DIRT [Danger Ideation Reduction Therapy] for Obsessive Compulsive Washers: A Comprehensive Guide to Treatment

Tamsen St Clare, Ross G. Menzies, Mairwen K. Jones

Sydney West Health Service and University of Sydney

DIRT for washers is a unique evidence-based program to treat people suffering from obsessive–compulsive disorder (OCD) specifically, OCD washers whose behaviour is characterised by expectancies of danger.

Unlike many traditional OCD treatments, DIRT is based on the rationale that the therapist should provide as much factual information as possible to decrease the expectancy of illness or disease and thus reduce the high dropout rate seen in conventional OCD exposure and response prevention programs. The program consists of six discrete treatment components aimed at reducing the number of intrusive thoughts experienced and concurrently allowing the client to successfully change the remaining thoughts and beliefs related to illness and contamination. The components may be used selectively or concurrently, as and how a therapist decides is appropriate for individual clients.

The treatment components are attentional focusing, cognitive restructuring, corrective information, microbiological experiments, filmed interviews and the probability of catastrophe task. Included in the program is a DVD of 8 filmed interviews about risk assessment. Additionally, a resource CD contains all 45 handouts and worksheets so that therapists don’t have to photocopy these resources from the book.

What makes DIRT different to other OCD treatments?

Unlike most other OCD treatment programs DIRT features:

  • inclusion of attentional focusing.
  • exclusive focus on threat expectancies relating to illness or disease.
  • direct challenging of negative automatic thoughts that relate to illness or disease.
  • use of factual information to provide assurance of the real likelihoods of various outcomes.
  • rote learning of restructured cognitions.


DIRT has been shown to be a highly successful treatment, able to shift even the most intractable of cases. Randomised control studies have established that DIRT represents a viable alternative to the standard behavioural approach. In addition, DIRT appears to have several potential advantages over behavioural and pharmacological treatments:

  • Unlike in an Exposure and Response Prevention (ERP) program, clients who undergo the DIRT regime are not asked to confront anxiety-provoking (feared) stimuli. This is particularly important since many sufferers either refuse exposure treatment or drop out before completion because of its anxiety-provoking effects.
  • Unlike medication used in the treatment of OCD, DIRT achieves its success without the complication of physical side effects. 
  • DIRT is a highly structured treatment package involving films, information sheets and worksheets which are relatively inexpensive to package and administer.
  • DIRT appears to require relatively few sessions for its therapeutic effect. Substantial reductions in OCD symptomatology have been achieved in as few as six clinical hours.
  • DIRT may prove beneficial for intractable patients who have failed with standard treatments, and for those who exhibit poor insight.


Some DIRT research references:


Drummond, L.M. & Kolb, P. (2008). Obsessive-compulsive contamination fears and anorexia nervosa: The application of the new psycho-educational treatment of Danger Ideation Reduction Therapy (DIRT), Behaviour Change, 25, 44-50.

Govender, S., Drummond, L. M., Menzies, R. G.(2006) Danger Ideation Reduction Therapy for the Treatment of Severe, Chronic and Resistant Obsessive-Compulsive Disorder. Behavioural and Cognitive Psychotherapy. 34(4), 477-480.

Hambridge, J. & Loewenthal, M. (2003). Treating Obsessive Compulsive Disorder: A New Role for Infectious Diseases Physicians? International Journal of Infectious Diseases, 7, 152-155.

Jones, M. K., & Menzies, R. G. (1997a). Danger Ideation Reduction Therapy (DIRT): preliminary findings with three obsessive-compulsive washers. Behaviour Research and Therapy, 35, 955-960.

Jones, M. K., & Menzies, R. G. (1997b). The cognitive mediation of obsessive-compulsive handwashing. Behaviour Research and Therapy, 35, 843-850.

Jones, M. K., & Menzies, R. G. (1998a). Danger Ideation Reduction Therapy (DIRT) for obsessive-compulsive washers. A controlled trial. Behaviour Research and Therapy, 36, 959-970.

Jones, M. K., & Menzies, R. G. (1998b). The role of perceived danger in the mediation of obsessive-compulsive washing. Depression and Anxiety, 8, 121-125.

Krochmalik, A., Jones, M. K., & Menzies, R. G. (2001). Danger Ideation Reduction Therapy (DIRT) for treatment-resistant compulsive washing. Behaviour Research and Therapy, 39, 897- 912.

Krochmalik, A., Jones, M. K., Menzies, R. G., & Kirkby, K. (2004). The Superiority of Danger Ideation Reduction Therapy (DIRT) over Exposure and Response Prevention (ERP) in Treating Compulsive Washing. Behaviour Change, 21, 251-268.

O’Brien, M., Jones M.K, & Menzies, R.G. (2004). Danger Ideation Reduction Therapy (DIRT) for Intractable, Adolescent Compulsive Washing: A Case Study. Behaviour Change, 21, 57–65.

St Clare, T. (2004). Danger Ideation Reduction Therapy (DIRT) for Atypical Obsessive-Compulsive Disorder: A Case Study. Behaviour Change, 21, 186-196.    

