Obsessive compulsive disorder - OCD treatment and therapy from NOCD

Does CBT work for OCD? What experts say

10 min read
Elle Warren
By Elle Warren

If you or someone you love is new to an obsessive-compulsive disorder (OCD) diagnosis, you may feel overwhelmed by navigating your treatment options. I know I did when I first started to suspect I had OCD. There’s a lot of information out there, and it can be hard to know what to trust.

Even worse, a lot of licensed mental health professionals lack the specialized training needed to treat OCD effectively. That’s because even highly experienced therapists may know nothing about OCD treatment beyond what they learned in graduate school or during a weekend workshop. But to treat such a severe, chronic condition, much more intensive and specialized training is needed—and a specific form of treatment that was developed for OCD specifically. 

With the expert insight of Tracie Ibrahim, LMFT, CST and Stacy Quick, LPC, this article will tell you everything you need to know about what works and what doesn’t for treatmenting OCD and how cognitive behavioral therapy (CBT) fits into the world of OCD treatment, based on the latest research. 

What is CBT?

Cognitive behavioral therapy (CBT) is a common type, or modality, of therapy that helps you gain awareness about the relationship between your thoughts, feelings, and actions. The ultimate goal, broadly speaking, is to change your undesirable behavior. It’s most commonly used to treat depression and, in some cases, anxiety.

For example, CBT might help you recognize self-destructive behaviors, and what beliefs or feelings lead you to engage in them. 

Does CBT work for OCD?

The most important thing to know about CBT is that there are many different types of it. A lot of therapists practice it generally using the overall guiding principles of understanding the relationship between thoughts, feelings, and actions. When you read about CBT, this general form is most likely the form of treatment you’re learning about. But therapists may use a wide combination of specific CBT techniques when treating different conditions. 

When it comes to OCD, the evidence-based treatment is one specific type of CBT called exposure and response prevention therapy (ERP), which was developed to treat OCD specifically. Research has found it to be the most effective form of treatment in the majority of patients. If a therapist claiming to treat OCD says they approach it with CBT, make sure you ask them what kind of CBT they use. If they don’t say ERP, you should continue your search for a therapist who truly specializes in ERP and has the rigorous training required to treat OCD.

Think of it this way: When it comes to OCD, CBT is the make of the car, and ERP is the specific model. There are many important differences between general CBT and ERP, so it’s crucial to get the right form of specialized treatment for OCD—you wouldn’t want to drive your scooter on an off-road racing track!

Why we need to talk about ERP (not CBT)

CBT is not only ineffective for OCD, it can even be downright harmful. In CBT, therapist and client will typically dig into the content of their thoughts. They’ll examine where the thoughts are coming from, whether or not they’re true, what they’re trying to tell you, and how you can change them. 

“Traditional CBT is really about challenging irrational thoughts or figuring out if a thought makes sense,” says Ibrahim. 

CBT is ineffective for OCD because the disorder is characterized by intrusive thoughts, which are irrational and out-of-sync with who you are by definition, and a need for absolute certainty that those thoughts aren’t true. 

With OCD, engaging in CBT gives more attention to these intrusive thoughts, which can fuel them and lead to even more compulsions. When a clinician is untrained in OCD, they can unknowingly encourage your compulsions. 

How general CBT can reinforce OCD compulsions

For example, one common compulsion is known as reassurance-seeking. This is the act of asking others or yourself to reassure you that your fears are not true. A CBT therapist, in response to your intrusive thoughts, may say things like, “You’re clearly a really great person who would never do those bad things you fear—your brain is just lying to you,” or, “Do you really think that could be true? Is there any evidence?”

And that just gives more legitimacy to intrusive thoughts. As Kimberley Quinlan, LMFT and OCD specialist puts it, “The reality is that everyone experiences intrusive thoughts. We do not have control over those thoughts, and with every attempt we make to resist them, fight them, and try to stop them, we only make them more prevalent because we’re giving them our attention.”

Because we all experience intrusive thoughts, they’re not a problem on their own. Most people will just think Well that was a strange thought and just let it go. What really perpetuates the cycle of OCD is compulsions. Compulsions reinforce the belief that your intrusive thoughts are dangerous by giving them time and attention. 

Therefore, OCD requires treatment that targets compulsions. That treatment is ERP, which I’ll get into below. “Behavioral change is central to OCD recovery,” says Quick.

How does ERP work?

To begin the process of ERP, your specialized therapist will gain an in-depth understanding of your unique symptoms. They’ll ask about what your intrusive thoughts sound like, what triggers them, and what compulsions you do in response. 

From there, they’ll structure a plan for exposures, which are guided exercises done to help you learn to resist engaging in compulsions. You’ll start small with exposures that bring a mild amount of distress. For example, perhaps your therapist simply says a word that is reminiscent of the content of your thoughts. If your intrusive thoughts are about contracting a deadly illness, perhaps they say “germs.” 

