Obsessive-Compulsive Disorder (OCD): Symptoms, Causes, and Treatment
Learn how OCD works beyond common stereotypes, the signs to look for, and how ERP therapy can lead to meaningful improvement.
Expert Interview: Katie Torres, LCSW, Director of the Center of Excellence at Compass Health Center
Interviewer: Britt Teasdale, Associate Director, Brand Management & Content
In this in-depth interview, you’ll learn:
- What OCD actually is, beyond common stereotypes
- Common OCD symptoms and the OCD cycle of thoughts, distress, and compulsions
- Early signs of OCD in children, teens, and adults — including how OCD in kids often gets missed
- OCD vs anxiety: how to tell the difference between the two
- Why exposure and response prevention (ERP therapy) is the gold-standard OCD treatment
- When to consider a higher level of OCD treatment, such as PHP or IOP
Understanding OCD: More Than a Stereotype
Obsessive-compulsive disorder (OCD) is one of the most misunderstood mental health conditions, too often reduced to a personality quirk or a preference for tidiness. In reality, OCD is a serious condition that can interfere with every part of a person’s life: school, work, relationships, and even basic daily routines like getting out of bed or taking a shower. It’s also one of the leading causes of disability worldwide.
OCD is also highly treatable. With evidence-based, specialized care, most notably ERP therapy (exposure and response prevention), people who have spent years debilitated by their symptoms can regain their functioning, their relationships, and balance in their lives. Understanding what OCD actually is, what the OCD cycle looks like, and what effective OCD treatment involves is the first step toward closing the gap between symptom onset and meaningful help.
In the conversation below, Katie Torres, LCSW, Director of the Center of Excellence at Compass Health Center, shares what she’s learned over nearly two decades of specializing in OCD and anxiety disorder treatment: how OCD presents across the lifespan, why it’s so often missed or misdiagnosed, how exposure and response prevention (ERP) works, and what progress can look like for patients and their families.
Meet Katie Torres: Nearly Two Decades Specializing in OCD and ERP Therapy
Britt Teasdale: Can you tell me a little bit about your clinical background and what drew you to working with OCD and at Compass?
Katie Torres, LCSW: I’m really excited to be here today and talking a little bit about this because I think it’s something that’s so relevant to so many families and individuals.
I’ve been in the field for about 16 years. I was completing my Master of Social Work at the University of Illinois at Urbana-Champaign and did my clinical internship at a Chicagoland behavioral health hospital that had a specialty OCD and anxiety clinic at the PHP and IOP level of care. I kind of just stumbled into it. My internship landed me there.
You don’t learn a whole lot about specialty OCD treatment in a grad school program. You learn about OCD within the context of diagnosis and the DSM, but you don’t learn much about specific evidence-based treatments for OCD. So it was all really new to me, literally my first day of doing any clinical work 16 or 17 years ago.
And I just fell in love with it. It was such an amazing experience. I got to see and do and learn so much, and I really saw people getting better — getting a lot better. People who were coming into treatment really struggling, really debilitated by their symptoms, were leaving treatment in such a different place. They were regaining so much of their functioning and so much of their life that I just kind of fell in love with doing that specific kind of work, exposure and response prevention, and knew that I wanted to keep doing that probably for the rest of my career.
I’ve been able to stay in that realm and worked at the place where I completed my internship in that program for quite a long time. Then I decided to make a shift and move over to Compass almost two years ago now to focus a little bit more on program development and overseeing our curriculum for our OCD and anxiety disorder programs here, which has just been a wonderful experience.
OCD Is Serious — and Highly Treatable
Britt: I love what you said about just seeing people get better. I know in some of the previous conversations we’ve had, we’ve talked about how OCD is really misunderstood, but it is highly treatable. Could you speak a little bit to that?
Katie: I think there are two really important things to understand about OCD.
The first is that it’s not a personality quirk. OCD can be really debilitating for a lot of people. It is one of the top causes of disability for people. It can really interfere with their entire life and every aspect of their life — the way that shows up at school, at work, in their relationships, and in their activities of daily living, like getting out of bed, getting in the shower, eating. OCD can impact all those areas.
So we have to hold that as one truth. We have to understand that this is a really serious mental health condition.
And then at the same time, we have to hold this other idea that we also know it is highly treatable with the right interventions, and that people do get a lot better and learn to have a different relationship with those symptoms, with some of the thoughts they experience, and with some of the behavioral urges they experience. When they can learn to shift their relationship to those things, we really see a lot of improvement for people.
