COGNITIVE BEHAVIORAL THERAPY

FOR OCD

Sabine Wilhelm, Ph.D.

Professor, Harvard Medical School
Chief of Psychology, Massachusetts General Hospital
Director, OCD Program, Massachusetts General Hospital
DISCLOSURES

I have the following relevant financial relationships with a

commercial interest to disclose:

Royalties from Guilford Publications, New Harbinger

Publications, Oxford University Press, and Springer

Speaking honoraria from various academic institutions and

foundations, including the Tourette Association of America and
the Centers For Disease Control and Prevention

Salary support from Telefonica Alpha/ Koa Health, Scientific

Advisory Board for One Mind (PsyberGuide), Koa Health, Inc.,
and Noom, Inc.
CURRENT TREATMENTS FOR OCD

1 Serotonin Reuptake Inhibitors

2 Behavior Therapy, i.e., Exposure and Response Prevention (ERP)

3 Cognitive Interventions

4 Mindfulness

5 In clinical practice: CBT + Mindfulness

6 For more severely ill patients, and/or patients with comorbid conditions -> CBT +
pharmacotherapy
EXPOSURE AND RESPONSE PREVENTION

Between 50 and 60% of patients who undergo BT

are much improved at the end of treatment

ERP is empirically supported as one of the most

effective psychological treatments

Foa et al. (1983)

EXPOSURE AND RESPONSE PREVENTION (ERP)

Long-lasting Effective for children,

improvements adolescents, and adults

✓ Patients maintained gains ✓ Safe, acceptable treatment

(40% and 46% decrease in Y- for pediatric OCD
BOCS score, respectively) at a
6-month follow up
✓ Relapse prevention techniques
help maintain gains

Fals-Stewart et al. (1993) Franklin et al. (2008)

CBT FOR OCD: A SYSTEMATIC REVIEW AND META-ANALYSIS OF
STUDIES PUBLISHED 1993-2014

Öst et al. (2015)

CBT OUTCOMES FOR OCD

N Treatment Age % Women Years Number Pre Y- Post Y- Pre BDI Post BDI
Type (n) Education Sessions BOCS BOCS
Treatment Type
BT 125 n/a 35.82 55% 14.43 16.00 24.08 13.86 17.91 11.09
(11.89) (2.79) (3.82) (5.96) (7.91) (10.66) (10.68)
CT 108 n/a 35.33 72% 14.77 17.12 25.20 12.63 17.71 9.41
(10.03) (2.56) (4.52) (5.12) (8.87) (11.06) (9.20)
CBT 126 n/a 36.57 54% 14.16 18.13 23.83 11.90 16.23 7.53
(11.34) (2.79) (2.00) (5.80) (6.67) (10.00) (7.57)
All 359 n/a 35.93 60% 14.44 17.08 24.33 12.80 17.27 9.33
(11.14) (2.72) (3.66) (5.67) (7.84) (10.56) (9.32)

Steketee, Siev, Yovel, Lit, & Wilhelm (2018). Behavior Therapy.

CBT OUTCOMES FOR OCD

Treatment Comparisons: Clinically Significant Improvements* ✓ Significantly more CT than BT

participants showed clinical
Treatment # Of Participants Who Met Total Number Of improvement, χ2(1) = 8.95, p = .003
Type Criteria Participants (N)
BT 45 (36.0%) 125 ✓ Improvement rates for CBT were
CT 60 (55.6%) 108 marginally greater than BT, χ2(1) =
3.48, p = .06
CBT 60 (47.6%) 126

Entire Sample 165 (46.0%) 359 ✓ CT did not differ from CBT, p = .23

*Clinically significant improvements are defined as reliable change and posttreatment scores in the non-
clinical range.

Steketee, Siev, Yovel, Lit, & Wilhelm (2018). Behavior Therapy.