From there, you’ll work your way up to more difficult exercises. All the while, you will be learning and practicing methods for resisting the urge to engage in compulsions. 

“This process of feeling uncomfortable and then resisting the urge to complete a compulsion works to help the person learn that they can tolerate distress,” Quick says. Over time, you will feel less and less distress overall when it comes to your intrusive thoughts. You will realize the truth of them: that they’re just thoughts. 

Is there anything else that can help with OCD?

While the research is strongest for ERP, medication is considered an evidence-based treatment, too, especially when taken in conjunction with ERP. A psychiatrist or other medical provider can help best determine if, and what kind of, medication is right for you. 

Another therapy that is sometimes used to treat OCD is acceptance and commitment therapy (ACT). It is far less evidence-based than ERP, but it has shown positive results when used alongside ERP. Rather than targeting specific compulsions via exposures, it teaches the client to accept their reality while learning to identify and pursue their values—rather than their fears. You can ask your therapist about incorporating ACT into your treatment plan, along with ERP therapy.

There are a couple other things worth noting that sometimes get tossed around when talking about OCD treatment. We want to make sure you understand the difference between evidence-based treatments and tools that can be used to complement treatment.

The first to note is mindfulness. Mindfulness describes the practice of being aware of your body, your thoughts, and staying present in your surroundings. It is absolutely a useful skill to have and can be a great tool to complement ERP. However, mindfulness alone is not a treatment that’s backed by research.

The same can be said for diet changes and exercise. Just like with mindfulness, it’s totally possible for those lifestyle changes, if done in a healthy way, to support your overall mental wellness. They are not stand alone treatments, though, and are unlikely to help you gain meaningful recovery from OCD without also going through evidence-based treatment. 

How it feels to finally get ERP for OCD after years of CBT

Ibrahim tells a story of one client she saw who had been to eight therapists and was ready to give up if this time didn’t work. She learned that this client had only been to CBT therapists—ones who had zero training in ERP. The client found that they’d feel better for a few minutes after therapy, but then the anxiety and doubt would rush back in. 

The client was a little intimidated by the idea of facing their fears in ERP, but they were ready to do whatever it took. Ibrahim says that this client got better shockingly fast because they were so desperate to get treatment that actually worked. They took every single tool, tip, and direction that Ibrahim gave them. After six weeks, Ibrahim and the client agreed they could start meeting less regularly, and eventually the client was discharged. They wished they would have tried ERP first, but they were so glad they finally found it. 

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“How accessible, evidence-based therapy helped me conquer my OCD”

Here are some stories from the OCD community about the recovery they were able to achieve once they finally accessed evidence-based therapy.

Ashley’s Story

“My therapist and I started with a list. I wrote down all of my fears regarding warts and then labeled them from 1-10, with 10 being the most anxiety I would face. We built a ladder together on paper ranking my worries. Just writing them down and seeing them in real-time was anxiety-provoking. I was ready to start ERP therapy, I was ready to get my life back. Number one on my list was to touch a picture of a wart on my therapist’s computer screen. My anxiety went up to a 10. She spoke to me throughout the exercise, letting me know that I can stop when my anxiety decreases by half. I could feel my anxiety level fall as my body signaled it to drop.” Read the rest of Ashley’s story.

Leana’s Story

“When I started with ERP therapy, there was such a clear difference. After I had spent 7 months with other therapists, neither of them called me out on my avoidance of specific words. My new therapist asked me to say one single word in our first session, and I cried. My OCD really wanted to stay around. It flipped around to finicky topics and decision-making and shifted just enough to have me staring at it again. However, after a few rounds of intensive treatments, I made it to the other side.” Read the rest of Leana’s story.

Tricia’s Story

“I knew the thoughts I was having were stressful, and I knew most people didn’t think the same way I did. I was replaying every single thing I ever said over and over again in my mind for hours, thinking about how I could’ve said it differently, or if I could have possibly offended someone. When I saw a new psychiatrist, I finally had the courage to speak up and talk about the way my brain worked, but it was difficult to share. Initially, I didn’t tell her everything. I wanted help but didn’t feel like I could be fully honest. I was so afraid of sounding ‘crazy’ or being told I would have to be committed. Being honest felt too risky. 
I left that appointment and felt extreme guilt over not being 100% honest. That led to me compulsively confessing over email to get rid of the anxiety I was feeling. At the next appointment, the psychiatrist suggested looking into OCD. I had misconceptions that OCD was more about handwashing and cleanliness, so I was skeptical but ultimately agreed. This led to a diagnosis of OCD in January 2022 and the beginning of my journey toward recovery.” Read the rest of Tricia’s story.

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