Cognitive Behavioural Therapy

General Information

NICE (National Institute for Health and Care Excellence) is the independent organisation responsible for providing national guidance for the UK on the promotion of good health and the prevention and treatment of ill health. They review current research about the treatment of different disorders and make recommendations about treatment options for these disorders. 
  • Cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) should be offered as first line therapy for children, young people and adults with mild to moderate OCD
  • Drug treatments (selective serotonin re-uptake inhibitors (SSRIs)) should be offered as an alternative to CBT (including ERP) for patients with more severe OCD or who decline, or do not respond to, psychological treatments
  • Adults with BDD should be offered the choice of either a course of an SSRI or CBT (including ERP) that addresses key features of BDD
  • A list of accredited therapists in Ireland and Britain can be found on the BABCP website. Please visit the Finding Psychiatrist/Therapist page on this website under the heading “Seeking Help”


CBT is based on a programme of structured self-help. Behaviour Therapy began in the late 1960’s and is the most researched psychological treatment for OCD. It involves repeatedly confronting feared situations that are avoided (a process called “exposure”). For the treatment to be successful, the exposure needs to be long enough for the anxiety to subside. The fear needs to be constant and the exposure should be repeated often. Exposure needs to be done without performing a compulsion (a process called “response prevention”) and to therefore learn to tolerate the discomfort that occurs. this technique is called exposure response prevention (ERP). If you do perform a compulsion, then you should repeat the exposure to “undo” the compulsion.

Each individual has a personal hierarchy. This means that each person starts by confronting easier situations and then gradually works up to more difficult ones. Facing up to each fear becomes easier and easier and the anxiety gradually subsides. The short-term side effects consist of anxiety and distress, but these will gradually decrease and, in the long-term, the fear will subside. No one is forced to confront their fears but the sufferer is encouraged to take responsibility to devise their own programme. A therapist does not have to be present, although it may help some individuals at the start of their treatment programme. Tasks need to be challenging but not overwhelming.

There are a number of excellent self-help books (For example ‘When once is not enough‘ by Gail Steketee)

Many refuse to take part in a programme of exposure and response prevention or fail to adhere to a programme. Of those that do adhere, about 75% are helped significantly after 10-20 sessions as an out-patient. The risk of relapse after treatment is about 25% when you may require additional treatment. More severe cases (especially washers) may be helped by a more intensive programme as an in-patient or at home. Due to the high drop out rate and partial success with exposure and response prevention, research is being carried out to make it better. One approach is adding cognitive therapy.

Cognitive therapy suggests that OCD results when an individual misinterprets intrusive thoughts or urges as a sign that not only harm will occur, but that they may be responsible for it through what they do or what they fail to do. Therapy seeks to help the individual understand that their problem is one of anxiety rather than danger and to react accordingly. Individuals with OCD are therefore trying too hard to prevent harm. The solution becomes the problem. For example, a mother may try to suppress or neutralise intrusive thoughts about stabbing her baby. This has the effect of increasing the frequency of intrusive thoughts. The problem is not the intrusive thoughts but the meaning the individual with OCD attaches to them; for example “having such thoughts means I might act upon them” or “I shouldn’t be having such thoughts”.

This has the effect of increasing the degree of threat and responsibility and will lead the person to avoid having knives around their kitchen or being alone with their baby. This will further maintain their fear and prevent them from demonstrating they are just ‘thoughts’. Cognitive therapy will also try to help the person overcome the need for certainty and to alter the criteria they may use to terminate a compulsion (e.g. when “I feel comfortable” or “just right” – beliefs that will tend to maintain a compulsion.)

When you are receiving CBT, the most important ingredient is the homework that you do between the sessions.The therapist can only act as a guide or teacher and the more you practice on your own, the quicker you get better. When patients have completed a successful course of treatment for OCD, most experts recommend follow-up visits for at least 6 months to a year.

Cognitive Behavioural Therapy is often used with anxiety disorders, depression and OCD as well as with Trich. The CBT therapist with work with the person to identify what may set off the urge to pull as well as to develop new skills to cope with the urges in a different way. The goal is that by becoming more aware of his/her triggers, such as stress, emotions, boredom, etc. this will help the person develop/ learn new skills to cope with the Trich more effectively. This type of CBT is called Habit Reversal Training (HRT). 
It is important for the person with Trich to check out a CBT therapist.s knowledge of this disorder. Not all people who say that they use CBT are properly trained or fully understand Trich and the appropriate treatments.
Watch the following video to learn more about the causes and treatment of TTM: Trichotillomania linked To Gene Defect!
Tips for self-management of the urge to pull

These are a collection of ideas from people who have TTM/Trich on how to substitute the sensory stimulation and emotional soothing that the pulling provides for you. Feel free to share your tips with OCD Ireland of what works for you.

