OCD: the eight-step exposure programme

1. Before you start

You have gone back three times to check the door. You know it is locked — you saw it locked — and you go back anyway. You wash your hands until the skin splits. You reread the same email eleven times to be certain you have not hurt anyone. Or there is nothing to see from outside, and inside an unbearable image has come back every twenty minutes for years, and you have never told anyone because you are convinced that what you think makes you dangerous.

You know it is excessive. That is one of the features of the disorder: most people who suffer from it find their own rituals absurd, and perform them anyway. OCD is not a failure of logic. It is an alarm going off with nothing there, and a security system that gets stronger every time you obey it.

Two things, straight away.

This disorder is treatable. It is among those for which psychotherapy has the most solid results in the whole discipline. That is not a polite consolation: it is what the trials cited in section 8 show.

And it is almost never treated early enough. Studies find a delay of several years — often more than ten — between the onset of symptoms and the moment a person finally receives the right treatment. Shame accounts for much of it, and so does lack of information: many people do not know that what they are living through has a name.

One sentence to keep

The whole treatment rests on one idea, and it is hard to accept: it is not the obsession that keeps OCD going, it is the compulsion. The anxiety is not the problem to be solved. What you do to make it stop, is.

2. OCD in two minutes

Here is the whole disorder. The rest of the programme only unfolds it.

An obsession is a thought, an image or an urge that imposes itself, comes back, and that you do not want. It is experienced as intrusive and distressing. It has nothing to do with a wish.

A compulsion is what you do to bring down the anxiety the obsession produces. Washing, checking, ordering, counting, praying, asking for confirmation, redoing, or — very often, and invisibly — going back over a scene mentally until you are sure.

The two form a loop, and the loop has a formidable property: it works in the short term. The ritual genuinely relieves. That is precisely why it takes hold, and why it is so hard to give up.

Thomas, 29

Thomas leaves his flat. On the way down the stairs a thought arrives: what if the hob was left on? He goes back up, checks, it is off. He goes back down. At the bottom of the building: did I really look, or did I look without seeing? He goes back up. He touches the knobs one by one, naming them under his breath, to "fix" the memory. He leaves.

On the underground he replays the scene mentally to check his memory. The memory is vague — of course it is vague, nobody records everyday actions in high definition. That vagueness becomes the proof that he must go back and check.

Thomas arrives at work forty minutes late, exhausted, and perfectly aware that all of it is unreasonable.

Look at what happened: every check brought relief, and every check made the next one more necessary. That is the central mechanism, and section 6 describes it precisely.

What the programme does, in this order

1. Map obsessions, compulsions and avoidances precisely — you will find far more than you expect.
2. Understand how you interpret your thoughts, because the interpretation is what triggers everything.
3. Build a ladder of situations, from easiest to hardest.
4. Expose yourself deliberately, starting low, to test a precise prediction.
5. Do not perform the ritual — including mental rituals, which almost everyone forgets.
6. Cut off reassurance, and stop the help from those around you that keeps the disorder alive.
7. Climb the ladder, vary, generalise.
8. Consolidate and prepare for setbacks.

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