OCD Treatment in Girona: How we apply the 5 latest scientific advances in our therapy

Obsessive-Compulsive Disorder (OCD) is one of the most complex mental health conditions. For decades, Exposure and Response Prevention (ERP) Therapy has been the cornerstone of treatment. However, scientific research is not a stagnant field; discoveries from recent years reveal a much more nuanced and, in many ways, more surprising picture than conventional wisdom suggests.

These findings challenge our assumptions about what works, why it works, and how we measure success. From the limitations of our best treatments to the power of personal values, new data compel us to be smarter, more critical, and ultimately more effective.

This article explores five of the most impactful truths that modern science is revealing about OCD therapy, and how these principles are applied in daily clinical practice in specialized centers.

1. The truth about exposure and response prevention (ERP)

Exposure and Response Prevention (ERP) Therapy is undoubtedly the first-line or “gold standard” treatment for OCD [1, 2]. Its logic, based on inhibitory learning, is solid: gradually facing fears (exposure) without engaging in neutralizing rituals (response prevention) teaches the brain that the feared catastrophe does not occur [3].

However, the scientific truth is more complex and less triumphalist. Despite its status, a significant portion of patients do not respond adequately to ERP, find it too aversive to complete, or fail to achieve full remission [4]. In fact, OCD remains one of the most treatment-resistant non-psychotic disorders [5]. Research shows that only approximately half of patients undergoing this therapy experience clinically significant change [4, 6, 7]. This does not invalidate ERP, but it does highlight the critical need to personalize treatment and seek complementary or alternative strategies for a considerable proportion of patients [4].

2. A Paradigm Shift: From Fighting Thoughts to Living According to Your Values

In light of the limitations of ERP, a paradigm shift has emerged with Acceptance and Commitment Therapy (ACT). This approach does not focus on eliminating obsessive thoughts, but on changing the relationship a person has with them [1]. ACT proposes something radical: instead of treating thoughts as enemies to be defeated, they can be seen as background noise that does not have to dictate actions.

The driving force behind this shift is the focus on personal values. ACT helps individuals identify what is truly important to them and use those values as a compass to guide their behavior. This is where its power to enhance ERP becomes evident, as in the following kitchen example:

Imagine a patient with harm-related obsessions who avoids using knives in the presence of their partner. Traditional ERP would require them to hold the knife to habituate to the fear. ACT goes one step further. First, it connects with the patient’s value: “It is important to me to be a present and loving partner, and to share quality moments.”

Then, the task is reformulated. The objective is no longer “to endure the fear of the knife.” The new goal is “to engage in the valued act of preparing dinner with my partner.” The knife becomes a necessary tool to live out that value. The therapy focuses on being willing to feel fear while performing a meaningful action. This shift in framework transforms a feared exposure into an act of desired commitment, drastically increasing motivation [1, 8].

3. The “Active Ingredient” Is a Mystery (and May Be Shared)

Here is a truth that puzzles researchers: it is not entirely clear why different OCD therapies work [9]. Although ERP and Cognitive Therapy (CT) have different theoretical foundations, their mechanisms of change may be much more similar than previously thought [10].

An exploratory study by Twohig et al. (2010) yielded an unexpected result. When treating six participants with ACT, CT, or ERP, the two patients in the Cognitive Therapy group reported that Psychological Flexibility (a core ACT process) and Extinction (the ERP mechanism) were more relevant to their improvement than Cognitive Restructuring, the supposed active ingredient of their own therapy [10].

This suggests that the labels of therapies are less important than the underlying transdiagnostic principles of change. Recovery may depend on a psychological flexibility that allows individuals to interact differently with their obsessions, regardless of the name of the manual the therapist is using [1, 10].

4. Researcher Bias

This is perhaps the most instructive finding. A factor that can distort research outcomes is the researcher allegiance bias [11]. This refers to the investigator’s belief in the superiority of a particular treatment, which can influence the design and interpretation of results.

A meta-analysis by Reid et al. (2021) on CBT with ERP for OCD found a surprising difference [7]. In studies where allegiance bias was suspected (three-quarters of the total), a large and favorable effect size was reported for the therapy (g = 0.95). However, in studies without this bias, the treatment showed no significant effect (g = 0.02)! [7]. This does not mean that ERP does not work, but rather that much of the reported efficacy in the literature may be artificially inflated. As consumers of science, we must be more critical and seek studies conducted by neutral teams with robust methodologies.

5. You Cannot “Reason” Your Way Out of OCD

Many OCD patients are highly intelligent and analytical individuals. They may understand the logic of the therapy on an intellectual level (“in the head”), but struggle to feel it on an emotional level (“in the heart”) [1]. This disconnect is a trap, as attempting to analyze or reason one’s way out of obsessions is, in itself, a mental compulsion that fuels the OCD cycle.

As one experienced clinician notes:
“I have never seen anyone think their way out of OCD, and I have certainly seen people try” [1].

Therapy, therefore, must be a laboratory of “learning by doing.” Real change comes from direct experience, from demonstrating to the brain, through action, that it can tolerate distress without resorting to rituals, whether through exposure (ERP) or valued actions (ACT) [1].

