CBT for OCD: How It Works, Examples & Effectiveness

How Does CBT for OCD Work?

People with obsessive-compulsive disorder (OCD) engage in specific compulsions to experience temporary relief from the obsessive thoughts that cause them severe distress. CBT for OCD works to break the automatic bond between obsessive thought and ritualistic compulsive behavior. CBT also trains the person to avoid ritualizing when they’re feeling anxious.²

Cognitive behavioral therapy (CBT) focuses on the interconnected nature of thoughts, feelings, and behaviors. CBT suggests that problems in one area (your thoughts, feelings, or behaviors) can be fixed by making changes in other areas. By changing thought patterns and behavioral habits, CBT can improve negative feelings.

Are There Any Risks?

There are no specific risks of CBT for OCD, with the exception that it may not be effective for everyone.¹⁰ CBT, when compared with no treatment, does effectively decrease the severity of OCD symptoms. In addition, CBT also improved the overall level of functioning and reduced the risk associated with OCD.¹⁰

How Long Will CBT Take?

The standard treatment model of CBT for OCD is about 12 weeks with one hour-long session per week. However, CBT’s effectiveness can take time depending on other mental health issues the individual is dealing with or other traumatic histories. The key to success in therapy is trust between the therapist and the client and willingness to follow through on homework and directives.¹¹

10 CBT Techniques for OCD

The CBT techniques used to treat OCD include a variety of therapeutic modalities and subtypes of CBT, along with relaxation exercises like deep breathing and progressive muscle relaxation. We’ve included a CBT worksheet to help you learn cognitive restructuring for OCD.

Here are 10 CBT techniques commonly used to treat OCD:

1.Cognitive Restructuring

Cognitive restructuring involves challenging irrational thoughts or thinking patterns and replacing them with rational thoughts. The aim is to use facts to challenge thoughts based on emotional responses. Try using the worksheet below to reframe your thoughts.

2. Exposure & Response Prevention Therapy (ERP)

Perhaps the most helpful CBT tool for treating OCD is exposure and response prevention therapy (ERP). The ERP for OCD process involves exposing the patient to stress-inducing obsessive thoughts without allowing them to engage in the compulsive behavior. Doing so prevents them from experiencing the temporary relief associated with the compulsion and forces them to face their anxiety until the anxiety fades and they become desensitized to it. ERP is the most common treatment for OCD.

Components of ERP include:²

• In vivo exposure: “Real-life exposure” in which someone is repeatedly placed in the presence of a feared stimulus over a prolonged period
• Imaginal exposure: The mental visualization of a feared stimulus and the consequences of being exposed to the stimulus
• Ritual or response prevention: Refraining from the ritualistic behavior after having been exposed to the feared stimulus

3. Inference-Based CBT

Inference-based CBT (I-CBT) is a treatment specially designed for OCD.12 Through I-CBT, the person with OCD learns the connection between obsessive doubts and the creation of faulty reasonings. I-CBT assumes that people with OCD confuse reality with imagination when they are distressed. Through therapy, they learn to practice alternative narratives that are grounded in common sense rather than obsessional doubts.

It is important to point out that I-CBT does not challenge the content of obsessional doubts. Instead, it challenges the doubting process. I-CBT assumes that it is the faulty reasoning or doubting process that keeps OCD symptoms around. Without the doubting process, the idea is that OCD symptoms will subside.

4. Deep Breathing Exercises

Breathwork exercises are exceptionally helpful for managing anxiety related to OCD. Although there are many different types of deep breathing exercises, they all work by slowing down the breath and heart rate, creating a calming effect.

5. Progressive Muscle Relaxation

Progressive muscle relaxation is a process that allows the person to tighten and release tension throughout their body physically. When we are stressed or anxious, our bodies can enter into the fight-or-flight response, often leading to tension. Training the body to disengage from this response is an essential component of stress management.

6. ABC Analysis

The ABC method of CBT is similar to cognitive restructuring and can help people challenge irrational thoughts and develop more rational thinking styles. ABC Analysis helps people break down a problem into smaller parts called antecedents (A), behaviors (B), and consequences (C). Through analyzing these parts, people can examine how their beliefs (B) affect their reactions (C) to the trigger (A). Through repetition, people can understand how to challenge and examine their irrational beliefs to produce better consequences.

7. Journaling

Traditional methods of journaling for CBT use a thought diary, which helps people mindfully track and process emotional experiences. Thought diaries typically break down emotional experiences into triggers, thoughts, emotions, physical sensations, and behaviors. Journaling  encourages the person to slow down the space between intrusive thoughts and compulsive behaviors. Through journaling, people with OCD can approach each thought with objectivity and openness. You can use a traditional notebook and pen or try a CBT app like Clarity for thought journaling.

