The core component of treatment is exposure with response prevention. This means exposing young people to whatever is scary to them without their reacting with their ritual or response. By learning to do that, they can teach themselves, “Oh, maybe this thing isn’t as threatening as I thought it was, or this feared outcome won’t happen.” The more you practice, the more likely it is that you extinguish the fear, or learn that you can handle the feared outcome.
So let’s take a classic example — excessive hand washing: a teenage girl is fearful of germs, unable to eat without the repetitive hand washing she believes will protect her from getting sick. First, we’ll do a complete evaluation to make sure we fully understand what she’s afraid of, what her rituals are, what she’s avoiding touching, how much she’s washing her hands, et cetera, and we’ll also do some psychoeducation. Patients need to understand what OCD is, what is anxiety is, and how cognitive behavioral therapy works. So, psychoeducation is not just a precursor to treatment but an important part of the treatment itself.
Then we move on to cognitive restructuring, in which we ask patients to re-evaluate their thoughts to try to make them more realistic, along with teaching relaxation and problem-solving techniques. But what I like to think of as the active ingredient is exposure to whatever the person is afraid of.
In the example of hand washing, we’re going to ask this patient—slowly, at a level she can handle—to touch things she thinks are dirty. We might start with asking her to touch a tabletop and then eat with her hands without first washing.
We might even proceed to more “disgusting” things like touching the floor or touching a toilet to show her that she can face her fears fully and be okay. Eventually, she will be able to do this on her own.