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OCD: who to see and what helps

OCD · Kitchener, Waterloo & Cambridge

Obsessive-compulsive disorder (OCD) is a cycle of obsessions, the unwanted thoughts, images or urges that keep coming back, and compulsions, the actions or mental rituals done to quiet them. Ontario’s quality standard says people with OCD should have timely access to cognitive behavioural therapy with exposure and response prevention (ERP), from a professional trained in it. At CARESPACE you start with a counsellor, who is a Registered Psychotherapist or a Registered Social Worker; when you book, ask whether one trained in ERP is available.

What OCD is

Obsessions are recurrent, persistent thoughts, urges or images that are intrusive and unwanted. Compulsions are repetitive behaviours, such as washing, ordering and checking, or mental acts, such as praying and counting, that you feel you need to do. In OCD the rituals get stuck, sometimes for hours. The usual yardstick is that they take more than an hour a day or cause real distress.

About 1 in 50 adults has had OCD at some time in their life, by Ontario Health’s estimate (CAMH puts it at about 1 in 40), and on average it starts at around age 20. People tend to live with it for years before saying anything: delays of 3 to 17 years before seeking treatment have been reported. OCD is a health condition like any other, and nothing to be ashamed of.

An unwanted thought on its own is not OCD; our page on intrusive thoughts explains the difference. If your worry is always about being ill, read about health anxiety as well.

Symptoms of OCD

Common obsessions:

  • Fear of contamination by dirt, germs, body fluids or disease
  • Repeated doubting
  • A need for symmetry or order
  • Fear of harming yourself or other people, on purpose or by mistake
  • Violent or sexual thoughts that you find repulsive or frightening

Common compulsions:

  • Cleaning and hand washing
  • Checking
  • Counting, or repeating words in your head
  • Ordering and arranging
  • Hoarding
  • Asking for reassurance
  • “Neutralising” thoughts, meant to cancel out the obsessive ones
  • Avoiding places and situations that could set the obsessions off

Most people with OCD have both, although one may be less obvious than the other. Family members can be drawn in, giving frequent reassurance or reshaping daily routines. This is called accommodation.

What causes OCD

The cause is not clear. It is thought to be a combination of psychological, biological and genetic factors: OCD tends to run in families, although no single gene is linked to it, and it may be more common in people who have been bullied, abused or neglected.

How OCD is diagnosed

A family doctor or nurse practitioner is a good first step, says Ontario’s guide for people with OCD: they gather enough to judge whether OCD is likely, then carry out a fuller assessment or refer you to someone who will. That assessment covers how severe the symptoms are and what else may be present, depression and anxiety disorders in particular. Registered Psychotherapists and Registered Social Workers provide counselling and do not diagnose or prescribe.

When it is urgent

People with OCD have a higher risk of suicidal thoughts and suicide attempts. If your obsessions are about harming someone, or you are a new parent with frightening thoughts about your baby, read the urgent section of our intrusive thoughts page too.

If you are thinking about suicide, or you do not feel safe, do not wait for an appointment: use the numbers below.

If you are in crisis or thinking about suicide, help is available right now.

  • Call or text 9-8-8, the Suicide Crisis Helpline, at any hour.
  • Call Here 24/7 at 1-844-437-3247 for addictions, mental health and crisis services in Waterloo Region, at any hour. here247.ca
  • Call 911 or go to the nearest emergency department if you or someone else is in immediate danger.

The emergency departments in Waterloo Region are:

  • WRHN @ Midtown (formerly Grand River Hospital), 835 King St. W., Kitchener
  • WRHN @ Queen’s Blvd. (formerly St. Mary’s General Hospital), 911 Queen’s Blvd., Kitchener
  • Cambridge Memorial Hospital, 700 Coronation Blvd., Cambridge

If you cannot get there safely, call 911.

What the evidence says about treating OCD

  • What these points rest on. Ontario Health’s quality standard for OCD in adults (2020), Canada’s 2014 guideline, and the UK’s guideline from NICE (2005, now being updated). “Should be offered” and “first-line” are firmer than “should be considered”; the wording shows a panel’s confidence as well as the strength of the trials.
  • CBT with ERP is the psychological treatment. In Ontario’s standard, psychological treatment should always be offered first for mild or moderate OCD. The Canadian guideline makes CBT, notably ERP, a first-line option and rates it equivalent or superior to medication.
  • How long it takes. For most people an adequate trial is 13 to 20 weekly sessions, each lasting from under an hour to two hours. Where OCD interferes only mildly, the UK guideline says a shorter version should be offered, up to 10 hours with a therapist: brief CBT with ERP using self-help materials, by telephone, or in a group.
  • The format is flexible, but a therapist matters. Group and individual CBT did not differ significantly in pooled analyses, although head-to-head trials conflict, and ERP by telephone was equivalent to face-to-face. ERP led by a therapist was superior to ERP carried out alone.
  • Medication. In Ontario, people with moderate to severe OCD, or whose OCD has not responded to psychological treatment, are offered an SSRI at an OCD-specific dose and duration: typically a higher dose than for other conditions, tried for 10 to 12 weeks, and continued for at least 12 months if it works. Canada’s first-line SSRIs are escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline.
  • One, the other or both. For moderate impairment the UK guideline says to offer a choice of an SSRI or more intensive CBT with ERP, because the two appear comparably effective; for severe impairment it says to offer them together. The combination has been shown to be superior to medication alone, but not to CBT alone.
  • If the first treatment does not work. At least 40% of people do not respond to the first medication they try. Next steps include clomipramine, which the UK guideline says should be considered after an SSRI has failed or was poorly tolerated, if the person prefers it or has responded well to it before; adding aripiprazole or risperidone, which the Canadian guideline reserves for treatment-resistant OCD; and referral for intensive treatment from a team with specialized expertise in OCD, which may be residential or inpatient.
  • What not to count on. The Canadian guideline says EMDR is not generally recommended for people with OCD. The UK guideline says people who ask for psychoanalysis, transactional analysis, hypnosis or couple therapy as a treatment for OCD should be told there is as yet no convincing evidence that these have a clinically important effect. It also says anti-anxiety medicines should not normally be used for OCD, except cautiously for short periods when an SSRI is started, and that antipsychotics alone should not normally be used.

