Cognitive behavioral therapy for OCD: all you need to know

f you live with obsessive-compulsive disorder (OCD), cognitive behavioral therapy for OCD can help you get your life back.

OCD is a mental health condition that causes intrusive and frightening thoughts and images (obsessions) and repetitive or ritualistic behaviors (compulsions). Many people find OCD debilitating, and symptoms can get worse if left untreated. 

But there’s hope. Obsessions and compulsions don’t need to rule your life. A type of cognitive behavioral therapy (CBT) for OCD, called exposure and response prevention (ERP), can successfully treat this condition. 

In this guide, we review the complex truth behind CBT for OCD, how not all types of CBT are as effective for OCD and can even be harmful, and how to find an OCD therapist who can help you or your loved one.

What is cognitive behavioral therapy for OCD?

A type of CBT for OCD called exposure and response prevention, or ERP, is the “gold standard treatment” for OCD. This type of CBT is unique. And it’s helpful to understand how it differs from more standard CBT techniques and approaches.

Traditional CBT

CBT is a broad category of therapeutic interventions based on the idea that our thoughts, behaviors, and emotions are all connected — and that by changing things in one area, we can change other areas.

Classic CBT focuses on changing patterns of thinking. This works well for someone with depression, anxiety disorder, and related disorders. For example, someone with depression who’s experiencing feelings of worthlessness may think, “I’m a failure. I’ll never get anything right.” 

A traditional CBT approach helps this person identify the irrational and negative thinking pattern and replace the thought with something helpful, like “I’m not a complete failure; I’ve had some successes and some failures, just like everyone else.”

This type of CBT isn’t usually effective for OCD. And it can potentially be harmful — see below. That’s because thought-checking and reassurance-seeking are compulsive behaviors for people with OCD. In addition, OCD obsessions aren’t just “anxious thoughts” — they’re much more severe.

ERP CBT

ERP (cognitive behavioral therapy for OCD) focuses on helping people with OCD change their behaviors, so they stop responding to obsessions with compulsions. 

In ERP, you work with your therapist to intentionally expose yourself to scary thoughts, and resist the urge to use compulsions to reduce your anxiety. This, in turn, helps your irrational thoughts become less and less powerful over time. In many ways, ERP asks you to do the opposite of traditional CBT — to learn to tolerate OCD thoughts without trying to change them.

If you’re looking for a behavioral therapist for your OCD symptoms, it’s essential to connect with one that practices ERP specifically, not traditional or more general CBT.

How does cognitive behavioral therapy work for OCD?

Let’s talk more about ERP, a CBT intervention that does work for OCD.

ERP works by helping people tolerate — not change — intrusive thoughts, and resist the overwhelming urge to respond to these thoughts with compulsive behaviors. 

OCD is so difficult to live with because it becomes a never-ending, vicious cycle. When people with OCD have an obsession, they respond to it by doing a compulsion. While this compulsion may temporarily reduce anxiety, it isn’t effective in the long run. The obsession returns, along with the need to perform compulsions — and so on.

ERP works by inviting obsessions rather than pushing them away. People who go through ERP are encouraged to sit with the obsession without trying to make it go away with a compulsion. This breaks the cyclical relationship between obsessions and compulsions and starts the healing process. 

In this way, although ERP is a less cognitive and more behavioral form of CBT. It focuses on changing the unhealthy relationship between thoughts and behavior that people with OCD have.

How ERP works

In ERP, you and your therapist work to gradually do exposures, which are activities designed to intentionally trigger anxiety and fear. It’s best to start with an exposure that causes a low to medium level of fear and work up to those that cause higher levels of fear. 

The “RP” in ERP stands for response prevention — a critical component of ERP. When you notice OCD thoughts getting triggered, ERP teaches you to resist the urge to perform compulsions or rituals to neutralize the fear. 

The idea behind ERP is that the more you expose yourself, the more you get used to the idea that your thoughts are harmless and that, even if you don’t carry out a compulsion, nothing terrible will happen. 

Exposures cause a spike in anxiety at first, but you get used to doing them over time. ERP breaks the OCD cycle and teaches you a different, healthier way of coping with intrusive thoughts.

Why most types of CBT are ineffective (and even harmful) for OCD

CBT is an umbrella term that includes many types of interventions — but other traditional CBT techniques aren’t effective, and can even be harmful, for OCD. ERP is the only type of CBT proven effective for the treatment of OCD. 