So it can feel like those two things are opposing, but they’re really not. It’s like a dialectic that we have to hold: OCD can be really debilitating, and it’s highly treatable with the right treatment and intervention.
Beyond the Stereotypes: What OCD Actually Looks Like
Britt: Why do you think when people hear OCD, they often picture this idea of handwashing or strict organization and cleanliness? From your perspective, where does that come from? And could you dig a little deeper into what OCD actually is?
Katie: I think it comes from our limited understanding of OCD, though there has been a lot more awareness in recent years about what OCD actually is versus what we see depicted in movies or in media, which is more the checking light switches, washing my hands kind of presentation — these are very narrow displays of what OCD might look like.
And OCD can look like that. Those are very real symptom presentations of OCD: checking, cleanliness, and contamination concerns.
But something I always remember that one of my supervisors told me early in my training was that if you’ve seen one person who struggles with OCD, then you’ve seen one person who struggles with OCD. That’s really been important for me to remember and understand throughout my clinical experience.
Even two different individuals who both have cleaning, contamination, or concerns about germs are going to have a really different core fear about what it would mean for them to actually be contaminated or to come into contact with germs. It’s not going to be the same. So we have to do a functional analysis and ask the right questions to really get at what that means for them.
I also think that beyond those things we see depicted in media, there are so many different nuanced ways that OCD can present, and OCD can really latch onto anything for an individual. A lot of times we talk about how it tends to latch onto the things that feel most important to us or values-aligned.
So that could be anything. It could be my relationships — obsessive thoughts about the relationship that I’m in. It could be really distressing obsessive thoughts about what if I’m not the person I think I am? What if I’m someone who actually could do something harmful or dangerous or violent? It could be about our identity. What if I’m not the actual gender identity that I think I am, or the sexual orientation that I think I am?
Those are all symptom presentations that we still don’t hear about as much. And that can lead to a lot of confusion for individuals who might be experiencing those things. They may have a connotation of OCD as something about checking or handwashing, but they’re having these thoughts, so they think that must not be what this is. A lot of times that leads to lack of early diagnosis or accurate diagnosis, which can delay getting them into the right treatment.
How OCD Symptoms Show Up: The Thought–Distress–Compulsion OCD Cycle
Britt: Could you go into the differences between compulsions and the thoughts, and the patterns around thoughts? If you have OCD, would you automatically experience both of those things, or is it just one or the other sometimes? How does that work?
Katie: That’s a really good question. What I think about when working with individuals who have OCD is this cycle.
Typically, it might start with a triggering event. Maybe I see something or I hear something. But sometimes even that may feel a little less clear, what the triggering event is. And then always the next part is that I have a thought. A thought in my mind, or maybe it’s more of an image, but a thought or an image that provokes some kind of distress.
For most people with OCD, that distress is going to feel like anxiety or fear. But some people describe more of an emotion of disgust, and they don’t resonate with that feeling of anxiety. That can be confusing too, because sometimes it then feels like maybe this isn’t OCD. I don’t feel anxiety. That’s not what I would call this. But I feel a sense of disgust, or maybe just a feeling of not just right — things feel off or not quite correct.
So there’s a thought, there’s that emotional experience of distress, and then there’s some type of behavior or mental act. That’s what we call the compulsion or the ritual. There’s some type of behavior or mental process to try to reduce the distress I’m feeling.
A lot of times it can be hard for people to separate when the compulsions they’re engaging in are more mental versus physical. So they’re not checking a door, they’re not washing their hands, but they’re doing some kind of mental undoing or mental replaying, or saying a certain word in their head to neutralize the distress they felt from the thought they had. And that’s the compulsion, which then, of course, leads to some short-term relief. The individual feels better in that moment.
So it becomes negatively reinforced that the next time I have that thought I don’t like and feel that emotional distress, I better make sure I do this mental act or this physical act that brought me relief before. That’s the cycle we see: thought, distress, compulsion, some short-term relief. And it tends to continue and perpetuate in that way.
OCD Symptoms in Children, Teens, and Adults: Age of Onset and Causes
Britt: Does OCD typically form in early childhood, the teenage years, or later in life? How does that work when you look at the lifespan? Can symptoms develop because of a traumatic event?
Katie: That’s a really good question. Just to lay out first and foremost, there’s a lot that is still unknown about why someone gets OCD and someone else doesn’t.
We know there’s likely a genetic component. There have been a lot of interesting studies on twins with OCD, and there are findings that show identical twins are far more likely to both have OCD than fraternal twins. So we know there’s a genetic component and some genetic markers.
