What Is Cognitive Behavioural Therapy (CBT)?
CBT is a type of talking therapy that aims to help a person learn to change the way they think and act. CBT is the most researched psychological treatment for Obsessive Compulsive and related disorders such as BDD or health anxiety 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 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. The therapist can only act as a guide or teacher and the more patients 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.
Different therapists may place a different emphasis on either the “cognitive” or the “behavioural” aspects of OCD. A more “cognitive” approach will focus on the meaning that you attach to your obsessions (for example “Because I have thoughts about being a paedophile it must mean that I could act upon them and I am bad for having them”). You will work with your therapist to look for an alternative understanding of the intrusive thoughts and a different way of responding to them.
A more “behavioural” approach might emphasise education about anxiety, how anxiety is experienced in the body, how facing up to your fears may initially increase but then become easier each time you repeat the activities that you are avoiding.
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.
It is very important to make sure that the therapy you receive is carried out according to best practice. The following are features of quality CBT:
- Session length: Sessions should last at least 45 minutes on average with an agenda that is agreed at the start of each session. Some sessions may be longer especially if confronting feared situations.
- Who can attend? Depending on your age and circumstances, with your agreement some sessions might involve your parents or other family members. Sometimes sessions may involve a spouse or other household member. This can be essential to help family members understand the nature of OCD for example how they can best help you by not accommodating your rituals and giving you reassurance.
- Content of sessions: The content should stay focused on the OCD problem for most of the time in most of the sessions (although sometimes other issues may be dealt with later in therapy).
- Setting of goals: The therapist should help you develop and work towards an agreed set of goals for and after treatment. These should be specific and achievable and described in terms of what you will do (e.g. to hold my baby; to sit on a public toilet seat).
- An explanation of how your OCD works: You should be provided with a clear rationale and explanation of how your OCD works, what keeps it going and therefore what you need to do to overcome it. This is usually called “a formulation” and might consist of a diagram.
- Therapist aided exposure: The therapist should do at least some exposure or behavioural experiments with you in the sessions to test out your predictions and allow yourself to experience anxiety. Ideally this should occur at least once in your home or where the OCD is worst. Alternatively the therapist might demonstrate the exposure task first in front of you. You should feel involved in this process, and not just be told to do it.
- Negotiated homework: The therapist should negotiate relevant homework tasks to do between the sessions. This is also likely to consist of exposure tasks or behavioural experiments to test out your predictions and should be relevant towards achieving your goals. The outcome of these tasks should be recorded and reviewed when you next meet.
- Encouraged to do exposure: You should be consistently encouraged or requested to perform activities that involve exposing yourself to activities, situations or thoughts that you avoid. Difficulties should be discussed and an agreed plan of action is made co-operatively.
- Encouraged to resist your rituals: You should be consistently encouraged and supported to resist rituals (for example the urge to seek reassurance or to “check” or “put things right”).
- Keep a record of outcome: The therapist should have some record of outcome (for example by a questionnaire or rating scale) that is specific for your OCD.
- Relationship with your therapist: There should be a good enough relationship with your therapist who you can trust and can support you. You should feel your views are sought and you are involved in the process. The therapist should generally have high expectations about your ability to change. The therapist is always encouraging and positive about your ability to make improvements, seeing problems as a way of learning better ways of dealing with the OCD.
Good CBT may also involve;
- Listening to recordings of sessions or keeping written summaries of sessions and your homework.
- Being recommended or given appropriate reading material.
- Being asked by your therapist to summarise what you have learned.
In CBT you would NOT expect to;
- Spend most of the sessions talking about your childhood.
- Spend most of the sessions with your therapist silent.
- Be encouraged to challenge your thoughts or keep thought records.
- Be seeking reassurance about your worries or be provided with reassurance by your therapist.
- Be encouraged to try and control, stop or block your intrusive thoughts, images or urges.
- Be given a mantra or phrase to repeat to yourself or reassure yourself when anxious.
- Feel that you are being given tasks that you don’t understand the rationale for.
If you have any concerns about the CBT that you are receiving it is important that you address this with your therapist. You can contact OCD Action if you would like to talk about how best to do this.
Sticking with it
CBT is challenging and at times it may feel like there is a lot of pain for little gain. CBT is a learning process and it takes time, patience and practice but remember, it is proven to be successful for many people and sticking with it can mean a real difference to your life.