Specialist ERP for OCD. The treatment with the strongest evidence, done properly, usually working in months rather than years.
About the speciality
About the speciality
OCD works as a loop. A frightening thought demands a response, the response brings short relief, and the relief teaches the loop to repeat. The treatment with the strongest evidence is exposure and response prevention, and it needs to be done by someone who has trained in ExRP and uses it regularly. This matters, because ordinary talk therapy can make OCD worse by treating the thoughts as if they mean something. Read more about the current state of OCD research, or take the OCD screener to see if OCD might be affecting you. I do not ask you to take my word for any of this. Further down this page you can read the research I base my OCD practice on, including the treatments that work, the ones that do not, and the ones that can make OCD worse.
OCD works as a loop. A frightening thought demands a response, the response brings short relief, and the relief teaches the loop to repeat. The treatment with the strongest evidence is exposure and response prevention, and it needs to be done by someone who has trained in ExRP and uses it regularly. This matters, because ordinary talk therapy can make OCD worse by treating the thoughts as if they mean something. Read more about the current state of OCD research, or take the OCD screener to see if OCD might be affecting you. I do not ask you to take my word for any of this. Further down this page you can read the research I base my OCD practice on, including the treatments that work, the ones that do not, and the ones that can make OCD worse.
OCD works as a loop. A frightening thought demands a response, the response brings short relief, and the relief teaches the loop to repeat. The treatment with the strongest evidence is exposure and response prevention, and it needs to be done by someone who has trained in ExRP and uses it regularly. This matters, because ordinary talk therapy can make OCD worse by treating the thoughts as if they mean something. Read more about the current state of OCD research, or take the OCD screener to see if OCD might be affecting you. I do not ask you to take my word for any of this. Further down this page you can read the research I base my OCD practice on, including the treatments that work, the ones that do not, and the ones that can make OCD worse.
What the research shows about the therapies that treat OCD, and the ones that do not.
The overall picture
The picture in OCD is unusually clear for a mental health condition, and it points to one psychological treatment above all: exposure and response prevention, or ERP. ERP means facing the triggers of an obsession on purpose, in a graded way, while resisting the compulsion, so the anxiety learns to fall on its own. Across the strongest reviews it is the psychological treatment of choice, producing large symptom reductions and far outperforming placebo therapies. The SSRI antidepressants, including clomipramine, are the medication option: they help reliably but less than ERP, and they are best used alongside ERP or when someone cannot yet engage in it. Combining ERP with medication tends to help most in more severe cases, and for treatment-resistant OCD there are further medication and, rarely, neurosurgical options. For children the same hierarchy holds, and the parent's role is central: reducing family accommodation, the well-meaning habit of helping a child avoid what frightens them, is now a treatment target in its own right, parent-based work can match child therapy for some children, and for families high in conflict or blame, adding focused family sessions to standard ERP nearly doubles the response rate. What consistently underperforms is anything that removes the exposure element or leans on medication alone when the person can tolerate therapy. Two approaches people often ask about have no real evidence for OCD: EMDR rests on a single small trial, and traditional psychoanalysis or open-ended insight therapy has no trial support and can even entrench symptoms by feeding rumination about the meaning of obsessions. The honest caveat running through the therapy research: many trials allowed participants to stay on stable medication, so the cleanest head-to-head comparisons are fewer than the volume of research suggests. Two options people often ask about remain unproven. N-acetylcysteine, a glutamate-targeting supplement taken alongside medication, has given conflicting results across trials, and the largest and longest study found no benefit. Psilocybin has only a single very small randomised trial behind it, an encouraging early signal that is far too preliminary to count as a treatment.
A note on scope: this library is here to help you evaluate the psychological therapies. The medication studies are included for honest context, because weighing therapy properly means seeing the whole evidence map. I support medication where it helps, but prescribing decisions sit with a doctor or psychiatrist, not with a psychologist.
How to weigh these studies. Not all evidence is equal. From strongest to weakest: network meta-analysis (pools dozens of trials) > meta-analysis > large randomised trial (RCT) > small pilot trial > observational study. Each card shows its study type, and you can sort by strongest evidence first.
Pharmacological and psychotherapeutic interventions for OCD in adults
Skapinakis et al. · The Lancet Psychiatry
At a glance
Facing fears with a therapist works best; antidepressants help less but reliably.
For parents
This is the big-picture study that put every adult OCD treatment on one map. Talking therapies that use exposure came out strongest, the antidepressants helped less but still clearly worked, and combining therapy with medication looked best for more severe OCD.
SSRIs and clomipramine as pharmacological options for OCD
Skapinakis et al. (SSRI class finding) · The Lancet Psychiatry
At a glance
Antidepressants reliably reduce OCD, though the benefit is smaller than therapy.
