.

See Program 1: Coping Strategies Counselling Advice – Thought Management Procedures.

Response reduction (gradually reducing the frequency of the rituals) should be used with caution as individuals can alter their behaviour to maintain their feelings of ‘comfort’ thus there is no change and not enough exposure. The emphasis needs to be on exposure and testing negative predictions with behavioural experiments.

If you give in to a compulsion and neutralize, for example, swapping upsetting images with neutral images, try to follow this by exposing yourself to the original thought.

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                  5. Dealing with Anxious Thoughts

Keep a daily record of:


Intrusions (thoughts, images, urges).

Rate your distress (0 is no distress and 10 is extreme distress).

Your interpretation of the meaning of the intrusions.

How you responded or wanted to respond (compulsions, urges, and safety behaviours).

Alternative rational response.

Consider how you can challenge your worrying thoughts by finding alternative ways of thinking. Think about the reasons both for the worrying thought and against maintaining it. What is the worst case scenario and how would you cope? Try to form a more rational and constructive view of the circumstances. Re-rate your distress.

You can deal with all-or-nothing/black-and-white/dichotomous thinking by using the continuum method and drawing a line with two extremes at opposite ends of the line (e.g. 100% failure to 100% successful). Mark on the line where you think you fall. Next, mark on the line where you think significant others would fall. Finally, mark on the line where you think you fall now.

Avoid making demands such as ‘should’,  ‘must’, of you or others. Demands are unhelpful and illogical.

It is not possible to eliminate all uncertainty and you will increase your tolerance for uncertainty by accepting that although certainty is desirable it is not absolutely necessary.

Do not suppress or respond to an intrusion but acknowledge it as it occurs. Accept your intrusions and let them pass without engaging with them and refocus your attention (e.g. concentrate on the external environment). There will be a reduction in anxiety and you will see that nothing awful has occurred.

See Program 1: Coping Strategies Counselling Advice – Distraction Techniques.

When we are afraid of something we become vigilant for examples of it and notice it more. If you are noticing something too much try to stop concentrating on your fear and pay attention to the external world.

Keeping a tight control over your behaviour may make you think that such action prevented a catastrophe and you will not be able to discover that your fear would not happen or be as terrible as anticipated.

The individual with OCD feels a ‘need to control’ beliefs and appraisals. The more you try to control your thoughts, the more the thoughts will enter your mind. You need to stop controlling your thoughts. OCD symptoms can be reduced by giving up efforts to control or neutralize the obsession and by diminishing the importance placed on the obsession.  

Avoid labelling your intrusive thoughts as ‘It’s just an OCD thought’ since this can become a ritual for reassurance. Take action and expose yourself to anxiety provoking situations and behavioural tests to show negative predictions do not necessarily lead to harm.

Thoughts about being gay or abusing a child passes through the mind of people without OCD. However, with OCD the thoughts are misinterpreted as dangerous.

To increase your conviction in your new more reasonable beliefs you need to act ‘As if’ you do not have OCD.

See Program 1: Coping Strategies Counselling Advice – Strengthen Conviction in Alternative Functional Beliefs.

You could use the Reattribution technique and re-distribute responsibility for an event. List all contributing factors to an event with you at the bottom. Next, allocate on a pie chart (scale 0-100%) responsibility as percentages for all the factors with you last. Hopefully, this will show that you are not the only one responsible for the event.

Physical exercise can be helpful with OCD and can break the vicious cycle of automatic rituals giving short-term relief.

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                  6. Preparing to Change

First describe your intrusive thoughts, images, urges; what they mean to you and how you respond (e.g. avoidance, safety behaviours). Next, define your goal attaching a realistic meaning to your intrusions and changing your response so that it no longer distresses you.

Rate the severity of your OCD (1 is low and 10 is extreme). Repeat this rating every four weeks.

Consider the possible contributory factors for your OCD (e.g. genetic vulnerability, life experiences, attitudes, or rules such as Thought Action Fusion).

See What is the Cause of Obsessive Compulsive Disorder?

Can you identify what triggers your OCD (e.g. life changes, death, pregnancy)?

To understand what maintains your OCD note:

A typical trigger.

Intrusive thought, image, urge.

The meaning of the intrusion.

Thinking bias.

Avoidance and safety behaviours.


