Overcoming OCD with CBT and ERP Self-Help Course

Do you ever have a thought pop into your head and you just can’t stop thinking about it? OCD consists of persistent and distressing intrusive thoughts, images, or urges referred to as obsessions. These obsessions trigger intense anxiety or discomfort, which lead people to engage in repetitive behaviors or mental rituals called compulsions in an attempt to cope with or alleviate the distress.

In this video, we’re going to look at four main types of OCD and the best ways to treat them, focusing on obsessions.

Contamination-based OCD is characterized by obsessions about germs or contaminants leading to illness and compulsions like obsessive handwashing, sanitizing surfaces, and avoiding touching objects out of fear of getting sick or making someone else sick.

Responsibility for harm-based OCD is characterized by obsessions about being responsible for accidentally causing harm, such as leaving the stove on and burning down the house or accidentally hitting a pedestrian while driving. Compulsions involve constant checking and rechecking to try to prevent harm or ensure that no harm was done.

Symmetry, ordering, and arranging OCD is characterized by feelings of discomfort or dissatisfaction associated with the perception that things aren’t ordered or arranged symmetrically or that they just don’t feel right. Compulsive behaviors may involve meticulously arranging items until they achieve a sense of symmetry or perceived perfection or feel just right. Unlike other types of OCD, there often isn’t fear or anxiety about negative consequences of things not being arranged just right, just a strong uncomfortable feeling of incompleteness that needs to be resolved.

Taboo or forbidden or unacceptable thoughts OCD is characterized by obsessions regarding thoughts related to harm and aggression, sexuality, morality, or religion, such as “What if I push someone into traffic?” not accidentally like with a responsibility for harm-based obsession, but “What if I push them intentionally?” or “Am I a sinner?” The compulsion often involves avoiding situations that could trigger these thoughts, or compulsions may be mental rituals such as neutralizing thoughts by replacing bad thoughts with good ones, repeating prayers or affirmations, or excessively analyzing thoughts and behaviors looking for reassurance.

OCD in which compulsions don’t entail overt actions and behaviors but consist of covert mental acts and rituals is commonly known as pure O OCD for purely obsessional. While this technically still involves obsessions and compulsions, the compulsions are primarily internal cognitive processes, though there are almost always these at least subtle overt compulsive behaviors as well.

Treatment for OCD involves cognitive therapy to help reduce obsessions, which is what we’re going to focus on in this video, and a type of behavioral therapy known as ERP (exposure and response or ritual prevention) that helps reduce compulsions and compulsive behavior. I’ll talk about this in another video that I’ll link to in the description once it’s out.

Everyone experiences intrusive, unwanted thoughts throughout the course of our everyday lives. There’s nothing special about these thoughts, and just having them doesn’t automatically lead to OCD. People without OCD have the same types of intrusive thoughts as people with OCD. What matters is how we interpret these thoughts, and there are six types of beliefs that are associated with OCD. So, we’re going to look at these beliefs and some strategies to counter them, which can reduce obsessive thinking and will help with exposure and response prevention for compulsive behaviors that we’ll be learning in the next video.

One of these beliefs involves assigning excessive importance to our thoughts. We believe that merely having a certain thought implies that it’s meaningful and potentially dangerous. “I wouldn’t be thinking about this if it weren’t important. There must be some truth to it, or I wouldn’t be thinking it. Or if I’m having this thought, that must mean I want it to happen.” But just having a thought doesn’t imply significance or importance.

We have thousands of thoughts every day, and most of these thoughts come and go without us really noticing them. They’re just like background sounds in our minds while we’re focused on other things. But with obsessive thinking, sometimes what might be just a fleeting thought to someone else captures our attention because we find it personally significant and believe it reflects our true character, intentions, or future actions. For example, we have a thought of harming a loved one and then worry excessively that we’re a potential danger to that person, so we start to obsess over it. Or a thought might have an emotional pull; it triggers anxiety, and our anxiety leads us to perceive the thought as important and a sign of threat or danger. This is an example of emotional reasoning, but our emotional reaction to a thought is subjective; it’s not evidence of any objective threat. My anxiety is not evidence that I probably did.

One way we can give undue importance to our thoughts is what’s known as thought-action fusion (TAF) likelihood bias. We perceive that just thinking about something makes it more likely to happen. But having the thought “What if I accidentally harm my child?” doesn’t increase the likelihood that I will harm my child, and we can test this out. See how often your phone battery dies this week and then, every day next week, think about forgetting to charge your phone so it dies and see if your phone battery is more likely to die this week than it did in the previous week when you weren’t thinking about it.

With TAF moral bias, we believe that thinking about something bad is morally equivalent to actually doing something bad. So, let’s explore the strength of our TAF moral bias. Imagine a person who has intentionally driven their car onto a sidewalk trying to harm pedestrians. On a scale from 1 to 10, rate how morally reprehensible you find this. Now, imagine another person who has entertained the thought of driving their car onto a sidewalk but has never actually acted on this thought and rate this person on the same moral scale. If we find these two scenarios morally equivalent or close to equivalent, that reflects TAF moral bias. So, if we do find them morally equivalent, we can seek the opinion of friends and family about these scenarios, which will likely reveal that most people don’t regard bad thoughts as remotely equivalent to bad actions. And this can help loosen our TAF moral bias.

