Ninewells Hospital & Medical School, Dundee, DD1 9SY

Behavioural modification (pacing) for OCD

This post is a summary of a poster that was presented at the EABCT conference in 2021. We talk about behavioural modification approaches for ritualised behaviour in OCD and other disorders. The full reference is as follows:

Buick, R., Cockburn, C. & Christmas, D. (2021) Applying a transdiagnostic approach to treating ritualised behaviour in specialised practice. Presented at EABCT 2021 Congress. Belfast, Northern Ireland; 8 - 11 September 2021.


Cognitive Behavioural Therapy/ Exposure and Response Prevention (CBT/ ERP) is the preferred intervention for people with Obsessive-Compulsive Disorder (OCD).

However, for people with comorbid Autism Spectrum Disorder, Anankastic Personality Disorder, or chronic/ treatment-refractory OCD, CBT/ERP is not always effective. Reasons include:

  1. The ritualised behaviour no longer has a trigger and has become habitual.
  2. Rituals may be driven by an internalised ‘feeling’ which is difficult to measure.
  3. Rituals may not be ego-dystonic.

In such cases, behavioural modification/ ‘pacing’ may be an alternative strategy.


We reviewed the literature systematically, to identify all types of published study reporting outcomes for behavioural interventions targeting ritualised behaviour. ERP was excluded.

We included both adults and children, and included conditions were OCD, ASD, or anankastic personality disorder.

Two representative cases are presented to illustrate the challenges facing therapists in treating complex cases and we describe principles for reducing the time spent on ritualized behaviour in adults and children with OCD and/ or ASD.


Description of studies

A total of 20 studies/ reports met criteria for inclusion, with 199 participants across all studies. The studies were published between 1977 and 2020, with most (87%) being published in the 2010s. Most studies (65%) were conducted in the USA and UK.

A more detailed breakdown is shown below.

Number/ mean ± SD % of participants
Type of study

Case report

Controlled trial

Follow-up study

Open study











M:F ratio 141:58 71%:29%
Age group













Modified CBT

Behaviour Therapy

Modified ERP









The interventions were not well described. Modifications to CBT and ERP included: visual aids; coping statements; self-monitoring behaviour charts; and positive reinforcement.

Key findings

We did not find a clear or consistent description of the approaches that we were familiar with. Further, the current literature does not provide clear guidance or implementation strategies that clinicians can easily access and use when working with these complex presentations.

Case 1

John is a 35 year old man who has OCD and ASD.

His ritualised toileting routines have been present since he was a child. There are no clear triggers for his rituals, but they have increased in recent years. He does not worry about contamination but he does try to achieve a sense of emptying which is more suggestive of ASD than ‘classic’ OCD. The behaviour is not completely ego-dystonic and he does not wish to eradicate the behaviour completely. He cannot work because he spends long periods in the bathroom.

His goal is to live a more fulfilling life, including returning to work or education.

Case 2

Jill is a 60-year-old woman with OCD and anankastic personality disorder, which have been present for at least 40 years.

She spends large amounts of time hand washing and showering. Jill is concerned about contamination and harm coming to her or others. The routines are fixed and have become habitual.

Jill has previously received ERP. Cognitive approaches have also been tried. Unfortunately nothing has helped in the longer term.

She has recently retired and would like to get some of her time back to enjoy retirement activities with her friends and husband.  She would like to reduce her time spent on rituals however she is aware that she will always have OCD and OCPD


Both cases underwent a behavioural modification/ pacing program. Behaviour change was assessed using clinical observation (including timing of rituals) and self-monitoring forms.

Both case significantly reduced the time spent on rituals and achieved their individual goals.

Principles of management

  1. The therapist should identify the specific behaviours that will be targeted using pacing, typically those that:
    • Occur in the absence of a trigger and have become or are habitual;
    • Are driven by an internal feeling/sensation which is difficult to measure; and,
    • Are ego-syntonic (or not clearly ego-dystonic).
  2. The clinician should identify target behaviours and record the length of time taken at baseline through either behavioural assessment/ observation.
  3. The therapist and patient should agree on what a ‘new’ typical day will look like. This should be viewed as the desired long term goal.
  4. Ideally the therapist should be present initially to assist, support, and encourage the patient whilst they practice completing their rituals) in a reduced amount of time.
  5. The therapist should use verbal and visual prompts (e.g. phone, clock) to encourage the patient to stop at the agreed time.
  6. If appropriate, the clinician should model/ use role rehearsal to demonstrate more ‘normal’ behaviours.
  7. The program may include behavioural strategies such as positive reinforcement, distraction, rewards, psycho education, redirection to agreed ‘appropriate behaviour’, habit reversal, social skills training.

Last Updated on 28 October 2023 by David Christmas
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