Obsessive-compulsive disorder (OCD) significantly impacts the lives of those affected by it. The obsessions and compulsions associated with this condition can disrupt everyday activities, causing distress and anxiety. While complex, there are treatments available that help with OCD.
Cognitive-behavioural therapy (CBT) and exposure and response prevention (ERP) are well-established therapies in the field of OCD treatment. Considered the gold standard and recommended by the National Institute for Health and Care Excellence (NICE) guidelines, these therapies have emerged as powerful tools for OCD. In this post, we will delve into how CBT and ERP offer effective strategies for individuals dealing with the challenges of OCD.
While every individual and situation is unique, CBT and ERP for OCD typically consist of two fundamental components: the cognitive and the behavioural aspects. In some cases, therapists place a strong emphasis on the behavioural component of the treatment, while others leverage the cognitive element to support and enhance the behavioural interventions.
Assessment
To formulate an effective treatment plan, the process of CBT and ERP for OCD invariably begins with a comprehensive assessment. This assessment phase typically occurs over the initial one, two, or three sessions of treatment.
During this period, therapists frequently employ various questionnaires and open-ended questions to gain a deeper understanding of the issue and its scope. The objective is to create a holistic overview, encompassing factors such as the specific obsessions and compulsions the client grapples with, their frequency and intensity, the client’s level of insight into the problem, the presence of any co-occurring issues, the primary mechanisms that sustain the problem, and a preliminary grasp of potential triggers.
Psychoeducation
An essential objective within CBT is to provide the client with a comprehensive understanding of OCD, enabling them to understand its origins and the factors that sustain it. To achieve this, therapists introduce the cognitive model, which elucidates these underlying mechanisms.
Cognitive model of OCD
The contemporary cognitive-behavioural theories provide the most relevant framework for understanding CBT with ERP treatment.
The initial trigger for the development of OCD often begins with a stimulus, which can take the form of an unwanted mental intrusion in the form of thoughts or images. However, it’s crucial to note that these intrusive thoughts are a common experience among the general population and do not inherently lead to the development of OCD.
It’s not the intrusive thoughts themselves but rather the way individuals interpret and engage with them that makes all the difference. Those who don’t go down the path of OCD swiftly dismiss these intrusive thoughts. They don’t give them importance, no matter how distressing or bizarre they may seem.
Now, let’s focus on individuals with OCD. Instead of letting those thoughts come and go, they attach a negative meaning to these thoughts, viewing them as genuine threats. Moreover, they often leap associating these thoughts with their character, leading to self-judgments like, “This thought means I am a bad person”.
Two elements must align for a person to become ensnared in the cycle of OCD. Firstly, they must engage in a faulty evaluation of their intrusive thoughts, wherein they ascribe unwarranted significance or misinterpret the content of these thoughts. Secondly, they resort to specific behaviours or rituals aimed at mitigating the anxiety stemming from their evaluation of these thoughts or preventing the anticipated adverse consequences from occurring.
Step 1: Evaluations of intrusive thoughts
Researchers have delved into the specific evaluations made by individuals with OCD regarding their intrusive thoughts, shedding light on the factors contributing to the development and maintenance of the disorder. For instance, those grappling with OCD frequently tend to excessively magnify the significance of their thoughts, perceiving the mere presence of any thought as inherently important. They also tend to overestimate threats, perceiving even minor risks as severe and likely. This is closely tied to an inflated sense of responsibility, wherein they believe they hold the power to prevent or cause negative consequences, often well beyond reality’s bounds.
Moreover, there might be a belief in the need for complete control over intrusive thoughts, along with the idea that achieving this control is possible and desirable. People with the problem may engage in elaborate rituals or mental exercises in a bid to neutralise or suppress intrusive thoughts. They might meticulously monitor their thoughts, attempting to filter out any deemed unacceptable or distressing. This vigilant self-monitoring can become mentally exhausting, consuming a significant portion of their daily lives.
Intolerance of uncertainty is another prevalent theme, marked by a compelling urge for certainty and a fear of unpredictable change. Those with OCD struggle with profound discomfort when confronted with ambiguity or unpredictability. They possess a compelling urge for certainty in all aspects of life, particularly regarding their obsessions and compulsions.
Another example is perfectionism, a common cognitive feature in OCD, compels individuals to relentlessly pursue unattainable ideals of flawlessness and obsessively scrutinise their actions, thoughts, and surroundings in search of any potential imperfections. Individuals with OCD might find themselves engaging in repetitive behaviours or rituals, driven by an overwhelming need to ensure that everything is just right.