We also know there’s a piece related to brain chemistry and different neurotransmitters at different levels that impacts that.
And then you asked a really good question about whether OCD can come from a traumatic event. I think it’s really important to understand that OCD generally is not caused by trauma. So many people experience OCD that is not connected to a traumatic event.
The reason I think that’s important to lay out is because otherwise it can feel like, if I believe my OCD must have been caused by a traumatic event, it can lead to almost compulsive searching and doubting around what could have happened to cause this, when the reality is there are a lot of factors that influence someone having OCD — hereditary, brain chemistry, and environmental.
When someone experiences a traumatic event, that absolutely can lead to someone being more likely to experience OCD symptoms around that specific trauma. It also may be one of those things that, if someone was already predisposed to having OCD or more likely to, a traumatic event can certainly be something that pushes that over the edge for people.
A lot of times we see overlap between individuals with PTSD and OCD, where some of the focus of their obsessive-compulsive disorder does have to do with a traumatic event they experienced.
You also asked about age of onset. Typically, we see a really common age of onset in childhood between ages eight to 12, and then also later in early adulthood, around 18 to 21. But just because that’s the age of onset does not always mean that’s when it is being diagnosed or when individuals are receiving treatment. There are a lot of different reasons for that.
I’ve certainly worked with a lot of adults in my lifetime who are seeking treatment for the first time at 45 or 50 years old, and yet they can recognize that they’ve really struggled with these symptoms since they were teenagers. So that’s very common. Even though symptoms started earlier, it takes, I think on average, about seven years for individuals experiencing symptoms to get linked to evidence-based, helpful treatment. So that’s a real gap too.
Why OCD Is Often Missed or Misdiagnosed
Britt: That does feel like a real gap. Do you think that’s back to the idea of it being so misunderstood, or that there aren’t enough professionals trained strictly in OCD to be able to recognize it? Why do you think that gap exists?
Katie: I think all the things you named. It is still fairly misunderstood, both for individuals and sometimes even for healthcare providers.
OCD can often look like a lot of different things. Sometimes in childhood, if we see that a child is really distracted and having trouble focusing, our minds might go to ADHD or trouble with attention. Unless we know to ask some of these questions and find out that actually it feels like their mind is going a million miles a minute because they’re having all these obsessive thoughts and things they feel they have to tend to and respond to all day, well, of course that’s going to shift their attentional focus in school, with homework, and at home.
It can look like so many other things that I think it can be hard to tease out, both for the person experiencing it and for people who are in helper roles and really want to be helping and treating this. But it can be difficult and sticky to make sure we understand what it is we’re treating.
I also think that with a lot of presentations of OCD, there is just a lot of shame around it. It’s really unfortunate, but with some of the ways OCD can show up — these intrusive, distressing thoughts that feel like they totally go against who you are as a person, thoughts like what if I did something harmful or violent or dangerous — I think for a lot of people, it is very difficult for them to feel like they can share those thoughts, even with a treatment provider. And so unfortunately, when they don’t share those thoughts, there may not be an accurate understanding of what it is they’re experiencing and what’s going on for them.
Early Signs of OCD in Kids and Teens: What Parents and Caregivers Should Know
Britt: Would you be able to break down for each age group — children, teens, young adults, and adults — what some of the early signs or just signs of OCD can look like? Would you be able to pinpoint those different signs across the different age groups?
Katie: It’s an interesting question. I’m thinking about it because part of my mind goes to what will look different is what’s going on for those different age groups developmentally. So it will show up differently in the context of their lives.
What’s interesting is that with the different ways OCD shows up, it can show up in all age groups, all those different symptom presentations. It’s not just adults who are experiencing intrusive thoughts about harming someone. Kids experience that. Now think about how scary that is for a kid who’s experiencing that.
The way that might show up for a young child or a teenager can really vary. It may be that if they’re experiencing really distressing thoughts that they don’t know what to make of, we see them shut down. Maybe we’re seeing them isolate more because they’re so scared that they’re having these thoughts and they don’t want to be around people because they’re having this compulsive doubt of what if I were to hurt someone? Those are the thoughts I’m having. I better stay alone in my room and not be around people because that scares me so much. I don’t want to do that.
Another way this may show up for younger individuals is a lot of confessing or reassurance seeking. So often we’ll see children who are experiencing a lot of distressing thoughts feel the need to confess them to their parents to seek reassurance: Is this okay? Is this okay that I’m having this thought? This doesn’t mean I want to do this. And that gets into that compulsive feedback loop of parents saying, no, it’s okay, which provides short-term relief until the next time they have a thought and feel like they need to go see their parents and confess the thought and get that reassurance again. That can be a really common way that we see OCD start to show up for kids.
