CBT for OCD: What is it & How Does it Work?

What is CBT?

For example, if you feel anxious about a certain situation, and have thoughts such as “there’s no way I can face this” or “I’m always going to be frightened of this”, then the behaviours that will follow are likely to be avoidance of that situation. Rather than dealing with the problem, this feeds into the cycle and builds more fear.

The British Association for Behavioural and Cognitive Psychotherapies explains that, “When people feel worried or distressed we often fall into patterns of thinking and responding which can worsen how we feel. CBT works to help us notice and change problematic thinking styles or behaviour patterns so we can feel better.”

This is where CBT comes into play. Through CBT, patients can learn to replace negative thoughts and often unhelpful or negative behaviours which accompany them, with more positive, helpful thoughts and behaviours.

Unlike many other psychological therapies, CBT doesn’t focus on the patient’s past, but instead focuses on their feelings and what they are experiencing in the present. CBT is all about helping patients be more aware of their thought processes, aiding them in gaining greater control.

While CBT takes a different approach to other therapies, it still brings extremely positive results. The American Psychological Association state that, “In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.”

CBT sessions tend to be short-term, but the goal is to equip patients with the tools they need to continue practicing CBT techniques in their day to day lives going forward. In this way, patients can maintain and continue their progress, making their recovery sustainable.

Who can CBT help?

CBT has been proven to be helpful in treating a wide range of mental health conditions, as well as some physical health problems, such as chronic pain. A list of the most common conditions CBT is used to treat are is included below:

• Anxiety and panic disorders (including OCD)
• Depression
• Bipolar disorder
• Post traumatic stress disorder (PTSD)
• Phobias
• Eating disorders
• Psychosis
• Schizophrenia
• Chronic pain
• Other chronic illnesses (such as chronic fatigue syndrome)

CBT can also be used to help those without diagnosed health issues, such as those who need help to control their anger, those who struggle with insomnia, or people who are struggling with addiction. Often CBT will be used to aid those who are experiencing a hard time in their life, particularly if they are having relationship or family problems.

CBT will often be integrated into other therapies to bring the optimum results for patients. More than one issue can be tackled at once through CBT, for example if a patient is struggling with both mental illness and chronic pain, their sessions can be used to address both issues. CBT can be used to help anyone, of any age, including children.

How can CBT treat OCD?

CBT is a highly effective treatment for OCD, and is routinely recommended when patients are beginning their recovery journey. This study concluded that, “Over 40 years of published research has led to the wide consensus among researchers and clinicians that CBT is an effective treatment for OCD.”

Rather than trying to figure out the root cause of an individual’s OCD, or the causes behind their thoughts and behaviours, CBT focuses on the present. CBT focuses on how your thoughts processes work and influence behaviours, and works on breaking the cycle of OCD to improve your quality of life.

While tackling OCD can at first feel insurmountable, through CBT you can break down your problems into manageable parts. This way you can deal with things a step at a time. The NHS explains that CBT, “can help you make sense of overwhelming problems by breaking them down into smaller parts.”

Understanding how thought patterns lead to actions

A big part of CBT is helping patients to understand how their thought patterns affect their behaviour. While there is, of course, likely to be an already existing surface understanding that intrusive and obsessive thoughts can lead to compulsive behaviours, CBT helps you to understand exactly how this works.

This stage of the therapy aids patients in understanding that it’s how they interpret the thoughts they have, and the behaviours that stem from those thoughts which are causing the problem. CBT will help you to see that the same event can have very different outcomes depending on how it’s interpreted.

For example, if you are making a meal and you accidentally drop the finished product, you might think “Oh no, how clumsy I am” and laugh at yourself, then remake the meal again. Alternatively, you might think “I am so stupid, I cannot believe I did that, that’s ruined my whole day”, and you may feel quite negative and down on yourself. Your thoughts may spiral and your anxiety may rise. You may start to seek reassurance and carry out checking behaviours. These are two very different ways of interpreting the same situation, with significantly different effects for the individual.

This understanding provides a basis for you to work from during your sessions.

Learning that everyone has intrusive thoughts

When you live with OCD, it can often feel very isolating. It’s very common to feel alone, and as though you’re the only one who has these awful thoughts. Through CBT, you can be guided to understand not only that there are other people out there who are going through the same as you, but also that everyone experiences intrusive thoughts.