PHARMACOLOGICAL & PSYCHOTHERAPEUTIC INTERVENTIONS FOR
OCD: A NETWORK META-ANALYSIS

Skapinakis et al. (2016)

 Conducting CBT
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For
• SecondOCD
level
• Third level
• Fourth level
• Fifth level CONDUCTING CBT
FOR OCD
TREATMENT STRUCTURE

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• Second level
• Third level
• Fourth level
5
• Fifth level
4
3
2
1

Assessment/Goal Enhancing Cognitive Interventions, Exposure & Ritual Relapse

Setting/Psychoeducation Motivation Mindfulness Prevention (ERP) Prevention
TREATMENT DURATION

Varies, depends on Booster sessions Fade the frequency

severity, ~12-22 after treatment has of booster sessions
sessions ended slowly
HOMEWORK

Assign after Includes specific Frequency of homework varies

every strategies by type of task – usually
session (e.g., ERP) daily/several times per week
OCD ASSESSMENT

Current OCD triggers and related obsessions

Rituals, avoidance and other strategies

to neutralize painful experience

Feared consequences if patient does

not neutralize

Circumstances related to the

onset of OCD

History of OCD
OCD ASSESSMENT

Cultural
• Click to edit Mastercontext/religious
text styles Traumatic
upbringing and current experiences,
• Second level
religious beliefs/practices if any
• Third level
In relationship to OCD
• Fourth level
• Fifth level

Family history of Patient’s explanation for the

OCD and other cause of OCD (often based
psychiatric on strategies that are no
problems longer adaptive)
OCD ASSESSMENT

Comorbid conditions, including influence on

• Click to edit Master text styles OCD symptoms & associated beliefs
• Second level
• Third level
• Fourth level
• Fifth level
Coping strategies for Impairment related to the OCD
OCD symptoms (daily routine, family & social life,
employment)

Previous psychological Type, dosage & effects of current

treatment and effects and past medications
OCD ASSESSMENT

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• Second level
• Third level
• Fourth level
• Fifth level

Motivation/readiness for change Goals/how can treatment aim at increasing

(rewards associated with making a life valued life activities
change/perceived obstacles) (intimate relationship, career, spirituality)
OCD MODEL

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I might stab my baby with a knife
• Second level
• Third level
• Fourth levelI’m at risk for losing control. I want to do this.
• Fifth level Good mothers don’t think like this.

Anxiety, guilt, shame

Avoid knives, sharp objects

Checking if baby is OK
Ask husband for reassurance
CONSTRUCTING A CBT MODEL FOR OCD

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TRIGGER
• Second level NEGATIVE EMOTIONS
• Third level (e.g., Anxiety, Shame, Depression)

• Fourth level Emotion Regulation Skills

• Fifth level (e.g., Activity Scheduling)
INTRUSIVE THOUGHTS
Mindfulness Skills /Education

MALADAPTIVE COPING STRATEGIES

Rituals, Avoidance
MALADAPTIVE INTERPRETATIONS ERP, Behavioral Experiments

Monitoring, Metaphors, Cognitive Restructuring,

Behavioral Experiments
SESSION 3

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• Second level
• Third level
• Fourth level
• Fifth level
Use Cognitive Therapy
Strategies Flexibly
THOUGHT FORM
Name: Date:

Situation/ Intrusive Interpretation Emotion Compulsions/

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Trigger Thought a)write interpretation a) specify Avoidance
b)write belief in emotions a) compulsive
• Second level interpretation (0-100%) b) write urge (0-100)
• Third level strength of b) what rituals
emotion (0- or avoidance
• Fourth level
100%) did you do?
Holding •I am
Fifthgoing
level to If I am thinking that I might anxious (85) Urge (100)
my baby smash her head smash her head, I’m going Gave baby to
against the wall to do it (90%) husband right
away
SOCRATIC DIALOGUE

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SHOW text styles Curiosity about patient’s thinking
• Second level
• Third level ASK Ask questions
• Fourth level
• Fifth level The patient’s logic
FOLLOW (“do you mean that if X, then…?”)

Logical inconsistencies
ASK ABOUT (“so if that were true, then…?”)

