Obsessive-compulsive disorder (OCD) is most effectively treated with exposure and response prevention (ERP) therapy—a form of cognitive behavioral therapy (CBT) designed specifically to address symptoms of OCD.
When it comes to treating obsessive-compulsive disorder (OCD), not all forms of therapy are equally beneficial. Because OCD is a complex mental health condition, it requires therapy that targets and disrupts the cycle of obsessions and compulsions.
Cognitive behavioral therapy (CBT) is an umbrella term for many types of evidence-based therapies. CBT is based on the idea that our thoughts influence our behaviors as well as how our behaviors influence how we think and feel. By working on one, you work on all of them.
CBT is used to treat various mental health conditions by helping people identify and challenge negative thought patterns and behaviors. Exposure and response prevention (ERP) therapy is a form of CBT, but it’s specifically tailored to address the symptoms and mechanisms of OCD.
While both CBT and ERP share the goal of changing harmful thinking patterns, traditional CBT is not necessarily beneficial for OCD. Certain CBT interventions, such as reframing your thoughts, can reinforce obsessions and compulsions, which is counterproductive when treating OCD.
Here’s how to ensure you’re receiving the best possible treatment for your OCD.
What is cognitive behavioral therapy (CBT) and how does it work?
CBT focuses on the relationship between your thoughts, feelings, and actions. During CBT, you learn skills to identify and change unhelpful thoughts and behaviors—especially when under stress.
CBT focuses on your present experience and is intended to be short-term. During traditional CBT, you examine the core beliefs driving your decisions and learn practical skills to deal with your circumstances more productively.
“The most classic CBT approach is for people to identify what we call cognitive distortions,” says NOCD therapist Taylor Newendorp MA, LCPC. “These are any kind of unhealthy, unproductive, thinking processes they’re engaged in.”
One example of cognitive distortions include all-or-nothing thinking. You may have thoughts like “I have to get this perfectly or else I’m a complete failure.” Another example of a cognitive distortion is fortune telling, which involves predicting a negative outcome. This could involve thoughts like, “Even if I work really hard on this project, no one is going to care.”
The skills you’ll learn in CBT are to recognize how your thinking may create problems, using problem-solving skills to cope with difficult situations, and developing a greater sense of confidence.
“There’s a lot of emphasis on identifying cognitive distortions, recognizing what thoughts are unhelpful and unproductive, and then directly challenging them or reframing them, meaning thinking of another way to think that same thought,” says Newendorp. “Generally, the goal of CBT is helping people learn how to be their own therapists.”
What conditions is CBT used for?
CBT is versatile, which is why it is utilized for a variety of mental health conditions including depression, anxiety disorders (generalized anxiety disorder (GAD), panic disorder, and social anxiety), attention deficit hypersensitivity disorder (ADHD), post-traumatic stress disorder (PTSD), eating disorders (like anorexia and bulimia), phobias, and bipolar disorder.
Some research suggests that CBT can also be effective in addressing physical conditions, such as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and even the emotional and psychological challenges associated with breast cancer.
What makes ERP different from other types of CBT?
Exposure and response prevention (ERP) therapy
OCD requires structured, action-oriented therapy in order to be treated effectively. That’s why ERP is a specialized form of CBT that is aimed specifically at disrupting the cycle of obsessions and compulsions that happen in OCD. ERP has been found to be effective for 80% of OCD patients who use it, and the majority of patients experience results within 12-20 sessions.
In partnership with a trained therapist, you’ll work to confront your obsessions—the intrusive thoughts, images, urges, feelings, and sensations that cause anxiety. Instead of responding with compulsions you’ll sit with the distress that this causes you and allow the anxiety and distress to naturally dissipate. ERP can be challenging because it involves facing your fears and putting yourself in situations you’ve been avoiding.
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All our therapists are licensed and trained in exposure and response prevention therapy (ERP), the gold standard treatment for OCD.
When doing ERP, you first work with your therapist to create an exposure hierarchy, which includes a list of exposures, starting with less anxiety-provoking ones and exposures gradually increasing in difficulty.
