Treating OCD with Cognitive Behavioural Therapy

Obsessive-Compulsive Disorder or OCD is a psychological disorder which used to be known as an anxiety disorder, it is now in a classification of its own - but the term is often used to describe people who are particular about order, hygiene or tidiness.

The reality is that Obsessive-Compulsive Disorder is a distressing psychological condition which can take over a person’s life, preventing them from carrying out the simplest of day to day tasks or experiencing enjoyment or relaxation.

It presents as unusual behaviours, often involving safety or cleanliness, such as frequent handwashing, repeatedly checking light switches and door locks, or scrubbing and bleaching an already-clean house. This is by no means an exhaustive list and there are many different ways that Obsessive-Compulsive Disorder can show up in a person’s life.

To say that you or someone else is “a bit OCD” when you’re not really, is doing a disservice to those who live with this very real - but very treatable disorder.

To illustrate what a profound impact OCD can have on a person’s life, we present here another real-life case study from one of our clients. As always, we remind you that we are legally and professionally bound by strict confidentiality rules. Anything that could possibly identify the person has been removed from this article and the client has given permission for their story to be told in the hope it may help others.

If you come to Impossible Mental Health for help or treatment, your story will never be told here unless you give your express permission for us to share it.

Repeated unwelcome thoughts

Did you know most of us have between 12,000 and 16,000 thoughts every day? A study by the National Science Foundation found that, of those thousands of thoughts, around 80% are negative and 95% are the same repetitive thoughts as the day before.

Worry, random ideas popping into our heads, repeating the same thoughts over and over - these are all things that happen to everyone. It’s like trains passing through the station, some fly through without stopping, others stop for a moment before moving on again.

However, someone with Obsessive-Compulsive Disorder will have repeated, intrusive thoughts which are unwelcome and unpleasant. These usually centre around the idea or possibility of causing harm to oneself and/or to others and are so upsetting that the person develops a compulsive behaviour in an effort to neutralise the thought(s).

Intrusive thoughts lead to behaviours which set to neutralise the thoughts; they can often be seen as the safety-seeking behaviours we discussed in our previous blog. They are there to reduce the distress of the thought, or to avoid or be distracted from the thought.

Our client came to us for help when their safety checking behaviours were negatively impacting their work and their personal life and relationships.

They worked in retail and the problems began at work. This person found themselves obsessively over checking customer change, to the point they struggled to hand change over, never feeling they had got it right. And what if that led to problems when the till was counted? Receipts also became an issue as they worried about the potential impact of a customer not receiving a receipt - what if there was a fault with the good?

They were happy enough in aspects of their work that involved predictable, repeatable routine, but anything that took them away from this caused great distress. Changing between tasks further increased their distress and therefore their compulsions became more time-consuming. Their checking behaviours escalated to the point where they were hoarding customer receipts, and any work involving counting or checking became nearly impossible to complete in a reasonable period of time.

They also found themselves unable to complete car journeys without an enormous number of safety checks and after any journey, they worried they may have hit somebody with their car without realising. This led to them retracing their journey in the car to check if they had unwittingly injured someone - and then they would worry that they had hit someone on journey number two.

Treating OCD with CBT

Cognitive Behavioural Therapy can be highly effective in the treatment of Obsessive-Compulsive Disorder.

For this client, we broke it all down, looking at each area of their life - home life, personal relationships and work - and outlining the unwanted behaviours in each, one by one. What were they doing? What were they not doing? What did they want life to look like instead in each scenario?

We then rated each area using SUDs (subjective units of distress) from the least to the most distressing. We then worked on the least distressing and worked our way through the other arenas of their life which were being most negatively impacted by their behaviour. They decided to tackle work first, so we rated all of their work anxieties and began with the thing that caused them the least anxiety.

Exposure response prevention (ERP)

This is a technique which involves exposing someone to the thing which causes them anxiety, in order to gradually reduce the anxiety. It sounds very daunting, but we have found this method to be highly effective.

For this client, we tackled their anxieties using habituation and extinction. Habituation is a form of learning which reduces or eliminates the person’s response to a certain stimulus after repeated presentations.

So, what does this look like in the real world? A good example with our client is their car checks - they had a 15-point procedure for checking their car; 15 individual things which they had to check. Using our SUDs again we asked them, “Which one of those checks would cause you the least anxiety to miss out?”

They decided they could leave out the light checks, and that’s where we began. When they checked the car, they just had to leave out that one thing from their usual routine. Gradually we use this technique to extinguish the unwanted behaviours, one by one.

Thoughts, feelings and behaviours in Obsessive-Compulsive Disorder

This habituation and extinction technique is the behavioural element of Cognitive Behavioural Therapy for OCD. We talked about behaviour experiments in our depression treatment case study - the idea of trying something out, even if you don’t feel like it, even if you’re not convinced it will work, and simply seeing what happens.

It allows the person to experience what actually happens when they expose themselves to the source of their anxiety without performing their safety-seeking behaviour. Feeling that fear, resisting the urge to carry out their compulsive behaviour and seeing that nothing bad happened is powerful in reducing their anxiety around certain triggers. This helps to reduce their automatic negative thoughts about the trigger and replace them with more balanced and rational thoughts, which in turn leads to fewer feelings of anxiety.

The cognitive element of treatment can be achieved through tracking their anxiety levels over time and plotting these visually in tables or graphs, then following up with things they have learnt from the previous week’s ERP.

We asked the client to make a note of their anxiety levels when their exposure to the anxiety trigger began. So, on a scale of one to ten, they might have started off at a 4, gone up to a peak of 7 or 8, and after maybe 20 minutes or so, they may note it going down to a 2.

Seeing this expressed on paper and seeing visually how they have progressed is very powerful - they are presented with the fact that they were exposed to one of their worst fears and after 20 minutes, their anxiety was reduced.

By day seven of tracking their anxiety, this person was starting out with a lower level of anxiety, peaking at lower levels, and coming down to lower levels.

Appropriate treatment and follow up

This person attended 26 weeks of CBT for OCD. Not everyone is the same - Obsessive-Compulsive Disorder is unique to every individual experiencing it and so it is important to take the time, as we did with this client, to analyse and treat all its presentations in every area of life. Although this took 26 weeks you can decide how many sessions you wish to do to complete your goals. It is hoped that once the skill of ERP is learnt, the client can then go on to repeat the process in the other areas of their lives, without such intense input from the therapist.

As you can see, it takes work and commitment from the individual, but with a high chance of permanent positive change. At our one-month review, they detailed one slip up into their old behaviours and we were able to work with them in developing a strategy to avoid this reoccurring. At their three months review, we were delighted to see they had successfully maintained their healthy behaviours.

If you have read this story and think that you or someone you know may have OCD, we would be happy to have a conversation with you about the most appropriate treatment. We are also available to advise any GPs or medical practitioners who may wish to discuss referring a patient or client with Obsessive-Compulsive Disorder.

Get in touch today and we will be happy to advise.