What Every Therapist Should Know About OCD: Evidence-Based Treatment Without the Guesswork

Featuring Beth Brawley, LPC on Not Boring CEs

If you’re a therapist who’s ever sat across from a client nervously confessing, “I’m afraid I’ll hurt someone,” or “I can’t stop checking if I ran someone over,” and felt a wave of panic or confusion—this episode is for you.

In this enlightening and candid conversation, Allison Puryear (she/her) sits down with OCD specialist Beth Brawley, LPC (she/hers) to talk all things Obsessive Compulsive Disorder—from the misunderstood subtypes to gold-standard treatment. Whether you’re new to OCD work or looking to sharpen your skills, this conversation will make you rethink how you approach anxiety, intrusive thoughts, and those high-stakes client disclosures.

What OCD Is—and Isn’t

Beth kicks things off with a foundational overview:

• Obsessions: Unwanted, intrusive thoughts, images, or urges that are ego-dystonic (they go against a person’s values).
  
• Compulsions: Behaviors (mental or physical) meant to reduce the anxiety triggered by those thoughts.
  
• Negative Reinforcement Cycle: Compulsions provide temporary relief, which only strengthens the OCD loop over time.
  

Spoiler: Everyone has intrusive thoughts. The difference? For folks with OCD, those thoughts feel meaningful, terrifying, and demand action.

Understanding OCD Subtypes

Think OCD is all about handwashing? Think again. Beth breaks down how OCD manifests across various subtypes:

• Contamination OCD: Not just germs—can also be disgust, harm to self/others, or spiritual “contamination.”
  
• Harm OCD: Fears of hurting others, even loved ones, often accompanied by avoidance of sharp objects or situations.
  
• Hit-and-Run OCD: “Did I just run someone over?” followed by checking news, returning to the scene, or seeking reassurance.
  
• Pedophile OCD: Deep distress about being around children, not due to desire but overwhelming fear of harming.
  
• Scrupulosity OCD: Morality or religion-based fears of doing something “wrong” or offensive to God.
  
• Sexual Orientation OCD: Obsessing over whether one’s sexual orientation is authentic or deceptive.
  
• Existential OCD: Fears about the meaning of life, the afterlife, or even one’s own existence.
  

Each subtype is simply a different “flavor” of OCD—and all are treated with the same gold-standard method.

Evidence-Based Treatment: ERP

Beth lays out Exposure and Response Prevention (ERP), the go-to online education course content for anyone treating OCD. In short:

• Exposure: Intentionally triggering the obsession (in a safe, controlled way).
  
• Response Prevention: Resisting the urge to engage in the compulsion.
  

It’s not about making clients suffer. It’s about helping them learn that they can tolerate discomfort, that anxiety isn’t dangerous, and that they are capable of living a full life—even when fear is present.

Common Clinical Pitfalls

Beth and Allison get real about what therapists often get wrong:

• Reassurance giving (“You’re a good person, you’d never do that”) becomes part of the OCD cycle.
  
• Rationalizing doesn’t work. OCD isn’t convinced by logic.
  
• Uninformed reactions (especially around harm or pedophilia-themed OCD) can lead to unnecessary reports or ruptures in trust.
  

Beth urges clinicians to recognize when a client is experiencing ego-dystonic thoughts—meaning the thought horrifies them—and when to refer out to an OCD-trained therapist.

Cultural Norms & OCD

Beth touches on how societal expectations can sometimes support compulsions, like “cleanliness” being seen as virtuous, making it harder to challenge contamination fears. But sometimes, social norms can help clients resist—like feeling too embarrassed to carry out a compulsion in public, which can act as a surprising exposure win.

What About Medication?

Roughly 75% of Beth’s clients take medication. It’s not required for ERP to work, but for many, meds can take the edge off enough to do the hard work. Ultimately, Beth believes the real transformation comes from learning: “Medication can’t teach your brain. You teach your brain.”

ERP for Kids and Perinatal OCD

Yes, ERP works for kids—and it can be fun and playful, too. And yes, it’s effective for perinatal OCD, which can show up in both birthing and non-birthing partners. Beth emphasizes the importance of values-based exposures: if a parent fears harming their baby, the treatment doesn’t involve risky behavior—it involves showing up as the parent they want to be, despite the fear.

Partners, Parents, and Psychoeducation

OCD doesn’t exist in a vacuum. Beth often brings in loved ones to help them understand:

• Accommodation (like helping avoid exposures) might feel loving—but it reinforces OCD.
  
• Surprises and ultimatums (like “I bought plane tickets because you’re better now!”) usually backfire.
  
• Everyone involved may need to do some of their own ERP.
  

When to Refer (and When to Train)

If you’re not ERP-trained, Beth encourages you to refer out if:

• You don’t feel confident treating OCD.
  
• The content is beyond your emotional capacity to manage ethically.
  
• The OCD is the dominant clinical issue.
  

But if you’re ERP-curious? Get trained. Get consultation. There’s no shame in bolstering your skill set—whether or not you choose to specialize.

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Key Takeaways for Therapists

• ERP is the gold-standard treatment for OCD, and it works across subtypes.
  
• Reassurance and rationalization are landmines, not solutions.
  
• OCD thoughts are ego-dystonic and terrifying for the client—don’t confuse them with real risk.
  
• Values-based exposures are critical, especially when the content is untestable.
  
• Failing is data—and part of the healing.
  

Whether you’re new to OCD work or refining your skills, this episode offers critical insight into treating OCD effectively and ethically.

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