At some point in everyone’s life, they’re likely to experience intrusive thoughts: the form these thoughts come in may vary from person to person. The difference for those with OCD, is that these intrusive thoughts become more regular and debilitating.

Learning that intrusive thoughts are in fact ‘normal’ can challenge self-stigma, and help OCD patients to understand that how an individual deals with their thoughts and the emphasis they put on them, can have a significant impact on what follows.

A study on the use of CBT to treat OCD explains that, “The initial strategy in CBT is to normalise the occurrence of intrusions and to emphasise that they are irrelevant to further action.”

Understanding how your OCD works

There are so many types of OCD. Even within specific OCD diagnoses, each individual may have different triggers and vary in the way they experience their symptoms; we’re all individuals after all! By engaging in CBT, you can learn how your OCD works specifically, giving you a greater understanding of what’s going on within your own mind.

This is often done by you being asked to recall an example of when your OCD was particularly severe. You will then be guided through this example, mapping out the thought processes. This can help you to see how your thoughts led to the actions you took in that situation.

Sometimes you may be asked to keep a journal or diary, making note of your thoughts and any actions which follow. This helps you to become more self-aware and aids you in seeing patterns in your OCD. This study explains that, “The patient keeps a daily diary of obsessions, called a thought record. In the thought record, patients write down their obsessions and the interpretations associated with the obsessions.”

Learning not to avoid intrusive thoughts

It’s completely natural to want to try and ignore intrusive thoughts or distract yourself from them; they can be incredibly distressing and by nature we would want to get away from them. However ignoring intrusive thoughts or trying to ‘push them away’ can actually perpetuate them and make the thoughts stronger.

Through CBT you can learn to acknowledge the intrusive thoughts, over time understanding that they are ‘just thoughts’, and don’t need to lead to behaviours, which takes away some of their power.

The goal isn’t to eliminate intrusive thoughts, but rather to be able to let them flow past you without allowing them to affect you. You will be guided through identifying the difference between intrusive thoughts that someone without OCD may have, and intrusive thoughts which someone with OCD may have.

You’ll learn over time working on this, that intrusive thoughts are ‘normal’ and even healthy; it’s how we react to them that’s important. This helps to take away the threat that intrusive thoughts may pose in your mind, and helps you to see that they can even be helpful if we deal with them in the right way. This study on the use of CBT for OCD mentions that, “Patients learn that intrusive thoughts and urges are part of the human condition and are necessary for problem-solving and thinking creatively.”

During CBT you may be asked to actively think about your intrusive thoughts to bring them on, so that you can deal with them in a safe space. This can sound scary but don’t worry, you will be guided through it and you will move at a pace that works for you.

Challenging negative thoughts

Once you fully understand how your thoughts and behaviours are inherently connected, you will be guided through tackling these thoughts and their associated behaviours.

Through CBT, you can learn to seek alternative meanings regarding negative thoughts, and to challenge the beliefs you hold which stem from your OCD. You’ll be given the tools to actively stop negative thoughts in their tracks by assessing them and re-framing them in a more logical, productive way.

Re-assessing responsibility

This study explains that, “One of the core features of OCD is an overinflated sense of responsibility for harm or its prevention.” For example, someone with OCD may feel that they need to carry out specific compulsions in order to prevent harm to their family. In this case they feel that they are responsible for their family’s safety.

CBT helps patients to re-conceptualise this sense of responsibility, to give you a clearer view of what you are, and are not, responsible for.

Tackling risk hypervigilance

OCD makes patients more hypervigilant to risks, as well as causing them to perceive risks even where they are none. This can heighten anxiety and understandably make the world seem like a scary place.

CBT works to teach patients that most situations in life have some risk attached if you search for it. CBT sessions will typically help you to see that by focusing on these risks and being in a state of ‘alertness’, you’re feeding into the OCD cycle rather than tackling it. As you come to an understanding of this and realize that these risks do not have to dictate your thoughts or behaviours, you can learn to become less alert and instead feel calmer and more in control.

Facing fears

Those with OCD often avoid certain situations due to fear, and try to prevent risk through their compulsions. It’s common to end a compulsive behaviour when you feel ‘mentally comfortable’ that you have carried out the compulsion well enough, or often enough.

CBT can teach you how to face your fears, learning to let thoughts pass you by without engaging in checking or reassurance seeking behaviours. You may be asked to rate your thoughts from least distressing to most distressing, and gradually you’ll be able to tackle them one at a time.