Physical reactions/emotions or feelings.

Before you start the program you need to rate your problems (1 is low and 10 is extreme) and goals (1 is no progress and 10 is complete achievement). Make sure your goals are specific, measurable, achievable, realistic, and time bound (SMART). If you have several obsessions and compulsions try dealing with related goals together.

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                  7. Dealing with Obsessions and Compulsions

                  Contamination Fears

Goals for washing your hands: If you are washing your hands excessively try to reduce the frequency and duration. Apart from the obvious reasons to wash (e.g. after you defecate), try to wash when you see your hands are dirty and stop when you see (not feel) they are clean. Typically wash within 30-40 seconds finishing while you feel uncomfortable.

When you are unable to resist a washing ritual, finish by re-exposing yourself to something contaminating (e.g. touching the floor then your body and possessions). Deal with avoidance or cleaning rituals by removing all safety behaviours (e.g. using gloves or tissues). Expose yourself to the feared contaminant (e.g. use public toilets and sit on the seat).

Limit showering or bathing to five or ten minutes once or twice a day. Finish after the specified time even if you feel uncomfortable. Do not use any rituals to make you feel ‘comfortable’. If you do, then re-contaminate yourself (e.g. touch the toilet seat followed by touching all over your body).

Try cleaning your home when you see it is dirty rather than when you feel it is dirty.

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Checking to be ‘certain’ maintains OCD. People without OCD do not bother to check whether:

Gas and water taps are off.

Light and electrical appliances are off.

Most people without OCD only check the door lock or window once before they go out. In your profession you may feel you must not make mistakes. In all these cases try to finish checking while you still feel ‘uncomfortable’. Use objective information such as smell of gas, water gushing, seeing light, sensing heat of an iron or try to open a locked door once, and use OCD free colleagues as role models.

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                  Repeating Actions

Try to complete these actions just once without repeating them and finish when feeling ‘uncomfortable’.

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If you hoard, try to throw out or give to a charity shop any unnecessary possessions. In future buy only useful items and organize a sensible system of storage.

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       Demanding Symmetry

If you demand order, try causing disorder and asymmetry until you feel ‘uncomfortable’.

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8. Obstacles to Change

People with OCD are often very isolated and this can result in low mood and pessimism.

See Program 12: Overcoming Depression and Program 15: Overcoming Grief And Bereavement.

If you feel suicidal, please contact your doctor immediately.

Practise unconditional self-acceptance and treat yourself as you would a friend. In order to do so you need to acknowledge that you are a complex, fallible human being and demands for perfection are unrealistic. Stop comparing yourself with others and do not use negative labels to rate yourself (e.g. ‘inferior’).

See Program 1: Coping Strategies Counselling Advice – Criticism, Countering Self-Criticism, Improving Your Self-Image and Combating Self-Harm and Coping with the Need for Approval.

Pride often linked to shame may be an obstacle to OCD by preventing feelings of shame that may occur if you accept that your present coping skills are inadequate.

See Program 1: Coping Strategies Counselling Advice – Shame.

You need a healthy diet, exercise, sufficient sleep, avoid stimulants such as tea, coffee, nicotine, limit alcohol intake and go easy on recreational drugs.

See Program 1: Coping Strategies Counselling Advice – Nutrition, Exercise, Managing Your Time and Sleep Management.

Make optimum use of your time.

See Program 1: Coping Strategies Counselling Advice – Planning an Activity Schedule.

Develop a high frustration tolerance so you can tolerate anxiety, uncertainty and risk long enough to see that your negative predictions do not actually happen.

See Program 8: Overcoming Anxiety.

Seeking reassurance and transferring responsibility to others will only reinforce your worries. You cannot demand certainty that no harm will occur if you drop rituals and carry out exposure tasks – such demands drive OCD.

Your OCD may make you angry and guilty too.

See Program 1: Coping Strategies Counselling Advice – Guilt, Forgiveness and Program 6: Overcoming Anger.

OCD sufferers may prefer a lower quality of life than to expose others to possible harm.

Build a good support network.

See Program 1: Coping Strategies Counselling Advice – Social Skills Training, Communication Training, Negotiation Training, Troublesome Emotions and Program 13: Overcoming Destructive Relationships.

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                  9. Cost-Benefit Analysis

Doing a cost-benefit analysis will motivate you to work at overcoming OCD.

