What is Cognitive-Behavioral Therapy?

Reprinted by permission of the OCD Center of Los Angeles

For many years, Obsessive Compulsive Disorder (OCD) was thought to be an exceptionally problematic disorder to treat, and was often misdiagnosed. Traditional psychoanalysis consistently had little impact on the disorder, and other psychotherapies were equally unsuccessful.

However, over the past fifteen years, developments in Cognitive-Behavioral Therapy (CBT) have resulted in a treatment protocol that is especially beneficial for individuals with OCD. In fact, numerous clinical studies conducted over the past fifteen years have conclusively found that CBT, either with or without medication, is dramatically superior to all other forms of treatment for OCD.

Compared to traditional psychotherapy, in which sessions are spent merely discussing the client's problems, CBT is far more proactive. Working together, both the client and the therapist take active roles in assessing the problem, and in devising concrete, active steps towards alleviating the symptoms.

Exposure and Response Prevention (ERP)

Using the Yale-Brown Obsessive Compulsive Scale (YBOCS) and numerous other assessment tools, the therapist helps the client create a detailed list of his or her symptoms. This symptom list is then used as the primary tool in a form of CBT called "Exposure and Response Prevention" (ERP), or "exposure therapy."

Using the symptom list, the client experiments during therapy sessions with exposure to his or her fears, starting with the least anxiety-provoking items from the symptom list. Regular "homework" assignments are given so that the client can continue to challenge symptoms between therapy sessions.

These homework assignments are specifically designed for each individual client, and are an essential part of treating OCD, OC Spectrum Disorders, and related anxiety disorders. They are particularly valuable in helping clients challenge certain symptoms that occur at home, at work, or at school, and that cannot easily be duplicated in the therapy office.

Imaginal Exposure

Additionally, a variant of ERP, sometimes called "imaginal exposure," is frequently used in the treatment of OCD, OC Spectrum Disorders, and related anxiety disorders.

Imaginal exposure involves using short stories based on the client's obsessions. These stories are audiotaped and then used as ERP tools, allowing the client to experience exposure to their fearful thoughts.

This form of exposure is particularly beneficial for obsessions that cannot be experienced through traditional ERP (e.g., killing one's spouse or molesting a child). When combined with standard ERP, and other cognitive-behavioral techniques, this type of imaginal exposure can help to greatly reduce the frequency and magnitude of these intrusive obsessions, as well as the individual's sensitivity to unwanted thoughts and mental images.

Treatment Approach

Following a structured CBT protocol, the client gradually challenges all of his or her symptoms, and learns new, more productive methods of coping with anxiety. Over time, the individual becomes de-sensitized to previously anxiety-provoking situations and thoughts, and the obsessions and compulsions are eliminated, or significantly reduced in frequency and magnitude.

Using this treatment approach, most clients make dramatic improvement by meeting with their therapist on a weekly basis over a period of just four to six months, followed by two or three "booster sessions."

After a short time, many clients also become involved in an ongoing weekly OCD therapy/support group. Some clients may also benefit by having a small number of family or couples therapy sessions to address the impact OCD is having on their relationships.

A minority of clients may require a more intensive approach that includes two to three sessions per week or even home visits.

CBT Combined with Medication

Some individuals with OCD, OC Spectrum Disorders, or related anxiety disorders may also benefit from combining CBT with one or more medications that are sometimes prescribed for these conditions. The goal of medication, or "pharmacotherapy," is to reduce obsessional anxiety, thereby increasing the individual's ability to utilize and benefit from CBT.

This is particularly helpful with clients for whom the prospect of exposure therapy is so anxiety-provoking that they are initially unwilling to try CBT. For these individuals, after the medication has begun to reduce their obsessions, it is recommended that they complete a regimen of CBT while continuing the pharmacotherapy.

Medication may also be beneficial for individuals experiencing depression, which is sometimes present in those with OCD and related disorders, or with other psychiatric conditions. But it is important to stress that CBT is the primary treatment for OCD.

Studies Prove CBT Most Effective

Numerous research studies completed over the past fifteen years have concluded that CBT is the most effective treatment for OCD. In fact, in 1997, the Journal of Clinical Psychiatry surveyed over sixty OCD researchers and treatment specialists from across the world in order to determine the best treatment for OCD.

The resulting publication, entitled Expert Consensus Treatment for Obsessive-Compulsive Disorder, described CBT as "the psychotherapeutic treatment of choice for children, adolescents and adults with OCD" and noted that it is "the key element of treatment."

Despite this endorsement, many clients are tempted to rely on medication alone. But four facts provide a compelling case against the "medication-only" route.

First, analyses of numerous studies comparing CBT and pharmacotherapy have concluded that CBT is more effective in both the short and long-term.

Second, the potential short-term side-effects of these medications are well-documented and include anxiety, insomnia, nausea, diarrhea, difficulty concentrating, and sexual dysfunction. Conversely, CBT has no side effects.

Third, many of these medications have not been fully studied over an extended period of time, and many researchers and clinicians are concerned about the possibility of long-term side-effects, particularly for children, and for pregnant or breast-feeding women.

And finally, studies have shown that when individuals treating OCD exclusively with pharmacotherapy discontinue the medication, as many as 90 percent may experience a complete return of their OCD symptoms. Conversely, those who complete a course of CBT usually have a far lower rate of relapse.

With CBT, the techniques you learn are always with you and provide a set of tools that can immediately be utilized if and when symptoms return.

Reprinted by permission of the OCD Center of Los Angeles