You’ll be asked to face your fears by not engaging in checking or compulsive behaviours in response to each thought, starting from the least distressing. This can be tough at first but is vital for progression, as explained here: “Patients usually need to do tasks uncomfortably and unconfidently before they can achieve comfort and confidence in doing them.”

This will be done with the guidance and support. Although it may feel frightening, as you begin to see results your confidence will build. You won’t move forward until you’ve overcome each level of your fear hierarchy at a time.

Through this process, patients learn that engaging in compulsions keeps the cycle of OCD going, and instead learn how to break this cycle and are given the tools to continue doing so going forward. This study states that, “Over time, patients learn to identify and re-evaluate beliefs about the potential consequences of engaging in or refraining from compulsive behaviors and subsequently begin to eliminate compulsions”

A summary of the benefits of CBT in treating OCD

Now you can see how CBT can be an effective treatment for those with OCD, let’s go over the benefits:

• Understanding how your OCD works: CBT helps you to understand what is going on in your mind, giving you a clearer perspective of how your OCD works.
• Relief from symptoms: CBT can help you to overcome intrusive and obsessive thoughts, as well as compulsive behaviours.
• Giving you control back: Despite OCD revolving around trying to gain control, it can actually feel as though OCD has taken over and the illness has taken control of your life. CBT can help you to start regaining that control and aid you in reclaiming your life. Knowing that you are proactively engaging in treatment can feel empowering.
• Building confidence: As you see the benefits of your CBT treatment, you can find your confidence building.
• Sustainable change: CBT works to equip you with the tools to continue tackling your OCD, leading to long term sustainable changes even after the therapy sessions are over. The Royal College of Psychiatrists’s guide to CBT explains that, “CBT aims to get you to a point where you can ‘do it yourself’, and work out your own ways of tackling these problems.”
• Giving you hope for the future: Once you begin to see your symptoms reducing, you can start to feel hopeful about the future once again.
• Can be used alongside medication: CBT can be utilized alongside OCD medications with the guidance of your doctor.

Common CBT techniques

We know how CBT can treat OCD, so let’s dive into some of the techniques that are commonly used during CBT sessions to achieve the outcomes we’ve discussed. These are only a few of the techniques used: depending on your therapist or the online programme you use, techniques can vary.

The ABC technique

The ABC technique was originally developed by a man called Dr Albert Ellis in 1957 to tackle ‘irrational beliefs’.

• A stands for Activating event: This refers to the event that leads to an irrational thought process or a highly emotional reaction.
• B stands for Beliefs: Beliefs are the thoughts that occured after the activating event.
• C stands for Consequences: The consequences are the behaviours which followed the beliefs.

The ABC technique helps patients to see that the activating event (A) can have many outcomes, depending on how the patient interprets it (B). This technique usually involves using a worksheet with the 3 columns. You’ll be asked to think back to an event which led to a negative thought and fill in the 3 columns, giving you a clearer perspective. A very basic example would be: if you dropped something on the floor (A), and thought that this meant you were a failure (B), so you carried out a checking compulsion (C).

You will then typically be guided through thinking about what the consequences would have been, if the beliefs about that event had been different (and perhaps more positive). In our very simple example, you would then be asked to think about what other beliefs could have followed in response to dropping the object on the floor (A). You may be guided through beliefs such as, “that was an accident and everyone has accidents” (B), which would lead to you picking up on the object and getting on with your day (C).

Essentially the ABC technique works to equip you with the tools to rethink negative beliefs and consider other options, and in turn carry out more adaptive behaviours. Positive Psychology explains that the ABC technique can help a patient, “reinterpret their irrational belief system helps to forge new ways for them to interpret their beliefs resulting in alternative behaviors.“

Exposure therapy

When facing fears as we discussed, a form of exposure therapy may be used. This means that you are gradually facing your fears, essentially exposing yourself to them so that you can overcome them. This type of CBT can be done through graded exposure therapy, which fundamentally means you will be facing your fears in a very step by step way so that it’s manageable.

Exposure and response prevention (ERP) is a type of CBT within which the therapist, “gradually exposes you to the situations that trigger your obsessions and compulsions.” This isn’t necessarily going to be part of your CBT sessions unless previously agreed upon, but can be another form of CBT treatment which may be used to help you face your fears.

