CBT
This page explains what Cognitive Behavioural Therapy (CBT) is and how it is used for OCD.
CBT is often the first psychological treatment offered for OCD, and for many people it ends up being the only one they hear about. When you are feeling overwhelmed by intrusive thoughts, the idea of “therapy” can feel daunting, but it helps to think of CBT as a toolkit designed to help you reclaim your life. At its heart, CBT for OCD is a combination of two different approaches: one that focuses on the mind and the thoughts that cause us pain, and one that focuses on the behaviours that keep the anxiety cycle going.
My goal is to help you navigate this process clearly. CBT is often the first vital step in OCD recovery because it can produce small, manageable reductions in anxiety within just a few weeks. Over a few months, it can significantly lower the distress caused by the specific thoughts you are struggling with right now. To show how CBT works in practice, we will look at both sides of the approach — starting with Cognitive Therapy and then moving onto Behavioural Therapy.
Cognitive Therapy
Cognitive therapy is the part of CBT that works directly with your thoughts, particularly the intrusive thoughts that spark your anxiety. It gives you tools to understand these thoughts more calmly, which can make them feel less urgent and frightening.
The basic model of cognitive therapy is ‘Event – Cognition – Emotion’. This model proposes that events do not cause emotion, instead it’s what the individual thinks about the situation that causes the emotion. Let’s give an example:
The event is you are walking on one side of a street, and on the other side of the street you see your friend. You wave, but your friend seems to ignore you.
The cognition (i.e. your thought) could be that your friend no longer likes you.
The emotion generated could be sadness, as losing a friend can make a person sad.
Cognitive therapy says that the issue in the above scenario is not that your friend ignored you, but your cognition (i.e. your thought) about it. This is because your friend might not have been able to see you from the other side of the street, or that your friend was so engrossed with a problem in his head that he was oblivious to the outside world.
In CBT, these types of thoughts are called negative automatic thoughts, because you are not consciously generating them (they just come automatically), and they are always negative (e.g. ‘my friend no longer likes me’).
So, as its thoughts that cause emotions, if you change what you think, then you will be able to change how you feel.
Cognitive therapy teaches how to change what you think. It does this by asking the patient to do thought challenging. Basically, each time the patient gets an irrational thought, they are meant to find arguments against it (e.g. doctors say I don’t need to wash my hands more than once after going to the toilet). The therapy claims that if the habit of replacing irrational thoughts with rational ones is practiced long enough, then the irrational thoughts will go away, and the patient will no longer be mentally ill.
I argue that ‘Cognitive Therapy’ isn’t particularly useful for OCD thoughts for three reasons
The first reason is that the part of us that produces the OCD thoughts (i.e. the subconscious mind) doesn’t care whether the thought is rational or not, all it cares about is will the thought generate anxiety. Trying to persuade the subconscious mind that it shouldn’t generate the thought is difficult, as the thought is doing what the subconscious wants i.e. generating anxiety
The second reason why cognitive therapy typically doesn’t work is that if you are in fight or flight mode, our rational side (i.e. the conscious mind) basically gets switched off, and so there is no one around to tell the subconscious that the thought is irrational
The third reason why cognitive therapy typically doesn’t work is that even if you manage to stop a particular OCD thought for a significant period — be it one, four, or even more years — another one will eventually replace it. This is because OCD thoughts are a warning that something else needs attention; they won’t properly stop until that underlying issue has been resolved.
The below academic paper supports my opinion that cognitive therapy is not helpful. To read the paper you need to scroll down four or five times when you go on the website, and then you will see it in PDF form, where it says 'ScienceDirect'
To be fair, the paper doesn't concentrate on OCD, but that doesn't matter, as the premise of cognitive therapy is that all mental health issues derive from faulty thinking, so it should work for pretty much everything, but as the paper shows, it doesn't really work.
Now let’s move on to the second part of CBT, called ‘Behavioural Therapy’.
Behavioural Therapy
Behavioural therapy is the part of CBT that focuses on your actions rather than your thoughts. Its aim is to help you change the behaviours that keep the anxiety cycle going, so that over time the anxiety triggered by your intrusive thoughts begins to lose its power.
The most useful technique behaviourism gives us for OCD recovery is ‘Exposure and Response Prevention (ERP)’.
