Cognitive Behavior Therapy (CBT) involves the use of two evidence-based techniques. Cognitive Therapy (CT) and Exposure and Response Prevention (ERP), the behavioral aspect which with OCD is treated. ERP is the treatment of choice for OCD and is often supplemented with Cognitive Therapy. Together, with the addition of medication when appropriate, CBT with ERP is the only scientifically supported and effective treatment for OCD.
Exposure and Response Prevention involves guiding a person to gradually be exposed to and face the situations that trigger their obsessions and compulsions. Over time, the client learns to respond differently to these triggers, and this experience eventually decreases the frequency of compulsions and the intensity of obsessions.
The first step in ERP is to list and rank fears from the least bothersome to the most difficult. Then, beginning with the easiest symptoms, the therapist designs “exposures,” or challenges, that put the individual in situations that trigger obsessions. During these exposures, the client avoids performing compulsive behaviors (“response or ritual prevention”) for increasingly longer periods of time. Through repeated exposures, individuals with OCD realize that when they avoid performing compulsions (RP), their anxiety increases temporarily, but the duration of that spike decreases in time and intensity often more quickly than they expect.
Sometimes recreating the actual situation that triggers a compulsion is impossible, and in these cases imaginal exposure is quite effective Designing scripts, visualizations and recordings that increase anxiety levels allow a person to do ERP in their own mind.
Once these exposures have been repeated enough, the associated anxiety decreases and then the next most challenging exposure is tackled. With effective ERP, people learn through experience that anxiety is natural, not dangerous and that it subsides on its own without the need for rituals. It is the same mechanism that allows to learn language, instruments, and sports or to do things that make us nervous. Anything we practice we get better at.
If you have an obsessive fear of germs, for example, an ERP therapist would help you to encounter the feared item and then wait for a specific period of time wash your hands and eventually to avoid washing altogether. The idea is not just to tolerate the misery but to experience a new way to respond to the fear or thoughts about germs. This leads to a decrease in the frequency and intensity of the obsessions. Cognitive Therapy focuses on noticing and letting go of thought patterns and dysfunctional beliefs that parts of you habitually utilize.
Most CBT with ERP treatment is conducted on an outpatient basis once a week with “homework” consisting of daily exposures to be completed between therapy sessions. In severe cases, people may require more frequent or intensive sessions or even residential treatment.