OCD therapy in London: CBT with exposure and response prevention

OCD is one of the main areas of my clinical work. Most of the people I see with OCD have lived with it for years before getting in touch. Often they have already tried therapy that didn't quite address it. Many function well at work while spending hours a day on checking, analysing, seeking reassurance or mentally reviewing, sometimes in ways nobody around them has noticed.

The treatment with the strongest evidence for OCD is Cognitive Behavioural Therapy that includes exposure and response prevention (ERP). That is the approach I use, adapted to the person and to the way their OCD actually operates.

What OCD actually looks like

OCD has two parts. Obsessions are unwanted thoughts, images, urges or doubts that feel alarming and hard to dismiss. Compulsions are anything done to reduce the anxiety, prevent a feared outcome, or get a sense of certainty that things are alright.

Some compulsions are visible: washing, checking locks and appliances, arranging, asking the same question again. Many are not. These are some of the most common things I see:

• Mentally reviewing past events to make sure nothing bad happened
• Analysing a thought to work out what it "means" about you
• Replacing a "bad" thought with a "good" one, or repeating a phrase until it feels right
• Seeking reassurance from a partner, friend, doctor or search engine
• Checking your own body or feelings for a reaction (an urge, attraction, the "right" feeling)
• Avoiding people, places, objects or information that might set off the thought

Each of these brings short-term relief. Each one also teaches the brain that the thought was dangerous and needed dealing with. That is the loop that keeps OCD going, and it is what treatment targets.

Common forms of OCD I work with

The content of OCD varies enormously, and people often worry that their particular version is unusual or too shameful to describe. In practice, the themes tend to fall into recognisable patterns:

• Harm OCD - unwanted thoughts or images of hurting someone, often someone you love, and fear of losing control. More on harm OCD.
• Relationship OCD (ROCD) - persistent doubt about whether you love your partner, are attracted to them or are with the "right" person, accompanied by constant checking of your own feelings.
• Contamination OCD - fear of germs, illness, chemicals or of spreading something to others, with washing, cleaning or avoidance.
• Paedophilia OCD (POCD) - unwanted, distressing thoughts or images about children, and fear of what they might mean. People with POCD are horrified by these thoughts, and often go to great lengths to avoid children or to check their own reactions as a result.
• Sexual orientation OCD (often called HOCD) - persistent doubt about your sexual orientation, with repeated checking of your reactions and feelings. The distress comes from the doubt itself, not from any particular orientation.
• Moral or religious scrupulosity - fear of having done something wrong, sinful or dishonest, and repeated confession or reviewing.
• "Just right" OCD and checking - needing things to feel complete or correct, or repeated checking to prevent a mistake.
• Primarily mental OCD (often called "Pure O") - where compulsions happen almost entirely in your head. More on mental compulsions and reassurance seeking.

It helps to know that these are not separate conditions needing separate treatments. The theme differs, but the mechanism underneath is the same: an intrusive thought gets treated as meaningful and threatening, and the person responds with something that brings temporary relief and longer-term entrenchment. ERP works on that mechanism. What changes from person to person is how the work is designed, not the underlying principles.

How CBT with ERP works

ERP involves gradually and deliberately approaching the thoughts, situations and uncertainty that OCD tells you to avoid, while not performing the compulsions that would normally follow. Over time, this allows the brain to learn something it can't learn while the compulsions are still running: that the anxiety passes on its own, and that you can carry doubt without having to resolve it.

In practice, treatment with me usually involves:

• Assessment and formulation. A careful picture of your obsessions, the full range of your compulsions (including mental ones and avoidance), and what keeps the cycle going for you.
• Understanding the model. Knowing why compulsions backfire makes it far easier to choose to drop them. This part is collaborative, not a lecture.
• Planning exposures together. We build a graded list of triggers, from manageable to hard. You decide the pace with me. Nothing is sprung on you.
• Exposure and response prevention. Some exposures happen in session; most of the change comes from practice between sessions. Response prevention includes the less obvious compulsions, such as reassurance seeking and mental reviewing.
• Working on the beliefs that fuel OCD. For example, an inflated sense of responsibility, the idea that thinking something makes it more likely, or the need to be certain.
• Relapse prevention. Learning to spot OCD's new disguises early and respond to them yourself.

For a fuller account of what sessions involve, see How ERP therapy for OCD works.

What ERP is not

People are sometimes put off by what they have heard about exposure therapy, so it's worth being clear. ERP is not about being forced into your worst fear, and it is not about proving that your thoughts are false or getting a guarantee that nothing bad will happen. Seeking that guarantee is usually part of the problem. Good ERP is planned together, graded, and explained at every step. It asks a lot of you, but it shouldn't feel like something being done to you.

It is also different from general talking therapy. Spending sessions analysing the content of obsessions, or reassuring someone that they are a good person, can feel helpful in the moment but tends to feed the cycle. Part of my job is to notice when therapy itself is becoming a compulsion.

How long does treatment take?

This depends on how severe the OCD is, how long it has been present, how many areas of life it affects and how much practice is possible between sessions. Sessions are 50 minutes and usually weekly. We review progress together at regular points, so you always have a clear sense of where things stand rather than committing to an open-ended course.

Online or in person

I see people in person on Thursdays at The Re-mind The Body Centre in Queen's Park, North West London, and online across the UK. ERP works well online. For some forms of OCD, such as contamination fears or checking at home, working by video can actually be an advantage, because exposures can take place where the OCD happens.

Is this the right service for you?

I work with adults (18 and over) on a private, self-pay basis. CBT with ERP in weekly outpatient sessions suits most people with OCD. If, at assessment, I think you would be better served by a different level of care or a different approach, I will tell you and explain why.

If you are a GP, psychiatrist or another clinician considering a referral, the information for referrers sets out what I offer and how to get in touch.