1. The content of the obsessions is irrelevant. OCD patients attend to the content of their obsessions (germs, burning the house down, running someone over, etc.) instead of the process of generating obsessive thoughts. In treatment, the content of their obsessive thought is unimportant; therefore, their task is to discount the content and simultaneously cope with the distress it provokes. Encourage them to practice a new belief: these obsessions are essentially meaningless and purposeless.

This is not an easy task to accomplish when patients are dreading that they might pass on deadly germs, kill their own child or cause a terrible accident. Nonetheless, the clinician should encourage patients to dissociate from those thoughts, and to get perspective on them by labeling them as an OCD event.

2. Accept the obsessions instead of resist them. The more they resist their obsessions, the stronger the obsessions tend to become. Patients need a new inner voice that says, "It's OK that I'm obsessing right now."

It is only through accepting the first challenge-the content of the obsession is irrelevant-that they will be willing to accept the obsessive thought when it comes unbidden to their mind. If they believe that the thought is meaningless, then they will be more likely to let it go. If they still think it actually is a reflection of reality, they will keep resisting it.

To accept is to begin to build a paradoxical approach to treatment: first, patients are to accept the obsession, and then, while they continue to accept it, they are to manipulate it. (More on this in a moment.)

3. Seek out uncertainty. This is a disorder of uncertainty. It is the nature of OCD to make patients overvalue certainty. By being willing to be uncertain, patients have a chance to overcome OCD's stranglehold. They can never know, absolutely, that a burglar will not break into their home, that there will be no salmonella in the chicken or that they did not run someone over in their car 12 years ago when they were visiting Spain. To demand certainty means that they cannot reach closure regarding past or future events.

Health professionals, just like family and friends, try to help patients by reassuring them that everything is OK. Reassurance rarely helps those with OCD, because it is the nature of the disorder to provoke a sense of uncertainty. Patients need to inoculate themselves from the suffering that goes along with uncertainty by learning to tolerate "not knowing."

4. Seek out distress. If they practice the third principle, to seek out uncertainty, then patients will automatically become anxious and distressed. They are conditioned to respond to that distress with a compulsion. The compulsive ritual brings relief from their dreaded outcome and relaxation of their distress. The clinician should counter this pattern by giving an explicit instruction to seek out discomfort and maintain it. When they follow this directive-to voluntarily, purposely, choose to seek out discomfort instead of avoid it-their discomfort tends to diminish.

The primary way to provoke uncertainty and discomfort is to modify or withhold compulsions. Most OCD patients believe that if they fail to ritualize, not only could something terrible happen to them or others, but they might also remain distressed for an intolerably extended period. They must be willing to challenge this pattern-of uncertainty and distress followed by compulsion-in order to discover that there are other ways to reduce their distress. Strategic techniques for modifying compulsions, described in a later section, serve as opportunities to practice these injunctions to seek out uncertainty and seek out discomfort.

As a simple example, one 20-year-old male patient had approximately 15 washing or checking compulsions. In one ritual, he repeatedly cleaned the kitchen counters of his house after meals. Once through cleaning, he then rinsed the sponge under the faucet while squeezing it 10 times and simultaneously subvocalizing the count of each squeeze (squeeze, "one", squeeze, "two", squeeze, "three", and so forth). Suggestions were directed at disrupting this pattern in a manner similar to the behavioral technique of conditioning by successive approximations to the goal. In his first week's homework he was asked to shift the sponge to the opposite hand for each squeeze (left hand for squeeze "one", right hand for squeeze "two", and so forth). This he accomplished with ease. The change in hands produced no distress because his ritual was ostensibly the same in his mind. During week two, he was instructed to toss the sponge between hands instead of passing it (squeeze, "one", toss, squeeze, "two", toss, and so forth). Again, he reported no difficulty. By week three, he was capable of exposure and response prevention: he squeezed the sponge only one time while rinsing, then set it down and walked away. While the patient still had approximately 14 other compulsions in his repertoire, this one did not return.

This case illustrates the essence of the strategic approach. With each manipulation comes an opportunity for new learnings within a less threatening environment. Here, patients discover that modifying their compulsive patterns does not lead to significant, lasting anxiety. As patients certify their ability to change their behavior without causing undue, long-lasting distress or harm, then they will be increasingly willing to take elevated therapeutic risks. Each step further breaks down the fortress walls and adds another building block toward exposure and response prevention. In this case, the patient shifted to the exposure and response prevention (ERP) stage of treatment with little distress. This learning can then be generalized to support his decision to challenge his other 14 compulsions.

There are a number of strategic interventions for obsessions and compulsions. In this short article, I'll give you a couple of examples. It is important to understand that these techniques are used within the context of the four primary homework assignments: the content of the obsession is irrelevant, accept the obsession when it comes, seek out uncertainty, and seek out discomfort. While the four challenges are direct confrontations of a patient's beliefs, the strategic techniques are designed to avoid initial direct confrontation with the patient's long-standing, well-reinforced patterns. Early interventions in strategic treatment are designed to interrupt the obsessions and compulsions in minor ways, not to conduct a direct frontal assault. The patient attacks the fortress by dissolving the mortar of the brick walls. Once the basic pattern is interrupted, the new pattern has a brief history (several days or weeks), and the patient becomes less attached to its individual components. This offers the chance for further manipulation of the pattern. These first interventions, whether used at the moment of obsessing or ritualizing, allow a core part of the pattern to continue while modifying another part. This increases the patient's willingness to comply with the instructions.