Non-ERP CBT methods encourage people to challenge their thoughts. This can make OCD symptoms worse and keep people stuck in the OCD cycle.

For example, let’s say that a person with OCD has an obsession, “What if by touching that doorknob, I contract a contagious disease and pass it on to my family?” They use a compulsion and avoid touching doorknobs and wash their hands at least 7 times after being near a doorknob.

A traditional CBT therapist may help this person gather evidence for and against the thought to challenge its rationality. For example, the therapist could challenge the “irrational thought” by trying to help them see that there’s little chance that germs survive after washing their hands just once.

This intervention doesn’t help the person with OCD. People with OCD already know that their obsessions aren’t based on logic. That doesn’t keep the obsessions from causing fear and compulsions. Even if there’s only a 0.01% chance that their fear will come true, their brain latches onto the minuscule possibility — “But what if?” 

This type of CBT intervention can also make OCD symptoms worse. For example, a person with contamination OCD may start seeking constant reassurance from their therapist about the low likelihood of getting sick after hand-washing. Or they could repeat to themselves, “My therapist says that as long as I wash my hands, I won’t get sick.” to try to make obsession go away.

This just replaces one compulsion (hand-washing or avoiding doorknobs) with another (reassurance-seeking and mental repetition). And the sufferer is still stuck in the OCD cycle. Behavior therapy itself can even become a compulsion, which is counterproductive to treatment.

ERP and cognitive behavioral therapy techniques used for OCD

You and your therapist may use different techniques when using ERP as a CBT therapy for OCD. Here are some of the most common ERP techniques used for OCD.

Exposure hierarchy

The exposure hierarchy is a technique that ranks triggers, whether real or hypothetical, from least to most anxiety-provoking. Creating this hierarchy helps you and your therapist know which exposures to start with, and which may be too overwhelming.

For example, if you have OCD symptoms that center on contamination and germs, a lower-level exposure on the hierarchy could be to write the words, “Germs are all around me.” Higher-level, more intense exposures may involve using a public bathroom or touching a “dirty” surface.

Starting low on the hierarchy and working up helps you gradually expose yourself to stronger triggers without becoming overwhelmed.

In vivo exposures

In vivo exposures are exposure activities done out in the world, in real life. This is the most effective type of exposure technique. It can also be the scariest. During in vivo exposures, you’re asked to put yourself in real situations that trigger your OCD fears. To be an effective exposure activity, it must be a situation where your OCD fear could come true.

For example, if you have a contamination fear, you might use a public restroom where you know  the possibility of germs exists as compared to your home restroom. If you have scrupulosity OCD that involves religious or moral obsession, you might intentionally be untruthful about a minor detail, knowing that it’s possible you’ll get caught.

Imaginal exposures

Imaginal exposures are needed when actual exposure (in-vivo exposure) isn’t possible or realistic, such as if it’s too violent or illegal. For example, if you have an OCD obsession that you’ll stab your partner, it isn’t possible to expose yourself by actually stabbing your partner. In these cases, imaginal exposures are helpful.

In imaginal exposures, you imagine yourself in a fearful situation to trigger an OCD obsession. For example, for obsessions about fearing you’ll stab your partner, an imaginal exposure activity might be to write a journal entry as if you had just stabbed and killed your partner. You could also hold a knife while looking at a picture of your partner.

Imaginal exposures are an effective CBT tool, especially when in vivo exposures aren’t possible.

Response prevention

Response prevention is what makes exposures effective for OCD. This technique is about resisting the urge to push obsessions away by carrying out compulsions, and simply doing nothing when OCD fears come up — whether you intentionally triggered the fear during an exposure exercise or they were naturally triggered. You choose to simply be aware of the obsession without reacting to it, or continue what you were doing without stopping to perform a compulsive behavior.

For example, if you’re chopping vegetables for dinner when you have the obsession: “What if I lose my mind and stab myself with this knife?” OCD might lead you to engage in compulsions like putting the knife out of sight or counting to a lucky number over and over again to “protect” yourself.

Using the technique of response prevention, you would resist the urge to perform any compulsions, whether physical or mental. You might say something to yourself like, “Maybe I will stab myself. There’s no way to know for sure.” and continue preparing dinner.

