When exposures go wrong: troubleshooting guidelines for managing difficult scenarios that arise in exposure-based...

Cognitive-behavioral therapy (CBT) with exposure and ritual prevention (ERP) is widely accepted as the most effective psychological treatment for obsessive compulsive disorder (OCD). However, the extant literature and treatment manuals cannot fully address all the variations in client presentation, the diversity of ERP tasks, and how to negotiate the inevitable therapeutic challenges that may occur. Within this article, we attempt to address common difficulties encountered by therapists employing exposure-based therapy in areas related to: 1) when clients fail to habituate to their anxiety, 2) when clients misjudge how much anxiety an exposure will actually cause, 3) when incidental exposures happen in session, 4) when mental or covert rituals interfere with treatment, and 5) when clients demonstrate exceptionally high sensitivities to anxiety. The goal of this paper is to bridge the gap between treatment theory and practical implementation issues encountered by therapists providing CBT for OCD.