Picture of handwashing to represent OCD

Exposure-based treatment during COVID-19


Earlier this year, a group of OCD experts and specialists published guidelines on managing OCD during COVID-19. It was quickly becoming evident that traditional exposure and response prevention (ERP) was going to be very difficult to deliver during a pandemic where the virus was highly contagious and where strict hygine precautions (such as handwashing) needed to be practised by everyone.

Traditional ERP for contamination-related obsessions involves increasing contact with feared stimuli but this is difficult when everyone has to be careful about contact with inanimate objects, surfaces, doorknobs, and switches. Response prevention requires the individual to delay or prevent the typical compulsions which (for contamination obsessions) usually involve handwashing and/or cleaning. However, during a pandemic this handwashing becomes necessary for everyone and whereas previously the handwashing was 'excessive and/or unreasonable', it is now appropriate. This makes delivery of ERP very difficult.

The authors of the guidelines recognised this and made some additional comments:

  • "Based on the risks associated with exposure and response prevention (ERP) in the pandemic (see below), and uncertainty as to which of the two evidence-based treatments, pharmacotherapy or cognitive behaviour therapy (CBT), represents the most efficacious first line treatment modality, pharmacotherapy should be the first option for adults and children with OCD  with contamination, washing or cleaning  symptoms during the COVID-19 pandemic."

  • "Moreover, as COVID-19 is highly contagious, and patients can easily be confused by exposure exercises, particularly during the early stages of therapy or when practising exposure on their own at home, the risk of patients becoming seriously infected with the coronavirus could be increased. This risk becomes even more true for children whose knowledge base and judgment is not yet matured."

  • "However for OCD patients with contamination fears and cleaning or washing compulsions, active and in vivo CBT with exposure and response prevention (ERP) will need to be sensibly adapted and may need to be paused. This specifically relates to active, in vivo exposure aimed at tackling contamination. Instead we suggest using therapist time to support patients and trying to prevent them from deteriorating, e.g. by encouraging them to restrain their compulsions as far as possible, rather than directed at actively treating contamination fears and concentrating on techniques such as behavioural activation and activity scheduling which can assist in preventing deterioration and help with depressive symptoms. Indeed, activity scheduling can be particularly useful as a form of CBT at this time. Obsessions often expand to fill a vacuum of time and keeping busy is particularly important as a means of staying well."

What does this mean for ERP in the AIS?

In short, it has meant that treating OCD with ERP has had to be paused. Although contamination-cleaning obsessions/compulsions are not the only kind of symptom (and indeed, are not necessarily the most common), delivering any kind of therapy where: a) there are clear risks to the individual and their contacts; and b) the therapy might not be effective, has to be rethought.

Most of our patients have a level of severity of symptoms that mean that general supportive psychotherapy and/or activity scheduling is unlikely to have significant effects. We therefore assessed the suitability of alternative treatments, focusing on deliverability and sustainability. Any treatment had to meet two requirements:

  1. It could be delivered remotely, ideally via videoconferencing.
  2. It had appropriate evidence of effectiveness.

We chose a form of therapy called Inference-Based Therapy (IBT), which was developed by OCD specialists in Canada. You can read more about it on our IBT page.


FINEBERG NA, VAN AMERINGEN M, DRUMMOND L, HOLLANDER E, STEIN DJ, GELLER D, WALITZA S, PALLANTI S, PELLEGRINI L, ZOHAR J, RODRIGUEZ CI, MENCHON JM, MORGADO P, MPAVAENDA D, FONTENELLE LF, FEUSNER JD, GRASSI G, LOCHNER C, VELTMAN DJ, SIREAU N, CARMI L, ADAM D, NICOLINI H, DELL'OSSO B. How to manage obsessive-compulsive disorder (OCD) under COVID-19: A clinician's guide from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive Research Network (OCRN) of the European College of Neuropsychopharmacology. Comprehensive Psychiatry. 2020; 100: 152174. https://doi.org/10.1016/j.comppsych.2020.152174