As you continue to confront these triggers without performing compulsions, you start to build tolerance to the distressing feelings, helping to weaken the cycle of obsessions and compulsions. Through repeated practice, ERP helps you rewire your brain’s response to fear, gradually reducing the power that the obsessive thoughts have.
For example, if you have contamination OCD, a subtype of OCD which is characterized by obsessive fears of germs, dirt, or contamination, ERP therapy might involve gradually exposing you to situations that trigger these fears. This could start with something relatively distressing, such as thinking or imagining yourself touching a doorknob without washing your hands afterward. Then, you can progressively work up to more challenging scenarios, like touching objects that you believe are highly contaminated.
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Some studies indicate that traditional CBT can be integrated into ERP therapy—leading to significant symptom reduction compared to the standard ERP therapy. However, Newendorp recommends the integration of CBT methods if you have a co-occurring mental health condition.
“Someone could do both CBT and ERP. However, you could take more of a CBT approach with the symptoms of the anxiety disorder. If you are using it to treat OCD, you need to make it very clear that the goal is not to directly challenge your intrusive thoughts, images, or urges. Instead, just sit with it and allow the anxiety around it to fade.”
Why traditional CBT isn’t effective for OCD
One strategy used in CBT is thought reframing, where you aim to reframe a negative thought as a more realistic one. In this exercise you may mentally check for evidence of whether or not your cognitive distortion is true, and by actively challenging the thought, you can prevent it from spiraling and affecting your behavior. The problem here is that for people with OCD, neutralizing thoughts and checking for evidence are actually compulsions. Doing this exercise can actually reinforce the OCD cycle.
“A lot of times with OCD, thought neutralization is a mental compulsion,” says Newendorp. “People can get really stuck in that process, trying to neutralize obsessions with, ‘better, happier’ thoughts. If we’re trying to directly challenge intrusive thoughts in OCD with CBT methods of thought challenging or thought reframing—it becomes a compulsion.”
Returning to the example of contamination OCD, it’s easy to see how the checking for evidence tactic could do more harm than good. “CBT would probably have you look at the likelihood that you’re contaminated,” explains Newndorp. “You might ask yourself, ‘How likely is it that I’m actually contaminated right now?’ We wouldn’t do that with ERP for OCD because we run the risk of the person getting stuck when they get that sense that they’re contaminated. They’re stuck in their head compulsively telling themselves, ‘No, I’m not contaminated.’ That becomes just as disruptive as any other compulsion.”
Take another example, where a person feels it’s unsafe to let anyone into their apartment. Using traditional CBT, the focus would be to examine this belief in order to overcome it. A therapist may ask, “What do you think will happen if you have a guest over?” or, “How likely do you think something bad will happen?” or, “Since nothing bad has happened in the past, do you think it’s reasonable to assume nothing bad will happen in the future?”
These are all reasonable questions, and for someone with a different condition, they may be helpful. However, when it comes to OCD, this treatment can actually encourage compulsions by providing reassurance. Many people with OCD seek reassurance to gain relief from the anxiety of their intrusive thoughts. When reassurance is used as a compulsion, the patient will find temporary relief but will not be working to treat their OCD in the long term.
If you’re slightly confused about the differences between traditional CBT and ERP, don’t worry—it’s a somewhat nuanced distinction. If you have OCD and are looking for the most effective treatment, it’s crucial to find a therapist who specializes in ERP. They’ll know how to guide you through exposure and response prevention exercises so you can interrupt the cycle of OCD instead of unintentionally reinforcing it.
Bottom line
While CBT and ERP share some similar qualities—they are time-bound, action-oriented behavioral therapies—ERP is designed specifically to target and disrupt the OCD cycle. With the guidance of a trained therapist, ERP can lead to significant long-term improvements in managing your symptoms.
Key takeaways
- Cognitive behavioral therapy (CBT) is a treatment approach that is designed to identify and change negative thought patterns and behaviors.
- Exposure and response prevention (ERP) therapy is a specialized form of CBT that involves confronting intrusive thoughts and triggers while resisting the urge to do compulsions to reduce distress.
- Some CBT strategies may be counterproductive for people with OCD—as they can unintentionally reinforce the OCD cycle.