Does CBT always work for OCD? Dealing with guilt from CBT not helping:

CBT (Cognitive Behavioral Therapy) with Exposure Response Prevention works really well for a lot of people with OCD, however there are some people who may not benefit from it as much.


Because CBT and ERP involve resisting compulsions and challenging obsessions, people may feel as if they have 'failed' if CBT has not helped them. This thought is false. One therapy isn't going to help everyone, even though the people doing it have the same condition. There are some situations in which CBT for OCD may not be appropriate, such as if the person has PANS/PANDAS. Some people with PANS/PANDAS/BGE report that they do not see benefit from CBT until the inflammation and underlying infectious triggers and other triggers are addressed. People may use CBT after this if necessary, to address residual symptoms. People with tic-related / Tourettic OCD may also not see much benefit from CBT, as Tourettic OCD is physical sensation based, whereas CBT is used mainly for Classic OCD. In Tourettic OCD, there are no intrusive thoughts or fears before a ritual to work on, and resisting compulsions may work like tic suppression, and exacerbate issues later on. (Both Tourettic OCD and Classic OCD are common in the Tourette's community, a person can have Tic-related OCD without having Tourette's.)


Some people may be dealing with many other issues, such as brain fog, psychosis, loss of coordination, loss of emotional regulation, memory decline, etc, that makes doing CBT more of a challenge.


TW SH: For some people, doing CBT may be too dangerous, as resisting rituals may cause so much distress that it triggers the person to harm themselves or others (due to meltdowns or rage attacks).


Some people feel that their anxiety is too intense to resist compulsions, and this is completely valid. This is why some people take anxiety-reducing medication before they start CBT. Some people find CBT too distressing, and that is okay, not everyone is ready for recovery straight away. There are a lot of people who have some little rituals their whole life, so there is no shame in it, but things can get better and you do deserve a better quality of life.


CBT / ERP works on the premise that the thoughts are not the problem but the beliefs about the thoughts and the reactions to them are. This is very often true, but there are some cases where the thoughts may not be associated with compulsions, but may be an issue in themselves because they are distracting and may be so frequent that a person struggles to write or perform actions which take a lot of focus.


Some people may have very limited insight into the irrationality of their OCD, so some people may feel that their compulsions do serve a necessary purpose. Some of my compulsions were something that I thought could help solve a perceived problem and I felt like they may be necessary to an extent, though trying to stop was a challenge that caused anxiety. If I learnt over time that what I was doing wasn't fully necessary, that helped it reduce. I had to relearn how the world worked again and eventually see that my obsessions were false. Some of my obsessions and compulsions I could tell were irrational though and I did try exposures for some of these.


Some people may try to resist mental compulsions but find that an intrusive thought or mental tic may do the compulsion for them, as mental tics and intrusive thoughts may do what a person doesn't want to do, so a person may perform the mental compulsion uncontrollably, as if another person in the mind does it just to annoy us. This could happen because we are trying so hard not to do it.


Sometimes we may feel so guilty doing the rituals that trying to avoid the rituals becomes a compulsion in itself - this gets very confusing!


If CBT doesn't help, a person may blame themselves and be judged by others. They may judge themselves as being 'weak' and 'lacking willpower', when this is NOT the case at all. This can lower someone's self-esteem and make them feel worthless, and this can sometimes do more damage to someone's mental wellbeing than the OCD itself. You NEVER need to feel guilty if CBT didn't work for you.


Some people feel like an outcast from the OCD community... They may see so many OCD advocates talking about the importance of doing exposures and resisting rituals, that a person feels as if they do not belong in that community. I have been there. It's isolating.


You do belong and there will be people who understand you and who have been in the same situation as you. Different things work for different people. CBT has never helped my OCD in the long-term, but Sertraline and antibiotics did (antibiotics as my OCD is from PANS/PANDAS).


Sometimes we end up having to work more on the guilt and self-blame stemming from CBT not working than the OCD itself. We need to stop blaming people for CBT not working and be aware that hearing about the importance of doing exposures all the time can be isolating and upsetting for some people.


People are not textbooks, so everyone's OCD is different. Just because a textbook says something will work, doesn't necessarily mean it will.


If you can do CBT / ERP, and if it helps you, then that is fantastic and I recommend you keep working on it to improve your quality of life. If it doesn't work however, I understand and that is okay. You never need to blame yourself.


Key Points:

  • One specific type of therapy may not help everyone.

  • Blaming someone for CBT not working lowers their self-esteem and can worsen their mental health.

  • You never need to feel guilty for therapy not working. It NEVER makes you weak.

  • You didn't fail CBT, CBT failed you.


Disclaimer:

Disclaimer: I am NOT a medical professional, this is NOT to be used as a substitute for diagnosis or treatment from a qualified physician, this is to be used for educational purposes only. For medical advice, please see a medical practitioner. I do NOT claim to treat, cure or mitigate any condition.