Cognitive defusion

Cognitive defusion is a CBT technique that helps you gain some distance from your intrusive thoughts. Cognitive defusion isn’t the same thing as compulsively pushing scary thoughts away. It’s simply about learning that not every thought is important and meaningful. 

One way CBT therapists may teach you to practice cognitive defusion is by externalizing your obsessions. You can imagine different fictional characters narrating your thoughts out loud — the more outlandish, the better — or actually say your thoughts yourself in a funny voice. The more you do this, the more you realize that thoughts are just thoughts and can’t hurt you.

Psychoeducation

Psychoeducation is often the first step when starting your CBT journey for OCD. By gaining knowledge about how your brain works, you become more capable of observing your mind during OCD spikes rather than letting it control your behavior. 

Your therapist will provide psychoeducation, but you can also read about OCD and the brain on your own.

How CBT (ERP) is used for different types of OCD — examples

ERP is effective across different subtypes of OCD — which means it can help you regardless of what kind of OCD you live with. This is because OCD subtypes aren’t separate diagnoses, but categories of different types of OCD obsessions and compulsions. 

Here’s how ERP might work for some of the most common types of OCD.

ERP for contamination OCD

This type of OCD causes people to have obsessions and compulsions around germs, bodily fluids, illnesses, toxins, and other types of contamination. 

Someone with contamination OCD may have the obsession, “What if someone I passed on the street had a cut, and I caught a blood-borne disease from them?” They may perform compulsions like repeatedly showering or washing their clothes or mentally reviewing their memories to try to remember if anyone they walked past was bleeding.

ERP for this person may start with looking at photos of blood or mentally imagining blood while resisting the urge to perform compulsions (like showering). As they work through ERP, higher-level exposures might involve standing next to someone who is bleeding or even touching blood.

Relationship OCD and ERP

People who have relationship OCD have obsessive thoughts about their significant other. They might have the obsession, “What if I don’t really love my partner?” In response, they compulsively “test” how they feel about their partner or ask their partner for reassurance (“Do you feel that I truly love you?”).

An ERP therapist will invite this person to resist the urge to ask their partner for reassurance, even when their fear comes up. They might perform exposures like reading stories of others who realized that they weren’t truly in love with their partners, or writing a break-up letter to their partner.

Sexual orientation OCD ERP example

Sexual orientation OCD is a lesser-known OCD subtype where people obsessively question the sexual orientation they’ve identified with throughout their lives. 

Someone who identifies as gay and has sexual orientation OCD will have obsessions like, “What if I’m actually straight and I’m just tricking everyone?” They might engage in compulsions, like watching heterosexual interactions, to check for a response, or compulsively reading articles online about how others know if they’re gay or straight.

In ERP, this person may be guided to write sentences like, “I am straight. I am fooling everyone.” and resist doing compulsions to reassure themselves. Other exposure ideas might be to look in the mirror and tell themselves they’re straight or to watch a movie about someone who lies about their sexual orientation. The idea is that exposure to the intrusive thought will eventually lose its meaning, reducing the need to respond to it. 

Does cognitive behavioral therapy help with OCD

Now that we’ve seen what ERP could look like for different types of OCD, let’s discuss why it’s the gold standard for OCD treatment.

Although some CBT techniques can be harmful for OCD, exposure and response prevention is so effective it’s considered the gold standard treatment for OCD. There’s a good chance ERP will work for your OCD. In fact, some studies have found that ERP is as effective, if not more so, than existing psychiatric medications for OCD treatment.

Research shows that ERP effectively helps up to 80% of OCD patients reduce symptoms. And while many studies claim that “CBT” is an effective intervention for OCD, this gives the false impression that traditional CBT is helpful by using it as an umbrella term for ERP.

What to expect if you choose ERP CBT for your OCD

Exposure therapy (ERP therapy) is the most effective treatment for OCD, and a majority of people find relief from their symptoms with this treatment. That means that you can expect that ERP will likely work for you, too.

On average, people start seeing improvement after about 12 therapy sessions. You may experience some setbacks along the way, but as long as you keep working on exposures, your recovery should move forward. Note that ERP is typically more beneficial when you commit to working toward progress between sessions (like doing exposures on your own time).