Before I explain how ERP works, I feel it would be useful to remind you about which parts of us are involved in OCD. With OCD, essentially the subconscious mind is tricking the brain to generate anxiety (via an irrational/scarry thought). The aim of ERP is to un-trick the brain.
ERP is a two-part process. The first part involves a person exposing themselves to the feared thing/situation. For example, if you are scared of the dirt on door handles, you have to deliberately touch a door handle. At this point your brain will start generating anxiety, as the subconscious is telling it that the door handle is ‘dangerous’.
The second part involves deliberately not washing your hands. By not washing your hands, the brain gets even more worried, and so generates more anxiety. But, after experiencing this anxiety for a period of time, which could be one minute, or perhaps 15 minutes, the brain will start to learn/realise that the danger is not real, and the anxiety will start to come down. This process is called habituation.
Typically, doing ERP once on the feared thing/situation is not enough to completely stop the anxiety from generating. You normally have to do ERP a number of times for the brain to be fully un-tricked.
You are probably wondering ‘how many times? That’s a hard one to answer, as everyone's situation is different.
Instead of thinking about how many times you need to do ERP for the feared thing/situation, I think it is more useful to measure it in terms of how many weeks/months you have continuously done the ERP. That is, if you have done ERP once a day for a month and your anxiety hasn’t come down at least a bit, then that’s not enough ERP. So, you will need to increase it to twice a day, then three times a day etc.
As a general rule, if your anxiety from the feared thing/situation hasn’t reduced by at least 25% in a six-month period, chances you are not doing enough ERP. At which point, you either need to step up your efforts, or see a therapist, who can make helpful suggestions.
A word of warning. When you do increase the number of times you do ERP, you have got to be careful you don’t increase it by too much. Some people do far too much too soon, at which point they become overwhelmed, and end up stopping ERP completely, and so get worse.
Below are some ways/tips on how to do ERP
1. What helps with ERP is doing it in a in a hierarchical manner. That is, if your OCD fears are about three different things (e.g. contamination, symmetry and checking), you would start with the one that is less troubling. Once you have defeated that one, then you would move onto the next feared thing/situation.
2. For each feared thing/situation, it could helpful to do the ERP in a graded manner. That is, if you are scared to go outside (because of contamination), then you start by going out for only say 5 seconds, then come back in. The next day, you could try staying outside for 10 seconds, and so on. This is a gentler approach.
3. While doing ERP, some people find it helpful to use a distraction. For example, if you’re scared to go outside because of contamination fears but can manage 30 seconds outdoors for ERP, you might think about an upcoming task during that time. The key is that the distraction must not block the initial anxiety that is generated — that would be a bad distraction, because you need to experience that anxiety to recover. The point of the distraction is to stop the extra anxiety that comes from catastrophising about how high the anxiety might get — this is a good distraction, because it allows the initial anxiety but prevents the unnecessary secondary anxiety. This good distraction works for all forms of OCD, but it can be particularly useful for pure O — where the anxiety is triggered internally rather than by a situation. A helpful option in that case is watching a weekly TV programme you enjoy and deliberately allowing any OCD thoughts or anxiety that arise during it. The interesting parts of the programme often make it easier to let the anxiety be there, and knowing you’ll do this at least once a week can be a useful start to the ERP process.
4. For some people writing in a diary/notepad how much of ERP you have done is helpful. That is, let’s say on a particular day you got 10 OCD thoughts, and you managed to do ERP for 4 of them. You would write that down in your notepad, so that the next day/week it may encourage you to increase it 5 lots of ERP a day. An additional benefit of writing down the number of ERP’s you do, is that sometimes you have a bad day where you can’t do any ERP, and so it will appear you are failing. But if you look at your notepad over the past six days, you will see you have done lots, so your one day of ‘failure’ won’t seem so bad.
5. Some people feel more encouraged to do ERP if they watch a YouTube video about it, just before they start doing it. That is, if you plan to do some ERP in the morning, do your morning routines first (have breakfast etc), then just before you start your ERP, watch a video that encourages you to do it. There are lots of ERP videos on YouTube, search for one that works for you.
