CBT is the most researched psychological treatment for Obsessive Compulsive Disorder and the only talking therapy that is recommended by the National Institute for Health and Clinical Excellence (NICE).There are three important things to realise about CBT:
- CBT does not focus on where obsessive thoughts and urges come from, everybody has them, but how a person reacts to those thoughts and how much importance they attach to them.
- CBT is based on the idea that what a person feels about something is influenced by the way that they think and behave and that a person can learn a different way to think and behave in certain situations.
- Like any learning process it takes time, commitment, patience, motivation and above all practice to work.
Cognitive therapists suggest that OCD results when an individual misinterprets intrusive thoughts or urges as a sign that not only will harm occur, but that they may be responsible for it through what they do or what they fail to do. CBT seeks to help the individual understand that their problem is one of anxiety rather than danger and to react accordingly. It will also try to help a person overcome the need for certainty and to alter the criteria they may use to terminate a compulsion (e.g. when “I feel comfortable” or “just right”).
Individuals with OCD are therefore trying too hard to prevent harm. Their solutions become part of the problem. For example, a mother may try to suppress or neutralise intrusive thoughts about stabbing her baby. This increases the frequency of those intrusive thoughts.
The problem is not the intrusive thoughts but the meaning an individual with OCD attaches to them. For example, “having such thoughts means I might act upon them” or “I shouldn’t be having such thoughts”. This increases the degree of threat and responsibility felt, and will lead the person to avoid having knives around their kitchen or being alone with their baby. This will further maintain their fears and prevent the person from demonstrating that their fears are just ‘thoughts’.
When a person is receiving CBT, the most important ingredient is the homework that must be done between the sessions. I can only act as a guide or teacher and the more clients practice on their own, the sooner they will get better. When patients have completed a successful course of treatment for OCD, most experts recommend follow-up visits for at least six months to a year.
Exposure and Response Prevention (ERP)
ERP is used as part of CBT. It involves repeatedly confronting feared situations that are usually avoided (a process called ‘exposure’). For the treatment to be successful, the exposure needs to be long enough and over a prolonged period of time for the anxiety to subside. The fear needs to be constant and the exposure should be repeated often so the individual becomes desensitized and acclimatized to the anxiety and stimuli. Exposure needs to be done without performing a compulsion (a process called ‘response prevention’) and in this way allow the person to tolerate the discomfort that occurs. If a compulsion is performed, then the exposure should be repeated in order to ‘undo’ the compulsion until the individual has become acclimatised to the fear and able to tolerate it.
In using CBT with ERP an individual evaluates anxiety and creates a personal hierarchy. This means that each person starts by confronting relatively easy situations and then gradually works up to more difficult ones. Facing up to each fear becomes easier and easier and the anxiety gradually subsides. The short-term side effects consist of anxiety and distress, but these will gradually decrease and, in the long term, the fear will subside. No one is forced to confront their fears but the person with OCD is encouraged to take responsibility for devising their own programme.