Psychotherapy for OCD

Adapted from the Obsessive-Compulsive Foundation website

Cognitive behavioral psychotherapy (CBT) is the psychotherapeutic treatment of choice for children, adolescents, and adults with OCD. CBT helps the patient create an internal strategy for resisting OCD that will be of lifelong benefit.

What Is CBT? The “BT” in CBT stands for behavior therapy. Behavior therapy helps people learn to change their thoughts and feelings by first changing their behavior. Behavior therapy for OCD involves exposure and response prevention (E/RP).

  • Exposure is based on the fact that anxiety usually goes down after long enough contact with something feared. Thus people with obsessions about germs are told to stay in contact with “germy” objects (e.g., handling money) until their anxiety is extinguished. The person’s anxiety tends to decrease after repeated exposure until he no longer fears the contact.
  • For exposure to be of the most help, it needs to be combined with response or ritual prevention (RP). In RP, the person’s rituals or avoidance behaviors are blocked or prevented. For example, those with excessive worries about germs must not only stay in contact with “germy things,” but must also refrain from ritualized washing.
  • Exposure is generally more helpful in decreasing anxiety and obsessions, while response prevention is more helpful in decreasing compulsive behaviors. Despite years of struggling with OCD symptoms, many people have surprisingly little difficulty tolerating E/RP once they get started.
  • One key to successful CBT is in starting with symptoms that cause somewhat less anxiety than the most bothersome symptoms. In this way, someone doing CBT can learn the techniques and learn how to reduce his anxiety without starting with the very hardest problems first.
  • Cognitive therapy (CT) is the other component in CBT. CT is often added to E/RP to help reduce the catastrophic thinking and exaggerated sense of responsibility often seen in those with OCD. For example, a teenager with OCD may believe that his failure to remind his mother to wear a seat belt will cause her to die that day in a car accident. CT can help him challenge the faulty assumptions in this obsession. Armed with this proof, he will be better able to engage in E/RP, for example, by not calling her at work to make sure she arrives safely.
  • Other techniques, such as thought stopping and distraction (suppressing or “switching off” OCD symptoms), satiation (prolonged listening to an obsession usually using a closed-loop audiotape), habit reversal (replacing an OCD ritual with a similar but non-OCD behavior), and contingency management (using rewards and costs as incentives for ritual prevention) may sometimes be helpful but are generally less effective than standard CBT.

People react differently to psychotherapy, just as they do to medicine. CBT is relatively free of side effects, but all patients will have some anxiety during treatment. CBT can be individual (you and your doctor), group (with other people), or family. A physician may provide both CBT and medication, or a psychologist or social worker may provide CBT, while a physician man ages your medications. Regardless of their specialties, those treating you should be knowledgeable about the treatment of OCD and willing to cooperate in providing your care.

How To Get The Most Out Of Psychotherapy

  • Keep your appointments.
  • Be honest and open.
  • Do the homework assigned to you as part of your therapy.
  • Give the therapist feedback on how the treatment is working.

How successful is CBT? While as many as 25% of patients refuse CBT, those who complete it report a 50%-80% reduction in OCD symptoms after 12-20 sessions. Just as important, people with OCD who respond to CBT usually stay well, often for years to come. When someone is being treated with medication, using CBT with the medication may help prevent relapse when the medication is stopped.

How long does CBT take to work? When administered on a weekly basis, CBT may take 2 months or more to show its full effects. Intensive CBT, which involves 2-3 hours of therapist-assisted E/RP daily for 3 weeks, is the fastest treatment available for OCD.

What is the best setting for CBT? Most patients do well with gradual weekly CBT, in which they practice in the office with the therapist once a week and then do daily E/RP homework. Homework is necessary because the situations or objects that trigger OCD are unique to the individual’s environment and often cannot be reproduced in the therapist’s office. In intensive CBT, the therapist may come to the patient’s home or workplace to conduct E/RP sessions. On occasion, the therapist may also do this in gradual CBT. In very rare cases, when OCD is particularly severe, CBT is best conducted in a hospital setting.

How can I find a behavior therapist in my area? To locate a therapist skilled in CBT for OCD, you may want to ask your physician or other healthcare provider, an academic psychiatry or psychology department, your local OCD support group, or the Obsessive-Compulsive Foundation (a Treatment Providers List is available upon request), the Anxiety Disorders Association of America, or the Association for the Advancement of Behavioral Therapy.

In some cases, you may find that a local cognitive-behavioral psychotherapist has experience with depression or other anxiety disorders, but not with OCD. However, using one of the excellent treatment manuals now available, it is relatively easy to translate CBT skills from another disorder to OCD. So if there is no one immediately available, look for a skilled psychologist or psychiatrist who is willing to learn. Remember, though, if you are not getting real CBT, which involves exposure and response prevention using a list of OCD symptoms that are ranked from most difficult to easiest to resist, you are probably not getting the treatment you need.

Don’t be afraid to ask for a second opinion where necessary. In rare cases, traveling to a specialized center where intensive CBT is available on an outpatient or inpatient basis may be the most practical solution.