It can be hard sometimes for caregivers to discern what’s normal childhood worry and stress versus what is that cycle of a distressing thought and needing to do something to get rid of that distress so that I can feel better.
Intrusive Thoughts vs. the OCD Cycle: When Patterns Warrant Curiosity
Britt: That brings up the question of what’s a typical cadence of intrusive thoughts that I think everyone has, right? At some point, everyone’s going to have an intrusive thought or intrusive thoughts, versus when it warrants more curiosity. I guess it’s the pattern — the thought, then the reassurance-seeking or the way to cope with the discomfort. That cycle would pinpoint potentially having OCD, versus I have an intrusive thought and then it goes away and I move on.
Katie: Yeah, exactly that. There have actually been a lot of studies that show just what you said, Britt, that we all experience intrusive thoughts, OCD or not. We have thoughts that are like, that’s not a Katie thought. That’s interesting that that came to my mind.
The way we talk about it with kids sometimes is that it can feel like the sorter in your brain gets flipped off if you struggle with OCD. So if I have a thought that doesn’t align with me, I can maybe recognize it, see it, and kind of go, not a Katie thought — I’m moving on.
For someone with OCD, that becomes really challenging. It’s more that process of what happens after the thought — the thinking about the thinking, the thinking about the thought, saying to themselves, what does it mean that I have this thought? What does that say about who I am? What should I do to make sure that thought doesn’t come true, or that I don’t act on that thought, or that I try not to have it again?
So it’s all about that process afterward and the stickiness that those thoughts tend to grasp onto.
And you asked another good question for caregivers and family members to think about: what’s the intensity of those thoughts, the intensity of the distress kids are feeling, the frequency, the duration, how long is that lasting?
Those are all really important things to look at to gauge and understand whether this is something we might need more support with, and whether it seems to be increasing or becoming more challenging.
Is OCD Hereditary? What Families Should Know
Britt: You mentioned that OCD can be hereditary. If a family knows that a parent has struggled with OCD, is there proactive intervention for the next generation? Is that something that’s happening? I’m curious whether there are studies on that, and whether families or clinicians are looking into it.
Katie: There are studies being done around what kind of proactive intervention might help if we know there’s a family predisposition or someone has OCD. We know genetics are a part of it, but there’s still a lot that’s unknown there.
And I say that also because I think there’s already so much anxiety in general for parents today that it certainly is not about telling parents if you struggle with this, then your child is going to struggle with this.
But to your question, I think probably the most proactive thing that caregivers or family members can do if they know they experience OCD is really just engaging in their own treatment and working through how that shows up for them. There are environmental components to how people develop OCD as well, so doing that work for themselves helps ensure they have the freedom to not feel like their life is controlled by OCD symptoms, and that they’re able to foster that environment for their kids too.
I’ve also worked with a lot of parents who have a child in treatment for OCD and who have self-disclosed that they themselves struggle with OCD. I’ve seen so much positive support come from that parent to child relationship because they truly know what it feels like, what their child is going through.
That can be a really interesting family dynamic too. Especially if there’s one parent who really resonates with, I experienced this too, it allows them to really see their child and support them through that in a way that, with the right therapeutic support and intervention, can be really helpful and help that child feel seen and supported. So there are strengths in that too.
A Day in the Life: How OCD Symptoms Affect a Teenager
Britt: Would you be able to walk me through — and I know it’s so different, like you said, if you treat one person with OCD, that’s just one person with OCD — but I think it’d be interesting if you can maybe walk through what a day in the life of a teen with OCD might look like, managing school to extracurriculars to home life.
Katie: I think it helps to take a specific symptom presentation to help bring this more to life. Maybe we’ll think about a teenager who is in high school and struggles with OCD surrounding moral or almost scrupulous, religious-based concerns — like, am I a good person? Am I doing the right thing?
I think that’s something that shows up more and more today too, especially for teenagers, when there’s so much division in our country and our world. That’s an example of how current events and things going on in our world can become something OCD latches onto for people who may already be predisposed. That’s something we see a lot for kids who are going through treatment.
So let’s say this is an individual who has obsessive fears about, am I being a good person? Am I doing the right thing? Am I making good decisions? Am I maybe inadvertently causing harm to someone in a way that I don’t realize?
They may wake up and start their day, and we can tell that something they value is wanting to be a kind person because that’s what they’re obsessively doubting.
