CBT therapy for OCD: Techniques, Examples, and Effectiveness
Cognitive behavioral therapy (CBT) describes a group of science-backed methodologies proven to treat a multitude of mental health conditions.
ERP (exposure and response prevention) is a type of CBT that is considered the gold standard treatment for obsessive-compulsive disorder (OCD).
There are many different therapies available and it can overwhelm sufferers when trying to figure out which would be most helpful in their recovery.
It is important to understand that certain therapies work better for certain disorders.
In the case of OCD, it is crucial that you work with an OCD specialist who is qualified in CBT, and ERP in particular.
Certain therapies can actually negatively impact your recovery and reinforce the OCD cycle, so please ensure that you work with a qualified mental health professional who can offer the correct course of treatment.
Because when you receive a tailored treatment plan under the guidance of OCD specialists, the results can be extraordinary!
In the case of OCD, this includes a combination of CBT, ERP, and medication (where necessary).
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What is CBT?
CBT stands for Cognitive Behavioral Therapy. It is an umbrella term that encompasses a range of different evidence-based therapies.
The underlying premise of CBT is that the way someone thinks and behaves directly impacts how they feel. And these thoughts, feelings, and behaviors all impact one another in a cyclical fashion.
For example, if an OCD sufferer were to experience an intrusive ‘what if’ thought such as “What if I lose control and harm my child?” they may then feel anxious, uncertain, and out of control. Physiologically speaking, they may experience an adrenaline dump (thanks, anxiety!) and feel an increase in heart rate, nausea, and perspiration.
Suddenly, they may then respond by avoiding their child ‘just in case’ they lose control. But in doing so, they experience feelings of guilt which leads to a spiral of ruminating thoughts that they must be a bad person for not being with their child.
For those with OCD, CBT is designed to address the two core components of this disorder, obsessions, and compulsions.
CBT therapy asks that we change our relationship to problematic, anxiety-inducing thoughts (obsessions) and identify and alter our problematic behaviors in response to those thoughts (compulsions).
As noted in the American Psychological Association, CBT is based on multiple core principles, including:
- Psychological problems are partly based on faulty or unhelpful ways of thinking
- Psychological problems are partly based on learned unhelpful behavior patterns
- Those who suffer from psychological problems can learn more helpful coping mechanisms and therefore relieve their symptoms and become more functional in their daily lives.
CBT asks us to find helpful and healthy coping mechanisms in how we think and behave.
Cognitive therapy for OCD
The cognitive component of CBT can often be tricky to grasp for those with OCD.
It’s common for clients to ask our team, “How can I stop my intrusive thoughts?”.
The reality is that everyone experiences intrusive thoughts. We do not have control over those thoughts, and with every attempt we make to resist them, fight them, and try to stop them… we only make them more prevalent because we’re giving them our attention.
Within cognitive therapy, you will learn how OCD functions and why these thoughts conjure such feelings of terror and torment for you.
Once you understand that those with OCD find themselves stuck in a loop of wrongness, responding too much to errors and too little to stop signals, you can use this knowledge to your advantage.
In the context of OCD, those intrusive thoughts become a perceived source of danger that requires an immediate response.
In cognitive therapy, you learn to give these thoughts less weight and validity and therefore less attention.
You learn that thoughts are not facts.
You learn that you are not your thoughts.
You learn that just because you think it doesn’t mean you want it or will act upon it.
It is important to note that it is the behavioral component of CBT that has the greatest impact on OCD recovery and that cognitive therapy alone will not create the desired result.
So here comes the good stuff…
Behavioral therapy for OCD
ERP (exposure response prevention) is a type of CBT therapy that tackles the behavioral element of OCD.
ERP is arguably the most important type of CBT for OCD recovery. A meta-analysis has shown that two-thirds of patients who received ERP improved their symptoms while one-third were considered to be recovered.
ERP continues to outperform other treatments. Although this therapy works best alongside medication, if an OCD sufferer were to try only one type of treatment and work through their OCD recovery without medication, ERP would be the first port of call.
The goal of ERP therapy is to change our response to our obsessions.
We want to teach our brain that we tolerate anxiety and uncertainty without the use of compulsive behaviors, therefore reducing the urge to engage with them over time.
There are three different types of exposures typically used to help OCD sufferers:
In Vivo Exposure: Also known as ‘real-life’ or ‘actual’ exposures, the person with OCD is encouraged to stay in the presence of the feared stimuli for longer periods of time. For example, someone with Harm OCD would practice engaging in daily activities such as using a knife to chop fruit and vegetables whilst in the presence of their loved ones. They would be encouraged to resist the urge to put it down or hide it away for as long as they can. With each practice, they would increase the amount of time they spend holding the knife.