Journalling

A form of journaling may be used, typically between sessions. This usually entails you keeping track of your symptoms to aid with self awareness. Journalling can help you to see patterns in your thoughts and behaviours.

Worst and best case scenario

Often CBT will involve you learning how to assess whether your thoughts are realistic and helpful. For example if you have a thought about a specific risk (such as what would happen if you didn’t carry out a compulsion), you may be asked to think about the worst case scenario, the best case scenario, and the most realistic scenario. This helps you to reframe the idea of ‘risk’, and gain greater control over your thoughts.

Mindfulness

Mindfulness is all about being present in the moment, being grounded and feeling a sense of relaxation. Mindfulness techniques can be used during CBT to help you release stress and anxiety, helping you to engage in the therapy from a calmer standpoint. This can be particularly useful in helping patients cope when they are facing uncomfortable thoughts or tasks.

An article from Positive Psychology explains that using mindfulness techniques during CBT can, “allow the person to be present in the moment and calmly soothe the unfocused mind. With the relaxation comes the stronger ability to tune in and alter automatic negative thoughts.”

Cognitive restructuring

Cognitive restructuring is a technique used to help patients look at their maladaptive (meaning unhelpful) thought processes in a new, adaptive (helpful) way. You will be guided through a negative thought process and be aided in seeing whether it’s productive and realistic, or whether it needs to be changed. You’ll then learn how to restructure this thought pattern in a more adaptive way.

Activity scheduling

A big part of the ‘homework’ you may be asked to engage in between CBT sessions will be based around activity scheduling. You will be asked to schedule agreed upon activities which challenge your OCD and help you to overcome your compulsions. Once these activities are written down and you’ve scheduled a time for them, you’re more likely to follow through, even if you feel uncomfortable.

Role Playing

Sometimes role playing can be used to simulate a specific scenario which would usually trigger your OCD. This can be a great way to practice the CBT techniques you have learnt in a safer environment before you try them out in your day to day life. Often this can build confidence and make ‘homework’ tasks seem less intimidating.

Where to access CBT and what to expect from CBT sessions

Now that you understand how CBT works and how it can treat OCD, you might be wondering what to actually expect during CBT sessions. You can access CBT in an individual face to face setting, through in person group therapy sessions, or online through a CBT programme or a therapy app.

If you live in the UK, you may be able to access CBT through your doctor or mental health team. Alternatively, you can seek sessions privately if your resources allow.

When you’re choosing an online programme or a therapist, ensure you do your research. Ensure any therapist is appropriately qualified and ideally has experience in treating patients with OCD. When looking at apps or online programmes, read the website thoroughly, check out reviews, and don’t be afraid to ask customer service any questions you may have.

In person sessions

CBT is typically a short term treatment, usually lasting between 8 to 12 weeks, with 1 to 2 sessions per week depending on the patient and the therapist. Sessions are typically between 30 and 60 minutes in length.

When you first attend your CBT sessions, you will chat with your therapist and get to know them. They will usually ask you questions and perhaps have you fill out a form. With your help they will try to build up a general picture to:

• Help them understand how your OCD affects you and how it impacts your day to day life
• Assess what stage you are at in your treatment journey
• Figure out what support you have
• Understand how you feel about treatment
• Establish what you want to achieve from treatment

From there the therapist will determine a treatment plan for you and usually let you know what your sessions will be focused on moving forward. During each session from then on, you’ll carry out exercises with the guidance of your therapist to help you treat your OCD.

Usually you will be given ‘homework’ at the end of each session to carry out in your own time before the next session. This ‘homework’ helps to continue the work you’re doing in your sessions in a more practical way in your daily life. In the next session, you will discuss your progress with the homework, and how you got on trying out the techniques. Your therapist will keep note of your progress and adjust your sessions and homework accordingly.

Online or app based sessions

Every online or app based CBT programme is different, but they will be based on the same concepts as in person sessions. The NHS lists one of the main advantages of CBT as: “the highly structured nature of CBT means it can be provided in different formats, including in groups, self-help books and apps”

With online CBT, you will typically carry out a similar number of sessions, and just like in person sessions, will have homework to carry out between sessions. Similar exercises will be instructed during your sessions, based on your own goals and targets for the programme. When working with online CBT it’s important that you’re able to keep yourself motivated and be honest with yourself, and with the app or online programme so that it can accurately track your progress.

