Cognitive-behavioural therapy (CBT) is one of the most widely researched and practiced models of psychotherapy in the world. Developed initially for treatment of depression in the 1950s, it is now used as an effective treatment for obsessive compulsive disorder (OCD).
What follows is an understanding of the phenomenology and the mechanism by which specific cognitive processes and behaviours maintain the symptoms of the disorder:
An obsession is an unwanted intrusive thought, doubt, image or urge that repeatedly enters a person’s mind. Obsessions are distressing as they are acknowledged as being unreasonable or excessive.
A cognitive behavioural model of OCD begins with the observation that intrusoive thoughts, doubts or images are almost universal in the general population and their content is indistinguishable from that of clinical obsessions. The difference between a typical intrusive thought and an obsessional thought lies both in the meaning (the interpretation) that individuals with OCD attach to the occurrence or content of the obsessive thought and in their response to the thought or image.
The most common obsessions concern:
- the prevention of harm to the self or others reulting from contamination (e.g., dirt, germs, bodily fluids or faeces, dangerous chemicals)
- the prevention of harm resulting from making a mistake (e.g., a door not being locked)
- intrusive religious or blasphemous thoughts
- intrusive sexual thoughts (e.g., of being a paedophile)
- intrusive thoughts of violence or aggression (e.g., of stabbing one’s baby)
- the need for order or symmetry
Compulsions are repetitive behaviours or mental acts that a person feels driven to perform. A compulsion can either be overt and observed by others (e.g., check that a door is locked) or a covert mental act that cannot be observed (e.g. mentally repeating a certain phrase). Covert compulsions are generally difficult to resist or monitor, as they are “portable” and easier to perform. The term “rumination” covers both the obsession and any accompanying mental compulsions and acts.
The most common compulsions include:
- Checking (e.g., to ensure appliances, lights are off; reassurance-seeking)
- Repeating actions
- Mental compulsions (e.g., special words or prayers repeated in set manner)
- Ordering, symmetry or exactness
Early experimental studies established that compulsions, especially cleaning, are reinforcing because they seem to reduce discomfort temporarily. Furthermore they strengthen the belief that, had the compulsion not been carried out, discomfort would have increased and harm may have occurred (or not have been prevented). This increased the urge to perform the compulsion again, and a vicious circle is then sustained. However, compulsions do not always work by reducing anxiety and are often intermittently reinforcing. Compulsions may function as a means of avoiding discomfort. They are usually carried out in a relatively stereotyped way or according to idiosyncratically defined rules.
The individual’s criteria for terminating compulsions are an important factor in their maintenance. Someone without OCD finishes an action such as hand-washing when they can see that their hands are clean; someone with OCD and a fear of contamination finished not only when they can see their hands are clean but when they feel “comfortable” or “just right.” Others may end a compulsion when they have a perfect memory of an event. These additional criteria for terminating compulsions may cause them to last even longer. Progress in overcoming OCD can be made only when the criteria for terminating a compulsion are restricted to objective criteria.
Exposure and Response Prevention
Cognitive-behavioural therapy for OCD is based on learning theory. It is suggested that obsessions have, through conditioning, become a learned association with anxiety. Various avoidance behaviours and compulsions prevent the extinction of this anxiety. This theroy has lef to “exposure and responce prevention” (also known as systematic desensitization), in which the person is exposed to stimuli that provoke their obsession and then helped not to react with escape and compulsions. Repetition of these stages leads to extinction of the feared response. Exposure and response prevention as specific technique of CBT, continues to be good evidence-based treatment for OCD.
Challenging and Re-Scripting Automatic Thinking
CBT as a highly effective method for eliminating the occurrence of irrational and intrusive thoughts lies in its ability to provide reasonable evidence for how a client’s thinking is illogical and unfounded. By showing an adult client how to diminish the intensity of their obsessive and compulsive thought by challenging and disproving their thinking; it eliminates the urge for typical behaviours used to satiate anxiety. CBT is personalized for each client by identifying the specific (intrusive) thoughts that they experience in a case-by-case situation where their OCD tendencies are most serious. As a client learns the tools for challenging and re-scripting their automatic thinking with thoughts that truth-based, they are encouraged to use this tool frequently as a means of effectively eliminating fear-based, obsessional thoughts and compulsions.
In CBT, clients learn a self-directed method to change their perceptions of a situation rather than attempting to change or control the situation. Illustrating for a client how their ” automatic thoughts” – habitual negative thinking – instinctively drives their behaviour, offers a rational understanding of what causes obsessive thinking and compulsive behaviour. Recognizing the automatic thoughts and immediately challenging it, immediately intervenes, curtailing the habitual behaviour.
Obsessive thoughts for individuals with OCD are not truth-based. Therefor, challenging these thoughts by asking the questions: “Where’s the evidence?” gives clients an opportunity to alter their incorrect and often irrational thinking.
Asking whether a particular thought is really true forces a client to examine their perceptions and core beliefs about a particular tast or situation.
Teaching people with OCD to reflect on objective evidence that is true helps them learn a new method of thinking as they approach everyday life tasks and situations.
The final step of this CBT strategy is to re-script the automatic thought based on what is actually true. In correcting their obsessive cognitive distortions, clients learn to seek “truth-filled” thoughts (thoughts that can be proved with available factual evidence). This immediately lessens, and in many cases, eliminates feelings of anxiety and fear, which enable clients to experience greater control over compulsive tendencies.
Using this specific CBT strategy each time they feel a strong negative emotion and the urge to react in compulsive tendencies to irrational and incorrect thinking. The result is a feeling of autonomy and empowerment since the focus is on identifying and challenging ones’ thinking – and the meaning that the individual attaches to those thoughts – which is the true origin of the problem.
Meditation and Relaxation
While impulsive and irrational thoughts and urges are a part of the “human condition,” people with OCD experience a heightened degree of distress and duration of these intrusive thoughts. Therefore, it is important that CBT treatment includes a learned practice of relaxation and self-regulation. When a client becomes skilled at calming their body (and subsequently their mind), particularily in times of high stress (but also in the anticipation of stress), they experience an improved ability to use the self-directed CBT strategies to their fullest potential. Using meditation and relaxation tools on a regular basis reduces anxiety and strengthens a client’s ability to focus their mind (and attention) at will; both of which are helpful for overcoming OCD inclinations.