Ritual Prevention

Description of the Strategy

Ritual prevention is a technique typically used for curbing compulsive behaviors in those with obsessivecompulsive disorder (OCD). Obsessions are ruminative, bizarre thoughts that create distress, and compulsions are behaviors performed after an obsession to lower distress. An example would be a person obsessed with thoughts of contamination and who compulsively washed his or her hands frequently throughout the day.

Ritual prevention involves some stoppage of the compulsion either via a client's self-control or with a therapist's help. Ritual prevention is typically used in conjunction with other procedures such as somatic control exercises, cognitive restructuring, and exposure. Initially, clients with OCD are taught to control aversive physical sensations such as trembling or hyperventilation. Cognitive restructuring is also employed to help clients fully explore alternative and more realistic explanations for events.

Following the development of somatic and cognitive control strategies, a client with OCD is generally exposed to his or her obsession by establishing a situation that triggers the thought. For example, a therapist may ask a client with contamination obsessions to plunge his or her hand into dirt or ask a client with checking obsessions to check the oven once and then leave the house to meet the therapist several miles away. With exposure comes ritual prevention, which involves not allowing the client to engage in the compulsion (e.g., hand washing, returning to the house to check the oven). As the client refrains from the compulsion, he or she practices somatic and cognitive control strategies and should eventually realize that anxiety will decrease without the need for compulsive behavior. Contemporary exposure/ritual prevention protocols for OCD indicate that a client should eventually practice these techniques as independently as possible.

Research Basis

Many single-case experimental and large betweengroup studies have empirically supported the use of ritual prevention for OCD. Ritual prevention is not highly effective, however, when separated from exposure-based assignments.

Relevant Target Population

Ritual prevention has been developed and used primarily for people with OCD. In particular, the procedure is useful for those with hand washing, checking, ordering, counting, and other compulsions that involve clearly defined motor behavior. However, ritual prevention has also been used to successfully treat people with bulimia nervosa.

Complications

Ritual prevention is less useful in cases where people with OCD have very severe obsessions and compulsions, are unable or unwilling to attempt the procedures independently of a therapist, and/or utilize mental compulsions such as praying or repeating words silently. Clients must fully understand the rationale behind this technique for it to be useful.

Case Illustration

“Amanda” was a 17-year-old female who presented to a specialized outpatient therapy clinic for OCD. At the time of her referral, Amanda was checking mirrors at school for any cracks that could lead to bad luck. In particular, she believed that if she did not check for cracks, terrible events would happen. She checked for several hours per day, which precluded her ability [Page 1010]to attend classes and concentrate on her schoolwork. Following training in somatic and cognitive control strategies, Amanda was instructed to check a mirror at school only once per class period. This allowed her some release of tension while simultaneously reducing her checking behavior. Initially, Amanda was escorted by the therapist or a school official to ensure that she was not checking mirrors beyond her approved schedule. Although her anxiety spiked at first, Amanda was shown that her anxiety did eventually diminish independent of checking and that terrible events had not occurred. Amanda's schedule of checking was eventually reduced to once every 2 hours and then gradually longer. After a period of 5 weeks, Amanda's checking behavior diminished substantially.

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