When Exposures Go Right: Effective Exposure-Based Treatment for Obsessive–Compulsive Disorder
Cognitive behavioral therapy with exposure and response prevention (CBT-E/RP) is the first-line treatment for obsessive–compulsive disorder (OCD). Several CBT-E/RP treatment manuals exist, yet clinicians still struggle to implement this evidence-based form of therapy. This article aims to help clinicians implement exposure-based treatment for OCD by providing practical treatment-enhancing strategies. In particular, literature and treatment recommendations related to effective hierarchy formation, strategic exposure design, and optimal exposure implementation is reviewed. Clinical case examples are provided throughout the paper to illustrate important principles, concepts, and recommendations. This paper aims to enhance the delivery of CBT-E/RP and address common questions and concerns that both new and advanced clinicians encounter when learning and applying this form of psychotherapy. Improving the integrity of CBT-E/RP delivery can improve therapeutic outcomes, patient compliance, and successful treatment completion.
KeywordsExposure-based therapy Psychotherapy Evidence-based treatment OCD Clinical recommendations
This paper did not have any funding.
Compliance with Ethical Standards
Conflict of Interest
Author Cary Jordan, Adam Reid, Jessica Simmons and Michael Sulkowski authors declare they have no conflicts of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., ... Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the dimensional obsessive-compulsive scale. Psychological Assessment, 22, 180–198. doi: 10.1037/a0018260.CrossRefPubMedGoogle Scholar
- Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional Processing Theory: An Update. In B. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24). New York: Guilford Press.Google Scholar
- Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S. O., Campeas, R., Franklin, M. E., ... & Tu, X. (2005). Treatment of obsessive compulsive disorder by exposure and ritual prevention, clomipramine, and their combination: a randomized, placebo-controlled trial. American Journal of Psychiatry, 162, 151–161. doi: 10.1176/appi.ajp.162.151.CrossRefPubMedGoogle Scholar
- Franklin, M. E., & Foa, E. B. (2014). Obsessive-compulsive disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: a step-by-step treatment manual (pp. 155–205). New York: Guilford Press.Google Scholar
- International Obsessive Compulsive Foundation (2015). Retrieved November 3, 2015, from https://iocdf.org/.
- Kendall, P. C., Ashchenbrand, S. G., & Hudson, J. L. (2003). Child-focused treatment of anxiety. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 81–100). New York: Guilford Press.Google Scholar
- Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., ... Dowd, E. T. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: report of the inter-organizational task force on cognitive and behavioral psychology doctoral education. Behavior Therapy, 43, 687–697. doi: 10.1016/j.beth.2012.05.002.CrossRefPubMedGoogle Scholar
- March, J. S., & Mulle, K. (1998). OCD in children and adolescents: a cognitive-behavioral treatment manual. New York: Guilford Press.Google Scholar
- McGuire, J. F., Piancentini, J., Lewin, A. B., Brennan, E. A., Murphy, T. K., & Storch, E. A. (2015). A meta-analysis of cognitive behavior therapy and medication for child obsessive-compulsive disorder: moderators of treatment efficacy, response, and remission. Depression and Anxiety, 32, 580–593. doi: 10.1002/da.22389.CrossRefPubMedPubMedCentralGoogle Scholar
- Pediatric OCD Treatment Study (POTS). (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the pediatric OCD treatment study (POTS) randomized controlled trial. Journal of the American Medical Association, 292(16), 1969–1976.CrossRefGoogle Scholar
- Schumacher, S., Gaudlitz, K., Plag, J., Miller, R., Kirschbaum, C., Fehm, L., & Ströhle, A. (2014). Who is stressed? A pilot study of salivary cortisol and alpha-amylase concentrations in agoraphobic patients and their novice clinicians undergoing in vivo exposure. Psychoneuroendocrinology, 49, 280–289.CrossRefPubMedGoogle Scholar
- Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., & Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63, 925–934. doi: 10.1001/archpsyc.63.8.925.CrossRefPubMedGoogle Scholar