Cognitive Therapy for OCD by Brad Riemann, PhD
BRIEF DESCRIPTION:
Cognitive therapy (CT), also known as cognitive restructuring or thought challenging, focuses on identifying and challenging distorted or irrational thoughts and beliefs that lead to negative emotions and unhelpful behaviors (Beck, 1976).
In the context of OCD, CT aims to address the “cognitive distortions” that contribute to the maintenance of obsessions and compulsions, including an exaggerated sense of responsibility, unrealistic belief in the importance of thoughts, need to control thoughts, overestimation of threat, need for perfection, and the intolerance of uncertainty (Abramowitz, 2006).
Therapists work with individuals with OCD to challenge and reframe their irrational beliefs, fostering a more balanced and realistic cognitive perspective.
Despite evidence to support the use of CT with OCD, many therapists avoid using this treatment because CT techniques can easily become reassurance-seeking strategies and thus serve as compulsive rituals that interfere with treatment progress. As a result, CT is mainly recommended to enhance ERP rather than as a stand-alone treatment.
WHY/HOW IT WORKS:
The cognitive model of emotion proposes that our emotions and behaviors are largely influenced by our thinking. Specifically, certain types of exaggerated or overly negative thinking patterns (such as, “I’ll probably fail the test because I am a failure”) lead to negative emotions (e.g., anxiety and depression).
Wilhelm and Steketee (2006) outlined a step-by-step process for a cognitive approach to treating OCD that involves 12 to 20 individual therapy sessions. Treatment begins with identifying the exaggerated beliefs and cognitive distortions leading to obsessional fear and compulsive rituals. Next, individuals learn strategies for challenging these thinking patterns, which may involve questioning the evidence supporting these thoughts, evaluating their validity, and generating alternative interpretations or explanations.
CT also involves “behavioral experiments,” which may be similar to exposure and response prevention in which the person tests out their new ways of thinking by facing their fears, resisting rituals, or doing other exercises that put their beliefs to the test.
For example, a person with contamination obsessions may believe that touching a doorknob will lead to illness. Through CT, they learn to challenge this belief by considering evidence to the contrary and generating more realistic interpretations, such as acknowledging the resilience of their immune system. Then, they might try touching a doorknob to help convince themselves that their new ways of thinking are realistic.
SUMMARY OF THE RESEARCH SUPPORT:
Several studies support the efficacy of CT in the treatment of OCD. In a review of the literature, Ost et al. (2015) found that across numerous studies, CT led to significant reductions in OCD symptom severity, with results comparable to those of exposure and response prevention (ERP). A randomized controlled trial by Whittal et al. (2008) compared the effectiveness of ERP versus CT in treating OCD. This study found no differences between the two treatments delivered individually over 12 consecutive weeks.
Studies, however, suggest that the behavioral experiments are a key ingredient, and that without these exercises, CT is not as effective as ERP. Therefore, there is consensus that CT without these exercises is less effective than ERP.
AGE CONSIDERATIONS:
CT is a sophisticated treatment, requiring the person to be able to identify and analyze one’s own thoughts. As a result, it can be difficult to implement with younger children.
WHEN TO TRY THIS TREATMENT:
CT is considered a second-line treatment for OCD, or one to try once a first line treatment(s) have been attempted. However, despite evidence to support the use of CT with OCD, many therapists avoid using this treatment because CT techniques can easily become reassurance-seeking strategies and thus serve as compulsive rituals that interfere with treatment progress. As a result, CT is mainly recommended to enhance ERP rather than as a stand-alone treatment.
CT may be most useful when the person has poor insight into their OCD and strong beliefs that their obsessions and compulsions are realistic. In such instances, CT helps in “tenderizing” these beliefs and allowing the person to begin to identify their unrealistic beliefs and distorted thinking patterns. They then can become better able to comply with ERP assignments once they have gained insight into their irrational thoughts.
Another example where CT can be useful is when someone with OCD has “magical thinking” related symptoms (e.g., “if I do something at three minutes past the hour, something bad will happen to my parents”).
CT can also be helpful when someone also suffers from coexisting depression, anxiety, or panic disorder, or when someone doesn’t respond to ERP or is hesitant to start or comply with ERP due to concerns over anxiety caused by conducting OCD-related exposures.
REFERENCES:
Abramowitz, J. S. (2006). The psychological treatment of obsessive-compulsive disorder. Canadian Journal of Psychiatry, 51(7), 407-416.
Beck, A. T. (1976). Cognitive therapy and emotional disorders. New York, NY: Penguin.
Ost, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive-compulsive disorder: A systematic review and meta-analysis of studies published 1993-2014. Clinical Psychology Review, 40, 156-169.
Whittal, M. L., Thordarson, D. S., & McLean, P. D. (2008). Treatment of obsessive-compulsive disorder: Cognitive behavior therapy vs. exposure and response prevention. Behaviour Research and Therapy, 46(10), 1211-1220.
Wilhelm, S., & Steketee, G. S. (2006). Cognitive therapy for obsessive compulsive disorder: A guide for professionals. New Harbinger Publications.