Cognitive Behavioural Therapy (CBT)
The treatment found to be the most effective in successfully tackling Obsessive-Compulsive Disorder (OCD) is a special form of talking therapy called Cognitive Behavioural Therapy (CBT). The principal aim of this therapeutic approach is to enable the person to become their own therapist and to provide them with the knowledge and tools to continue working towards complete recovery from OCD.
Research has shown that 75% of people with OCD are significantly helped by Cognitive Behavioural Therapy. Whatsmore, this form of therapy does not have any risks or side effects associated with it, which is why it remains the treatment of choice for tackling OCD by the National Institute for Health and Clinical Excellence (NICE) and specialist centres such as the Centre for Anxiety Disorders and Trauma (CADAT).In many cases, CBT alone is highly effective in treating OCD, but for some people a combination of CBT and medication is also effective. Medication may reduce the anxiety enough for a person to start, and eventually succeed, in therapy.
Cognitive Behaviour Therapy makes use of two evidence-based behaviour techniques, Cognitive Therapy (C) that looks at how we think, and Behaviour Therapy (B) which looks at how this affects what we do. In treatment we consider other ways of thinking (C), and how this would affect the way we behave (B). Exposure and Response Prevention therapy (ERP) is used as part of the behavioural approach to help explore alternative ways to respond to the obsessional thoughts or doubts.
The problem that OCD creates is an increase in anxiety following an intrusive thought, whilst a normal response to an anxiety provoking situation is for the anxiety to slowly decrease after the initial event. For someone with OCD the anxiety is maintained and often increases, usually because of their overestimation of the perceived level of threat. What we also know from research is that almost everyone has intrusive thoughts, that are either nonsensical or alarming. The aim of CBT is not about learning not to have these thoughts in the first place, because in essence, as will be discussed later, intrusive thoughts cannot be avoided. Instead it is about helping a person with OCD to identify and modify their patterns of thought that cause the anxiety, distress and compulsive behaviours.
What therapy will teach the person with OCD is that it’s not the thoughts themselves that are the problem; it’s what the person makes of those thoughts, and how they respond to them, that is the key to recovery from OCD.
CBT is used successfully in many psychological problems, including other anxiety problems such as panic, post-traumatic stress disorder and social phobia. It also figures in treating eating disorders, addictions and psychosis.
The basic principles of CBT are the same across all these different problems, and across all aspects of OCD, regardless of the form the illness takes. A good way of understanding how different responses to thoughts can affect the way we behave can be demonstrated in the example below, which sufferers and non-sufferers alike will be able to relate to.
It’s the middle of the night, you’re in bed. You hear a noise from downstairs.
You might think: ‘It’s the stupid cat again’, feel angry, put your head under the pillow and try to go back to sleep.
You might think: ‘It’s my partner coming in, I haven’t seen them all day!’, feel happy and get out of bed to say 'hello'.
You might think: ‘It’s a burglar’, feel frightened and call the police.What this example shows is that the same event can make people feel completely different emotions (angry, happy, anxious), and result in them behaving in very different ways, due to their different beliefs about the event.
CBT is based on this intuitive understanding of how we all think. So how does this help us understand how to treat OCD?
We believe that OCD works in exactly the same way: A disturbing image crosses your mind: you throwing your dog under a train.
You might think: ‘Damn it, that’s made me forget what I was going to say’ and feel angry, and frown.
You might think: ‘Wow, what a creative and funny person I am! I’m going to write that down’ and feel happy that your mind can be so creative.
You might think: ‘Because I’ve thought that, I must want it to happen, therefore I must be sure I try to undo it’. You then feel anxious, check, seek reassurance and ultimately avoid taking the dog near the train track.In summary, it’s not the thoughts themselves that are the focus of treatment; it’s what we make of those thoughts in the first place.
In treatment for OCD, one of the first things a person will be asked to do is to think of a recent specific example of when the OCD was really severe. They will be asked to go into a lot of detail, and try and understand what thought(s) (or doubts, images or urges) popped into their head at this time.For example some intrusive thoughts might be:
A horrible thought that I may have said something inappropriate.
A thought that there might be blood in my food.
A thought that I am contaminated from the toilet. People with OCD often ask if treatment can help them get rid of these intrusive thoughts, as they are so distressing and horrible. But if you instead consider whether all intrusive thoughts are always horrible you will see that they are not. Usually people can think of an occasion when they suddenly had a thought that was helpful, such as suddenly remembering a friend’s birthday is coming up, or having a memory of a lovely holiday pop into their head. We can conclude from this that getting rid of intrusive thoughts themselves isn’t a realistic, or sometimes, desirable goal. It is also worth remembering that everyone has all sorts of intrusive thoughts – including the nasty ones: thoughts of harm coming to people, images of violence, urges to check things, doubts about whether they have done something. The difference with other people is that their intrusive thoughts do not become bothersome.