8. Mindfulness

Mindfulness encourages people to nonjudgmentally live in the present moment. Mindfulness is helpful for treating OCD because it helps people understand the difference between the content of the intrusive thought and the meaning attached to the thought. Once someone is able to separate the meaning attached to the thought from the intrusive thought itself, they can gain insight into stopping the compulsive cycle of OCD.

9. Activity Scheduling

The basic premise of activity scheduling is that pleasurable activities contribute to an elevated mood. People with OCD are prone to feelings of anxiety and depression, which may lead to isolation. Activity scheduling  encourages the person with OCD to re-engage with hobbies, supportive people, and forms of movement. Regularly participating in these activities may also help discourage agoraphobia, another condition associated with OCD.

10. Worst & Best Case Scenario

Exploring scenarios gently exposes the person to their feared outcome, while also making room for other possible outcomes. Exploring the worst scenario is important for OCD because it exposes the person to the distress of their intrusive thoughts, which over time decreases anxiety around intrusive thoughts. When exploring the best case scenario, the person learns that their intrusive thoughts will always pull them toward negative and unlikely scenarios.

Examples of Cognitive Behavioral Therapy for OCD

Obsessions with or without compulsions characterize obsessive-compulsive disorder. The obsessions and compulsions related to OCD are irrational and highly distressing, and significantly impact a person’s quality of life.³

Here are a few examples of the way OCD manifests differently and the treatment plan for OCD using CBT in each situation:

CBT for Fear of Germs & Illness Anxiety

Angie, a 46-year-old stay-at-home mom, constantly worries about falling ill and being unable to care for her children. Her fear is likely contamination OCD, and it drives her to take extreme precautions to avoid exposing herself to germs. She spends hours every day disinfecting her home while her children are at school. Any time she comes into contact with surfaces she believes are unclean, she feels compelled to immediately shower or wash her hands. Because of her excessive hand-washing, she has extremely dry, red, chapped, and cracked skin on her hands and arms.

The therapist will explore early experiences related to illness, cleanliness, and availability and health of caregivers when Angie was ill. They will determine when these obsessive thoughts began and what was happening at that time, discussing Angie’s perceived benefits of these obsessive thoughts and what she gets out of them.

Then, the therapist will use exposure to a used utensil or item and identify Angie’s intrusive thoughts. They will work to challenge these thoughts, using concrete reasons to understand how her behavior is detrimental (i.e., losing hours in a day, dry and damaged hands). Angie will work to understand these real consequences versus the perceived benefits of her compulsions, using these new thought patterns to guide behaviors moving forward.

CBT for Constant Checking

Tony recently moved into his first apartment on his own, is starting college, and lives with checking OCD behaviors. Before he leaves his apartment, he checks the stove to make sure it is turned off. He then walks to the bathroom and checks that the water is not running in the sink. He turns the water on and off making sure the handle is turned all the way to the off position. He does this eight times. He then returns to check the stove again, ensuring that it is turned off. He goes out his front door and locks it. He immediately worries that the stove is on and returns two more times to check it. He locks his front door and twists the handle eight times ensuring that it is locked and won’t open.

The therapist will role play Tony’s routine of leaving his apartment and challenge him to not recheck something, helping to identify intrusive thoughts. The therapist will explore with Tony why he questions himself and dissect these thoughts to reprogram them so he can challenge them as they arise. Tony and his therapist will work through what is found when uncovering the underlying issues related to these obsessive thoughts and coping methods to move forward without obsession.

CBT for Harm OCD

Sam is a freshman in high school. She fears that if she touches a person first that they will somehow come to serious harm. Because of this fear, she avoids social interactions and physical touch. If she accidentally touches someone she believes that the only way to prevent them from being hurt is to hurt herself. She carries a razor blade with her at all times and makes small cuts to her arms and legs whenever she is unsuccessful in avoiding contact.

The therapist will explore where these fears come from, when they started, and what occurred in her childhood that could be a contributing factor to her harm OCD. They will also discuss when this started and a history of her physical encounters beforehand to get an understanding of any history of trauma.

The therapist will discuss the likelihood of an accidental bump causing harm to another and Sam’s current perceived benefits of self-harm. The therapist will role play with Sam in sessions to identify intrusive thoughts and potentially uncover any underlying depression, anxiety, post-traumatic stress disorder (PTSD), or another mental health issue that may be a contributing factor, as well as an assessment of her home situation. Sam will work to challenge these behaviors and keep a log of when these thoughts begin, where she is, and what her response is, and she will continue to keep a thoughts journal that she brings to therapy to work through.

The therapist may also work with Sam to come up with a hierarchy of anxieties and gradually work their way through them through exposure. Doing graduated exposure can help Sam learn that she can tolerate not knowing what will happen as well as the discomfort associated with the thoughts, without performing compulsions such as cutting herself.

Is Cognitive Behavioral Therapy for OCD Effective?

