Re:OCD with non-specific rituals

The first step, of course, is a good assessment so we're sure that we're dealing with OCD (I've crossed paths with a few schizophrenics who presented initially with strange obsessions or compulsions) and establishing a good collaborative relationship.

The central principle in CBT with anxiety disorders is that the client needs to gradually eliminate avoidance behavior and do the things which elicit their anxiety. If they face and tolerate the anxiety on a regular basis, the anxiety becomes less intense, they cope with it more effectively, and the disorder fades. In the treatment of OCD this process typically takes the form of Exposure and Response Prevention (E&RP) ... the therapist has the client face the stimuli, actions, thoughts, or images which elicit anxiety and has the client refrain from performing the rituals, behaviors, thoughts, etc. that are used to avoid or escape the anxiety.

In the case of your client, what increases his anxiety? Verbalizing his intrusive thoughts does, doing something "incorrectly" does, etc. What does he do to avoid anxiety? He wears "lucky" clothes, he re-does tasks until they are "correct", etc. Therefore, (assuming he isn't schizophrenic) it will be necessary to have him do the things that increase his anxiety and refrain from doing the things he usually does to reduce anxiety. This means having him verbalize his intrusive thoughts and refrain from doing anything to make it OK, having him do things "incorrectly" and refrain from re-doing them in the correct way, having him wear "unlucky" clothes without doing anything to compensate, etc.

This can be done intensively or in a series of gradual steps, starting with the less difficult items. The intensive approach has been researched more thoroughly but when one is doing outpatient therapy the gradual approach is often necessary and it seems to work fine IF THE CLIENT WILL FOLLOW THROUGH ON IT BETWEEN SESSIONS.

So far I haven't said anything about cognitive interventions. The cognitive interventions aren't essential, a purely behavioral E&RP approach works fine if you can get the client to follow through on it. On the other hand, cognitive interventions which are not accompanied by E&RP will prove ineffective. However, cognitive interventions can be quite useful for increasing the client's willingness to follow through on E&RP.

I find that it is important to develop a good understanding of the client's fears regarding what will happen if he or she doesn't control the intrusive thoughts or complete their compulsions/rituals. It may be necessary to address some of these fears cognitively before the client will be willing to follow through on the E&RP. It also is important for the client understand that engaging in his various anxiety-reducing behaviors makes him feel better at the moment but perpetuates his problem while persistently facing his fears and tolerating the anxiety is the way to overcome his problem.

Finally, it is important for the client to understand that they will feel worse (more anxious) in the short run as they do this. In fact, I often suggest to clients that they can use a simple rule of thumb when working on their OCD "If what I'm doing makes me more anxious, it is probably a good idea to do it and tolerrate the anxiety. If what I am doing makes me more comfortable, it is probably a good idea to stop doing it and tolerate the anxiety."

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