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What Is Cognitive Behavior Therapy?

Behavior Therapy and Cognitive Behavior Therapy are types of treatment that are based firmly on research findings. These approaches aid people in achieving specific changes or goals.

Changes or goals might involve:

  • A way of acting: like smoking less or being more outgoing;
  • A way of feeling: like helping a person to be less scared, less depressed, or less anxious;
  • A way of thinking: like learning to problem-solve or get rid of self-defeating thoughts;
  • A way of dealing with physical or medical problems: like lessening back pain or helping a person stick to a doctor’s suggestions.
Behavior Therapists and Cognitive Behavior Therapists usually focus more on the current situation and its solution, rather than the past. They concentrate on a person’s views and beliefs about their life, not on personality traits. Behavior Therapists and Cognitive Behavior Therapists treat individuals, parents, children, couples, and families. Replacing ways of living that do not work well with ways of living that work, and giving people more control over their lives, are common goals of behavior and cognitive behavior therapy.

HOW TO GET HELP: If you are looking for help, either for yourself or someone else, you may be tempted to call someone who advertises in a local publication or who comes up from a search of the Internet. You may, or may not, find a competent therapist in this manner. It is wise to check on the credentials of a psychotherapist. It is expected that competent therapists hold advanced academic degrees. They should be listed as members of professional organizations, such as the Association for Behavioral and Cognitive Therapies or the American Psychological Association. Of course, they should be licensed to practice in your state. You can find competent specialists who are affiliated with local universities or mental health facilities or who are listed on the websites of professional organizations. You may, of course, visit our website (www.abct.org) and click on "Find a CBT Therapist"

The Association for Behavioral and Cognitive Therapies (ABCT) is an interdisciplinary organization committed to the advancement of a scientific approach to the understanding and amelioration of problems of the human condition. These aims are achieved through the investigation and application of behavioral, cognitive, and other evidence-based principles to assessment, prevention, and treatment.

Far more common than previously thought, obsessive-compulsive disorder (OCD) now receives widespread attention from the general public. Reports in the media are frequent, but not always correct. The terms “obsession” and “compulsion” are sometimes incorrectly applied to various psychological difficulties, such as gambling or overeating, which are in fact quite different from OCD. Since the treatment methods used for OCD are not necessarily useful for other types of problems, it is important to understand exactly what OCD is.

What Are Obsessions?

Obsessions are ideas, thoughts, images, or impulses that are senseless and “get in the way.” They continue even though a person may try to ignore or forget about them. They are experienced as unpleasant and unwanted and may provoke anxiety, guilt, shame, or other uncomfortable emotions.

The most common obsessions are concerns that objects or other people might be “contaminated” by contact with germs, disease, dirt, chemicals, or some other source. The feeling of contamination is accompanied by an urge to wash or to clean. Other obsessions focus on fears that doors or windows have been left unlocked, appliances have been left on, important papers have been thrown away, mistakes have been made, and so forth.

Frightening thoughts about burglary, fire, and other losses often accompany these fears, forming part of the obsessive ideas. Some obsessive thoughts concern accidents or unfortunate events that might occur unless one superstitiously repeats particular actions or thoughts to prevent the disaster. Other obsessions take the form of unwanted urges or impulses to do something harmful, such as to stab one’s child with a kitchen knife. Some people experience horrific or upsetting images having to do with religious figures.

Obsessions can take many forms. Ordinary people are concerned by many of the ideas, thoughts, images, or impulses underlying obsessive fears. Most of us are concerned about AIDS and other diseases, and about harmful chemicals in the environment. We are careful not to leave hot appliances near materials that might catch fire. We periodically experience odd impulses or form upsetting images. However, for those with OCD, the fear and guilt or other unpleasant emotions are out of proportion to the actual risk of danger or harm, driving them to carry out compulsions to rid themselves of the worry.

What Are Compulsions?

