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Mar 14, 2022

Podcast 283: The O of OCD:

Featuring Thai-An Truong, LPC, LADC

Overview: The "O" of OCD (obsessions) is treated differently from the "C" (compulsions.) Thai-An Truong teaches us what really works! Compulsions can be treated with Response Prevention. The techniques for treating the Obsessions include Flooding, Cognitive Techniques, Motivational Techniques for Outcome and Process Resistance, the Hidden Emotion Technique, and more.

OCD (Obsessive Compulsive Disorder) consists of frightening thoughts, or obsessions, plus rituals people do in an attempt to prevent or undo the danger. So, for example, if you go to bed and have the thought, “what if I left the burners on the stove turned on,” you might get up and check the burners. Doing this once could be considered normal. But if you do this repeatedly, you definitely have the symptoms of OCD.

Rhonda wanted me to share how I treat the obsessions in OCD (Obsessive Compulsive Disorder), also known as "pure O."

I often say I wasn’t looking to treat OCD, but OCD found me, since I do a lot of work with postpartum women struggling with feelings of depression and anxiety, they are actually about 2.5 times more likely than the general population to develop OCD. We're not sure why, but my theory is OCD attaches to the things we value the most (e.g., health, children’s well-being), and not much is valued more greatly than our baby.

“Pure O” is actually a misnomer. We think that some people with OCD only have obsessions, without the rituals, because they have lots of mental rituals that people can’t see. So therapists wrongly conclude that they just have a “pure O” variety of OCD.

We usually think of compulsions in OCD as mainly behavioral (e.g., handwashing too prevent contamination or checking the mail box repeatedly when you put your letter in to make sure it didn’t get “stuck”), but mental compulsions (rituals) are also very common. Obsessions are the thoughts or images that cause distress; compulsions, in contrast, are the behavioral or mental acts people engage in to try to decrease the distress.

Mental acts, compulsions, and rituals can include:

  • Praying
  • Counting
  • Repeating words silently
  • Recalling events in detail
  • Repeating a mental list to ensure safety
  • Mentally reviewing the past like a video
  • Self-assurance: “I’m okay, nothing bad will happen.”
  • Saying the number 4 to reduce the distress of seeing 6, associated with the devil
  • Thinking of a positive image to replace the disturbing obsession/thought

Those are just common examples, but there are many more.

Dr. Edna Foa, who has done a lot of research on OCD and the effectiveness of Exposure and Response Prevention (ERP) for the treatment of OCD states that patients who have ONLY obsessions or ONLY compulsions are unlikely to have OCD.

  • Over 90% of people with OCD reported having both obsessions and behavioral compulsions/rituals.
  • When mental rituals were included, just 2% reported “pure O”.
    • Foa, E., et al (2012). Treatment That Works: Exposure and Response Prevention for OCD, Second Edition, p. 12

She states we need to assess patients carefully to weed out other disorders:

  • Only O may be depression or GAD.
  • Only C may be trichotillomania, Tourette’s syndrome, autism, schizophrenia – all can display repetitive and ritualistic actions.
  • Trauma can look like OCD. For example, a woman who was raped obsessed about harm coming her way and compulsively checked the doors and windows in her apartment. She may need trauma treatment instead of OCD treatment.
  • Specific Phobias: fear of animals (dogs, snakes, etc), heights, needles, storms, flying, driving, etc.
  • Paraphilia: pedophilia, voyeurism, exhibitionism, etc.

Dr. Burns’ EASY Diagnostic System can be a great tool for pinpointing these and many other diagnoses.

How I’ve helped clients: A step-by-step approach:

Disclaimer: This is not meant to be a substitute for therapy. It is frequently most helpful to have a therapist work with you through this process.

  1. Initial Assessment:
    1. Dr. Burns EASY Diagnostic System
    2. Y-BOCs – Yale-Brown Obsessive Compulsive Scale - not diagnosti. This tool is great for identifying types of obsessions, compulsions, and avoidance behaviors.
    3. T = Testing – Brief Mood Survey
    4. E = Empathy
    5. Psychoeducation about OCD and nature of obsessions
      1. The more we engage with them, try to suppress them/control them, the stickier they become
      2. Share with them about exposure and response prevention and TEAM-CBT approach to treatment
      3. Ultimate goal is to eliminate all compulsions – since they the OCD and are the food that feeds the OCD monster
      4. Normal for obsessions content to shift from one subtype to another
      5. Let them know I will not provide reassurance. Anything expressed/done once is educational, more than once becomes reassurance
      6. Include the family in this process
    6. A = Assessment of Resistance
      1. DML of most disturbing obsession
      2. Identify the feelings and thoughts to increase your understanding of the content and level of disturbance
      3. Can use the What-If Technique to identify the patient's root fear
      4. Do positive reframing ONLY ONCE – otherwise can become a big reassurance (e.g., you are a good person, etc.)