6. Mindfulness. I will talk about mindfulness in more detail in a later page, but for some people combining ERP and mindfulness helps speed up the recovery process. One of the techniques from mindfulness that helped me massively, is putting my attention on the area of the body that is impacted most by the anxiety. Let me explain.
Each time I got anxious, it would hit me in my chest. So, I would stop what I was doing and place my entire attention on my chest.
In addition to placing attention on my chest, I would resist the urge to stop the anxiety.
Doing the above things has two benefits. The first is that if your attention is on your chest, then you are less likely to think 'what if my anxiety gets worse' (i.e. you are less likely to catastrophise) . And, secondly, if you don't stop the anxiety, your brain will learn that there is no real danger.
If you do the above, over time, which could be as little as a few days, you will find that the feelings will bother you less, and they will move on quicker.
7. For those of you who are able to go outside, doing exercise in the gym or the park can also help you do more ERP. Exercise has a number of benefits, but the main benefit (for ERP) that is it makes you feel better, and if you feel better, you are more likely to tolerate the anxiety that ERP produces.
8. Be wary of therapists that suggest extreme forms of ERP. For example, they may ask a patient who is scared of contamination to lick the bottom of their shoe. Or if the patient is scared they may have run over a person when driving their car (when going over a bump in the road), the therapist may ask the patient to remove their rear-view mirror in the car, so that they can’t check if they have run someone over. I think this is a cruel way to administer ERP, and should be avoided.
9. For some people, when they start doing ERP, they can end up experiencing more anxiety in the first two or three weeks than they did before starting ERP. The reason is that before, when you were stopping the anxiety, the subconscious felt its message was not being heard (by the conscious mind), but when you do ERP, the conscious mind is hearing the message, and so the subconscious thinks ‘I’ve now got the attention of the conscious mind, so I will take advantage of this situation by generating more thoughts than usual’. But this doesn’t happen to all sufferers, so hopefully you get lucky.
10. ERP is rarely a smooth process. Some weeks you will say ‘It is going really well’, and then some weeks the anxiety will be quite high, and you will say ‘I may be failing’. Always look at the big picture, which is that recovery (from the current set of OCD thoughts) takes time, and you will get there in the end.
Above I have given ten ways/tips for doing ERP. However, everyone is different, so if you they don’t work for you, please search for more ways online, until you find what works for you.
At this point you may be thinking 'ERP is too difficult for me to do.' I will mention five things about this.
The first is that you will probably spend the next few years searching for an easier way. On the internet, there are many websites that promise a quick and easy recovery for OCD. There is no quick and easy recovery for OCD; these websites are promoting false hope. However, if you commit to doing ERP, you should start to see real improvements within three months. By starting now, you save yourself those years of searching for an easier way that doesn't exist.
The second is that the longer you delay ERP, the more ingrained your OCD becomes. This means that when you do eventually start ERP, it will be more difficult than if you had started today. By starting now, you are facing the 'easiest' version of your OCD you will ever have.
The third thing is that overall, ERP won't be as bad as you think it is going to be. This is because when you are in anxious state, the mind tends to exaggerate the difficulty of challenges (including ERP). This reminds me of a scene in the Indiana Jones movie where Indiana has to cross from one mountain to another mountain, with a massive gap between them, and there appears to be no bridge to help him cross - you can watch this scene by clicking the below link
https://www.youtube.com/watch?v=q-JIfjNnnMA
When you come to do ERP, you do a feel a little bit like Indiana, in that you are expecting the worst, but it is never as bad as you think, and typically, each time you do it, it gets easier.
The fourth thing is perhaps you are experiencing secondary gain. This is a psychological term that refers to the benefits people receive from not overcoming a problem. For example, lets say that if you recovered from OCD, it may mean you have to return to work. If your job is a particularly stressful one, then you may sabotage your OCD recovery, so that you don't have to go back to work.
The fifth thing is comorbidity, which is where a person has more than one mental illness at the same time. Studies suggest that 60% of people with anxiety disorders (such as OCD) also have depression. You may have depression without knowing it, and one of the things depression does is generate thoughts such as 'I won't be able to recover from OCD, so what's the point in trying'. If you get such thoughts, try your best to ignore them.
So my advice to you is to start doing ERP as soon you can. Read the key parts of this website a number of times, until you have fully absorbed it. Then start doing ERP in a gentle manner.