Some patients find online sessions more suitable, because they have the same benefits and you don’t need to travel to a therapist’s office. A 2018 study from the Journal of Psychiatry and Neuroscience concluded that, “There is evidence to support the efficacy of remote CBT for OCD, which may improve accessibility to treatment.”

With remote treatment, you’re able to carry out the work in your own environment, which can often be reassuring for patients. However some may prefer a face to face interaction. Take your time to figure out what’s right for you.

Things to remember during a course of CBT

Whether you’re doing in person sessions or an online course of CBT, there are some things you should remember during your sessions:

• Be honest

  Be honest with yourself about how you’re feeling and about the progress you’re making. If you’re having in-person sessions, ensure you are honest with your therapist.

• Keep an open mind

  Go into your sessions with an open mind. You may be asked to face things that may make you feel uncomfortable at first, but this is part of the healing process. It’s important to be open to the therapy and willing to consider challenging your thought processes.

• Be dedicated and motivated

  CBT is not easy, but the outcomes can be well worth it. It’s important you’re ready to be dedicated to the work you will do during sessions, and the homework you will do between sessions. It’s also vital you are committed to utilizing the techniques you learn in the long term, even when things get hard, so that you can continue to overcome your OCD.

  OCD Action conclude their guidance to CBT by stating, “CBT is a learning process and it takes time, patience and practice but remember, it is proven to be successful for many people and sticking with it can mean a real difference to your life.”

• Speak up if you are worried or have questions

  If you’re concerned, speak to your therapist or the provider of your online CBT programme. It’s better to ask questions and seek guidance than keep things bottled up.

• Things may feel worse before they feel better

  You have to face your fears and your disorder head on in order to overcome it. This can feel really difficult and worrying at times. Your anxiety might increase at first, before you experience a gradual relief from your symptoms. Remember that when this happens, it doesn’t mean the treatment isn’t working! You must stick with it in order to see results.

• It’s completely valid to be nervous

  It’s understandable and natural to be nervous about starting any new therapy. Remember not to be too hard on yourself. The fact that you are attending therapy to tackle your OCD despite your nerves is a wonderful thing; praise yourself and encourage yourself gently.

• You can take someone with you

  You could choose to have a loved one you trust accompany you to your sessions. They may be able to wait outside, or depending on the therapist may be able to sit in the room with you. We all need moral support sometimes.

• If it doesn’t work, you can try again, or seek other options

  If after putting your all into the sessions and seeing it through, you find that CBT isn’t working for you, don’t lose heart. You can try CBT as many times as you like. You can seek a different therapist or switch from online therapy to in-person sessions and visa versa. You can even decide to seek another treatment option if you really feel CBT isn’t for you.

  OCD UK state that, “if you have tried CBT once or twice (or more) with limited success, there is no reason you can’t work with another therapist, perhaps an OCD specialist and have a completely different experience.”

  Remember this is all about you and your recovery journey. There is hope. You can overcome your OCD.

References

David Veale, (2007), “Cognitive–behavioural therapy for obsessive–compulsive disorder”. Advances in Psychiatric Treatment, vol. 13, 438–446

Foa E. B. (2010). “Cognitive behavioral therapy of obsessive-compulsive disorder.” Dialogues in clinical neuroscience, 12(2), 199–207.

Royal College of Psychiatrists, (2020), “Cognitive Behavioural Therapy (CBT)”.

Saul McLeod, (2019), “Cognitive Behavioral Therapy”. Simply Psychology.

Kelly Miller, BA, CAPP, (2020), “CBT Explained: An Overview and Summary of CBT”. Positive Psychology.

BeyondOCD.org, (2019), “Cognitive Behavior Therapy”.

NHS, (2019), “Cognitive behavioural therapy (CBT)”.

Pringsheim, T., & Piacentini, J. (2018). “Tic-related obsessive–compulsive disorder.” Journal of psychiatry & neuroscience : JPN, 43(6), 431–432.

OCD Action, (2020), “What Is Cognitive Behavioural Therapy (CBT)?”

OCD UK, (2020), “What is Cognitive Behavioural Therapy (CBT)?”

British Association for Behavioural and Cognitive Psychotherapies, (2020) “CBT | therapy worth talking about”.

American Psychological Association (2017), “What Is Cognitive Behavioral Therapy?”