BE Collaborative, exploratory, patient

AVOID Arguing
THOUGHT FORM
Name: ______________________ Date

Intrusion Interpretation Emotion Compulsions/ Rational Outcome

Situation/ Avoidance Response
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a) write a) specify a) re-rate
Trigger interpretation emotions a) rate urge to a) write rational interpretation
b) rate belief in b) write neutralize or response to (0-100)

• Second level
interpretation strength of avoid (0-100) interpretation b) specify and
(0-100%) emotion b) specify
b) rate beliefb)
in rate belief in rate
(0-100%) rituals
interpretation
or rational response subsequent
• Third level avoidance (0-100) emotions
(0-100)

my baby
• Fourth
Holding I am level If I am thinking
going to that I might
anxious
(85%)
urge (100)
Gave baby to
This is just a
thought. I have
a) 35
b) anxious
•smash
Fifth level
her head
smash her
head, I’m
husband right
away.
had this thought
over a thousand
(20%)

against going to do it times and I never

the wall (90%) acted on it…This
shows me that
thoughts cannot
cause actions
(70%)

Adapted from J. Beck (1995)

ACCEPTANCE OF INTRUSIVE THOUGHTS

Examples
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• Second level
• Third level
• Fourth level
• Fifth level

Clouds Leaves Fish swimming Wiley Coyote Allow the train

in the Floating down in the And to arrive &
sky the river ocean train tracks leave the
station
INTEGRATING CT AND ERP
STEP 1 STEP 2 STEP 3
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• Second level
• Third level
• Fourth level
• Fifth level

START MOVE COMBINE

With CT On to ERP both in session/at home
EXPOSURE & RESPONSE PREVENTION

• Click to edit Master text styles TRIGGERS

CONDUCT
• Second level
Conduct ERP 1
Identify triggers for
4 anxiety/avoidance behavior
• Third level (people, places, situations)
• Fourth level
• Fifth level

DESIGN 3 2 RITUALS
Design ERP hierarchy (but don’t get Identify rituals (times,
too focused on working your way frequency)
up in a step by step fashion)
EXPLAIN HOW EXPOSURE WORKS

• Click to edit Master text styles T: “Exposure will help you

go into situations you currently avoid,
• Second level like…
• Third level [Give examples]. You might be
• Fourth level anxious at times, but you can learn to
• Fifth level tolerate the anxiety.”
EXPLAIN HOW EXPOSURE WORKS

• Click
T: “During
to the exposure
edit Master practices,
text styles
you can find out
•if the
Second level
outcomes you fear really
• Third
occur. You level
get firsthand experience
• Fourth level
if your predictions are accurate
or•not.”
Fifth level
TROUBLESHOOTING

Motivate Your Patient To Tolerate The Anxiety

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• Second level
Discuss the short-term and the long-
• Third level 1 term consequences of avoidance
• Fourth level
• Fifth level

Discuss reinforcement circuits as

2 shown in the patient’s CBT model.

Review the costs* and the benefits

3 that come along with reducing
avoidance.
* How It Robs The Patient Of Enjoyment Or Achieving Things
 Exposure
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Situations
• Second level
• Third level
• Fourth level
Exposure
• Fifth level

Situations
SARAH - CONTAMINATION

Distressing Situations Worksheet Distress (0-100) Avoidance (0-100)

• Click to edit Master text styles
• Second
1. Door handles and elevator buttons
level 45 70
• Third level
2. Sitting in a bus 55 60
• Fourth level
• Fifth level
3. Touching money (esp. coins) 70 60

4. Touching trash cans at home 72 60

5. Touching garbage cans outside 78 90

6. Images of becoming terribly ill 85 100

7. Public bathrooms 90 100

SARAH’S RESPONSE PREVENTION PLAN

• ClickNO
toCONTACT
edit Master text
with water exceptstyles
for one 10-minute shower and 2 X 2-
minute tooth brushing each day, after using bathroom (20 sec) and when
• Second level hands are visibly dirty
• Third level
• Fourth level
DO NOT use hand sanitizer
• Fifth level

DO NOT change clothes even if you think they are

contaminated

DO NOT ask family members to change when they come in

the house
RESPONSE PREVENTION STRATEGIES

Stimulus control
• Click
1 to edit Master text styles
(Making it difficult for the ritual to occur)
• Second level
• Third level
2 Selective ritual prevention
(Picking your battles)
• Fourth level
• Fifth level
Restricting your rituals
3 (Watching the clock)

Postponing a ritual
4 (When procrastination is a good thing)

