Updated: Jun 29
Treatment for OCD is challenging. Recently, there has been an emphasis on exposure and response prevention (ERP) as the only effective method. While ERP is an important part of treating OCD, there are other tools that should be used as well. In this blog, I am going to explain how ERP is just one of the tools.
Decades of research has shown us that Cognitive Behaviour Therapy (CBT) for OCD works. Edna Foa in the 1960s first did intensive CBT for inpatients with OCD and it proved to be effective. From that time onward, clinicians have learned the importance of implementing CBT treatment for individuals experiencing OCD symptoms. What we know now, is that CBT offers a comprehensive approach that works on both the thoughts and actions of individuals experiencing OCD symptoms.
We know that engaging in compulsions and rituals only provide short term relief.
So, let’s break it down. What are the behavioural components of CBT and what are the cognitive components? This is where ERP comes in. This involves exposing oneself to action/activities/thoughts/events that trigger one's obsessions and intrusive thoughts without engaging in one’s usual rituals and compulsions.We know that engaging in compulsions and rituals only provide short term relief. The prevention of compulsions and rituals allow for long-term recovery and wellness because it stops the ongoing cycle of OCD. In other words, it allows an individual to stop feeding their OCD cycle and stop giving in to the urges.
The cognitive components of the CBT involve cognitive restructuring with tools such as thought records (most commonly used), cumulative probability techniques, responsibility pie and the continuum technique. All these tools enable an individual to learn strategies to shift their negative thinking, restructure their negative appraisal systems and begin to engage in a more balanced thinking approach.
We do not challenge intrusive thoughts in CBT for OCD. Why? Because we all experience intrusive thoughts. Individuals with and without OCD. However, our relationship to our intrusive thoughts can be very different. An individual without OCD will often let their intrusive thoughts come and go. An individual with OCD will often get stuck on their intrusive thoughts and will have thoughts about these thoughts and this will drive their anxiety and distress. Thoughts about thoughts are really one’s appraisals of their thoughts.
These thought appraisals are responsible for making our intrusive thoughts sticky and anxiety-provoking. It is important to target them through cognitive work. This is a major difference when using CBT for OCD compared to CBT for anxiety and depression. This is one of the most common mistakes that clinicians make when delivering CBT for OCD.
When we challenge negative appraisal systems (i.e., our thoughts about our intrusive thoughts/our belief systems) then we start to see significant and important shifts in our belief systems. We know that a combination of ERP and cognitive strategies are extremely effective for individuals experiencing symptoms of OCD.
Clinicians often discuss whether to begin treatment with ERP or cognitive work and this has been a question of great interest to me. ERP is often wonderful to begin with as it enables an individual to jump out of their mind, lean into their anxiety and begin to navigate the world differently. That being said, beginning with cognitive work can also help some individuals who find the ERP work overwhelming.This can help them gain confidence first and then embrace the behavioural work after. My approach always involves a combination of both, tailoring treatment to the individual and the type of OCD that an individual is experiencing.
This is because CBT clinicians should focus on Exposure and Response Prevention and cognitive work while also integrating acceptance and mindfulness components into their approaches for CBT for OCD.
I have often written about the importance of leaning into anxiety and embracing it. I definitely believe this is true. However, this is not only accomplished through the work of ERP. CBT, as a whole, provides individuals with the skills to tolerate uncertainty, embrace new ways of thinking and behaving, accept the unacceptable and move towards our values and what is important to us.
This is because CBT clinicians should focus on Exposure and Response Prevention and cognitive work while also integrating acceptance and mindfulness components into their approaches for CBT for OCD. This allows for clients to engage in attentional shifts, values-based work and accept the uncertainty that life has to offer. All of these skills, in their entirety, offer individuals a comprehensive approach to recovery and wellness.
Individuals also will gain the ability to navigate the world with their intrusive thoughts and have a much different relationship to those thoughts. Although we cannot get rid of intrusive thoughts, we can definitely learn that we can take them along with us for the ride.
I hope if you are reading this as a client, searching for help for your OCD, you will have learned more about the comprehensive nature of CBT and all it should be offering you when you seek it out as the gold standard treatment for your OCD. All of the associates at Forward Thinking Psychological Services are well-versed in such a comprehensive approach and look forward to working with you and moving together on the path to recovery.
Reach out to us at Forward Thinking Psychological Services. We look forward to working with you!
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