Let’s say they get on the bus to go to school and walk by a few kids and sit down next to one of their peers. An example of what might trigger something like this would be the obsessive thought of, oh my gosh, did I just hurt that other kid’s feelings by not sitting by them? What if I really ruined their day? What if their mental health isn’t in a good place, and now I’ve done something to further perpetuate that? Maybe I should have sat there instead of sitting here.
So that first obsessive thought is just, what if I did something to hurt their feelings? And then the mental compulsion could be to spin and ruminate about what this could mean: what if this could mean something bad happens for this person? I’m going to ruin their day. They’re going to flunk a test, or even all the way down to do something to harm themselves because I didn’t sit by them. They may be wrestling with these thoughts, trying to disprove them, which is all part of that compulsive response. Another compulsion may be feeling like they need to go check on that individual later in the day, force some kind of interaction with them to get proof they are ok.
So now this child is spinning with those thoughts as they’re sitting on the bus. It’s probably making it very difficult for them to start their day on a positive note or engage with the child next to them.
Then let’s say they go into their school day. In crowded school hallways, something I’ve heard come up is a child walking through a crowded hallway and being so concerned about not wanting to bump into anyone that they’re holding their books tight to their chest, walking in a very rigid way, making sure they don’t accidentally touch someone, or touch someone inappropriately, because that would be horrifying for them.
Then they get through the hallway and sit down in class, and those obsessions start to show up again. How do I know I didn’t accidentally bump someone as I was walking by? Now the compulsion is mentally replaying that walk through the hallway instead of focusing on math, because I need to try to get certainty that I didn’t hurt anyone, didn’t bump anyone, didn’t touch someone inappropriately and not remember it.
So that may just be a short glimpse of what the morning could look like for a teenager struggling with some of these OCD symptoms or themes, and just how impactful and all-consuming it could feel for them to constantly be hypervigilant, assessing for, and trying to find certainty that they are not this person they fear.
Britt: It must feel really exhausting.
Katie: So exhausting. That’s what a lot of people say with OCD — that it is so draining and exhausting to be doing that process and feeling like they need to be monitoring, filtering, and responding to every thought they have, which is not how the rest of us who don’t have OCD go through our day. So it’s a lot of work.
Britt: I hadn’t thought about it in that way, in terms of the moral thinking and how that could affect everything from getting on the bus to walking through the hallway, and how that can take up so much mental energy. So thank you for walking me through that, because that puts into perspective that type of intrusive thought and how that looks.
Choosing the Right Level of OCD Treatment: Outpatient, IOP, and PHP
Britt: Wondering if we want to shift into treatment: would you say that some presentations or symptoms of OCD can be managed in an outpatient therapy setting, like once-a-week therapy, or is it more effective for OCD to be treated at an IOP or PHP level where ERP can be administered on a daily basis? How does someone choose which level of care is right for them when it comes to OCD?
Katie: Some of that goes back to the frequency, intensity, and duration of their symptoms.
In general, I think it’s always helpful to start with the lowest level of intervention. So if I’ve never seen a treatment provider for my mental health, starting with an outpatient therapist who specializes in treating OCD and uses exposure and response prevention is a really good place to start. They’ll also be someone who can help guide and understand whether that support is going to be enough.
A lot of that depends on the individual. A lot of it depends on how willing they are to engage in the exposures and how able they are to implement some of those things outside of therapeutic sessions. Is this a situation where they can take what they’re working on in therapy and apply it outside for homework and repeating some of those exposures? Or is there more apprehension and really high levels of anxiety about doing any of that, where it may require more intensive support like an IOP or PHP setting?
At the end of the day, what PHP and IOP offer is that wraparound support, structure, and just a higher dose of the interventions that are going to help people get better faster. So it depends sometimes on what families are able to do and what the goal is. But absolutely, starting with outpatient therapy, if you’ve never seen someone for OCD before, is a really appropriate place to start.
What Is ERP Therapy and Why Is It the Gold Standard for OCD?
Britt: Can you dig in a little deeper into ERP and what that means? What does that treatment look like, and why is it the gold standard for OCD treatment?
Katie: ERP stands for exposure and response prevention. It is a type of cognitive behavioral therapy, but it’s a specialized kind of CBT that is specifically used to treat OCD as well as some anxiety disorders.
ERP is all about helping people face the things they fear without engaging in the normal rituals, compulsions, or safety behaviors they use to bring that fear down.