Another example may be that if you have just right OCD where you have to position something in a certain pattern or a certain way for to feel ‘just right’, you may practice positioning it incorrectly so that you intentionally induce the ‘not right’ feeling.
Imaginal Exposure: For this exposure, the sufferer is asked to imagine the feared situation and visualize the potential consequence of the feared situation. For example, someone with checking OCD may write an imaginal (or script) about going to bed without checking that the front door is locked. They may be then asked to imagine that someone does break into the house and robs them.
Ritual Prevention: This is about resisting the urge to perform those ritualistic behaviors. For example, touching the floor without washing one’s hands, going to bed without turning the light on and off a specific number of times, driving to work without avoiding a certain route that triggers your obsessions, etc.
How can CBT treat OCD?
It is important to understand that CBT has been scientifically proven to aid OCD recovery.
Unlike traditional talking therapies, CBT for OCD does not require a deep dive into a person’s past to identify the root cause of their suffering.
The truth is, this exact search for ‘why’ they have OCD becomes a compulsion in and of itself and can be harmful to those who struggle with this condition. OCD is also known as ‘the doubting disorder’. It thrives on an individual’s need to find a definitive answer to the uncertainty.
So you can see how traditional talking therapy would actually strengthen OCD’s grip and become a sneaky mental compulsion. The client can easily become trapped in a rumination cycle on the search for the ‘root cause.’ Talk therapy can also become a form of reassurance, which means you end up paying for therapy that is actually making OCD worse.
Instead, CBT has only two objectives that directly relate to the two key characteristics of OCD…
- Change our relationship to those obsessions and teach our brain that thoughts and feelings are not dangerous or an imminent threat.
- Change our response to those obsessions and resist the urge to engage in compulsive behaviors.
When we break the connection between feelings of anxiety and ritualistic behaviors, symptoms decrease, and you can begin living a rich and fulfilling life again.
Important CBT lessons for OCD recovery
We understand that it can be daunting to begin therapy.
The beauty of CBT is that it breaks treatment and recovery down into small, actionable steps.
But before we come to the ‘action’ component of treatment, we begin with psychoeducation. You’re armed with essential knowledge about OCD and how your brain functions so that you’re equipped to engage with the treatment in the most effective way possible.
Here are a few topics that will be discussed:
Thought-action fusion
For those with OCD, thoughts or images often become fused with reality. The belief here is that thinking about a thought makes them more likely to act on that thought.
This is why OCD can feel so terrifying.
The potential consequence of what might happen if they don’t intercept and try to resolve the thought can feel catastrophic.
Imagine a person who has Suicidal OCD. It feels risky to let those thoughts go unchecked because if there were any truth to them and the person were to act on them, it could be life-ending.
The fear of losing control then comes into play because, ultimately, OCD sufferers want to avoid the outcome of these thoughts becoming reality at all costs.
Included in this would be ‘moral thought-action fusion’, where thinking about something bad is as morally wrong as doing something bad.
Likewise, ‘thought object fusion’ is a belief that objects can ‘catch’ memories and become contaminated.
Before treatment begins, it is important to understand what thoughts are and what they are not.
Everyone has intrusive thoughts
The difference between those with OCD intrusive thoughts and a non-OCD sufferer who has intrusive thoughts is the meaning they attach to these thoughts and their response to them.
This is why the goal of therapy is never to stop intrusive thoughts.
Ultimately, OCD isn’t a thinking problem, it’s a feeling problem.
When your body’s physiological response to those intrusive thoughts is one of fear and uncertainty, we experience a dump of hormones that make us feel as though we are under very real threat.
This is why intrusive thoughts feel so real.
Because it’s a very real ‘danger response’ that’s happening in our bodies. The threat feels immediate and urgent.
As you move through the treatment, you place less weight and validity on these thoughts and reduce the compulsive behaviors. This, in time, reduces the intensity of the anxiety, and the intuitive thoughts can become less frequent and less disturbing.
Understanding this is an important first step before therapy begins.
Dysfunctional beliefs
Also known as cognitive distortions, these are not only typical of OCD sufferers. Anyone can experience cognitive distortions, and in fact, everyone does to some degree.
But when these are coupled with OCD, it can worsen the symptoms and make us more vulnerable to them.
For example, it isn’t uncommon for someone with OCD to suffer from an overinflated sense of responsibility.
That is, the belief that we are responsible for the bringing about or prevention of crucial negative outcomes.
Let’s take a common subtype to use as an example…
Imagine that you suffer from real-event OCD and someone you loved died of terminal cancer. You may have the thought that it could have been prevented if you had spotted the signs sooner and had made them seek treatment.
This would only feed into your OCD and make it more difficult to manage those obsessions.
It is important to understand your dominant dysfunctional beliefs and how they play a part in your experience with OCD.
Understanding your OCD
OCD has many different subtypes.