Create a barrier. … to reduce the tactile sensation

  • Transparent micro-pore tape (available in pharmacies) place a little bit on both thumbnails & it reduces the ability to grip short hair & it is quite discrete.
  • Put a barrier cream like Vaseline on brows or target hotspots to reduce grip.
  • Band aids and gloves are useful barrier tools.
  • Keep barrier tools available where needed – the hotspots round your house, office, car, anywhere you are likely to pull.
  • Wear gloves if you pull when driving… thin leather (like golfing gloves) are best – and put them on before you get into the car – each time! Remember to acknowledge your success when you arrive without pulling each time.
  • Other useful barriers include hats, scarves, wigs/hairpieces/volumizer, etc.

Alternative sensory input – Invest in some massage tools such as a:

  • Head massager (“the tingler” works for some, available online)
  • Hand/foot massager
  • Back scratcher

– Give yourself a treat with a head massage & hand massage at least once a day.

Toys for your hands

  • Latex stretchy toys, or plastic or wooden spikey toys (available in Euro shops, craft-shops and on-line – search for office stress toys)
  • Keep these toys in all your hot spots – zones where you pull most such as where you read, watch TV, talk on the phone, etc

Things for your mouth

  • Coffee stirrers – plastic/wooded coffee stirrers have saved many a hair by offering something interesting to do with your mouth. Be careful of your teeth though!
  • Try ice chips in the mouth but be careful of your teeth. This is also good for pressing onto an inflamed or itchy spot that is drawing your hand to pull.

Reduce scalp, eyelid irritation and inflammation: If inflammation, itching or localised skin irritation is drawing your hand to pull, see your doctor, or a dermatologist or perhaps your local chemist and ask about topical steroid soothing lotions, shampoos, etc.

Adopt a slogan that speaks to you:

  • Be gentle
  • Let it grow
  • Progress, not perfection
  • One day at a time
  • I am not alone
  • Let go and let God
  • Together we can make it
  • Keep it simple
  • Just for today
  • It begins with me
  • Recovery isn’t a straight line

If you have more ideas to add to these suggestions, please email them to OCD Ireland at . Good luck!

CBT for Body Dysmorphic Disorder
Cognitive Behavioral Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together. Specifically, it is believed that our thoughts determine our feelings and our behavior. Therefore, negative – and unrealistic – thoughts can cause us distress and result in problems.
Cognitive behavioural therapy as a treatment for BDD is based on the therapist’s understanding of each client’s individual problems with how they perceive themselves. Once this has been ascertained the therapist and client will work together to identify goals and to agree to a shared treatment plan. The aim is to enable the client to look at their harmful thinking patterns towards themselves and work towards altering them. The client is very involved in his or her own treatment path from start to finish.
The particular therapeutic techniques vary according to the client’s individual issues, but commonly include keeping a diary of daily related events and associated feelings, thoughts and behaviors. As therapy progresses, the client begins to recognize negative patterns of thought as they arise. Also, Exposure Therapy may be introduced, whereby the client is encouraged to question and test those assumptions, habits or thoughts that might be unhelpful and unrealistic. Therapists refer to this process as ‘Cognitive Restructuring’. The clients are then gradually exposed to activities which they may have been avoiding, or to new ways of behaving and reacting in certain situations.
An example of exposure therapy is to take a client who is ashamed of their arms, and gradually introduce short sleeved clothes into their wardrobe over time; beginning in the client’s own home, moving on to the therapists office, and eventually into social occasions. Exposure therapy may require several sessions in order to ease a client into a new mode of thought and action. It may in some cases also be quite stressful, so relaxation and distraction techniques are commonly included.
The crux of behaviour-based therapy for treating BDD is that sufferers will have so internalised their beliefs that traditional ‘talking therapies’ are inadequate- simply discussing the antecedents of the disorder cannot change the way a BDD sufferer sees themselves. Action therapies which work on negative thoughts and behaviours in the here and now are the clearest path to improvement.
Cognitive Behaviour Therapy may be embarked upon with or without the accompanying use of medications such as SSRI’s or anxiolytics, and has attained positive results for many sufferers of BDD in either case.
It is becoming increasingly apparent, however, that CBT (Cognitive Behavioural Therapy) coupled with Exposure Therapy, may be the most effective method of treating BDD. For further information please consult the National Institute of Health Clinical Excellence.