5 Using competing actions

SONJA - HARMING

Distressing Distress (0-100) Avoidance (0-100)

• Click toSituations Worksheet
edit Master text styles
1. Turn •light switch on
Second and off
level 45 50
• on/off
2. Turn faucet Third level 50 50
• Fourth level
• Fifth level
3. Open and close window 55 50

4. Open/close car door and enable/disable parking break 65 50

5. Turn coffee maker on and off, go upstairs 70 90

6. Turn iron on and off, leave house 80 100

7. Turn stove on and off, leave house 100 100

SONJA’S RESPONSE PREVENTION STRATEGIES

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• Second level Don’t check (ask her to leave room/house)
• Third level
• Fourth level
• Fifth level
Don’t seek reassurance (family members
might need to be involved in treatment plan)

Don’t listen to news/call police

OLIVIA’S ERP HIERARCHY

• Click to edit Master text styles SUD (0-100) Avoidance (0-100)

Distressing Situation
• Second level
Buttering bread while alone 30 35
• Third level
• on
Listening to loop tape stabbing
Fourth son,
level 50 60
do not start praying
• Fifth level
Cutting fruit while kids are in the house, 60 65
do not ask husband to watch me

Cutting fruit with kids at the table, do not ask 80 100

husband to watch me/do not ask for reassurance

Hold son and knife at the same time, do not pray 90 100
Hold son while cutting fruit, do not ask 100 100
husband for reassurance
SELECT A MODERATE ANXIETY LEVEL SITUATION

• Click to edit Master textFor The First Exposure

styles
• Second level
• Third level
• Fourth level
• Fifth level
Begin with Make patient an
exposure to situations
that provoke
active
distress & participant
avoidance ratings in deciding
on ERP.
near 40.
BEHAVIORAL EXPERIMENTS

COMPARE IDENTIFY Design

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An experiment to test validity
• Second level of hypothesis
• Third level e.g., “ I will show signs of illness in the upcoming week if I touch this
• Fourth level doorknob”
“My bad thoughts can harm others”
• Fifth level

Compare
Feared and actual consequences

Identify
DESIGN What you learned from experiment
MOVING FORWARD

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• Second level
• Third level
• Fourth level
PRACTICE • Fifth levelWORK ON BE SHIFT
Exposures and Increasingly Creative, Responsibility for
Ritual Prevention challenging leave office, designing ERP’s gradually
daily ERPs change context to patient (parents)
THINGS TO REMEMBER

Patients may feel It’s okay for the

• Click to edit Master text styles patient to feel anxious
anxious, disgusted
• Second level or “not right” during ERP
• Third level
• Fourth level
• Fifth level

Watch out for subtle

Patient should
avoidance strategies
conduct some
& mental
exposures by
rituals
him/herself
ACTIVITY SCHEDULING

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• Second level
To introduce
• Third level
healthier behaviors Guided by
• Fourth level
that result in
• Fifth level
feelings of values
Pleasure & Mastery
CBT FOR OCD IN THE TIME OF COVID-19

CBT For OCD

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In The
• Second level Time Of
• Third level
COVID-19
• Fourth level
• Fifth level

Image courtesy of NPR

COVID-19 & CONTAMINATION CONCERNS

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• Second level Set basic safety plan based on
• Third level CDC guidelines
• Fourth level
• Fifth level Consider context
Do you live alone or with others?
Does your job require you to work with the public?

Differentiate normative vs. OCD-related

compulsions
Are you handwashing in response to an obsession?
Are your behaviors time-consuming and impairing?
Are your behaviors consistent with CDC guidelines?
COVID-19, INTERNET USAGE, & NEWS
CONSUMPTION
Spending hours a day watching
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television or
viewing• online
Secondmedialevel
sources can
be a compulsion.
• Third level
• Fourth level Offer a balanced approach
• Fifth level (e.g., spend no more than 30 mins
in the morning and 30 mins
at night to stay informed
Suggest trusted sources to avoid
myths
(e.g., WHO, CDC, At Johns Hopkins
Center for Health Security) Avoid “learning everything”
and encourage patients to stick to the time and
frequency limits on news that you both have
agreed on.
RELAPSE PREVENTION