If we wonder why would we even have these bad thoughts if we weren’t bad people and didn’t want to do this at least on some level, well, everyone has thoughts pop into our heads about things we find immoral but would never actually act on. And that doesn’t make us bad people; that’s just how our minds work. And over-importance of thoughts is correlated with the belief that we need to control our thoughts and prevent ourselves from having these personally significant thoughts that we regard as dangerous. And this belief is particularly strong in taboo forbidden or unacceptable thoughts OCD. But no matter how hard we try, we just can’t control our thoughts in a way that allows us to prevent ourselves from ever having certain kinds of thoughts.

But learning to be mindful of our thoughts can help reduce obsessive thinking. Mindfulness involves being aware of the thoughts that enter our minds and simply observing them without judgment, allowing them to be there until they naturally pass away, similar to how we might respond to a sound we hear in the background. We just notice the sound and then let it fade away, and this is naturally what happens with intrusive thoughts if we don’t get caught up in them and start obsessing over them. They just come and go, much like background sounds. We can also use cognitive diffusion, which is a mindfulness technique that helps us get some distance from our intrusive thoughts so that we can let them go. I have videos that describe these strategies in detail that I’ll link to in the description.

OCD is also associated with a sense of inflated responsibility, the belief that we have the power to bring about or prevent negative outcomes, accompanied by feeling a strong responsibility to protect ourselves and others from harm. If there’s any chance we could prevent something bad from happening, we must do so at any cost. This can lead to compulsive checking. For example, someone with contamination-related OCD might fear that touching a doorknob or shaking hands will spread germs and cause people to get sick, leading to compulsive handwashing rituals.

One way to counter such beliefs is with what’s called a “responsibility pie,” which involves breaking down the feared scenario and systematically dissecting all of the possible contributing factors. It’s possible someone will get sick, and if so, sure, we might not have perfectly decontaminated our hands before shaking their hands. But the person could have been exposed to germs elsewhere in the office, or perhaps their kids caught a bug at school that they passed on. And even if they did contract something from shaking our hands, if they had practiced good hygiene and washed their hands afterwards, the risk of illness would have been diminished. Then, by assigning a percentage of possible responsibility to each factor and representing it on a pie chart, we gain a more accurate perspective and see that we’re not close to being fully responsible for preventing others from getting sick, which can reduce our need to engage in compulsive behaviors.

People with OCD also tend to overestimate threats, seeing situations as more dangerous than they actually are and exaggerating the likelihood and severity of harm, especially in situations that aren’t inherently dangerous. This belief is characteristic of contamination-based OCD as well as accidental harm-based OCD, where we overestimate the likelihood that we did leave the door unlocked and the severity of the consequences if that were actually true.

We can challenge these beliefs through cognitive restructuring, which involves changing or modifying a negatively biased thought with a thought that’s more accurate and better reflects reality. Here are some questions we can ask ourselves that can help us come up with a more balanced perspective that reduces the amount of anxiety we feel:

• What am I worrying or predicting will happen?
• How likely is it that what I’m worrying about will happen?
• What evidence do I have that it will happen?
• What evidence do I have that it may not happen?
• What are some other possible scenarios, other outcomes, other ways things might turn out?
• Looking at all of this information, what’s the most likely thing to happen?

I have a number of videos that go into cognitive restructuring in more detail.

OCD is also associated with an intolerance of uncertainty and the need to do everything possible to try to remove any and all doubt. Perfectionistic beliefs are also common with OCD, the tendency to think that there’s a perfect solution for every problem and that doing things perfectly without any mistake is not just achievable but also necessary. Even small mistakes are believed to have serious consequences.

So, how can we become more accepting of uncertainty and reduce our need for perfection? First, it’s important to recognize that in most aspects of life, absolute certainty and perfection are unattainable goals. We need to work on shifting our focus from aiming for certainty or perfection to tolerating a state of “good enough” and balancing our desire for certainty or perfection with the practical reality that absolute certainty or perfection is never entirely achievable.

In general, if we look at the benefits versus costs of seeking absolute certainty or perfection, we’ll often find that there are some short-term benefits, but these come at the expense of significant long-term costs. For example, we may get some temporary relief from anxiety and discomfort, and the illusion of control and attention to detail can lead to higher quality results. However, in the long term, we also experience increased anxiety and stress, and it’s very time-consuming and can damage relationships, lead to procrastination, and result in missed opportunities.

We can use cognitive restructuring to challenge our beliefs about the need for certainty or perfection, which we talked about in reference to assessing threats and danger more accurately. I describe strategies to do this in a number of other videos. Mindfulness can help us accept uncertainty and imperfections as we simply become aware of our thoughts, urges, or feelings regarding certainty or perfection and just acknowledge them, allowing them to be here without acting on them. We can try labeling these thoughts and urges and then gently letting them go. If they stick around, we allow them to be here but in the background of our awareness as we shift the focus of our attention to whatever we’re doing in the present or just something neutral like our breath. These mindfulness skills take some practice, but they’re things anyone can learn to develop.

Learning to reduce obsessive thinking is an important first step in managing OCD. In the next video, we’ll build upon this and look at exposure and response prevention, which targets compulsive behaviors and is regarded as the most effective treatment for OCD. You’ll find that video along with all the videos I mentioned here together on my website, so please check that out. Please hit the like button and subscribe to my channel. If you’d like to support my channel and help me make more videos like this, I really appreciate it. Please check out the donation links in the description.

Clark, D. A. (2020). Cognitive-Behavioral Therapy for OCD and Its Subtypes (2nd ed.). The Guilford Press.

Cognitive assessment of obsessive-compulsive disorder. Obsessive Compulsive Cognitions Working Group. (1997). Behaviour research and therapy, 35(7), 667–681. https://doi.org/10.1016/s0005-7967(97)00017-x