How I Led The Effort To Revise The International OCD Foundation’s Treatment Guidelines
This blog post is educational and is not medical advice. Any decisions regarding beginning, stopping, or changing medications should be made in consultation with a qualified prescribing professional, such as a psychiatrist or primary care provider. So, please be sure you consult with your prescribing professional before making any changes to your medication use.
The International OCD Foundation (IOCDF) is the leading OCD advocacy organization in the world. Its mission is to ensure that no one affected by OCD and related disorders suffers alone. As part of that mission, it raises awareness of OCD, helps individuals connect with effective care, equips clinicians through training, and advances understanding through public education and outreach.
I’m an enthusiastic supporter of the IOCDF and I’m the president of the Minnesota state affiliate of the IOCDF, OCD Twin Cities.
In June of 2025, the IOCDF released its updated treatment guidelines. These guidelines were designed to be an evidence-based set of recommendations for those considering OCD treatment. Since OCD is often not diagnosed and, even when diagnosed, not treated with evidence-based interventions, I was looking forward to reading and sharing these guidelines.
Yet, when I first read the guidelines, I was surprised.
Much of the content of the guidelines was what I expected. But, as I reviewed their “First-line Treatments” section, I noticed that the IOCDF had listed information that confused and alarmed me. Specifically, under the “Combining Medication and ERP Treatment” section, their text read:
“Combining ERP and medication treatment is generally considered the gold standard of treatment for OCD, because it is usually more effective than either treatment alone, particularly for people with multiple comorbid psychiatric disorders or severe OCD.”
Even though this sort of recommendation is (and has been) so common, this recommendation doesn’t match my understanding of the scientific evidence (more on this below).
My Concerns And My Understanding of the Science
As someone who wants to raise awareness about OCD and its treatments – in addition to being someone who lived with OCD for ten years and works with those suffering with OCD in my practice – the inaccuracy of these recommendations alarms me. My alarm has been repeatedly highlighted when clients in my practice inform me that they’d been told they needed to take medication to effectively treat their OCD.
Some of my clients don’t have significant concerns about taking medication (and reported they believe the medications were helpful). However, other clients very much do not want to take medications (and some have reported very troubling experiences when taking medications). My clients that don’t want to take medications are understandably concerned when they’re told that abstaining from medication will likely result in them not obtaining the best treatment outcomes.
Of course, personal preference plays a significant role in anyone’s decision to use medication in OCD treatment. I don’t tell people what decisions to make. Instead, my priority is making sure that my clients have access to the scientific information that’s relevant to them making their choice about medication. Put slightly differently, I want to ensure that my clients have genuinely informed consent about their treatment options, including possible advantages, disadvantages, and treatment outcomes.
Many of my clients tell me they’re willing to take medication – even if they don’t want to, even if this might mean tolerating adverse effects associated with that medication – if taking medication will maximize their treatment outcomes. And, thus, the question we bump into is:
Will taking medication maximize their OCD treatment outcomes?
The scientific evidence says probably not. In short, the evidence suggests that adding exposure and response prevention therapy (ERP) to medication, on average, improves treatment outcomes but (and this is the central point), adding medication to exposure and response prevention does not, on average, improve treatment outcomes. In other words, those participating in ERP and taking medications did not, on average, experience better treatment outcomes than those participating in ERP while not taking medications.
Because of this scientific evidence, I’ve had concerns about recommendations to combine ERP treatment with medication for years. I was so concerned that, in 2019, I published an article in the Journal of Obsessive-Compulsive and Related Disorders that included a portion describing my concerns and suggestions regarding these kinds of recommendations. Two years later, I was happy to see that my 2019 article was used by The International OCD Accreditation Task Force in creating knowledge and competency standards for the treatment of adult OCD.
My Letter To The IOCDF:
And yet, here I was in June of 2025 seeing the IOCDF repeat the same – in my view, mistaken – recommendations. I was perplexed.
The first thoughts that came to mind were:
Am I missing something? I thought I understood the research well. I certainly follow the research closely. But perhaps I’m not aware of relevant scientific data.
So I reached out to numerous leading OCD researchers, including multiple researchers affiliated with the IOCDF. My question to these researchers was always the same:
Here’s my understanding of the scientific evidence. Am I misunderstanding this evidence or is there evidence that I’m not aware of?
Taken as a whole, the feedback I received from these researchers was:
No. Your understanding of the scientific evidence is correct and you’re not missing data.
But if my understanding of the scientific evidence was correct, and I wasn’t missing any data, why was the IOCDF suggesting combined treatment as the gold standard in their recommendations?
To get to the bottom of this question, I led efforts in writing a commentary letter on the IOCDF’s guidelines. I was pleased that a who’s-who list of leading OCD researchers agreed to become signatories:
The IOCDF Changes Its Treatment Guidelines
I was even more pleased when the IOCDF, after reviewing our letter, agreed to modify their guidelines, changing their listed treatment recommendations from:
Combining ERP and medication treatment is generally considered the gold standard of treatment for OCD, because it is usually more effective than either treatment alone, particularly for people with multiple comorbid psychiatric disorders or severe OCD.
To:
Combining ERP with medication is a common treatment plan for many with OCD. The research behind this approach is inconclusive as to whether a combined treatment is better than doing either treatment alone. Clinical experience tells us that a combined approach may be better for people with more severe symptoms and/or comorbid mental health conditions. Every person’s journey is unique, please consult with your treatment team to figure out what’s right for you!
As we briefly touched on above, none of this means that those diagnosed with OCD shouldn’t take medications as part of their treatment plan. Instead, it means that when someone is considering adding medications to their OCD treatment plan, they should be aware that, on average, adding medications to ERP treatment doesn’t yield superior outcomes to participating in ERP treatment without medication.
As far as my ongoing, enthusiastic support of the IOCDF: This experience reinforced my enthusiasm. Numerous researchers I communicated with told me something to the effect of:
You’re wasting your time, William. Organizations like this don’t change.
But the IOCDF proved them wrong. The IOCDF demonstrated it can simultaneously be open-minded and rigorous. And that’s something we should all strive for.