Cognitive Behavioural Therapy (CBT) (including Exposure and Response Prevention) for Obsessive Compulsive Disorder (OCD)

Core Components 

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of mental health disorders. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours within a person’s environment and how alterations in one domain can impact other domains. CBT therefore helps people to notice, understand and question their thinking, emotions and behaviour to facilitate changes in areas that are unhelpful.  

In the context of Obsessive-Compulsive Disorder (OCD), CBT includes cognitive and behavioural strategies that aim to change OCD associated thoughts and behaviours and develop more helpful alternatives. These strategies include: 1) Cognitive strategies that address unhelpful cognitions related to obsessions; 2) Exposure Response Prevention (ERP) - a behavioural strategy specifically designed for OCD management. ERP involves the systematic introduction of anxiety/ obsession provoking triggers. This is for the purpose of confronting fears, increasing tolerance, and reducing the urge to engage in compulsive behaviours.  

Core components of CBT (that includes ERP for the treatment of OCD) are:  

• Assessment, education, and treatment planning. This includes a) psychoeducation to increase knowledge on the nature of OCD; improve understanding of the CBT/ ERP treatment model by collaboratively developing an individualised formulation, increasing knowledge of the cycle of maintenance of OCD; b) information gathering as it relates to patient symptoms, as well as external and internal triggers; and the content of the patient's obsessions and compulsions; and c) making a treatment plan to systematically approach fears without engaging in rituals;  
• Cognitive processing to identify and challenge the range of cognitive processes that maintain the OCD symptoms. This is intended to help patients address unhelpful understanding of situations, and create new beliefs about the meaning of the obsessions; 
• Behavioural experiments are also used to explore and test the meanings underpinning OCD to develop new beliefs and insights to help overcome OCD; 
• Exposure-response prevention therapy (including in vivo and imaginal exposures) to trigger the anxiety provoking situation in the absence of compulsive response to learn about the habituation of anxiety. 

CBT for OCD also includes a homework component which provides opportunities for patients to challenge themselves between sessions, and to generalise the skills learnt to their everyday lives (e.g. symptom monitoring, exposure exercises). Further information on the specific competencies that should be followed when delivering CBT for OCD are outlined in the UCL CBT Competency Framework. 

Fidelity 

Practitioners delivering CBT for OCD should receive training and ongoing clinical supervision. In particular, practitioners should be aware of the specific theories and approaches underpinning CBT for OCD. Practitioner competence can be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions and rated against a CBT competency assessment tool, such as the Cognitive Therapy Scale-Revied ​(1)​ or another similar scale.   

Modifiable Components  

The number of treatment sessions delivered is dependent on the persons’ degree of functional impairment. Low intensity CBT with ERP, which includes up to 10 therapist hours per patient, is typically delivered to patients with mild functional impairment. More intensive CBT with ERP is typically 16-20 sessions in duration and delivered to patients with moderate to severe functional impairment.  

Low intensity CBT (including ERP) can be delivered as brief individual CBT using structured self-help materials; brief individual CBT by telephone, online or as group CBT. People receiving low intensity CBT (including ERP) in group format may receive more than 10 hours of therapy. 

CBT (including ERP) for children can involve family or carers and should be adapted to suit their developmental level.  Active involvement of parents or carers (e.g. training parents or carers to assist their children with ERP) and specifically targeting family-based factors within the intervention are identified as factors that may contribute to improved outcomes ​(2,3)​. 

Individual cognitive therapy (without an ERP component) that has been specifically modified for OCD can be considered for individuals with OCD who are unable or unwilling to undergo ERP.   

CBT (including ERP) can be delivered in several settings including outpatient settings, hospitals, and residential treatment settings.  

Support for Organisation / Practice 

Implementation Support 

Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology Adult Mental Health and CAMHS workstreams, including webinars, and supervisor training. 

Start-up Costs 

There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations.   

Building Staff Competency 

Qualifications Required 

Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and as a minimum will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level). 

Training Requirements 

Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT is available through the NES Psychology adult and CAMHS workstreams.  

Supervision Requirements 

Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training: 

• NES Generic supervision competences training (GSC) (or equivalent) 
• NES Specialist Supervision Training: CBT (adult or child focus) 

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills.   

Theory of Change  

Cognitive theories have been proposed to explain the development and maintenance of OCD.  

