Three Therapists, One Bank Clerk, One Budget

Formulation: obsessions (contamination fear) generate anxiety; washing and checking reduce it; the relief negatively reinforces the ritual; because the feared outcome is never allowed to occur, the belief that washing prevents disaster is never disconfirmed. The rituals also consume well over an hour a day and are producing documented occupational impairment (written warning) - which is what makes this a disorder rather than a quirk. Nothing in the history suggests psychosis, mania or substance causation, but thyroid and dermatological effects of washing should be checked by a physician.

Recommendation: ERP first (Therapist B), with an honest account of the alternatives.

• ERP: the mechanism of change is habituation and disconfirmation within and across sessions, which targets exactly the loop described. It is time-limited, has the strongest evidence base for OCD and matches his budget. Its honest cost: anxiety rises temporarily before it falls.
• SSRI (Therapist C): also a recognised first-line option, often at higher doses than in depression, with effect in 4–8 weeks and side effects to discuss. It requires a psychiatrist, not a psychologist prescribing. For moderate-to-severe cases, combined ERP plus SSRI is the usual recommendation; it is not unethical to start with medication, but he must know it is not instant and not a cure by itself.
• Free association (Therapist A): not that it is harmful, but it has a weak evidence base for OCD, an open-ended and unpredictable cost, and eight months of impairment make delay a real harm. Ethical practice requires telling him this, not silently choosing for him.

To Sunil and his wife: present the trade-off plainly - slower and gentler (medication alone) versus faster and harder (ERP) - and note that 'least distress' is not the same as 'least suffering', since ERP's distress is planned, time-limited and the mechanism of cure.

Start from his objection, not against it. 'Touching dirty things' is his description of the exposure step he fears most; nothing in ERP requires starting there. Exposure is graded by his own ratings, and the first steps will be items he rates low.

Session 1 (formulation and consent):

• Share the loop diagram: trigger → anxiety → ritual → relief → stronger ritual next time. Ask him to mark where each of his behaviours sits.
• Build a hierarchy together, 10 items rated 0–100 for anxiety - e.g. touching a doorknob at home and not washing for 10 minutes (low), handling money (middle), touching the bathroom tap (high). Do not touch the top items yet.
• Explain response prevention: the washing is what keeps the fear alive; the session is a controlled test, not a dare.
• Warn explicitly that anxiety will rise temporarily. If he is not warned, dropout is likely and he may conclude therapy 'failed'.
• Written agreement: he may stop any step; no surprises; homework of self-monitoring only.

Session 2 (first exposure): start at the lowest hierarchy item, do it together, and prevent the ritual for a fixed, agreed interval (say 20–30 minutes), during which anxiety is rated every 5 minutes so he can see it fall without washing. Do not reassure ('no, you are clean') - reassurance is a ritual performed by the therapist. Debrief, record the peak and the drop, and set the next homework step. Extend duration before climbing the hierarchy, so that success is defined by tolerating anxiety rather than by avoiding it.

Changing a plan is a sign of competence, not inconsistency. Triggers for urgent referral:

1. Suicidal ideation, plan or intent. OCD carries elevated suicide risk, and his occupational warning is a significant stressor. Any such disclosure overrides the ERP plan.
2. Comorbid severe depression or inability to function - if he cannot attend work at all, or cannot eat or sleep, medication and psychiatric management come first, with ERP added later.
3. Emergence of psychotic symptoms or a manic switch, which changes the diagnosis and forbids treatment as planned.
4. No response after an adequate trial - six to eight weeks of good-adherence ERP with homework, or 8–12 weeks of an adequate SSRI dose. Non-response is information, not failure of the patient.
5. Intolerable distress or repeated dropout from ERP - switch to medication or a combined plan rather than repeating a failed course.
6. Medical complications - infected or excoriated hands, or findings suggesting another medical cause.

Also state the boundary clearly: a psychologist does not prescribe, so 'Therapist C' must mean a psychiatrist, and the referral should be made on competence grounds even if Sunil resists. Meanwhile, keep the alliance: explain that referral is an addition to therapy, not an abandonment, and confirm what will continue (sessions, homework, monitoring). Document the reasoning for the change, because the parents and the employer are both watching this case.