Compulsions, also called rituals, are usually actions that are repeated, but sometimes are thought patterns that are performed to rid oneself of a disturbing obsession. Rituals are usually carried out according to certain rules or in a rigid fashion and are clearly excessive. The person recognizes that the rituals are not reasonable but feels unable to control them. Most compulsions are logically related to the type of obsessive ideas they attempt to reduce or prevent, although this is not always true. Because they temporarily reduce discomfort, rituals become habitual, and the person with OCD often has difficulty control-ling them.

Examples of compulsions include hand-washing, showering, or cleaning to remove “contamination”; checking to prevent feared dangers such as theft, fire, or loss of important things; repeating actions or thoughts to prevent a catastrophic event from happening; having to arrange objects in a particular way before beginning an activity; or needing repeated reassurance from others that a feared event has not or cannot happen. Some compulsions are performed mentally without any behavioral manifestation.

Examples include praying to relieve guilt about an unwanted idea and repeating phrases or images in one’s mind to prevent a catastrophe.

Common Characteristics

Those who suffer from obsessions and compulsions vary widely in their personality characteristics, life circumstances, and the degree to which their lives are disrupted by these symptoms. Thus, it is difficult to make general statements about their habits. Some researchers have suggested that those with OCD tend to come from more perfectionistic and possibly more moralistic upbringings. They are more concerned with avoiding mistakes than are people who do not get so anxious.

Many OCD sufferers appear to overestimate the risk involved in their obsessive concern, and some dislike taking even small risks of any type. Many doubt their own decision-making ability and request reassurance from others to confirm their choices. On the other hand, many people with OCD do not exhibit these traits, but appear to be quite normal in their social, recreational, and work lives.

Behavioral Treatment

The most widely accepted form of psychological treatment for OCD is behavior therapy, using procedures known as “exposure and response (ritual) prevention.” In this treatment method, the therapist first helps the patient develop a list of obsessively feared and avoided situations and a list of all compulsive rituals. Then the list of obsessive situations is put into order according to the amount of discomfort provoked. Exposure begins with the client being asked to confront easier situations for an extended period of time. As therapy continues, the client works toward dealing with the more difficult situations until all the feared items on the list have been faced and no longer provoke more than mild discomfort.

Most commonly, exposure is carried out directly, with the therapist and the patient going to each situation on the list and remaining as long as necessary for anxiety or discomfort to be reduced substantially. In some cases, exposure may be conducted in imagination, with the person imagining him- or herself going step by step through a scene designed to imitate the type of situation that provokes obsessive fear.

At the same time that the patient is being exposed to obsessive situations, rituals must also be prevented. If continued, compulsions reinforce (support) obsessive fears, making exposure a useless exercise.

In some programs compulsions are reduced gradually: As the person is exposed to each new feared situation, he or she is asked not to perform any rituals after that or other similar situations. In other programs compulsions are blocked altogether. The therapist does not use force but relies on the patient’s motivation to improve to overcome the urge to ritualize. Many studies of exposure and ritual prevention have been conducted. Results have shown that about 65% to 75% of those treated with this method improve substantially, and most have maintained their improvement years later. Behavior therapy alone is less successful for patients who have obsessive thoughts but perform no or few compulsive rituals.

Drug Treatment

Many medications have been tried for OCD, and recent studies suggest that a particular group of drugs that affect the serotonergic system are most successful in relieving obsessions and compulsions. In particular, the drug clomipramine (Anafranil) has been subjected to much research and has been shown to be an effective anti-obsessive agent, reducing the symptoms of about two-thirds of those who have tried it. The degree of symptom reduction ranges from nearly symptom-free to mild improvement, with most patients reporting 30% to 60% improvement.

Most people are able to tolerate the common side effects of clomipramine (for example, dry mouth, dizziness on sudden standing, tremor, or constipation). For some, the side effects make the drug unusable. Another serotonergic drug that may be helpful for OCD is fluoxetine (Prozac). So far, however, there have been fewer studies of its effectiveness.

Drug treatment appears to be a valid option for many with OCD. However, since relapse often occurs when patients are taken off these drugs, those who use medication should probably undertake behavior therapy as well to achieve stable improvement.


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