So ERP really asks people to intentionally come into contact with their fears, which a lot of times are just our own internal experiences — our thoughts, our physical sensations. Those are most often the things we’re coming into contact with, or maybe other stimuli that bring up those thoughts or physical experiences.
ERP asks us to come into contact with those things and drop the normal ways we would bring our anxiety down. It asks us to intentionally allow our anxiety to come up and kind of reach that peak point, and to do nothing — to allow that anxiety to come back down on its own, because it will.
That’s really where the change and the shift happens: when patients learn and believe that their anxiety will come up when they’re exposed to things that make them anxious, and then it will come back down on its own. That’s a real change point for people because it means they don’t need those compulsions or rituals to bring their anxiety back down.
When they see that it will come down on its own, it allows this other path to say, I could do that too. I could stop engaging in these rituals, and yet my anxiety would still come down over time. It may be uncomfortable while I’m waiting, but it is not going to rise and rise exponentially and never come back down.
A lot of times that really is what people believe before engaging in ERP because they’ve never seen it differently. They’ve always been in that cycle of anxiety comes up, do my compulsion, and it comes back down. Anxiety comes back up, do a compulsion again, and it comes back down. So it’s this zigzag of high anxiety, short-term relief, high anxiety again, short-term relief.
ERP is about creating more of that intentionally: anxiety comes up, I pause, and then it more slowly starts to come back down. What we notice over time is that the anxiety is starting at a lower point, and it’s coming down naturally quicker than it was in the beginning.
How Exposure and Response Prevention Works in Practice
Britt: What would that look like for, say, that teen struggling with moral thoughts and going through their day if they were engaging in ERP? What would that look like for them?
Katie: This is a really interesting one because a lot of the compulsions in that example we talked about are mental. He was mentally reviewing what had happened and trying to establish some kind of unachievable certainty that he didn’t do something harmful.
So the exposures for him would first of all be coming into contact with the things he fears. An example might be: I’m going to get on the bus tomorrow morning. I’m going to intentionally look at two people, walk by, and sit somewhere else. And I’m going to sit with the anxiety that brings up.
Here’s the really important part: ERP is a two-part treatment. That’s the exposure part. I’m doing the thing that makes me anxious. I’m not sitting with the first kid I see because OCD is telling me, sit there — you might ruin his day if you don’t.
The response prevention is what comes after, when his mind starts to go to, how do you know you didn’t really upset him? How do you know that wasn’t a terrible thing? It’s for that person to be able to acknowledge that and kind of flip the script with OCD to say, I don’t know that that didn’t ruin his day, and I’m going to sit with that.
So instead of actively engaging in that mental compulsion of running through all the ways this could have happened and trying to prove it true or not true, it would be sitting with the uncertainty that I don’t know how that impacted him, and I can handle that. Allowing his anxiety to come up with that and come back down, which is really hard. It’s also really hard for people to learn how to undo some of the mental processes they put in place to keep themselves in that cycle of short-term relief.
How ERP Therapy Is Delivered in PHP and IOP Programs
Britt: We offer ERP on a daily basis for patients who are in our programs. How do you help patients, or how do our clinicians help patients, understand what they’re stepping into when they begin program and how ERP will be incorporated into their day?
Katie: We’re really straightforward with our patients who are coming in for treatment for OCD. ERP is the gold standard treatment, and it’s the first line approach for treating OCD. The reason we use it is because it’s the most researched treatment and has been shown to be successful for a majority of people. So of course that’s what we want to use with them at Compass.
We’re straightforward with them about what ERP is — that it does mean coming into contact with things you are anxious about, that you are fearful of. And we’re very straightforward about that second part, that ritual prevention or response prevention. Because in order for our patients to actually resist those behaviors, they first have to have a really good understanding of what those behaviors are.
A lot of times that can vary. Some people know these are the things I’m doing in response to my obsessions. Some people really benefit from awareness and insight-building into what those processes are, because sometimes they may feel more subtle even to them.
We always want people to understand that ERP is going to be gradual. It’s not about finding the thing that would make you the most anxious and coming into contact with that on day one. We want it to be gradual and developmental.
It’s really important that patients build up some confidence in their ability to sit with their anxiety without doing the normal response. So that means we have to find things that are more in that mid-range anxiety level to expose them to initially — not the nines and tens out of ten, but more like the fours and fives.
So we use a really gradual process based on the patient’s own input and their hierarchy of what makes them anxious at different levels, to make sure we’re starting at points that are going to be helpful and feel challenging, but also attainable and doable.