6. Evidence in Action: The Therapeutic Approach to OCD in Girona

The conclusions drawn from scientific research are not merely theoretical; they define what effective and humane OCD therapy should look like in practice. A modern therapeutic approach, such as the one cultivated at Centre de Psicologia Jaume Primer – Psicòlegs Girona, illustrates how these principles are integrated to offer coherent and personalized treatment in Girona.

The foundation of this approach is the recognition that therapy is not a formula. Adopting a cognitive-constructivist perspective means beginning with profound respect for the patient’s narrative, viewing them as the true expert in their own life. This philosophy directly responds to the evidence that standardized treatments like ERP do not work the same way for everyone (Truth 1). Instead of imposing a rigid protocol, the first step is to understand the person’s “particular way of seeing the world,” co-creating a therapeutic path rather than following a predefined map.

From there, the objective is not simply to apply a technique, but to coherently integrate the most powerful tools of science. In practice, this means that Exposure and Response Prevention (ERP) techniques are not applied in isolation. They are framed within the patient’s map of values and meanings. As discussed, change in OCD is fundamentally experiential and action-based, not derived from mere reasoning. At the same time, the success of this change depends on having a clear purpose.

By helping the person “re-narrate” their story and connect with what is truly important to them, an exposure task ceases to be an exercise to reduce fear and becomes an act of commitment to their values. This synergy between action and purpose transforms an aversive task into an act of self-affirmation, addressing one of the main barriers of ERP: lack of motivation.

Finally, science reminds us that change in OCD is experiential and often frightening. Therefore, the success of the intervention depends on creating a space of safety and trust—a therapeutic relationship where, as described in our treatment philosophy, “rigidity has no place and the patient’s voice is the protagonist.” Building a strong therapeutic alliance is the scaffolding that enables the person to dare to engage in the experiential work necessary to free themselves from the chains of OCD.

In essence, a modern OCD treatment in Girona, aligned with evidence, does not offer a technique, but co-creates a path. It is an approach that is both rigorous in its application of science and deeply human in its respect for the individual.

Final Notes on Clinical Implications and the Future of OCD in Therapy

• From the “what” to the “why” (functional approach): Therapy must focus on the function of compulsions (experiential avoidance) rather than just their form. This allows for a broader approach that includes subtle mental compulsions [1]. The future points toward Process-Based Psychotherapy (PBP), which intervenes on transdiagnostic mechanisms of change.

• The personalized future (biomarkers and neuroscience): Neurobiological research, such as studies linking the connectivity of the Language Network (LN) to CBT response [12], opens the door to identifying biomarkers that predict which patients will benefit most from certain interventions, enabling truly personalized therapy.

Conclusion

Scientific discoveries are pushing us toward a more humble and personalized view of OCD therapy. We have learned that our “gold standard” is not for everyone, that approaches like ACT offer new value-centered pathways, and that we must be extremely critical of published research.

The most important lesson is that there is no single solution. Recovery is not found in a rigid manual, but in the lived experience of each person, guided by a therapist who knows how to flexibly integrate the most effective scientific tools. The way forward lies in therapeutic flexibility and a process-based approach, adapting evidence to each individual’s unique narrative.

References

[1] Lee, E. B. (2025). Acceptance and Commitment Therapy for Obsessive-Compulsive Disorder. Psychiatr Clin N Am, 48, 457–466.
[2] Foa, E. B., Yadin, E., & Lichner, T. B. (2012). Exposure and response (ritual) prevention for obsessive compulsive disorder: Therapist guide. Oxford University Press.
[3] Craske, M. G., Kircanski, K., Zelikowsky, M., et al. (2008). Optimizing inhibitory learning during exposure therapy. Behav Res Ther, 46(1), 5–27.
[4] Fisher, P. L., Cherry, M. G., Stuart, T., Rigby, J. W., & Temple, J. (2020). People with obsessive compulsive disorder often remain symptomatic following psychological treatment: A clinical significance analysis of manualized psychological interventions. Journal of Affective Disorders, 275, 94–108.
[5] McKay, D., Sookman, D., Neziroglu, F., Wilhelm, S., et al. (2015). Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder. Psychiatry Research, 225(3), 236–246.
[6] Twohig, M. P., Hayes, S. C., Plumb, J. C., et al. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychol, 78(5), 705–16.
[7] Reid, J. E., Laws, K. R., Drummond, L., Vismara, M., Grancini, B., Mpavaenda, D., & Fineberg, N. A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106.
[8] Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25.
[9] Tolin, D. F. (2009). Alphabet soup: ERP, CT and ACT for OCD. Cognitive and Behavioral Practice, 16, 40–48.
[10] Twohig, M. P., Whittal, M. L., Cox, J. M., & Gunter, R. (2010). An initial investigation into the processes of change in ACT, CT, and ERP for OCD. International Journal of Behavioral Consultation and Therapy, 6(1), 67-83.
[11] Leykin, Y., & DeRubeis, R. J. (2009). Allegiance in psychotherapy outcome research: Separating association from bias. Clin Psychol Sci Pract, 16(1), 54–65.
[12] Machado-Sousa, M., Bertolín, S., Picó-Pérez, M., et al. (2025). Neurobiological correlates of CBT response in OCD through the analysis of resting state networks. International Journal of Clinical and Health Psychology, 25(2), 100585.