Step 2: Compulsions to reduce the anxiety or avoid the feared outcome
To establish the OCD cycle of obsessions and compulsions, a crucial second phase comes into play. This step involves the implementation of specific actions aimed at managing the intrusive thought, alleviating distress or anxiety, or preventing the anticipated negative consequences associated with the intrusive thought.
The combination of these actions with the earlier faulty evaluations of thoughts forms the essential duo responsible for elevating an intrusive thought into the realm of an OCD obsession.
The consequences of engaging in these actions are twofold. In the short term, they provide a sense of relief from anxiety and a heightened perception of control. As anxiety recedes, so does the perceived threat, creating a deceptive illusion of control. However, paradoxically, these very actions amplify the significance and frequency of the obsessions. This occurs because by actively addressing the obsessions, individuals inadvertently signal to their brains that these thoughts are important and should be vigilantly monitored. Consequently, the brain responds by presenting these thoughts more frequently, compelling individuals to exert further control over them, thus perpetuating the OCD cycle.
The cognitive element
The cognitive facet of the treatment encompasses self-awareness and the active process of challenging one’s thoughts.
Distinguishing between the obsession and the assessment/evaluation of the obsession
An integral aspect of the treatment process involves fostering awareness of one’s thoughts and obsessions. Frequently, these patterns become so ingrained that individuals primarily notice the compulsions rather than the underlying thoughts.
Furthermore, it’s essential to develop the capacity to differentiate between the obsession itself (e.g., “If things are not in order, something bad will happen”) and the evaluation of this obsession (e.g., “Having this thought is dreadful,” “I must eradicate these thoughts,” “I bear the responsibility for averting these consequences”).
Cognitive restructuring work
Various tools can be tailored to meet the needs of clients, all aimed at challenging the evaluations made by clients about their obsessions. It’s crucial to emphasise that the perpetuation of the cycle hinges not on the obsessions themselves but on the evaluations attached to those obsessions. Consequently, our aim is not to confront the obsessions but rather to address the evaluations intertwined with them.
These tools encompass methods such as scrutinising the available evidence both in favour of and against the appraisal of the obsession. Additionally, employing Socratic questioning techniques can facilitate enlightening dialogues, ultimately leading clients to recognize the fallibility of their perspectives regarding their obsessions. Other tools can be used to challenge thoughts.
However, it’s not just essential to contest flawed appraisals; equally crucial is the task of discovering alternative, more realistic, and helpful evaluations of the intrusive thoughts.
A range of cognitive tools and techniques can be customised to suit the unique requirements and circumstances of each individual.
Exposure and response prevention
In ERP, individuals work with a trained therapist to identify specific triggers or situations that provoke their obsessive thoughts and subsequent compulsive behaviours. These triggers can vary widely among individuals and encompass various thoughts, images, or scenarios.
The core of ERP involves systematic and controlled exposure to these triggers, deliberately designed to induce anxiety or discomfort. However, a critical aspect of ERP is the explicit instruction to refrain from engaging in the usual compulsive behaviours during this exposure. The “response prevention” component of ERP is fundamentally vital as it directly confronts the evaluations made by individuals about their obsessions. For instance, consider someone who holds the belief that “simply having this thought implies a high level of risk” (referred to as an overestimated evaluation of risk). In ERP, they may come to understand that the perceived threat is exaggerated, and the most probable outcome is safety, not the feared negative consequence. This process serves to challenge and reevaluate their appraisal of obsessions, a pivotal step in the treatment of OCD.
Over time, through repeated exposure without the accompanying compulsive responses, individuals often experience a reduction in their anxiety. This process, known as habituation, helps them to get used to the anxiety and to realise that their obsessions are not as threatening as initially believed.
Exposure to feared situations in ERP follows a gradual and systematic approach. It commences with situations that induce a manageable level of anxiety, typically in the low to medium range. This deliberate starting point allows individuals to comfortably confront their fears. As they progressively habituate to these situations and undergo shifts in their beliefs and perceptions, they gradually advance to more complex and challenging scenarios. This gradual progression ensures that individuals can build resilience and confidence in managing their anxieties over time.
As individuals progress in ERP, they learn to apply their newfound skills and perspectives to a broader range of situations, effectively managing their OCD symptoms in various aspects of life. Additionally, ERP typically includes strategies for preventing relapses, equipping individuals with tools to recognize and address potential setbacks, and ensuring that the progress made during therapy endures.
Further reading
Do you offer OCD therapy near me?
Edinburgh Therapy Service offers both in-person OCD counselling in Edinburgh (United Kingdom), and online therapy accessible worldwide. You can find our exact location here. We specialise in therapy for OCD, offering CBT with ERP as the main treatment option.