I have the most experience as a residential-level behavior therapist as an original staff member of the OCD Institute at McLean Hospital since 1997. I am the author of Understanding OCD: Skills to Control the Conscience and Outsmart Obsessive Compulsive Disorder. The patients with whom I have worked have taught me that there is a deeper level of distress people with OCD experience than just rituals interfering with functioning. I have learned that OCD doubt leads to self-doubt and people lost sight of who they are as their own person. Obsessive guilt from scrupulosity (religious OCD) and hypermorality often undercut the benefits from the hard gains made from ERP alone.