Cognitive behavioral therapy has been proven to help thousands of people learn to manage obsessive compulsive disorder. In fact, ERP (a subset of CBT) is one of the only proven methods for effectively treating OCD.⁴ Research shows that as many as 75% of patients who seek ERP as treatment for OCD find it to be effective in treating the disorder.⁵

Here are some statistics regarding the effectiveness of CBT for OCD:

• In a randomized control trial comparing CBT and EMDR, it was found that both were statistically significant in improving OCD symptoms post-study and at a follow up six-month mark.⁶
• In a study aimed at adults aged 18 years or older with OCD living in England, it was found that a 12-week course of group CBT led to improvements in OCD and co-occurring depression.⁷
• In another study aimed at the use of CBT after deep brain stimulation (DBS) for those with severe OCD, CBT was found to be effective in conjunction with DBS for severe OCD symptom management and treatment.⁸
• In another study of CBT for OCD, it was found that even virtual CBT interventions over a 10 week period yielded improvements of both depression symptoms and quality of life, as well as decrease of overall OCD symptoms.⁹

How to Get the Most Out of CBT for OCD

CBT is a great option for OCD treatment, but not everyone will experience the same benefits.

Here are several tips to maximize the impacts of CBT for OCD:

• Acknowledge the impacts of OCD: Some people struggle to acknowledge the negative aspects of OCD. Be sure to review the harmful and damaging effects of OCD on your life and others.
• Explore a range of treatment levels: Standard outpatient treatment may not offer enough assistance, so intensive outpatient, partial hospitalization, or inpatient setting could be a better fit.
• Explore a range of treatment modalities: Similarly, individual therapy may be helpful, but perhaps family or group sessions offer greater benefit.
• Do your homework: Often, CBT for OCD uses homework to extend treatment between appointments. Being engaged in sessions and completing this homework will help accomplish treatment goals even faster.
• Trust your team: CBT for OCD may seem uncomfortable or too challenging, so having trust in your treatment team is essential. Without trust, it could be too scary to attempt the interventions.

How to Find a CBT Therapist

Many therapists are certified to practice cognitive behavioral therapy, so it shouldn’t be too difficult to find one in your area. An easy way to find a therapist is by using an local therapist directory, as it allows you to narrow your search by location, type of therapy, and whether or not they offer CBT online.

Finding Online CBT for OCD

CBT is one of the most widely-available treatments in-person and online. Trying online CBT can provide a person with great benefits from the comfort of their home. If you don’t have mental health insurance coverage, or simply want to try online CBT, online-therapy.com is an affordable option.

At-Home CBT Exercises for OCD

While it is important to have the guidance of a qualified CBT therapist when starting treatment for OCD, you can also practice CBT for OCD at home on your own to help manage symptoms.

Here are some CBT exercises you can do at home to help with OCD symptoms:

Deep Breathing Exercise

There are an abundance of simple deep breathing exercises that can be performed at home.

Here’s a deep breathing exercise you can try when you’re feeling anxious:

• Breathe in through your nose for 5 seconds
• Hold your breath in your lungs for 5 seconds
• Breathe out through your mouth for 5 seconds
• Repeat

Grounding Exercise

While a grounding exercise can be done to stay focused on the present by seeking out sensory inputs in your current environment, this imagery-guided grounding exercise can also be used as a way to calm anxiety:

To begin, think of a place you find comforting: Somewhere in your house, a favorite spot in the park, a beach, or a memory from your childhood. Now spend 5-10 minutes visualizing this place that you have conjured in your mind.

Use your five senses to help you:

1. What do you see? Look around and take in your surroundings in this space. What can you see in the distance? What do you see close to you? Try to notice small details that you might normally miss.
2. What do you hear? Listen closely to the noises around you. Are the noises you hear soft or loud? Do they sound close by or far away?
3. What do you taste? Are you eating or drinking something? If so, what does it taste like? Is it sweet or savory?
4. What can you feel? Is it warm or cool? Is there a breeze? Is the sun shining on you warming your skin? Or are you bundled up in a soft blanket?
5. What can you smell? What does the air smell like here? Is the scent strong or faint? Do you smell any flowers, or a scent wafting from your beverage?

Use this exercise to relax your mind when you are feeling anxious or stressed. Spend as long as you need visualizing your comfortable space. Allow yourself to feel calm and safe.

Exposure Therapy

While intensive exposure therapy for OCD should be done with a trained professional, you can practice exposure at home under the right conditions. To do so, simply deny acting on your compulsive behavior that provides you temporary relief from the anxiety felt in relation to obsessive thoughts.

The longer you are able to deny the compulsion, the more likely it is that the anxiety will begin to ebb. Continue doing so until the anxiety is gone. Repeat this practice each time you feel the need to engage in compulsive behavior. You can combine this practice with a deep-breathing or grounding exercise to lessen the anxiety you might feel when denying the compulsion.

CBT Apps

Many therapy apps incorporate CBT techniques to help people cope with OCD symptoms. Sanvello, Happify or Wysa can help you practice CBT techniques between therapy sessions.