S3C1. The First Pillar: Cognitive Behavioral Therapy (CBT) for OCD

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A question that is frequently asked by many who want to understand how recovery in OCD works is, what is better for recovery: CBT or ERP? Or sometimes these concepts are used interchangeably. Even by doctors. Doctors recommend ERP for the treatment of OCD; sufferers go to CBT specialists and come back disappointed, with the belief that CBT does not work. This is because CBT without focused ERP will not work. Hence, a word of clarification. CBT is a psychotherapeutic approach that aims to identify and modify negative thought patterns and behaviors to reduce psychological distress and promote mental well-being. ERP is one of the several techniques in CBT, used specifically for anxiety disorders, OCD, and PTSD, and is considered to be the gold standard in the treatment of all types of OCD (McKay et al., 2015).

CBT is an umbrella term, and ERP is a specific branch within this umbrella. As an analogy, CBT is like science, and ERP is like biology. Just as all biology is science but all science is not biology, all ERP is CBT, but all CBT is not ERP.

CBT: CBT has two components: Cognitive and Behavioral. Cognitive comes from cognition, which refers to thinking. In the cognitive part of CBT, the attempt is to change the sufferer’s negative thinking patterns. The objectives are to understand the way the sufferer thinks and identify Cognitive Distortions (that is, thinking errors) to correct faulty thinking (Kuru et al., 2018). For example, if you think that you should not have any sexual thoughts towards your parent at all, or you are a pervert, you are a victim of a cognitive distortion referred to as ‘All or Nothing’ or ‘Black or White’ thinking. According to the ‘All or Nothing’ cognitive distortion, your mind tells you that unless you are perfect, you are deserving of censure and punishment.

Similarly, your mind may tell you that if you get thoughts of seeing your sibling naked when you are in the shower, you have committed a sexual crime and should be punished. This is a cognitive distortion referred to as ‘Jumping to Conclusions’. Once you understand the irrationality of your thinking, you can then work towards not falling prey to the Cognitive Distortions. Through the cognitive part of CBT, you are made to understand the irrationality of the thought. The cognitive part of CBT thus works to realign incorrect thinking.

The behavioral part of CBT works towards getting you to change your behavior through a process called cognitive restructuring. For cognitive restructuring, you would need to observe your intrusive and other negative thoughts and map them to the Cognitive Distortions you identify in each case. Once that is done, you would need to provide an alternate response that is healthier and more adaptive. The next step is to put the restructured cognition into action through implementation.

For example, for the ‘All or Nothing’ thinking example above, if you restructure your cognition by understanding that it is fine for you to get some sexual intrusive thoughts because they are automatic, and you do not have control over them, the behavioral change you bring about is accepting them without trying to make them go away or fight with them. Or in the ‘Jumping to Conclusions’ example above, if you restructure your cognition by realizing that your Jumping to Conclusions is erroneous, you may be able to stop yourself behaviorally from dealing with the thought by punishing yourself.

If CBT is not administered and the understanding of the irrationality of the thought is not provided, modifying behavior is possible, but the effort may seem unreasonable and difficult, and hence is likely to take longer. The CBT component answers the ‘what’ and ‘why’ parts of the recovery process.

The next chapter focuses on these Cognitive Distortions. Read through them many times and absorb the information well. Try to map your obsessions and other thoughts to the Cognitive Distortions to understand their irrationality. The more aware you are, the better you will get at handling your irrational thoughts.

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