EXPOSURE AND RESPONSE PREVENTION FOR OCD
What is Obsessive Compulsive Disorder (OCD)?
Sometimes referred to as the “doubting disease,” Obsessive Compulsive Disorder (OCD) is characterized by unwanted, automatic and intrusive thoughts called “obsessions.” In response to the distress generated by these obsessions, sufferers will engage in mental or physical rituals called “compulsions” to reduce distress or prevent feared outcomes. Compulsions can temporarily make the sufferer feel better and may seem to eliminate doubt for the time being. However, a powerful feedback loop begins to develop where doing compulsions reinforces the strength of the obsessions and teaches the brain to pay a lot of attention to what the obsessions are saying.
Many people living with OCD spend years suffering without receiving appropriate treatment. Some treatment approaches that are highly useful for other psychological difficulties stall when it comes to OCD, because of the unique nature of the disorder. Clients often enter the therapy room exhausted and frustrated after trying different treatments for their OCD with minimal success. Even worse, clients may start to blame themselves for being unable to reason their way out of intrusive thoughts, and become consumed by feelings of guilt, hopelessness, and self-loathing.
Read about OCD subtypes here.
How do I know if I have OCD?
OCD is often portrayed in the media in the form of excessive hand washing or extreme tidiness. The diagnosis is thrown around casually to indicate a strong preference for order and visual symmetry. While some OCD-sufferers do struggle with intrusive thoughts around cleanliness, symmetry and exactness, there are dozens of manifestations of OCD that we don’t see as often in the public eye.
Some examples of less openly talked about OCD themes include: fear of losing control and hurting a family member, friend, or stranger, fear of being a pedophile, fear of not knowing one’s “true” sexual orientation, fear of forgetting, fear of blurting out insults or offending someone, fear of losing important information, fear of being in the wrong relationship, fear of having blasphemous thoughts, fear of becoming suicidal, or the fear of someone else’s essence rubbing off on you. If your specific OCD theme is not listed here, don’t fear! There are dozens of ways that OCD can manifest. We can help you understand how your OCD functions and the cycle that maintains OCD symptoms. When people don’t know they are suffering from OCD, they begin to buy into their thoughts and can start to believe that they are horrible, bad, dangerous, sick, or doomed. Unfortunately, many people with OCD suffer for years without realizing that these scary thoughts have a name and can be treated.
How do you treat OCD?
Exposure and Response Prevention (ERP) is considered the gold standard treatment for OCD, and is strongly supported by scientific research. ERP involves gradually facing feared thoughts and situations with the support of a therapist (exposure), while at the same time resisting strong urges to engage in compulsive behaviors (response prevention). As a result, you build up the ability to respond differently to intrusive thoughts and learn that you can cope with even the most intense discomfort. You learn to sit with all of the thoughts your brain generates without having to act on them. You begin to see thoughts as strings of words on repeat rather than as mandates or absolute truths. You confront situations that have been avoided or tolerated with great distress, and regain the ability to engage with the world, even in the presence of unwanted thoughts. There are many reasons why OCD-sufferers do not receive ERP treatment: lack of information, resources, or access, fear of facing fear head-on, or difficulty setting aside time to prioritize treatment. As OCD specialists, we also integrate mindfulness and acceptance-based approaches into our work with clients when appropriate.
I don't think I do compulsions, I'm just in my head all the time. How can I get better?
Many people enter into treatment for OCD believing that they have “obsessions”, but no compulsions. Obsessions are intrusive thoughts, images, or impulses that cause distress, while compulsions are what you do to avoid or get rid of that distress. We often hear people say things like, “I don’t do anything in response to my intrusive thoughts, I just have them!” If someone were to watch you struggle with your OCD, they might not see you “doing” anything. This is why OCD symptoms can go undetected or unrecognized for a long time. Yet oftentimes, even when clients think they aren’t compulsing, subtle mental compulsions are at play. These compulsions may be less obvious than checking the stove, excessive hand-washing, or avoiding sidewalk cracks. Mental compulsions may involve:
· Gathering evidence for and against your obsessions
· Replaying a scenario or conversation
· Mentally tracking the movements of yourself and others
· Monitoring your words in conversation
· Repeating information to yourself
· Debating, arguing, or trying to reason with your obsessions
· Mentally reassuring yourself
· Trying to block out a thought
· Replacing a disturbing thought or image with a new thought or image
For example, a client with postpartum OCD may have fears of losing control and harming her newborn baby. In these cases, a client can spend hours mentally reassuring herself that she would never do anything to hurt her child, replaying all of her interactions with her newborn, or trying to suppress intrusive images of harm and violence. If we were to observe this client at home, we might not see any obvious compulsions—most of her compulsions take up tremendous time and space inside her own head. There are specific strategies for coping with mental compulsions, which we must address in treatment to interrupt the cycle of OCD.
I'm only triggered in specific situations, not when I'm with my therapist. How will treatment help me?
OCD treatment needs to go to where the fear lives. If the fear lives at home, we need to go home. If the fear lives in public restrooms, we need to get near those subway station toilets. Whether it be school, work, in parks, in stores, on dates, with children, in a car, on the train—we need to shine a flashlight onto all of the places where OCD resides. This means that if all of your exposure work is done in the therapy room, treatment can stall. Successful treatment often requires in-vivo exposures (meaning, exposures that take place in the setting that you fear the most). In treatment, you may start by completing these exposures with your therapist. This may mean leaving the office couch behind and tackling new environments together. Then, your therapist can assign the task of completing manageable exposures on your own. Remember, you are often only in therapy sessions for one hour of a 168 hour week! The brain requires a great deal of repetition and practice to learn new things. Further, we can often find creative ways to target your core fears, even within the confines of a session. OCD treatment requires a great deal of creativity and flexibility, which is what makes OCD so tricky and yet so rewarding to treat.
I've done exposures, but I'm still suffering. Why?
One of the main reasons that people continue to suffer even after being “exposed” to their core OCD-related fears is that they are continuing to engage in compulsions. Sometimes these compulsions are so subtle that the person is not even aware that they are compulsing (see the section on mental compulsions above). An OCD specialist can help you identify all of the behaviors functioning as compulsions, and then help you pull back on them. Exposure without response prevention (confronting fears without stopping compulsions) will typically fail to produce the change you wish to see, because compulsions are the key ingredient that fuels OCD’s fire.
You might also check in with yourself to see if you are “white knuckling” your way through your exposures. “White knuckling” is like bracing for a big impact. You are metaphorically gripping your seat so tightly that your knuckles turn white, your body becomes rigid, and you wait for the worst to be over. It is a perfectly natural response to perceived threat, and yet, it often hinders new learning. One of the exercises we often do in session with OCD-sufferers involves observing the difference between saying “NO” to uncomfortable thoughts, feelings, and sensations vs. saying “YES.” We read aloud some of their intrusive thoughts and practice resisting and tensing up against the thoughts. We then practice opening up and being willing to be present with the thoughts without excessive struggle. When you say “YES” to intrusive thoughts, you are not agreeing with them or arguing about their validity in any way. You are practicing allowing discomfort to show up without guarding yourself against it or trying to push it away. This can be quite difficult, which is why many people start to “white knuckle” their way through exposures to feared thoughts and situations. When you rush through exposures, hold your breath, look away, go through the motions while mentally saying “I’m fine” over and over, distract yourself, or just try to get it over with as quickly as possible—you continue to teach the brain that whatever you are facing is dangerous and those intrusive thoughts tend to stick around. Through repeated practice, you can learn to stop “white knuckling” and it becomes easier to relate differently to your thoughts and feelings.
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