According to Foa and Kozak’s theory, OCD is characterised by erroneous cognitions that include; a) the overestimation of the likelihood of danger in safe conditions; and b) the exaggeration of the graveness of consequences associated with negative events.  

According to Salkovskis’s theory, responsibility is identified a key issue for the onset of obsessions. Catastrophic appraisals of obsessions translate to increased sense of responsibility, which in turn increase anxiety and cause compulsions to exert control over obsessions.  

Behavioural theories for OCD include the Mowrer's two-factor theory of fear and avoidance. The theory suggests that, when triggered, anxiety provoking obsessions can prompt avoidant behaviours or compulsions for the purpose of reducing the anxiety associated with the situation. These behaviours reinforce fears, which in turn strengthens both obsessions and compulsions.  

Hence CBT, that includes ERP, targets the unhelpful cognitions that are crucial in the transformation of normal unpleasant thoughts into obsessions. It also targets behavioural responses that occur with the triggering of anxiety or obsessions. CBT that includes ERP is therefore expected to help patients challenge their existing fear response, increase tolerance to distress without engagement in unhelpful behaviours, and hence, eliminate avoidance and compulsive behaviours.

Fit 

Values 

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. In the context of OCD, CBT, which includes ERP, involves cognitive and behavioural strategies that address OCD associated thoughts and compulsive behaviours. Cognitive and behavioural theories that have emerged to understand the development and maintenance of OCD include Foa and Kozak’s theory, Salkovskis’s theory, and Mowrer's two-factor theory of fear and avoidance. 

• Does the focus of the intervention align with the requirements of your organisation?

Priorities 

CBT (including ERP) for OCD focuses on; 1) cognitive strategies that address unhelpful cognitions and beliefs which are crucial in the transformation of normal unpleasant thoughts into obsessions; 2) exposure therapy, which is the systematic introduction of anxiety/ obsession provoking triggers, and 3) response prevention to reduce the need to engage in compulsive behaviours. CBT (including ERP) therefore aims to help patients confront their fears, increase tolerance, and reduce their urge to engage in compulsive behaviours. CBT (including ERP) can be delivered to children, young people and adults, in individual, group or family formats, either in-person or as a remotely delivered intervention (with varying levels of therapist’s assistance). 

• Does the OCD focus of CBT (including ERP) align with the priorities of your service?
• What population will your service like to deliver this intervention to?
• In what format will CBT be delivered (in-person vs online; individual, group or family)?

Existing Initiatives

• Does your service currently deliver interventions to treat OCD?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce 

Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBT can be delivered to patients weekly, typically over 12-15 sessions. 

• Does your service have qualified practitioners who are available and interested in learning and delivering CBT?
• Can your service support the time commitment required for practitioner training and intervention delivery?
• Will your practitioners deliver CBT face-to-face or remotely (including guided self-help CBT)?
• If delivered face-to-face, is there capacity to support its delivery?

Technology Support 

Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision. 

• Will CBT be delivered in-person or remotely?
• Does your service have the technology to support CBT remote delivery?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support 

Low intensity CBT (including ERP) can be delivered in up to 10 therapist hours per patient, and is typically delivered to patients with mild functional impairment. More intensive CBT (including ERP) can be delivered in more than 10 therapist hours per patient, and is delivered to patients with moderate to severe functional impairment. CBT (including ERP) can be delivered remotely or in-person. In-person delivery can be held in several settings including outpatient settings, hospitals, and residential treatment settings. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports. 

• In what setting will CBT be delivered?
• Does your service have a venue to deliver CBT sessions?
• Can administrative supports be provided to deliver CBT as a low and high intensity intervention?

Financial Support 

Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost. 

• Can your service financially support practitioner training costs accessed outside the NHS?

Comparable Population

CBT (including ERP) has been shown to be effective in the treatment of OCD in children, young people, and adults. Its effectiveness has been demonstrated when delivered alone. It has also been shown to be effective when delivered in combination with pharmacological interventions (e.g. SRI) to people with persisting OCD symptoms despite the use of pharmacological interventions.  

• Is this comparable to the population your service would like to serve?

Desired Outcome 

CBT (including ERP) is associated with significant improvements across several outcomes including OCD symptom severity, depression, anxiety, functioning, and social adjustment.  

• Is delivering CBT (including ERP) for the treatment of OCD a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?