Cognitive behavioural therapy for OCD

Cognitive behavioural therapy

Cognitive behavioural therapy, or CBT, is one of the most widely used forms of therapy. It is used for a wide range of mental health problems, including OCD, because its effectiveness is well documented. The therapy is based on how people think and act.

Countless thoughts arise over the course of a day. Many are strange, fleeting or of little significance. No one can control all their thoughts, and most people let them pass without giving them much consideration. With OCD, however, a person may become highly attentive to thoughts on certain themes and attach a meaning to them that makes them difficult to let pass.

When thoughts feel significant and cause intense distress, this often creates an urge to find certainty or gain control. The person may respond with overt or mental actions that briefly ease the distress. But the relief does not last, and the next time the thought arises, the urge for control returns. As long as this response remains the answer, the person does not discover what happens if the thought is left unanswered.

This is one of the patterns addressed in CBT. Some of the most common methods are described below.

Automatic thoughts and psychoeducation

Therapy begins with a conversation in which the therapist gains an understanding of the client’s difficulties, and the client and therapist agree on the next steps. During therapy, the client and therapist explore the meaning the thoughts take on and how these appraisals affect the client’s feelings and actions.

With OCD, a person may overestimate risk and responsibility, or the significance of certain thoughts. Many people with OCD believe, for example, that they bear far greater responsibility for events than other people do. This might involve a fear of unknowingly having run over three people on the way to therapy and a belief that the risk of this having happened is much greater for them than for other people.

The appraisals that arise immediately in a situation are called automatic thoughts. They may be underpinned by more fundamental assumptions or rules for living, such as the belief that the person has a special responsibility to prevent others from being harmed. These are important to discuss because they may help maintain OCD.

As part of psychoeducation, the therapist may explain the anxiety system or work with the client to examine the actual probability of having run over three people during a 17-minute drive. Psychoeducation gives the client knowledge about the psychological processes and OCD patterns that are relevant to treatment.

Exposure and response prevention

In addition to discussing the client’s automatic thoughts, therapy involves working directly with aspects of the client’s life that provoke anxiety. Exposure and response prevention is one of the most widely used methods, quite simply because it is highly effective in treating OCD.

Exposure involves deliberately approaching thoughts, situations or actions that provoke anxiety, doubt or distress. Response prevention involves practising not responding to the experience with the usual compulsion or mental strategy. The client and therapist agree that the client will do something that would normally provoke anxiety or distress while refraining from the countermeasures that help keep the OCD going.

This might involve touching a door handle without washing your hands afterwards or leaving a lamp switched on while taking a short walk. The client and therapist also agree exactly what the response prevention involves and how the exercise will be carried out. The exercises train the person to manage anxiety and distress without the usual OCD response.

For someone with OCD, this part of therapy may feel frightening before they have tried it. Many fear that their anxiety will rise to an unbearable level. Exposure does not, however, mean beginning with what feels most frightening. The exercises are planned with the therapist and described on a scale from 0 to 10, where 0 is no anxiety and 10 is the worst anxiety imaginable.

At OCD Klinikken, we generally plan exercises at around level 3–4. At this level, the exercise is challenging, but the client can still maintain perspective, apply their knowledge of OCD and follow through with the agreed response prevention. This provides a safe and predictable framework for the work.

Level 3–4 is a working range, not a cut-off point for whether exposure can be effective. At higher levels of intensity, however, it becomes more difficult to apply knowledge about OCD, remain in the situation and refrain from the compulsion. The exercises are therefore planned so that the client can complete the agreed practice.

Many clients expect the intensity to reach 8–9 but discover that in practice it is around 3–4. They are often surprised by how much they are actually capable of. If an exercise is too difficult, the client and therapist agree on a smaller step.

The exercise is then usually repeated at home between sessions, typically four to five times a week. Through repetition, the client learns that anxiety, doubt or distress can be present without the usual OCD response being necessary. What was previously at level 5–6 or higher will often gradually feel more like level 3–4. The next step can then be introduced.

This process is often described as extinction: the old alarm response gradually loses its strength while the client learns a new way of acting. Anxiety often decreases during an exercise or from one exercise to the next, but it does not have to disappear during every exercise. What matters is that the client remains in the situation and follows the agreed course of action.

Alongside this work, the therapist may address how the client responds to physical symptoms of anxiety in everyday life. A breathing exercise can be used as a general regulation tool, but not as a way of making the distress disappear during the exposure itself.

Responses at different intensities

Anxiety and distress do not present in the same way for everyone. Some people notice the thoughts most, while others notice the feelings, the physical sensations or the urge to act.

Medication in combination with CBT

Medication, most often an SSRI, may form part of OCD treatment. Some people are treated with CBT, including exposure and response prevention, others with medication, and for severe OCD a combination may be appropriate. The choice depends, among other things, on the severity of the person’s difficulties, previous treatment, the person’s wishes and a medical assessment.

Medication can reduce symptoms and, for some people, provide more capacity to take part in therapy. It does not in itself teach the person the skills practised in CBT, but its symptom-reducing effect does not prevent the client from learning to manage OCD in therapy. When the two forms of treatment are combined, they can therefore support one another.