Self-managed CBT techniques to try between sessions

ERP as a CBT treatment for OCD is best done with the guidance of a licensed therapist. This type of CBT can cause a great deal of anxiety, and it’s important to have professional support. However, if you’re already seeing a therapist, there are some CBT activities you can try between sessions.

Exposure scripts

Although ERP is better done with a licensed therapist, especially when you’re starting out, it’s possible to do exposures on your own. It may be safest to do imaginal exposures through scripting — write out a story in which your worst fears come true. Practicing exposures between therapy sessions is an important way to continue habituating to your OCD obsessions. 

Response prevention

When OCD obsessions come up (whether you’ve intentionally triggered them or they came up naturally), you can try and resist the urge to defuse your anxiety with a compulsion. Simply practice being aware of the negative thought without reacting to it and continue what you were doing before you had the thought.

Mindfulness meditation

Some research suggests that mindfulness-based meditation for OCD is helpful. Mindfulness meditation lets you learn to stay fully attentive to the present moment. Practicing mindfulness regularly can help you resist doing compulsions when OCD obsessions come up.

Relaxation

Some people find that relaxation techniques, like progressive muscle relaxation or deep breathing, help them find a sense of calm when living with OCD or anxiety. If you find that practicing relaxation regularly helps you manage stress and prevent OCD episodes, it may be an effective self-help technique for you.

Keep in mind though that true OCD recovery can’t happen if you avoid feeling anxiety or distress. And if you’re not careful, relaxation can quickly become a compulsion. Pay attention to how and when you use relaxation techniques and talk to your therapist about your experiences.

If you think you’re using relaxation as a new compulsion, try leaning into the obsession instead. Although it’s tempting to do whatever it takes to make obsessions go away, remember that any compulsion, even relaxation, only brings temporary relief. The only way out of OCD for good is to learn how to tolerate the uncertainty of your obsessions.

What other treatments are used for OCD?

Despite the effectiveness of ERP for OCD, it’s not your only treatment option. ERP works for up to 80% of people. But there are more options if you’re in the 20% it may not work for.

Medication

Certain psychiatric medications are so effective for the treatment of OCD that, like ERP,  they’re considered first-line treatments, especially when combined with ERP. These medications include:

• Fluvoxamine (Luvox)
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Clomipramine (Anafranil)
• Escitalopram (Lexapro)

Transcranial magnetic stimulation (TMS)

TMS is a brain stimulation therapy that uses electromagnetic coils placed on the scalp to stimulate the areas of the brain active in OCD. One TMS device is approved by the FDA for the treatment of OCD. TMS is non-invasive and has only mild side effects, which makes it a great option for people who don’t find adequate relief from CBT and medications.

Acceptance and commitment therapy (ACT)

ACT is a type of therapy that falls under the CBT umbrella, and some research studies show it is effective in helping people with OCD, especially when combined with medication and other types of CBT, like ERP. Similarly to ERP, ACT focuses on accepting, not changing, intrusive thoughts.  

Brain surgery

A type of neurosurgical treatment called gamma ventral capsulotomy can help people with OCD when CBT and medications haven’t worked. However, brain surgery is very invasive, so consider trying standard approaches to treatment first.

Find a therapist for OCD on Klarity 

If you live with OCD, it’s essential to connect with an ERP therapist who specializes in treating the condition and/or a psychiatrist who can help you with appropriate medications. Other types of therapy, including other types of CBT or DBT, may not be helpful, and can even set your recovery back.

At Klarity, we make it easy for you to find a mental health provider who specializes in OCD treatment. Whether you’re looking for an ERP therapist or a psychiatrist to prescribe medications, find the provider you need on Klarity today and take control of your life.

 If you’re having a mental health crisis or experiencing a psychiatric emergency, it is crucial to seek immediate help from a mental healthcare professional, such as a psychiatrist, psychologist, or therapist. You can also call your local emergency services, visit your nearest emergency room, or contact a crisis hotline, such as the National Suicide Prevention Lifeline, by calling or texting 988 or dialing the Lifeline’s previous phone number, 1-800-273-TALK (1-800-273-8255) in the U.S. 

The information provided here is for informational purposes only and should not be taken as a guarantee of service, legal, or medical advice. The content here is not intended to be a substitute for professional advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider or lawyer with any questions you may have regarding a medical or legal issue. Klarity does not assume liability for any reliance on the information provided on our blog.

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