Here is a driving analogy for how we don’t lose our core values or safety just because anxiety has decreased. For example, think of when you first started learning how to drive. Where was your anxiety 0-100? Mine was probably about 90%. This was tied to the values of wanting to stay safe, keep other’s safe, valuing people’s lives and my own life.

Think of where your anxiety with driving is now, 0-100, after you’ve driven almost every day for months or years. Mine is mostly around 0-5%, unless I’m next to a semi, then it's maybe at 10%.

Did you find that your morals and values changed once your anxiety decreased? Did you suddenly start to drive recklessly without caring about others’ well-being?

Most likely not. This will be the same with our work with OCD. Through exposure, your anxiety around your obsessions will also be dialed way down, but your moral compass and values will still stay intact.

5. Use Burns' Triple Paradox for compulsions

        1. Goes beyond moment in time: make a list of all compulsions – want to stop all of them (response prevention).
        2. Go back to moment in time, list benefits of compulsions, values, and cost of change
        3. She described Voicing the Resistance (also known as Externalization of Resistance): The therapist might say:

“Let’s look at this list of powerful benefits of your compulsions, the important values it shows about you, and all the costs of change. Given all those powerful reasons to keep your compulsions,  why would you want to do this work to let go of them? “After all, your compulsion give you  immediate relief from your anxiety.”

"Then the therapist can review the entire list of benefits and costs of change, and ask, ”Why in the world would they want to change considering x benefit and y cost?”

4. Motivation script: I rate the patient’s motivation to get rid of compulsions (0-100) before and after the Triple Paradox, and after Voicing the Resistance. If Voicing the Resistance boosted their motivation to change, I have clients write out or record their responses when we went through Voicing the Resistance. Their homework is to read this motivation script or listen to the audio recording of it it every day and as needed, knowing that there will be moments when the temptation to engage in the compulsion is 100%.

7. M = Methods: Thai-An, do not used any traditional cognitive tools (e.g., id distortions, double standard, examine the evidence), but David does and finds them to be helpful, just not the whole ball of wax! Thai-An points out that John Hershfield, MFT,  a major author in the OCD field also talks about using identify the distortions to build awareness. Of course, David sees a missive contribution of TEAM-CBT methods that goes way beyond building "awareness."

      1. Address self-doubt in their ability to change with TEAM structure and cognitive tools
      2. Always explore hidden emotion first (case example of OCD cured by hidden emotion)
      3. Here and now exposure as obsessions come up
      4. Fear hierarchy
      5. In Vivo Exposure (case examples) – exposures in real life
      6. Imaginal exposure – exposures in your mind
        1. Anything that can’t be done in vivo
        2. Only with the most disturbing obsession (flooding
        3. Uncover core fear with What If Technique
      7. You can use David's Devil’s Advocate for the compulsions
        1. Rate how tempting it is to engage in compulsion (0-100)
        2. E.g., OCD: You really should replay that memory one more time to make sure you didn’t molest your baby; Client: That’s OCD talking and I’m choosing to move forward with my life.
        3. Record this and then process the experience after exposure:
          1. What happened during the exposure? Did your fear come true? Were you able to tolerate the distress?
          2. How was the outcome different from what you expected? What surprised you about the outcome?
          3. What did you learn from this exercises?
          4. What could you do to vary this exposure?
      8. Relapse Prevention Training should always be done following the initial recovery..

Thanks for tuning in today!

Rhonda, Thia-An, and David

Thai-An practices in Oklahoma City, but teaches online for everyone. For more information about her clinical work, visit For information about r her TEAM-CBT training, visit Through her training website, you can sign up for her free TEAM-CBT webinars, which are held every other month. Her upcoming TEAM-CBT Conference in Oklahoma will be from March 30-April 1, 2022.

Here's the info about the conference:
  • TEAM-CBT Conference: Practical Tools for Overcoming Anxiety, Depression & Addictions
  • Get more info, register, and pay here:
  • Dates: Wed, March 30th - Fri, April 1st
  • Times: Wed: 9:00-5:30 CDT, Thurs & Fri 9:00-5:00.
  • CEUs: 20 CEUs approved for Oklahoman psychologists, LPCs, LMFTs, LADCs, & LCSWs, including 3 of ethics and 10 specific alcohol and drug hours. 20 TEAM-CBT Certification Units approved.
    • Any therapist can attend, but CEUs only for Oklahomans at this time.
    • Must attend the conference in full to get your CEUs/certification units. Not late arrivals or early departures.
  • Perks:
    • 25% off coupon for Dr. Burns's tools
    • 50% off Level 1 TEAM-CBT Certification through FGI
    • Lots of interactive, practical learning through didactics, live demos, and a live session to show the TEAM treatment process from beginning to end.
    • You'll also see a recording of my habits & addictions process with a woman working on decreasing alcohol use.
  • Dipti  Joshi, PhD will be joining us all the way from India and will help to teach uncovering techniques on Thursday morning.