Cognitive therapists help patients accept symptoms of OCD as part of their illness and guide them to realize that obsessional content is irrelevant, is not predictive of future events, does not reflect poorly on their character, and that their attempts to stop their obsessional thoughts are not only unsuccessful, but can backfire by making those thoughts increase in frequency.

The cognitive therapist uses behavioral experiments to direct the patients’ attention towards obsessive thoughts and asks them to let their obsessions flow in and out naturally without trying to suppress them or to do anything to “undo” them. Patients learn that they can tolerate their anxiety, that their worst fears are unfounded, and that their obsessive thoughts reduce in frequency once they give up attempts to stop or to control them. 

Using a process of guided discovery and Socratic questioning, the cognitive therapist also helps them identify and modify the degree to which they uncritically believe the content of their secondary automatic thoughts. By decreasing the believability of their automatic thoughts and the dysfunctional assumptions and core beliefs on which they are based, cognitive therapy helps reduce the range of emotions observed in OCD such as anxiety, sadness, guilt, and shame.1 Cognitive strategies also reduce the individual’s urges to ritualize and prepare them to undergo exposure and response prevention.

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Behavioral Model and Therapy

The behavioral model of psychopathology arises from learning theory and posits that obsessional fears and behaviors are learned through a process of classical conditioning and maintained via operant conditioning.6,7,8 Exposure therapy is intended to break previously formed associations between stimuli that have become conditioned to generate anxiety, while response prevention is intended to break previously formed associations between avoidance behaviors such as compulsive rituals and feelings of relief.9,10,11,12

Once the patient is appropriately socialized to treatment, the therapist and patient create a graded hierarchy of specific obsessive fears and avoidance behaviors following which patients are required to systematically confront these graded stimuli in their imagination (imaginal exposure) and/or in reality (in vivo exposure).1 Although complete in-session habituation is not necessary, each exposure session is concluded when anxiety is considerably lower, when cognitions are disconfirmed, or when the urge to end the exposure session has subsided.

The therapist also helps the patient generate a graded list of avoidance behaviors, including compulsive rituals, and then proceeds to guide the patient to block them via response prevention. Although completely abstaining from rituals is the final goal, the therapist generally uses graded hierarchies to achieve this goal over time and may incorporate various habit prevention and behavior modification strategies to help facilitate the implementation of response prevention.1