What Surprises Patients Most About ERP Therapy
Britt: What tends to surprise folks the most once they actually start ERP?
Katie: There are a lot of surprises that happen when people start ERP. When you’ve been in an avoidance or compulsive cycle for so long, every time you avoid something that’s making you anxious, or every time you engage in a compulsion or ritual, it builds on the learning that that thing — whether it was a thought or something in the environment — really is unmanageable. It really is dangerous, not able to be handled.
So if someone comes to us having been struggling with this for five years, they have five years of that learning built up and reinforced. I think the biggest thing that surprises people when they engage in ERP is that my anxiety actually does come down even when I’m not doing these safety behaviors, and that they are able to handle so much more than maybe they thought.
A lot of times what we’ll hear people say is, that wasn’t nearly as bad as what my anxiety was telling me that was going to be like. And that’s such an important surprise and such important learning for them because that new learning is really what creates all the change for them in treatment.
What Progress Looks Like in OCD Treatment
Britt: Progress is so different for everyone. It’s really individualized. Could you map out what progress could actually look like within OCD treatment, specifically in the IOP and PHP setting? Beyond just symptom reduction, what could that look like within the lens of someone’s daily life?
Katie: When we think of PHP, again, it’s an opportunity for so much treatment to be condensed into a day. There are five to six hours where an individual can be doing treatment, so we tend to see progress happen a lot faster than maybe two years of once-a-week outpatient therapy.
So of course, progress, like you said, is going to look like symptom reduction. Individuals are able to both share and demonstrate that they are engaging in decreased compulsions, so those behaviors or mental acts aren’t taking up as much time and space in their day.
But I think the biggest thing that we really focus on at Compass too, and recognize, is that for anyone who’s experiencing OCD at a moderate to severe level, that does take up a lot of their day. That does become what the day often gets worked around.
So just as important as individuals decreasing engagement in rituals and learning to live alongside their obsessive thoughts without giving them that power and attention, is asking: what am I also going to fill all this free time and energy with now that OCD is taking up less space?
That’s such a gift, but I’ve also seen in treatment that if we don’t have a plan for that, it can feel really, really overwhelming. So we look at other areas of treatment that may not be exactly exposure-based but look at things like activity scheduling and coming in touch with our values.
Most of the time, what we see is that as OCD symptoms decrease, engagement in all those other areas of life really increases. People can return to school with more attention and focus on their work. They can return to peer relationships with renewed energy and focus in those areas. Family relationships often really start to improve because there’s decreased conflict around accommodations or just the amount of space OCD is taking up in the household. Productivity in work and other areas of their life that are important to them can improve too.
But it does require some focus and attention to that, and the calling out of: you’re going to be spending a lot less time engaging in these rituals. How do you want to fill that time? What feels most important to you and satisfying to you?
Reclaiming Your Identity Beyond OCD
Britt: Is that a fear — maybe fear is the wrong word — but a concern a lot of the time? What am I if I’m not thinking about these things? If I’m not engaging in this cycle, these rituals, what am I going to do?
Katie: Sometimes it’s a fear that people have. And sometimes, when it happens and there isn’t some structure and plan around that, it can feel really off-kilter.
I think there are also a lot of other fears that go into it. A lot of people feel like their OCD symptoms are somehow keeping them more responsible or alert to the many dangers that exist. So there can be a real kind of identity crisis too, as people start to loosen their hold on some of that. What does that actually mean and say about me? And what does OCD want me to believe it means or says about me?
Those two things can be really different, but it can be hard to grapple with that. Am I being irresponsible or unsafe somehow by letting go of some of these things and feeling more of that freedom?
What’s Used Alongside ERP Therapy: CBT, DBT, and ACT
Britt: What is used in conjunction with ERP in our programs? Is it used alongside CBT, DBT, ACT? Are we using other treatment modalities as well, or is it really just ERP?
Katie: ERP kind of gets center stage in our PHP and IOP programs at Compass for OCD and anxiety disorders because we know how important it is. It’s the treatment that’s going to have the most direct impact on OCD symptoms decreasing.
And then all those other things you named are absolutely really helpful adjunct and supplemental treatments for OCD. So we incorporate all of them. We incorporate other CBT groups and principles, and we also incorporate ACT and DBT into our programming.
That’s for many reasons. Those modalities are helpful for anyone with OCD because they focus on things like values and psychological flexibility, and they give another lens to look at ERP, especially with ACT. And when we think about DBT, emotional regulation skills and interpersonal effectiveness are things any of us can benefit from. Someone with OCD can absolutely benefit from learning how to communicate effectively with family members. Those are really helpful skills.
