Cognitive Behavioral Therapy (CBT) is an umbrella term that is often used as a “catch-all” phrase attributed to many forms of therapy. For example, many traditional talk therapists will state that they utilize CBT as their primary treatment model. But what does CBT mean really?
At its core, CBT is a short-term and goal-oriented treatment involving techniques that focus on changing unhelpful behaviors and thoughts, with a heavy focus on practicing skills in between sessions as “homework.” One of the core foundational principles of CBT is that the way we think and feel impacts how we respond or behave, so it helps the people seeking treatment take a non-judgmental view of their thoughts. In other words, CBT’s approach is that if we can change the way we think about something, we can change the way it makes us feel. Through awareness of these patterns of thinking, we can make the necessary changes in our lives to function more effectively.
What’s important to note here is that CBT is not a singular therapy, but rather multiple therapies. CBT is a broad term that basically indicates that a therapist works with the understanding of (or that the intervention directly targets) the relationship among behaviors thoughts, and emotions. Due to that, a therapist who says they practice CBT may also be referencing their general approach to treatment, perhaps using related interventions such as challenging thoughts, providing encouragement, and processing events. In these cases, the therapist may not be using evidence-based treatments, but rather may be providing unstructured therapy that allows the client to guide the session–this can be detrimental in the treatment of some conditions, like OCD.
That’s why when you find a therapist who mentions they practice CBT, we recommend that you ask more questions to understand the type of CBT they are trained in, and whether that specific therapy they’re trained in under the CBT umbrella is the best or right therapy to treat the condition(s) you’re seeking care for. For example, the clinically effective and recommended treatment for OCD is a specific type of CBT called exposure and response prevention (ERP) therapy.
Different forms of treatment that interweave CBT skills
Some of the more popularly used CBT treatments include the following:
Acceptance and Commitment Therapy (ACT): This is an action-oriented form of treatment in which the therapist guides the patient to accept instead of avoiding feelings and situations that are distressing and often uncontrollable. By accepting these things and committing to changing one’s behavior, one can continue to move towards valued life activities. ACT teaches that despite how a person feels in the moment, they can still choose to behave based on what they value in the long term. Mindfulness is also a key component in ACT: This helps with accepting problems as they arise without feeling the need to intervene or take control. It is also about giving yourself compassion, especially concerning one’s relationship with difficult experiences.
Motivational Interviewing (MI): This type of treatment is often utilized in the early stages of therapy. The goal of MI is to assist the individual in developing awareness of ambivalence surrounding areas of behaviors that have been hard to change. This is often used to help the person get to a place where they are more ready to participate in a structured form of therapy. Behaviors that are practiced for long periods can be incredibly difficult to change. Through acknowledging and addressing barriers to change, one can become more ready to face the challenges of change.
Dialectical Behavioral Therapy (DBT): This treatment focuses on the development of core skills that include emotion regulation, distress tolerance, mindfulness, and stress reduction. DBT also works to reduce self-destructive behaviors. When someone is experiencing intense emotional distress, it can be hard to remain in the moment. Mindfulness skills can help a person stay grounded during times of deep emotional turmoil. By pausing and paying attention to one’s surroundings and senses, an individual can slow down and be present in the moment. By remaining non-judgemental about the experience, and not engaging in automatic negative thinking and behavior patterns, individuals learn to use healthy coping skills.
Distress tolerance in DBT involves the acceptance of who one is, as well as acceptance of one’s experience. Distraction, self-soothing behaviors, and seeing things from a more positive outlook can help a person who is struggling to remain in control of situations as they arise. Another key component of DBT is interpersonal effectiveness. DBT teaches skills to help people be assertive and get their needs met in relationships. DBT also teaches skills of emotional regulation by helping a person to channel their emotions in a manner through learning to accurately identify their feelings and tolerate them. Through acceptance and change, people can begin to respond differently to their experiences.
Behavioral Activation: This can be a stand-alone treatment or is sometimes labeled as a skill of CBT. Behavioral activation is based on the belief that action precedes emotion; in other words, how you act will determine how you feel. This is a very effective treatment for depression. Through increasing positive reinforcement of behaviors, we can increase the probability of that behavior continuing. By learning to replace negative behaviors with more positive ones, a person can reduce feelings of depression.
The treatments for OCD and related conditions are specialized forms of CBT
Specialists trained in OCD treatment will not provide traditional “talk therapy,” as it can be unstructured, ritualistic, and does not include an emphasis on behavioral change, which is central to OCD recovery. Rather, they should be practicing very distinct types of CBT that were designed and work specifically for OCD and related disorders, such as hoarding disorder, tic disorders, and body-focused repetitive behaviors (BFRBs).