For parents
Drawing out the medication side of the same large review: the SSRI antidepressants and the older drug clomipramine both reliably reduce OCD symptoms. They help less than exposure therapy does, but they are a genuine option when therapy is not available or not enough on its own.
Rosendahl, Alldredge & Haddenhorst · Frontiers in Psychology
At a glance
Hypnosis helps with things like pain, not OCD. For OCD there are only a few individual case stories, no proper trials.
For parents
Hypnotherapy is sometimes marketed for OCD, and parents ask about it. The honest answer is that there is no real evidence it treats OCD. When researchers gathered twenty years of hypnosis studies together, the conditions where hypnosis genuinely helps were things like pain and distress during medical procedures, not OCD. For OCD itself, all that exists is a handful of individual case write-ups, which cannot tell you whether a treatment actually works. Exposure and response prevention is the approach with the real evidence, and it is what I use.
N-acetylcysteine: a glutamate supplement with conflicting results
Kishi, Sakuma & Iwata · Translational Psychiatry
At a glance
A supplement some people try. A few small trials hint at a slight benefit, but the best trial found none. Not a proven treatment.
For parents
N-acetylcysteine, or NAC, is an inexpensive antioxidant supplement that acts on the brain chemical glutamate, and it comes up often as a natural add-on to medication for OCD. The honest picture is mixed. Pooling the double-blind trials, one review found a moderate benefit when NAC was added to an antidepressant, but a different review found no real difference from placebo, and the largest and longest trial to date found nothing. It is safe and well tolerated, so it does little harm as an add-on, but the evidence does not support it as a treatment you would rely on, and it is not a substitute for exposure and response prevention.
Exposure and response prevention (ERP): the treatment of choice for OCD
Reid, Laws, Drummond et al. · Comprehensive Psychiatry
At a glance
The strongest psychological treatment for OCD, and the one I use. It works far better than a dummy therapy.
For parents
This is the treatment I use, and this review shows why. Exposure and response prevention, ERP, means gradually and deliberately facing the thoughts and situations that trigger the obsession while choosing not to perform the compulsion, so the fear can settle on its own. Pooled across every good trial, ERP produced a large reduction in OCD symptoms and was far more effective than a placebo therapy. It is the psychological treatment of choice, recognised as such across international guidelines.
Cognitive-behavioural family treatment for pediatric OCD
Iniesta-Sepúlveda et al. · Journal of Anxiety Disorders
At a glance
Bringing the family in produces big symptom gains; changing family habits needs its own focus.
For parents
This review pooled the trials that bring families into a child's OCD treatment. Symptom reduction was very large. The one area that moved less was family accommodation, which is exactly why it needs its own focused work rather than being left to improve on its own.
Exposure-based therapy produces big improvements, whether it is one-to-one or in a group.
For parents
A close look at every good-quality trial of CBT for adult OCD over two decades. The active ingredient is exposure: CBT built on exposure and response prevention beat waiting and placebo by a wide margin. It did not much matter whether the therapy was delivered one-to-one or in a group, which is reassuring for access, but the exposure work is what does the lifting.
Adding an antipsychotic when an SSRI is not enough
Dold, Aigner, Lanzenberger & Kasper · Int. Journal of Neuropsychopharmacology
At a glance
A doctor-led add-on. A low dose of a second medicine helps some people when an antidepressant alone is not enough.
For parents
When OCD does not respond to an antidepressant on its own, one option doctors consider is adding a low dose of an antipsychotic medication. Across the good-quality trials this genuinely helps a subset of people, though it is a second-line step with its own side-effect trade-offs, not a starting point.
2015 · Meta-analysis (combination finding) · Subset of 37 trials
Does adding medication to CBT help in adult OCD?
Öst et al. (combination finding) · Clinical Psychology Review
At a glance
For adults already doing good therapy, adding a drug added little on average.
For parents
A specific and often surprising finding: for adults already doing good CBT, adding an antidepressant did not clearly add much. This does not mean medication is useless, but it does temper the assumption that more is always better once someone is engaged in exposure work.
2015 · Evidence appraisal (meta-analysis) · Across the CBT evidence base
Psychoanalysis and insight therapy: no evidence base for OCD
Öst et al. (evidence appraisal) · Clinical Psychology Review
At a glance
No trial evidence that it helps OCD, and dwelling on the meaning of obsessions can make them worse.
For parents
Traditional psychoanalysis and open-ended insight or talk therapy, where the focus is on uncovering the hidden meaning of obsessions, have no research support as treatments for OCD. Reviews of the field find that cognitive behaviour therapy is the only psychological treatment shown to work. Worse, spending sessions analysing and discussing the content of obsessions can feed the doubt and rumination that drive OCD, so this approach can leave a person more entangled rather than less.