Challenging the meaning attached to the thoughts In CBT the person with OCD will explore alternative meanings or beliefs about the intrusive thoughts and rituals in all their guises (for example washing, checking, writing lists, tapping, touching, repeating, cleaning, trying to get a ‘just right’ feeling, praying) and will learn what it is that ultimately keeps alive the meanings they attach to such thoughts and rituals. So during the first few sessions a good therapist should spend time making sense of how the OCD works and what keeps it going. The idea and reason behind this is that if we can understand the factors that keep a problem alive, we can then take the next step, which is to think about alternative ways of viewing the problem and what we can then do to change it. Therefore in CBT we look at how OCD convinces you that the rituals and compulsions performed are necessary, in order to prevent something bad happening. If such a bad outcome were to be true as a result of the thought, the sufferer would be convinced it was entirely their fault and responsibility. We also look at the possibility that OCD is a liar.
All the sufferer's coping strategies have come about in the first place to make them feel safer and less anxious, when in fact they do the exact opposite, they make the person feel unsafe and scared. Even if they provide temporary relief from anxiety, all these rituals make the meaning attached to those intrusive thoughts, images, urges and doubts feel even stronger, therefore it becomes necessary for the sufferer to keep doing the rituals continuously. Ultimately this makes the thoughts seem even more real, and like there is even more truth in them.
The cyclical nature of the problem can be illustrated by drawing a diagram of how it works - we sometimes call it the ‘vicious flower’ – one of Professor Paul Salkovskis’s diagrams shows the general idea. So how do we deal with all these rituals? Here are some common ones, along with an idea of possible ways we might tackle them in CBT: For example, if the OCD problem is checking , the sufferer might be asked to try ‘behavioural experiments’ to find out what happens when they don’t check. A key stage in the evolution of CBT was the development of ‘Exposure and Response Prevention (ERP)’ which involves being exposed to whatever it is that makes a person feel anxious, without checking or carrying out other rituals.
CBT then goes beyond this, by using what we call ‘behavioural experiments’ which find out what happens when a sufferer doesn't check or perform their rituals. Rather than just riding out their anxiety in the feared situation (as in ERP), it goes further by testing out the sufferer's belief that they could ultimately be responsible for harm by not checking or performing their rituals. The therapist will always acknowledge that there is a risk that something bad will happen if the sufferer doesn’t check, but it is the perception of the level of risk that ultimately drives the OCD, by magnifying it to be greater than it actually is. The one guarantee is that with continued checking the OCD will always remain a problem.OCD also often tells people to avoid all sorts of things (for example public toilets, children’s playgrounds, people with diseases etc), but by avoiding such situations the sufferer never has the chance to find out what really would happen.
So in CBT, people are asked to consider doing the opposite to avoiding the situation (for example if OCD has made a person believe that they are at risk of dying from contamination from germs – in treatment the therapist and patient might put their hands down the toilet). This behavioural experiment allows the person to find evidence for themselves about whether OCD has been lying and whether they have been needlessly avoiding situations for no reason at all. Avoiding thoughts is another common example of avoidance – but this is impossible. In fact when we experiment with this idea in treatment, we find out that trying not to think of something makes it worse. Remember the ‘pink fluffy bunny rabbit’ example? When asked to try not to think of pink fluffy bunny rabbits or their fluffy pink faces… you usually can't think of anything else but pink fluffy bunny rabbits with fluffy pink faces! If you have a thought of harming children, OCD will make you believe that you will do it, and it makes sense to then try and banish those horrible thoughts from your mind. But ultimately it is unhelpful to then challenge the thought and look for evidence to prove it untrue.
Instead, in CBT, we might actually bring on those thoughts – perhaps going to a children’s playground and deliberately thinking of harm. Again with the ultimate aim of proving OCD to be a liar.If a person believes that they are responsible for harm, or capable of being a paedophile, or that they can’t be trusted to lock their house, it seems like a good idea to seek reassurance and ask someone close to you to tell you otherwise. Unfortunately this reassurance seeking ends up strengthening the belief that you really are responsible or capable of such things, thus keeping the anxiety high and driving the OCD cycle.