At NOCD, we focus on these forms of evidence-based therapy:
Exposure and Response Prevention (ERP): A specific type of CBT intervention used to treat OCD, and considered the gold standard treatment for OCD. ERP is a specialized treatment that has been clinically proven to work in treating OCD. Exposures involve exposing oneself to the thoughts, images, triggers, situations, objects, or urges that evoke anxiety and distress. These often surround the intrusive thoughts that someone is experiencing. Response prevention refers to not engaging in the compulsions that are typically done in response to the anxiety and distress that comes from obsessions. Sometimes these compulsions are mental, meaning they cannot be seen by someone else, but they are happening in the mind of individuals with OCD. Other compulsions may be physical or noticeable by others.
One of the most important parts of ERP treatment is helping the person not to engage in the typical rituals, and to instead not respond to unwanted thoughts, images, or urges. This process of being triggered and then resisting the urge to complete a compulsion works to help the person learn that they can tolerate distress. It provides long-term relief of symptoms versus the short-term anxiety relief of completing a compulsion. This process also allows the brain to learn that the thoughts are not actually threats or dangerous; they are just thoughts.
Habit Reversal Training (HRT): This is an effective form of treatment that is often used to treat Trichollotomania (hair pulling), excoriation disorder or Dermatillomania (skin picking), and other BFRBs. HRT is also an effective treatment for tic disorders, such as Tourette’s disorder. HRT works first by providing awareness training, allowing the individual to become more in tune with when, where, and how a particular behavior impacts them. By noticing the thoughts or situations that lead to the behavior, we can better predict when it will occur in the future. This is important for the prevention of the behaviors.
Once the person has developed a good sense of when these behaviors are more likely to occur, they are guided in developing a competing response. A competing response is an action that prevents the undesired behavior. Individuals are then tasked with practicing the competing response outside of sessions. Motivation to continue using the competing response is also worked on, encouraging the individual to remember why they stopped the original behavior in the first place. Then the individual begins to generalize the new behaviors into their daily life for long-term success. The involvement of a person’s support network is also another critical component of HRT.
Is ERP the same as CBT?
What can be confusing is that you might see the term CBT thrown around in reference to ERP and wonder if they’re interchangeable terms. After all, CBT treatments involve working with a therapist to address and change both thinking and behavioral patterns, making it a popular form of psychotherapy designed to help people learn how to cope with problems in order to reduce—or eliminate—symptoms. However, while these terms are related, ERP and CBT aren’t the same thing. That’s why it’s not enough to seek treatment for OCD from a therapist who says they treat OCD with CBT.
Remember that CBT is an umbrella term that houses several different therapy types. As we’ve reviewed, there are various specific forms of CBT that work best from patient to patient, and ERP is one type of cognitive behavioral therapy. It’s like CBT is ice cream and ERP is the flavor mint chocolate chip; it’s a type of behavioral therapy that often works best in treating OCD.
While other forms of CBT can be helpful in some ways when treating someone with OCD—as can medication options like serotonin reuptake inhibitors (SRIs)—the type of CBT treatment offered can vary widely from provider to provider. For example, while you might find a therapist who practices CBT, they might not have experience with ERP, meaning that even if they’re a wonderful and experienced therapist, they might not be able to provide the best treatment option for you.
If you or someone you love is seeking a provider for OCD treatment, we highly recommend looking for someone who is familiar with CBT as a whole but is trained in ERP as a specialty.
Why does the type of treatment matter?
You may be asking yourself why the form of treatment you seek is so important. It is important because as professionals, we determine a diagnosis based on a set of symptoms. These symptoms can cause people high levels of distress and an inability to function. We use diagnoses to guide the specific treatment that will be provided. We want to ensure that people get the best care possible so they can be successful and improve their quality of life.
It is not that therapies like talk therapy are bad; in fact, they can be extremely helpful for some specific problems. But unfortunately, talk therapy is not the treatment that is most effective for OCD or BFRBs, and getting the wrong treatment can even be harmful for OCD and can ultimately make things worse.
Additionally, while a person with OCD should be treated with ERP, it can be helpful for facets of other therapies to be incorporated into a personalized treatment plan, depending on their specific needs, comorbidities, and goals. Often, therapists will take elements from more than one form of treatment and interweave them in a way that makes sense for the individual. Each person presents with different needs, so having an individualized treatment plan will work to address these varying concerns. However, it is very important to remember that OCD is best treated with ERP, the evidence-based OCD treatment of choice. Finding a provider who specializes in ERP will always be most important for the long-term management of the disorder.
If you are experiencing OCD, BFRBs, or a tic disorder and want to change your behaviors, NOCD can help. All of our licensed therapists deeply understand OCD and are specialty-trained in treating OCD with ERP, and many are trained in treating BFRBs and tic disorders with HRT. We work side-by-side with the experts and researchers who designed some of the world’s top OCD treatment programs, and that means the best care for our members.
Your NOCD Therapist will provide you with a personalized treatment plan designed to best meet your unique needs. They will teach you the skills needed to begin your recovery journey and will support you every step of the way. You can book a free 15-minute call with our team to get matched with one and get started with treatment today.