How CARESPACE helps with OCD

Counselling & Psychotherapy

ERP has two halves. In exposure you confront the situations and objects you fear; in response prevention you refrain from the compulsion that would normally follow. Work usually starts with the situations that cause the least anxiety and builds up, with exercises to practise at home between sessions. Where the compulsions are mental, the UK guideline says to consider the same method aimed at the obsessive thoughts and at the mental rituals that answer them. For people who live with family, the UK guideline says involving a family member in ERP should be considered where everyone is willing; ask when you book whether that can be arranged.

ERP is a specific skill: Ontario’s standard asks that it be delivered by a professional with training in CBT for OCD.

See our counselling team →

More about cognitive behavioural therapy (CBT) →

Nurse Practitioner

A Nurse Practitioner can assess your symptoms, look for depression and other conditions that come with OCD, and prescribe and monitor an SSRI. Expect a slow start: many people feel no benefit for the first few weeks and improve greatly over time. For young adults, Ontario’s standard requires careful monitoring when an SSRI is prescribed, especially at the start, because SSRIs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30; if that happens, use the crisis numbers above and tell the prescriber.

See our nurse practitioner team →

Where most people start

With a counsellor. When you book, ask our Central Reception Team for one trained in exposure and response prevention. If none is available, ask a family doctor or nurse practitioner to assess you and refer you, because Ontario’s standard says this therapy should come from someone with expertise in treating OCD. See one of them in any case if your symptoms are severe or low mood has come with them, because that is where the guidelines bring in medication.

How your team works together

OCD is treated mainly by one service, counselling, with a prescriber alongside when medication is used. Ontario’s standard expects response to treatment to be monitored regularly with validated tools, and the plan reassessed if it is not working. If you are prescribed an SSRI, tell your counsellor.

Browse by service: counselling and nurse practitioner.

What to expect at your first visit

The first appointment is with a counsellor. OCD is easier to describe from notes, so consider writing down:

  1. The obsessions. The thoughts, images or urges that keep returning, said as plainly as you can manage.
  2. The compulsions. What you do in response, including the invisible ones such as counting or repeating phrases, and roughly how much of the day they take.
  3. What you avoid, and who at home gets drawn into reassuring you or helping with rituals.
  4. Earlier treatment. Any therapy, and any medicine and its dose.

You leave the first visit with a plan.

What you can do at home

Ontario’s standard treats self-help as a step in care in its own right: books, internet-based resources and support groups, which run in person, online and by telephone. Learning how OCD works is the first step. Because therapist-led ERP did better in trials than ERP done alone, this page gives no do-it-yourself exposure steps. If your family has been accommodating the OCD, Ontario’s guide says not to stop suddenly, but to talk together, and with your care provider, about how to reduce it.

Outlook

OCD is unlikely to get better without treatment and support. With them, recovery is possible, although symptoms may change over time: the course tends to fluctuate, which is why a plan for relapse is part of treatment. In follow-up studies, the benefits of CBT were maintained over one to five years.

OCD treatment in Kitchener, Waterloo and Cambridge

Kitchener. Counselling in Kitchener. Locations: Victoria North, Fischer-Hallman, Westmount East and Deer Ridge.

Waterloo. Counselling in Waterloo. Locations: Weber North, Uptown Waterloo and Waterloo GoodLife.

Cambridge. Counselling in Cambridge. Location: Hespeler Road.

The city pages linked above show the locations and practitioners for each service, with their next availability.

Common questions

Can you have OCD without visible compulsions?

Yes. Compulsions can be mental acts, such as praying, counting or repeating words in your head, and either the obsessions or the compulsions may be the less obvious half.

Does everyone with OCD need medication?

No. For mild or moderate OCD, psychological treatment comes first. An SSRI comes in when OCD is moderate to severe or therapy has not been enough, and that decision is made with a physician, nurse practitioner or psychiatrist.

Should my family go along with my rituals?

Going along with rituals, or giving repeated reassurance, is meant to help but only works in the short term. The advice to families is not to stop suddenly: talk with the person who has OCD and their care provider about how to reduce it together.

Are intrusive thoughts always OCD?

No. See our Intrusive Thoughts page for how the two differ.

Is counselling for OCD available in Kitchener, Waterloo and Cambridge?

Yes, CARESPACE offers counselling in all three cities. ERP takes specific training, so ask our Central Reception Team at 519-208-2273 whether a counsellor trained in it is available near you.

Do I need a referral?

No. Book online or call 519-208-2273. You pay at each visit and receive a receipt for your extended health plan. More on fees and insurance →

Sources

Related conditions

The CARESPACE Central Reception Team

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Book online with a counsellor, or call 519-208-2273 and our Central Reception Team will match you with the right person and the closest location.

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