Behavioural therapy (i.e. ERP) is the best treatment for OCD in the short run. It can massively reduce the amount of anxiety you experience in as little as a few months, if you are willing to put the work in.
However, while this reduces the intensity of your current OCD cycle, it often doesn't stop new thoughts from popping up in the future. This is because the deeper patterns that give rise to the thoughts haven't been resolved yet.
To create lasting, permanent change, you need to address those patterns through a type of therapy called psychoanalysis. Because you need "mental space" to do that deeper work, it is usually best to use behavioural therapy first to bring your anxiety down to a manageable level. Once the immediate symptoms are lower, psychoanalysis becomes the place where you can work toward a permanent fix.
You now have a good knowledge of CBT, and when you are ready, you can start implementing the ‘B’ part of it (i.e. ERP). While it is possible to do it on your own, it is also helpful to see a therapist, for a number of reasons.
Therapists can provide lots of encouragement to do ERP, which some sufferers need. Therapists can also provide clarification on things that the patient is not sure about, and there are many other reasons why seeing a therapist is beneficial.
I acknowledge that it might not be possible to find a therapist quickly. Depending on where you live, waiting times on the NHS range from 3 to 18 months. If you have to wait 18 months its best to start it by yourself, and who knows, by the time your therapist appointment comes, you may not need it!!
If you can afford it, you can also find a private therapist. The best place to start looking for one is on the website of the ‘British Association for Counselling and Psychotherapy’, which is the governing body for counsellors and therapists in this country
https://www.bacp.co.uk/search/Therapists
On the webpage, enter what your problem is (i.e. OCD or anxiety), enter your postcode, and it will come up with a list of therapists that are near you, and what they cost. Typically, each session lasts 50 minutes, and costs range from £45 to £100 per session.
Look for therapists that have many years of experience, as young/new therapists tend to stick to what they learnt in academic textbooks, but this doesn't really work in the real world, because peoples problems are rarely as simple as the situations presented in academic textbooks. Try to find a therapist that is willing to see you face-to-face, as sometimes a patient's body language can tell the therapist a lot more than getting a patient to answer a question. Also, the patient is more likely to trust the therapist if they are in front of them, therefore the patient may open up more about their troubles.
Be aware that a lot of therapists (whether NHS or private) may not be familiar with model I present in this website (i.e. the subconscious mind generates OCD thoughts to alert the conscious mind that there is an underlying issue that needs to be fixed). Lots of therapists are not taught about this in their education, they are instead taught mainly about CBT, which basically rejects the ideas of an underlying issue, and assumes the problem is purely in the mind.
But that doesn’t matter. You know what OCD actually is, and you are just using the therapist to encourage you to do what is needed in the short run (i.e. ERP).
A final thing I wish to mention about CBT is the way it is sold to patients. In particular, most therapists/psychologists say it is the gold standard when it comes to treating mental illness. They base this on the numerous studies that have been done on CBT which apparently show its high effectiveness. But when you look at the details of those studies, you will see that there is a lot of exaggeration or misinterpretation of the data contained within them.
The psychoanalyst ‘Jonathan Shedler’ has written a relatively short paper that explains some of these exaggerations or misinterpretations:
Further, studies show that approximately 80% of individuals with OCD continue to experience persistent symptoms in the long term after undergoing CBT.
One of these the ‘Brown Longitudinal OCD Study (Eisen et al. 2013)’, which tracked 213 patients over a seven-year period.
Another is the ‘Netherlands OCD Association Study (2018-2024)’ which tracked 419 patients over a six-year period.
If you want a more detailed explanation as to why CBT is not the gold standard, then read a book called ‘CBT: The Cognitive Behavioural Tsunami: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science’, by Farhad Dalal.
One of the issues raised in this book which I found alarming, was the fact that if a patient saw a therapist on the NHS for two sessions, and the patient chose not to come back for whatever reason, the treatment was deemed as a ‘success’ by the therapist!
To be fair, both of the people I have mentioned above (Jonathan Shedler and Farhad Dalal) come from a rival school of psychology, so they may have a bit of bias against CBT, but I feel their criticisms of CBT are valid.
The next page is about psychoanalysis, which is the school of psychology that the above two named people come from - click the below button