Decreasetext
• Click to edit Master session
styles Review CBT techniques
frequency with handouts
• Second level
• Third level
• Fourth level
• Fifth level

Residual problems are Schedule self-sessions/ Schedule booster

addressed patient as therapist sessions
RELAPSE PREVENTION

Plan time Learn to differentiate between lapses & relapses;

•without
Click symptoms/
to edit Master text styles
counter negative thoughts about setbacks;
• Second
activity scheduling
level and handle lapses & setbacks
• Third level
• Fourth level
• Fifth level

Unrealistically optimistic Anticipate possible

or pessimistic thoughts symptom recurrence &
about treatment its relationship to stress, mood
termination are evaluated & other variables
OCD THERAPY MANUALS

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• Second level
• Third level
• Fourth level
• Fifth level

Wilhelm, S., & Steketee, G. (2006). Treating OCD with Abramowitz, J. S. (2018). Getting Over OCD, Second
Cognitive Therapy. Oakland, CA: New Harbinger. Edition: A 10-Step Workbook for Taking Back Your Life.
The Guilford Self-Help Workbook Series
LOOKING TO THE FUTURE: APP-BASED &
INTERNET CBT (ICBT)

• Click to edit Master text styles Addresses some barriers to

• Second level in-person ERP/CBT
• Third level (e.g., accessibility)
• Fourth level
• Fifth level
NOCD Therapy includes video-based OCD
therapy and in-between session support

Outcome tracking and treatment is

personalized to the patient’s goals &
Images Courtesy Of nocd’s Website (www.treatmyocd.com)
symptoms
INTERNET-BASED COGNITIVE BEHAVIOR THERAPY FOR OCD:
RANDOMIZED CONTROLLED TRIALS
Andersson et al., 2012 Kyrios et al., 2018 Mahoney et al., 2014 Wootton et al., 2019

• Click to edit Master text styles 67 participants reporting 140 participants scoring ≥ 7 on
101 participants with a 179 participants with a
Sample • Second
primary level
diagnosis of OCD. primary diagnosis of OCD.
significant symptoms of OCD one subscale of DOCS and
on the DOCS. ≥ 14 on YBOCS.
• Third level
• Fourth level
• Fifth level Therapist-assisted iCBT vs.
Therapist-assisted iCBT vs. Technician-administered iCBT
therapist-assisted internet- Self-guided iCBT vs. waitlist
Method online non-directive vs. treatment as usual control
based standard progressive control group.
supportive therapy. group.
relaxation training (iPRT).

Pre-post improvements in
54% of iCBT dropped to non-
60% of iCBT showed clinically both conditions; however, 27% in iCBT showed clinically
clinical range by post-
significant improvement at iCBT superior for reliable and significant change at post-
Results treatment as compared to
post-treatment as compared clinically significant changes treatment as compared to 1%
17% in treatment as usual.
to 6% in CC. Persistent at (symptom severity Cohen d: in the waitlist. Persistent at
Persistent at follow-up.
follow-up. iCBT = 1.05, iPRT= 0.48). follow-up.
APP-BASED CBT COMPARED TO IN-PERSON CBT

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• Second level
• Third level
• Fourth level
• Fifth level

Hwang et al. (2012)

PAIRING APP-BASED ERP WITH IN-PERSON CBT

Gershkovich et al. (2021)

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• Second level
• Third level
• Fourth level
• Fifth level

42% responded to
8 weeks of Brief treatment (Y-BOCS More research needs to
3-5 sessions (90 min)
Exposure and decreased ≥35%). At be done to evaluate the
of face-to-face EX/RP
Response Prevention follow-up 35% met efficacy of integrated
+ mobile app EX/RP +
Assisted by Mobile criteria for treatment treatment platforms for
5 weekly phone calls
app (BEAM) with 2- response and 15% met cognitive behavior
month follow-up for treatment remission therapies for OCD
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Third level
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ACKNOWLEDGMENTS

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• Second level
• Third level
• Fourth level
• Fifth level

Abigail Szkutak Zoë Laky

Clinical Research Coordinator Clinical Research Coordinator
ACKNOWLEDGMENTS

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• Second level
• Third level
• Fourth level
• Fifth level