There are also a lot of comorbidities. A lot of individuals who struggle with OCD may also experience a mood disorder, PTSD, or substance use. Those other modalities can be really helpful so that we can treat individuals who have comorbidities and dual diagnosis without having to give up one or the other. It’s not, you can’t do ERP because you’re focusing on this. We really want to be able to treat the whole person and whatever needs they may be bringing to treatment.
OCD vs Anxiety: How to Tell the Difference
Britt: If someone was listening or reading this and they were struggling, but they weren’t really sure if what they were struggling with was anxiety or maybe OCD — this feels like more than anxiety, I’m kind of identifying with some of the themes and some of the discussion points you’ve touched on — what would you want them to hear and recognize in themselves?
Katie: I would ask them, if some of this information about OCD is resonating with them, number one, to tap into the really helpful resources that are out there. The International OCD Foundation, IOCDF, is a really great resource. You can go to iocdf.org, and there are a ton of really helpful resources, blogs, articles, and factual, scientific information about understanding OCD and evidence-based treatments. A lot of those are meant to speak directly to individuals who might be experiencing some of these symptoms to help them explore and understand more whether this is something that’s going on for them.
I also think what you brought up is really common, that it can be hard for people to suss out: is this more generalized anxiety, or is this more OCD? That can be hard even for treatment providers sometimes.
Some of the ways that people explain this that feel helpful to me are asking the basic question: does it feel more like I worry a lot, I’m a worrier, which might be more consistent with generalized anxiety? Or does it feel more like these thoughts are not me, and I am really distressed by them?
That’s one helpful question to help separate it.
And then I think just looking at that cycle. A lot of times with generalized anxiety, we find there’s worry and maybe rumination about those worries.
But with OCD, a lot of times there is that really clear obsessive fear: I feel really distressed by this thought, and I do something to try to get rid of it. Versus with generalized anxiety, someone might find that they’re continuing to think about or dwell on that worry, rather than doing some kind of act or process to get rid of it. That can feel very unique to OCD and may be a sign that that’s what’s going on for them.
One Thing to Remember About OCD
Britt: If there’s one idea about OCD that you wish more people understood, what would it be?
Katie: I think I already shared this, but probably that idea of it not being a personality quirk, that it can be something really debilitating, and that it is highly treatable, and that there are evidence-based treatments available. I think that’s really important too. That may vary depending on where in the world or country you are, but just that evidence-based treatments are available and that OCD is something that is highly treatable.
ERP as a Mindset for Life
Britt: Is there anything that I haven’t asked you that you wish that I did, or that you want to speak to that you think is important?
Katie: The one thing I was going to say maybe, that I would want people to know that we didn’t talk about, is just that idea — you kind of asked it in one of the questions — that ERP can sound kind of counterintuitive and uncomfortable, and that’s because it is uncomfortable. We’re asking people to intentionally come into contact with their discomfort, but it’s for longer-term gains.
So that’s not an easy thing to do, but it is a really worthwhile thing to do. And when I think about some of the tenets of ERP, I think about that as something I want for my own kids — I want them to be able to take an approach-versus-avoid mindset into their life and to feel like they can be brave and do hard things. That’s a lot of how we talk about ERP.
It’s something that, yes, is an evidence-based treatment for OCD, but we want our patients to take that as a mindset into the rest of their life. I think that sets them up for so many future things they’re going to face, OCD-related or not, that can be a really helpful mindset and approach.
About the Contributors
Katie Torres, LCSW, is a clinical leader with 15 years of experience in the mental health field. She earned both her undergraduate degree and Master of Social Work from the University of Illinois at Urbana-Champaign.
Katie currently serves as Director of the Center of Excellence at Compass Health Center, where she focuses on obsessive-compulsive disorder (OCD) and anxiety disorders. Prior to joining Compass in 2024, she led Partial Hospitalization (PHP) and Intensive Outpatient (IOP) programs at a Chicagoland hospital.
Throughout her career, Katie has specialized in working with children, adolescents, and adults with OCD and anxiety disorders. She is particularly focused on exposure and response prevention (ERP), helping patients reduce avoidance and build lives that reflect what matters most to them.
Britt Teasdale is Associate Director of Brand & Content at Compass Health Center and co-host of You Only Know What You Know, Compass’s mental health podcast for parents and caregivers. With a background in journalism and creative nonfiction, Britt specializes in translating complex clinical insights into accessible, human-centered storytelling for families, clinicians, and communities.
