This blog post is based on a paper I recently published with my colleagues at MGH, in which we described the rationale and the procedures for conducting cognitive therapy in the treatment of OCD. My goal for this post is to briefly describe the similarities and differences between cognitive therapy (CT) and exposure and response prevention (ERP), and explain how it can be used in the treatment of unwanted taboo thoughts.

ERP and CT are both evidence-based psychological treatments for OCD. Both are cognitive-behavioral treatments for OCD, which have garnered significant research support for their efficacy and effectiveness. Despite this, ERP and CT have slightly different explanations for how they are thought to improve OCD symptoms. ERP is based on the theoretical principle that avoidance behaviors and compulsive rituals (that aim to provide relief from anxiety in the short-term) interfere with people’s ability to learn safety and tolerate uncertainty. As a result, ERP relies on the use of exposures, which are designed to help patients confront their feared situations. In contrast, CT is based on cognitive models of OCD, which propose that maladaptive beliefs and interpretations about one’s unwanted intrusive thoughts play a role in the development and maintenance of OCD symptoms. As a result, CT relies on the use of behavior experiments, which are designed to gather information and test hypotheses about feared consequences. Whereas exposures are thought to work by helping patients habituate to anxiety levels, behavior experiments are thought to work by helping patients evaluate and challenge their faulty thinking. Thus, in theory, exposures and behavior experiments diverge on the basis of the proposed mechanism of action underlying OCD symptom improvement. In practice, however, I often find it to be the case that patients challenge their thinking through both behavior experiments and exposures, which explains why some clinicians use the terms exposures and behavior experiments synonymously.

For treating unwanted taboo thoughts in OCD, CT offers an important treatment alternative for patients who are unwilling to do exposures. CT strategies involve a systematic approach to identifying faulty thinking patterns that are labeled as OCD, as well as steps to evaluate their validity and generate more balanced beliefs. These techniques include the courtroom technique, continuum strategy, role plays, conducting a survey, consulting an expert, and downward arrow exercise. Why the emphasis on changing thoughts? It is a core tenet of CT that thoughts impact feelings (e.g., anxiety) and ultimately people’s behaviors. Many of my patients have experienced unwanted, intrusive, taboo thoughts about saying or doing something morally or sexually inappropriate, or accidentally hurting (emotionally or physically) others or loved ones. One of my patients had fears about being a pedophile even though she was completely disgusted by the thought and would never hurt a child. We conducted behavior experiments to test out her predictions about what would happen (and whether she could tolerate her anxiety) if she were to look at small children in the eyes, or even babysit for her nephews and nieces. Another one of my patients believed that his rituals prevented bad things from happening to his family, so we conducted a behavior experiment to curse a family member during one of our sessions while withholding rituals. In addition to a line of questioning in our sessions about how could he possibly hold such power and responsibility for preventing harm, he was able to reframe his thinking to let go of his rituals. Although taboo thoughts are sometimes the hardest to let go, they are totally treatable, and CT strategies are a highly therapeutic treatment alternative or complement to ERP.

For more information about CT for OCD, please see our original article:

Berman, N. C., Fang, A., Hansen, N., & Wilhelm, S. (2015). Cognitive-based therapy for OCD: Role of behavior experiments and exposure process. Journal of Obsessive Compulsive and Related Disorders, 6, 158-166.