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About the Author

Tamsen St Clare is currently Senior Clinical Psychologist and Head of the Sydney West Area Health Service’s Anxiety Treatment and Research Unit, and formerly Clinical Director of the University of Sydney Anxiety Disorders Clinic. She now divides her time between clinical work, research, and student training. She has published several peer-reviewed journal articles on obsessive–compulsive disorder, and has extensive clinical experience with the DIRT package, having used it in research, public health, and private practice settings. 
Associate Professor Ross G. Menzies has been providing CBT for OCD, phobias, anxiety and depression in the inner-west of Sydney for over 15 years. He is currently Associate Professor of Psychology in the Discipline of Behavioural and Community Health Sciences at the University of Sydney. In 1991, he was appointed founding Director of the Anxiety Disorders Clinic, Faculty of Health Sciences, University of Sydney. He is an Advisory Board Member of the Sydney Anxiety Disorders Practice and is the Clinical Director of Anxpsych, an organisation bringing anxiety management skills to the corporate sector. He is the Head and Director of the Anxiety and Stress Research Group, the University of Sydney, and the editor of Australia’s national CBT scientific journal, Behaviour Change. 
Professor Menzies holds several other honorary appointments and is a senior clinical supervisor for psychologists. He has been the overseas expert trainer in cognitive behaviour therapy at the National University of Singapore and is the co-editor of the 2003 International Handbook on OCD for the prestigious Wiley Series in clinical psychology. In addition to his work on OCD in adulthood, he has considerable experience with child and adolescent forms of the disorder. He is the Clinical Patron of the Tasmanian Support Network for Child and Adolescent OCD, and an active researcher with numerous national competitive grants. Ross has produced over 100 international journal manuscripts, books and book chapters and is regularly invited to speak at conferences and leading universities and institutions around the world. He continues to attract patients from across metropolitan Sydney, rural NSW, interstate and from overseas, with many individuals and families travelling thousands of kilometres to receive treatment at his private practice.

Dr Mairwen Jones is currently Senior Lecturer in Psychology and Sub Dean Graduate Coursework and Students in the Faculty of Health Sciences, The University of Sydney. Dr Jones completed a Bachelor of Arts with first class honours in psychology in 1992 at the University of Sydney. She was awarded the Australian Psychological Society Prize for first in the year and the Dick Thompson Prize for First Placed Student in Psychology Honours. In 1993 she was awarded an Australian Postgraduate Research Award for her doctoral project. Mairwen has been Acting Director of the Anxiety Disorders Clinic and Clinical Consultant to the clinic at the University of Sydney and was the co-director of a university research centre in 2001 and 2002. She is currently Co-Chair of the Faculty’s Mental Health Research Team. She has been a chief investigator on a number of successful competitive grants which have funded research into the nature and treatment of obsessive–compulsive disorder. Her research has been published in journals and book chapters and has been presented at numerous prestigious international and local events. Finally, her research has been of local and international interest in the media and she has conducted more than 20 radio and/or newspaper interviews in recent years.

Table of Contents


DVD contents
CD resource contents
About the authors
How to use this manual

Chapter 1 - Introduction to DIRT
Chapter 2- Treatment Rationale
Chapter 3- Attentional Focusing
Chapter 4- Cognitive Restructuring
Chapter 5- Corrective Information
Chapter 6- Microbiological Experiment
Chapter 7- Filmed Interviews
Chapter 8- Probability of Catastrophe Task


DVD contents 

Interview with Mark (Canecutter)
Interview with Mark (Special Education Teacher)
Interview with Kim (Registered Nurse)
Interview with Ann (Lab Worker)
Interview with Claudia (House Cleaner)
Interview with Eddy (Fitter and Turner, Printer)
Interview with Julie (Gardener)
Interview with Ann-Marie (Bank Teller)

CD resource contents 

Chapter 2 Handout
1.  Why Do I Have OCD? And How Can DIRT Help?

Chapter 3 Handouts
1.  Attentional Focusing Card
2.  Attentional Focusing Monitoring Form

Chapter 4 Handouts
1.  Cognitive Restructuring
2.  Thinking Exercises
3.  Cognitive Monitoring
4.  Cognitive Monitoring Form
5.  Cognitive Challenging
6.  Thought Challenging Worksheet

Chapter 5 Handouts
1.  Normal Behaviours Information Sheet
2.  Normal Behaviours Worksheet
3.  The Immune System Fact Sheet
4.  Immune System Worksheet
5.  Faeces Fact Sheet
6.  Faeces Worksheet
7.  Urine Fact Sheet
8.  Urine Worksheet
9.  Hepatitis Fact Sheet
10. Hepatitis Worksheet
11. Vomiting Fact Sheet
12. Vomiting Worksheet
13. HIV and AIDS Fact Sheet
14. HIV and AIDS Worksheet

Chapter 6 Handouts
1.  Microbiological Report
2.  Microbiological Experiment Worksheet

Chapter 7 Handouts
1.  Occupational Interview Worksheet 1: Mark (Canecutter)
2.  Occupational Interview Worksheet 2: Mark (Special Education Teacher)
3.  Occupational Interview Worksheet 3: Kim (Registered Nurse)
4.  Occupational Interview Worksheet 4: Ann (Laboratory Worker)
5.  Occupational Interview Worksheet 5: Claudia (House Cleaner)
6.  Occupational Interview Worksheet 6: Eddy (Fitter and Turner/Printer)
7.  Occupational Interview Worksheet 7: Julie (Gardener)
8.  Occupational Interview Worksheet 8: Ann-Marie (Bank Teller)
9.  Occupational Interview Transcript: Dr Ralph (Infectious Disease Physician)
10. Occupational Interview Worksheet 9: Dr Ralph

Chapter 8 Handouts
1:  Probability of Catastrophe Worksheet 1
2:  Probability of Catastrophe Worksheet 2
3:  Probability of Catastrophe Worksheet 3
4:  Probability of Catastrophe Worksheet 4
5:  Probability of Catastrophe Worksheet 5
6:  Probability of Catastrophe Worksheet 6
7:  Probability of Catastrophe Worksheet 7
8:  Probability of Catastrophe Worksheet 8
9:  Probability of Catastrophe Worksheet 9
10: Probability of Catastrophe Worksheet 10