Falling into the OCD trap: Are clinicians hesitant to encourage exposure therapy for repugnant obsessions?

Obsessive-compulsive disorder (OCD) can involve repugnant obsessions with aggressive, sexual, and/or religious themes. Although exposure and response prevention (ERP) is an effective treatment for OCD, negative beliefs about exposure are common and may cause clinicians to be hesitant to encourage exposures, especially for repugnant obsessions. This study examined whether clinicians’ willingness to encourage challenging exposures differed depending on the repugnant obsession subtype (i.e., intentional harm, accidental harm, religion, pedophilia, and sexual orientation). The impact of clinical experience on the results was also investigated. A survey of five clinical vignettes was completed by 155 clinicians with experience treating OCD. Results suggested that clinicians were significantly less likely to encourage an in vivo exposure for intentional harm, accidental harm, and pedophilia obsessions as compared to other subtypes and were less likely to encourage an imaginal exposure for pedophilic obsessions as compared to all other subtypes. Clinicians reported varying levels of comfort in encouraging clients to face feared thoughts/triggers depending on the content of symptoms, which may contribute to suboptimal treatment for those with pedophilic and harm obsessions. Clinician experience had limited impact on these findings, highlighting the need for more training about ERP being a safe and effective intervention across symptom presentations.