Coaching the parent alone worked as well as treating the child directly.
For parents
This trial tested something powerful for worried parents: a treatment delivered entirely to the parent, with the child never seeing a therapist. Supportive Parenting for Anxious Childhood Emotions (SPACE) teaches parents to stop accommodating the anxiety and to respond supportively instead. It worked as well as treating the child directly, and reduced accommodation more. It makes the parent a genuine agent of change in a child's OCD and anxiety treatment.
2014 · Randomised controlled trial · 127 young children
Family-based CBT for young children with OCD
Freeman et al. (POTS Jr) · JAMA Psychiatry
At a glance
In young children, parent-guided exposure clearly beat a simple calming programme.
For parents
Proof that OCD treatment works even in very young children, and that the family is the vehicle. Five to eight year-olds were treated with a family-based exposure programme, with parents actively guiding the exposures. It clearly beat a family relaxation programme of the same length. In this age group the parent is not optional; they are how the therapy happens.
2004 · Randomised controlled trial · 112 young people
Pediatric OCD Treatment Study (POTS): CBT, sertraline, and their combination
POTS Team · JAMA
At a glance
For children, therapy plus medication worked best; therapy alone was a strong second.
For parents
The landmark trial in childhood OCD. It compared CBT, an SSRI (sertraline), both together, and a placebo. Combining CBT with medication worked best, CBT alone was a strong second, and the medication alone was the weakest of the three active options.
Psilocybin for OCD: promising, but still experimental
Moreno, Allen, Wiegand et al. · Journal of Psychopharmacology
At a glance
A promising early signal from one very small trial. Experimental, not an established treatment.
For parents
Psilocybin, the active compound in so-called magic mushrooms, is being studied as a possible treatment for OCD that has not responded to anything else. The early signal is genuinely interesting: in a small trial, people given psilocybin under close medical supervision improved more than those given a placebo, and many responded. But this rests on a tiny number of people, the doses are given in a controlled clinical setting with monitoring, and it is nowhere near being an approved or established treatment. It is a research frontier, not an option to seek out or try alone, and certainly not a reason to delay the treatments that already work.
Marsden et al. · Clinical Psychology & Psychotherapy
At a glance
Only one small trial exists, and most people did not improve. Not an established OCD treatment.
For parents
EMDR (eye movement desensitisation and reprocessing) is well known for trauma, and people sometimes ask about it for OCD. The honest position is that it is not an established OCD treatment. The only randomised trial is a small feasibility study, and even there fewer than a third of people meaningfully improved. Exposure and response prevention remains the treatment with the real evidence behind it.
2012 · Randomised controlled trial (pilot) · 20 young people
Positive Family Interaction Therapy (PFIT) for high-conflict families
Peris & Piacentini · J. Clinical Child & Adolescent Psychology
At a glance
In tense families, adding family sessions nearly doubled how many children got better. Small early trial.
For parents
This is the clearest demonstration that the family environment changes a child's outcome. When families were struggling with blame, conflict or distance, adding six sessions of family work to standard CBT nearly doubled the response rate compared with CBT alone. The family sessions target psychoeducation, parental self-efficacy, affect regulation, parenting skills and family dynamics. Both parents showed up: mothers and fathers attended 95% of the family sessions.
2019 · Meta-analysis of observational data · 56 studies, 681 cases
Brain surgery and deep brain stimulation for the most severe, refractory OCD
Kumar et al. · J. Neurology, Neurosurgery & Psychiatry
At a glance
Can ease the most severe, treatment-proof OCD, but carries real surgical risk. A last resort.
For parents
For the small number of people whose OCD is severe and has not responded to any therapy or medication, neurosurgical options exist. They can meaningfully reduce symptoms, but they are a last resort: complication rates are high, and they are only considered after everything else has genuinely failed.
Dr Rick Smith, is a dual-doctorate clinical psychologist in Hong Kong specialising in ADHD, OCD, anxiety, executive functioning, and performance psychology. He works with adults and adolescents in his Central Hong Kong practice and online.
Dr Rick Smith, is a dual-doctorate clinical psychologist in Hong Kong specialising in ADHD, OCD, anxiety, executive functioning, and performance psychology. He works with adults and adolescents in his Central Hong Kong practice and online.
Dr Rick Smith, is a dual-doctorate clinical psychologist in Hong Kong specialising in ADHD, OCD, anxiety, executive functioning, and performance psychology. He works with adults and adolescents in his Central Hong Kong practice and online.
