Cognitive Behavioral Therapy (CBT) encompasses a range of therapy techniques that are highly beneficial in treating obsessive compulsive disorder (OCD), including exposure and response prevention and cognitive restructuring. Most people who receive CBT treatment for OCD start noticing improvements within weeks.
Treatment of OCD is usually short-term, with lasting therapeutic benefits. CBT generally consists of weekly, one-hour therapy sessions lasting approximately six months, depending on the severity of someone’s OCD symptoms. As with most diagnoses treated through CBT, the client is required to do work outside of the therapy session to get the most benefit.
How Can CBT Help With OCD?
People with obsessive compulsive disorder engage in specific compulsions to experience temporary relief from the obsessive thoughts that are causing them severe distress. Cognitive behavioral therapy works to break the automatic bond between the obsessive thought and the ritualistic compulsive behavior. CBT also trains the individual to avoid ritualizing when they’re feeling anxious.2
Common CBT Techniques for OCD
The following are common techniques used in CBT to help treat patients with OCD. Exercises like deep breathing and progressive muscle relaxation can be done alongside therapy sessions to help improve someone’s anxiety.
Here are four CBT techniques that are commonly used to treat OCD:
1. Exposure & Response Prevention Therapy (ERP)
Perhaps the most helpful CBT tool for treating OCD is exposure and response prevention therapy (ERP). This process involves exposing the patient to the stress-inducing obsessive thought 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.
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 of time
- 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
2. Deep Breathing Exercises
Breathwork exercises are exceptionally helpful for managing anxiety related to OCD, and can be beneficial for use during ERP. There are many different types of deep breathing exercise, but they all serve the purpose of slowing down the breath and heart rate, creating a calming effect.
3. Progressive Muscle Relaxation
Progressive muscle relaxation is a process that allows the person to physically tighten and release tension throughout their body. When we are stressed or anxious, our bodies can enter into the fight-or-flight response, often leading to tension throughout the body. Training the body to disengage from this response is an important component of stress management.
4. Cognitive Restructuring/CBT
Cognitive restructuring involves challenging irrational thoughts or thinking patterns and replacing them with rational thoughts that are based in reality. The aim is to use facts to challenge thoughts based on emotional responses.
Examples of Cognitive Behavioral Therapy for OCD
Obsessive compulsive disorder is characterized by obsessions with or without compulsions. The obsessions and compulsions related to OCD are irrational and highly distressing, having an impact on 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:
1. Fear of Germs & Illness Anxiety
Angie, a 46-year-old stay-at-home mom, worries constantly about falling ill and not being able to care for her children. Her fear drives her to take extreme precautions toward avoiding 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.
2. Constant Checking
Tony recently moved into his first apartment on his own and is starting college. 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 8 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 2 more times to check it. He locks his front door and twists the handle 8 times ensuring that it is locked and won’t open.
The therapist will explore early childhood experiences pertaining to certainty or absolutes, as well as exposure to traumatizing accidents and any blame that was placed on Tony as a child. They will continue to discuss together the likelihood of an appliance being turned on after checking it is off, the reliability of Tony’s memory, and how valid and confident he feels about it.
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.
3. Fear of Harming Others
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. 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.
Is CBT Effective for OCD?
Cognitive Behavioral Therapy has been proven to help thousands of people learn to manage obsessive compulsive disorder. In fact, CBT is one of the only proven methods for effectively treating OCD.4 Research shows that as many as 75% of patients who seek CBT as treatment for OCD find it to be effective in treating the disorder.5
- 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 symptoms as well as 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 (telemedicine) 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
Are There Any Risks?
There are no specific risks of CBT for OCD, with the exception that it may not be effective for everyone who receives CBT as a treatment option.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.
How Long Will CBT Take?
CBT treatment for OCD depends on the individual and the severity of their symptoms and this can impact the duration of treatment. The standard treatment model of CBT for OCD is about 12 weeks with one hour-long session a week. CBT 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
At-Home CBT Exercises for OCD
While it is important to consider having the guidance of a qualified CBT therapist when starting treatment for OCD, there are also some exercises that you can do on your own to help manage symptoms.
Here are a few relaxation exercises that can be easily done 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:
- 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.
- 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?
- What do you taste? Are you eating or drinking something? If so, what does it taste like? Is it sweet or savory?
- 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?
- 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 a 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.
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 CBT therapist is using an online therapist directory, as it allows you to narrow your search by location, type of therapy, and whether or not they offer CBT online. These searches also provide a list of other factors you may want to consider, such as whether they accept insurance or if they are private pay, and if so, their hourly rate.
When searching for a CBT provider, you may want to ask about their CBT training and educational background, as well as how experienced they are with treating OCD.
How Much Does CBT Cost?
CBT can be covered by health insurance in some cases, which would include the diagnosis of OCD. For example, if a parent is diagnosed with OCD, individual/family therapy would be covered as the issues which arise from an OCD diagnosis can lead to a need for therapy for children. While most insurances cover CBT, there is still usually a copay for mental health services, which can range from $10 and upwards of $100 depending on the network. Looking at “in-network” providers might be able to help with the out-of-pocket costs with copays and keep it on the lower end.
Out-of-network providers or those who do not accept insurance may change anywhere from $80 to $200 a session, which is similar to the cost of psychotherapy in general. Some may have a sliding scale option for those client who qualify. It’s important to consider therapists and practices which may offer sliding scale prices for sessions to ensure you are able to attend the full course of treatment.