On a sheet of paper write:

The short-term cost/disadvantage to you of giving up OCD

The short-term cost/disadvantage to others of giving up OCD

The short-term benefit/advantage to you of giving up OCD

The short-term benefit/advantage to others of giving up OCD

The long-term cost/disadvantage to you of giving up OCD

The long-term cost/disadvantage to others of giving up OCD

The long-term benefit/advantage to you of giving up OCD

The long-term benefit/advantage to others of giving up OCD

On another sheet do the same for not giving up your OCD.

Write on a flashcard the most important costs of not giving up your OCD and the benefits of change. Refer to this when you feel your motivation is decreasing.

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                  10. TIC-TOC Technique

Divide a sheet of paper into two columns and in the left list thoughts that are preventing progress in overcoming OCD. These are TIC's (task interfering cognitions). In the right column write the alternative attitude that will help to overcome each of the TIC's you have noted in the left column. These are TOC's (task orientating cognitions).

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                  11. Big I, Little i

Develop self-acceptance by considering the ‘Big I/Little i’ diagram (Lazarus 1977). Draw the outline of a Big I and fill it with lots of little i’s. The Big I is the self and all the little i’s represent everything about you that can be rated (e.g. height, weight, age, etc.)

When you focus on the Big I you are likely to be self-critical. By concentrating on the little i’s you will be in a frame of mind that is goal orientated and problem-solving. From the diagram, by circling little i’s (aspects of yourself) it will become clear that these points cannot describe your complexity as a fallible human.

You can apply this technique from A to Z (e.g. a large M for mother with lots of little m’s inside).

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                  12. Improving Your Self-Confidence

Make a list of the rights your OCD is violating such as:

Enjoy life without feeling guilty.

Place own happiness as a high priority.

Work and have adequate relaxation and recreation without being dictated to by OCD.

Accept intrusive thoughts, images, urges and allow them to pass without responding to them.

Go to public places without fearing harm to oneself or others.

Take daily risks without too much anxiety.

See Program 1: Coping Strategies Counselling Advice – Assertiveness Training, Neuro-Linguistic Programming (NLP), Building Confidence I, Building Confidence II, Building Confidence III, Building Confidence IV and Program 16: Overcoming Low Self-Esteem.

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                  13. Proceeding in Steps

Making progress:

Specify your problems and goals.

Identify your obsession.

Understand that your distress is due to the meaning you attach to your obsession (intrusive thoughts, images or urges) [Theory A] – for example, ’Thinking about harming someone, means it is likely to happen’.  

How do you respond to avoid experiencing your obsession? Do you use ‘solutions’ such as avoidance, rituals, compulsions, neutralizing, reassurance-seeking?

Understand that these ‘solutions’ are a problem and experiment how using more or fewer of these strategies affects the frequency, intensity, and duration of your intrusions.

Formulate a more positive alternative explanation for your obsessions [Theory B] – for example, ‘Fearing harming loved ones shows how much I want them to stay safe’.

Behave ‘As if’ you believe [Theory B] and gather evidence for whether [Theory A] or [Theory B] fits the facts best.

Confront the things you have been avoiding and resist rituals, compulsions, neutralizing and reassurance seeking.

What are your obstacles to progress? How can you overcome them?

Make sure you have a relapse prevention plan.

Be patient and do not become anxious if progress is slow or there are setbacks. Tolerate and learn from ups and downs. Keep records of your progress as this will maintain your motivation. Reward yourself for every little achievement and your hard work.

It can be helpful to have the support of a friend or relative who understands your OCD and has the time to sit down with you regularly to discuss your progress.

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                 14. Conclusion

To prevent a relapse you need to:

Consider the things that have helped you overcome your OCD and which techniques were most helpful.

Maintain good physical health – eat healthily, exercise regularly and get sufficient sleep.

Maintain good mental health – fill the gap left by overcoming OCD.

Keep active and pursue interests.

If OCD was interfering with your job, plan realistically the goals for building your career. Improve relationships and spend quality time you enjoy, with others. Improve your communication skills. Consider what spirituality has to offer you.

What might trigger a setback and how would you cope? Take action to deal with the setback as soon as you notice the warning signs.

See Program 1: Coping Strategies Couselling Advice – Relapse Prevention.

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