Every individual is different and so OCD presents itself in different ways. It is important to understand how OCD works on a functional level, and then identify how it typically presents itself for you.
This may involve keeping a diary to note down your triggers, for example. Then you may be asked to map out the thought process you had, through to the feelings you felt and the actions you took.
By doing this, you can better understand the process of OCD.
And when armed with this process, you heighten your awareness and increase your ability to spot and intercept it when the OCD cycle kicks into motion (not today, OCD!).
Common CBT Techniques for OCD
Let’s delve into specific examples of how each of these common CBT techniques can be applied in the treatment of OCD using contamination OCD as an example:
1. ABC (Antecedent-Behavior-Consequence) Analysis:
Example: Suppose a person with OCD has a fear of contamination and compulsively washes their hands whenever they touch a doorknob (trigger/antecedent). The compulsion is washing their hands thoroughly (behavior). The consequence is temporary relief from anxiety (consequence). Through ABC analysis, the person can recognize that the compulsive handwashing behavior temporarily reduces their anxiety but reinforces the connection between touching doorknobs and fear.
2. Exposure Therapy:
Example: A person with OCD has a fear of germs and contamination. In exposure therapy, they would gradually confront their fear by touching doorknobs or other potentially “contaminated” objects without washing their hands immediately afterward. With each prolonged exposure, the sufferer learns that they are capable of managing the anxiety without the use of compulsive behaviors.
3. Journaling:
Example: The individual maintains an OCD journal in which they record their intrusive thoughts and the corresponding compulsive behaviors. For instance, they may write down the obsessive thought, “I might have touched something dirty” and the resulting compulsion of washing hands for 5 minutes. By consistently documenting these occurrences, patterns and triggers become more apparent.
4. Worst and Best Case Scenario:
Example: The person with OCD fears that if they don’t shower after using a public restroom they will get violently ill (worst-case scenario). The best-case scenario could be that they don’t shower after using the public restroom and they feel perfectly fine. By considering both scenarios, the person can take a more realistic view of whether or not their actions are necessary.
5. Mindfulness:
Example: During a mindfulness exercise, the individual is encouraged to acknowledge their obsessive thoughts about contamination without reacting emotionally or performing compulsions. They might observe the thoughts like clouds passing in the sky, recognizing them but not engaging with them. This helps to develop a sense of detachment from the thoughts and reduces their power over the person.
6. Activity Scheduling:
Example: The individual with OCD may engage in compulsive rituals for several hours a day. The therapist helps them create a structured schedule that incorporates enjoyable and meaningful activities. This might include spending time with friends, pursuing hobbies, or engaging in physical exercise. The goal is to reduce the time available for compulsions and to shift the focus away from obsessive thoughts.
7. Response prevention:
Example: In response prevention, the goal is to resist the urge to engage in compulsive behaviors, therefore breaking the OCD cycle over time. First the OCD sufferer intentionally exposes themselves to the feared stimuli. Then they practice sitting with the uncomfortable feeling without the use of those safety behaviors. For example, someone with pedophilia OCD may walk around a local park (inducing feelings of uncertainty and anxiety) while resisting the urge to leave the park or avoid certain areas so as to avoid children.
It’s essential to note that these examples are just illustrations of how these CBT techniques can be applied for OCD recovery.
The actual treatment plan will be tailored to the individual’s specific obsessions, compulsions, and needs, and it should always be guided by a qualified mental health professional with experience in treating OCD.
How to find a CBT therapist near me?
A simple online search can bring up a wealth of experienced, highly qualified therapists in your area.
Some helpful directories include:
National Association of Cognitive Behavioral Therapists
Association for Behavioral and Cognitive Therapies
Simply pop in your zip code to find specialists in your area!
If you’re based in California, look no further…
In-person therapy
Our compassionate team of expert OCD specialists are trained to the highest standards and work under the supervision of top OCD specialist, Kimberley Quinlan.
Helping those in California, we offer a warm and non-judgemental environment.
Each treatment plan is tailored to our clients’ needs and we take a collaborative approach to therapy so you feel supported every step of the way.
Although clients often come to us feeling hesitant and skeptical about starting therapy, they’re always glad they started.
If you’re ready to take the first step, we’d be honored to hear from you.
Please submit an initial intake form here to speak to a member of the team.
Online program
If private therapy is currently unaccessible for you, ERP SCHOOL has got you covered.
ERP SCHOOL takes the top-line tools and techniques for effective OCD recovery and delivers them to you in an easy-to-digest, self-paced online program.
Created by Kimberley Quinlan, it will give you the proven practices to help you resist the urge to do compulsions and stop letting intrusive thoughts ruin your life.
You’ll be shown how to apply them to your specific obsessions and compulsions so you understand how to use them in the context of your OCD.
Join ERP SCHOOL here to take your life back from OCD.