CBT will experiment with this by asking the sufferer not to ask for reassurance, and then seeing what happens to the obsessional belief.OCD tunes a person in to risk. It makes them more likely to spot ‘risky’ situations – and to notice those intrusive thoughts. This makes it seem as if the world really is a dangerous place, and increases anxiety. CBT will consider the possibility that there is a risk attached to most things, but experiment with whether being on ‘full alert’ the whole time makes the OCD belief weaker or ber.On ‘Who wants to be a Millionaire’, when Chris Tarrant says ‘Are you sure? Is that your final answer?’ – does that make the contestant feel less anxious? Or does that questioning make them feel less sure, and more anxious? In fact for these contestants, their sense of belief in having the right answer suddenly disappears when they start asking themselves, “is that definitely correct?” Whereas before Chris Tarrant asked them if they were sure, they may well have been 90-100% certain of their answer, this level of belief drops to 75% the moment Chris Tarrant asked them if they are sure they are right. The more they question themselves, the less certain they are.
OCD often makes people mentally check or argue with themselves, and the person with OCD will be asked to try not to engage in these arguments, and see what happens.These types of behavioural approaches deliberately create anxiety, but at a level the person with OCD is ready to tolerate, often in a very structured and hierarchical step-by-step approach, starting with small exposure exercises, building up to much more difficult ones. So one of the first steps the person with OCD may be asked to do in therapy – and in fact one which they could start before therapy begins – is to describe the obsessions and compulsions and rank them with the most severe ones at the top, and the least severe at the bottom. This is called the graded hierarchical approach. There is another treatment approach, once commonly used but less so now, where a person would be exposed to their worst fears very early on, an approach called ‘flooding’. Flooding is the treatment approach that that involves immersing the person with OCD in the situation they fear the most and staying in the situation until the anxiety becomes less bothersome.
Perhaps a good way to understand these two approaches is an analogy that involves a swimming pool. Have you ever jumped straight into the deep end and had the shock of the cold water take you by surprise? Every inch of your body is momentarily shocked by the cold and your body is shaking and struggling to stay afloat whilst it tries to acclimatise to the water? Flooding is very much like that. It involves jumping in at the deep end of the swimming pool, and staying there until your anxiety, or in this case your body, gets used to the water temperature. Using the same analogy, graded step-by-step exposure would involve slowly walking into the swimming pool from the shallow end, slowly placing that first toe, and then the foot, into the water, and one step at a time placing the next foot up to your ankle, then your knees, slowly getting used to and acclimatising to the temperature before taking another step.
Slowly getting, deeper and deeper but at a much more tolerable pace, which does not leave your body shaken in the same manner jumping in at the deep end would.Although flooding can work if it can be tolerated by the sufferer, and although it is the quickest way to tackling OCD, for most people the graded step-by-step approach is much more tolerable and effective. But equally, it is important to remember that before you attempt to swim, you must first learn the cognitive theory, otherwise you will just sink. So in treatment, both the Cognitive and Behavioural aspects are equally important. Being asked to face your fears is perhaps one of the bravest aspects of treatment, and this is where the approach of the therapist will be most valuable in helping a person understand the cognitive reasons behind the exercise, and being there to help encourage and motivate them to be able to face the challenges it involves. Effective CBT leads to ‘habituation’ where the person with OCD will learn that nothing bad happens when they stop performing their compulsive rituals.
Will CBT be able to help your form of OCD, without obvious physical compulsions? Perhaps you don’t check, or wash, or count, or do any of the things that people readily think of as part of OCD. But remember, OCD is a chameleon – it appears in many forms in different people. One of the great things about CBT is that however the problem manifests itself, now or in the future, the same tools are useful in getting rid of it. One important factor in the effectiveness of CBT is the ability of the treatment provider. In some cases, a course of CBT will not always be effective the first or even second time and if this happens you should consider seeking a referral to an OCD specialist, or similar.
CBT should perhaps be considered like learning to drive, not everyone passes their test first time and sometimes a person may need several courses of lessons with different instructors (therapists) who will teach them the same basics of pressing the pedals (CBT) but in slightly different ways. Although many people do make successful long term progress in treating their OCD, sometimes setbacks do happen. So should someone ever experience a setback after successful tackling their OCD, NICE recommend that healthcare professionals see you as soon as possible rather than putting you back onto a lengthy routine waiting list.
Remember, OCD is ‘Just a Thought’ and what CBT will teach people is that it’s not the thoughts themselves that are the problem; it’s what people make of those thoughts and how they respond to them that is the key to recovery from OCD.