My approach to working with OCD
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Psychotherapy for OCD, in person and via telehealth, based in Dupont Circle. Click the Free Consultation button to schedule with Dr. Levine.
My Approach to OCD
OCD is closely related to anxiety disorders, but it calls for its own approach.
OCD is closely related to anxiety disorders, but it is a somewhat unique presentation, and therefore it often requires a fairly unique approach to treatment. Like anxiety disorders, it involves both biological and psychological factors, and we will address both. In my view, the core mechanism of OCD can often be thought of as an intolerance of uncertainty or ambiguity—the uncertainty surrounding getting sick, being a good or bad person, the veracity of one’s memory, being surveilled, whether or not one’s circumstances are “just right,” the safety or peril of a loved one, etc. Compulsions usually function as attempts to reduce uncertainty and ambiguity, sometimes in ways that feel rational, albeit excessive, while other times they can feel totally irrational and yet feel irresistible. Therefore the core of treatment for OCD can be thought of as building tolerance of uncertainty, which requires learning to resist behaviors that are intended to reduce that uncertainty. Learning to relate differently to the thoughts, feelings, and sensations that come with uncertainty, so they feel less like urgent problems you have to solve or instructions you have to follow, can also be tremendously helpful in treating OCD. This may feel impossible at first, but learning to experience and respond to your thoughts differently is a skill you can develop, much like mental arithmetic, learning a language, or memorization, through repeated practice with structured, gradually more challenging exercises. The former treatment approach describes ERP (exposure and response prevention therapy) and the latter is one of the core elements of ACT (acceptance and commitment therapy).
The gold standard treatment for OCD is exposure and response prevention.
Traditionally, the gold standard treatment for OCD has been a protocol called ERP, or exposure and response prevention therapy.¹ ERP works to build your tolerance of the anxiety-provoking things that are the focus of your obsessions, and ultimately to reduce the need to engage in the compulsions which function to relieve that anxiety. ERP is considered highly effective for OCD, and, while it is a highly structured approach with a specific protocol, it requires a carefully individualized approach given the uniqueness of every OCD presentation. This requires creativity and collaboration from both clinician and patient, who must work together to come up with the specifics of each exercise and homework assignment, as well as the way in which the protocol progresses over time, such that the treatment moves in concert with the patient’s comfort level, life circumstances, and specific symptomatology.
In my experience, ACT can be especially helpful with obsessions about your own internal experience.
In recent years, there has been increasing evidence that mindfulness-based approaches like acceptance and commitment therapy (ACT) can be highly effective for OCD, either on their own or alongside ERP. For years, ERP was considered the unparalleled gold standard treatment for OCD. However, a recent randomized trial found that group-based ACT produced symptom improvements comparable to group-based CBT with ERP.² Rather than trying to change your thoughts and feelings, ACT focuses on building the ability to relate to them differently. In my own clinical experience, I've found that ACT can be especially helpful for people whose obsessions center on internal experiences, like thoughts or urges that they judge to be morally inappropriate or unacceptable.
Insight still matters with OCD, including insight into how it affects the rest of your life.
While we will obviously work hard to reduce OCD symptoms, improving insight in the context of OCD is still important with OCD. By insight I don't only mean understanding the mechanics of your OCD and what triggers it. I also mean understanding how it affects the other areas of your life. It’s important to explore questions like: How is OCD affecting your relationships? Your identity? Your career, or your experience in school?
As with every concern I treat, I don't want therapy to address only your symptoms. Of course, reducing symptoms is often what initially brings people to therapy. But, in my experience, when patients focus on symptom resolution alone, they're left feeling unresolved. I have many patients come to me from other providers because they feel they only addressed their symptoms in previous therapy experiences, and are left feeling that the areas of their life that had been affected by those symptoms still cause them distress—relationships that had been strained by their OCD symptoms, a system of values that no longer feels true to them in the absence of obsessions and compulsions, religious convictions that have changed, or a desire to have support in exploring the newfound freedom they have in their life. So, when working with me in therapy, to avoid this feeling of partial resolution, we'll focus on both: managing the symptoms of OCD, while also taking a holistic approach that treats you as an entire human being who is more than the sum of your symptoms, or their absence.
1. Reid, J. E., Laws, K. R., Drummond, L., Vismara, M., Grancini, B., Mpavaenda, D., & Fineberg, N. A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials. Comprehensive Psychiatry, 106, Article 152223. https://doi.org/10.1016/j.comppsych.2021.152223
2. Nielsen, S. K. K., Stuart, A. C., Winding, C., Øllgaard, M., Wolitzky-Taylor, K., Daniel, S. I. F., Vangkilde, S., Rosenberg, N., Hageman, I., & Jørgensen, M. B. (2025). Group acceptance and commitment therapy versus cognitive behavioral therapy/exposure response prevention for obsessive compulsive disorder: A block randomized controlled trial. Psychotherapy and Psychosomatics, 94(3), 135–146. https://doi.org/10.1159/000544070