situation that scares you. Do this for an hour or two every day until
the fear diminishes. Then, expose yourself to the actual frightening
situation (it may be wise to have a friend or therapist with you when
you do this). This exposure (e.g. to dirt or urine) will result in a strong
urge to perform the ritual (e.g. wash hands), but the ritual (e.g.
washing for 30 minutes) must be prevented so you can learn that the
ritual is unneeded. Finally, after several hours of exposure and
response prevention each day for several days, the unreasonable fears
are extinguished and the compulsive rituals are no longer needed. The
compulsion is, of course, replaced with a more reasonable and useful
response, e.g. washing off the urine in a minute or two perhaps (be
sure the total washing time doesn't increase to two or three minutes).
These behavioral "exposure and response prevention" methods
work about 75-80% of the time. Both exposure and response
prevention are necessary. Exposure reduces the fears; response
prevention stops the compulsions. Gradual exposure works as well as
flooding (creating intense fear), so why traumatize yourself? Self-
treatment, if you are able to do it, in the natural environment works
well, sometimes better than with a therapist present. Exposures for
longer times (without the compulsion) works better than short
exposures. Exposures do not have to be frequent, two or three times a
week may work. The effects seem to last best if "relapse prevention"
procedures (see method #4 in chapter 11) are used following the
"exposure" procedures (Hiss, Foa & Kozak, 1994).
Since thinking is so obviously involved in compulsions and
especially obsessions, the cognitive therapists have sought to treat
these disorders by correcting the thinking directly (instead of indirectly
by simple exposure). Oppen and Arntz (1993) point out that
obsessions are often about awful future events for which you feel
responsible. Thus, they are like depressive thoughts, except in the
future. Therefore, cognitive therapists attack the obsessive-
compulsive's overestimation of the danger and of their responsibility
for the awful consequences. Suppose a fire-phobic person repeatedly
snuffs out his/her cigarettes and checks the ash trays, but still
obsesses about the danger of burning down the house with a cigarette.
A cognitive therapist would have this person calculate the probability
of each step necessary for the catastrophic fire to happen: 1 chance in
100 that the cigarette will not be snuffed out, 1 chance in 100 that
ashes will be knocked on the floor, 1 chance in 10 that the carpet
would burn (this could be tested out with a scrap of carpeting), 1
change in 100 that neither I nor the smoke alarm nor anyone else will
notice the fire, and 1 chance in 100 that no one will be able to put out
the fire. Multiplying all these probabilities together shows that there is
1 chance in 1,000,000,000 cigarettes that the house will burn. So, the
person's thinking and feeling that every cigarette is a big fire threat
can be challenged.
The awful part of many things that obsess or worry us is the
feeling that some terrible outcome will be our fault. Oppen and Arntz
recommend using the "pie-technique." Example: like many drivers, I