Many people who struggle with OCD symptoms do not know where to turn for help, and common therapeutic practices like talk therapy can sometimes cause symptoms like hyperfixation to worsen. My hope for the last part of this series is for people with OCD symptoms to find and connect with therapists who can provide quality, affirming treatment. These therapists will most often be trained in Exposure Response Prevention (ERP), mindfulness, and somatic practices, and they specialize in helping clients break free from persistent thought patterns and compulsive behaviors.
Exposure Response Prevention (ERP) is often referred to as the “gold standard” of OCD treatment. It is a subtype of Cognitive Behavioral Therapy (CBT) designed specifically to help clients identify the causes of their anxiety and abstain from compulsive behavior. The more a client can keep from compulsing, the less intense the anxiety will be. Over time, they will come to learn that the compulsion was never helping, but rather feeding the anxiety more and more.
Habituation is necessary to filter out irrelevant information and to focus on what’s important. Without it, we would be constantly overwhelmed by sensations. A baby who hears a new sound for the first time may be scared, but after they hear it repeatedly, they get used to it. For most people with OCD, they struggle with letting go of fears that should be filtered out. ERP helps people make letting go a habit.
Examples of ERP Treatment
The primary types of exposure are:
In vivo exposure
Imaginal exposure (including virtual reality)
Thought exposure
Bodily sensation exposure
Let’s look at how a therapist might use each type to treat a client with OCD about symmetry and order:
In vivo: Client must move an object in the office out of its “correct” order
Imaginal exposure: Client must imagine moving an object out of its “correct” order
Thought exposure: Client must sit with the thought “I am an awful person if I am not perfect”
Bodily sensation exposure: Client must sit with the uncomfortability in their body when something is out of order
Each of these examples will be done in a specific time increment before the client is allowed to engage in compulsion or move on from the task. As shown, the exposures are meant to teach clients how to sit with uncomfortability and the unknown.
The ERP Process
Exposure therapy is different than many other types of therapy and can sometimes be intimidating to start. To help you get a glimpse into the process, here is a step-by-step example of what I do with clients.
Assessment
Psycho-Education
Exposure Hierarchy
Exposure
Response Prevention
Let’s explore each stage in more detail:
Assessment
It is essential to start by assessing whether or not your symptoms or issues are coming from OCD or something else, like PTSD or anxiety. Otherwise, you could end up doing exposures that may worsen or exacerbate your symptoms. One of the best ways to discover where your issues stem from is the Y-BOCS, an assessment specifically made to measure the severity of OCD symptoms.
The Y-BOCS and other OCD assessment tools can often be triggering, so therapists should prepare to help clients ground themselves afterwards. But its answers will help decide if ERP is right for you, and lead into these next steps.
Psycho-Education
ERP can often be a confusing therapy tool for first-timers as the therapist will be intentionally triggering you to help you learn how to ride through the dysregulation. Because of the intensity of this process, it is important to find a therapist you can trust and who can teach you about the process before you begin.
Before you begin exposures, the therapist should get to know you outside of your OCD; who you are, what you like, and how you fill your time. They should also be helping you build up some coping and regulation skills that you can use to help you through the exposures. Going too far too fast can often rupture the relationship and leave you worse off than when you started.
Psycho-education will also include learning the function of your compulsions and what they are helping you avoid. For instance, someone with Harm OCD might be ruminating on their feelings and memories in order to avoid the fear of being a bad person or losing control.
Once they can name these main fears, many people feel like they have more of a handle on their OCD. Instead of an evil monster, it becomes an annoying pest they are learning how to exterminate.
Exposure Hierarchy
Once trust is built and you have a basic understanding of your fears and how to address them, it’s time to build a hierarchy. Here, you will create a list of exposures from least distressing to most distressing. The idea is to start small and work your way up as you gain confidence and ability to face your fears.
Here is an example of an exposure hierarchy for someone with Contamination OCD along with their distress levels (SUDS), ranked from 0-10.
SUDS 3: Being around a sick person
SUDS 5: Shaking the hand of someone who is sick
SUDS 9: Shaking the hand of someone who is sick and then shaking another person’s hand (thereby spreading it)
In this example, the client is afraid of being sick but is even more afraid of making someone else sick. We can assume here that their main fear is losing control or harming someone else.
Response Prevention
Now here is the hardest part: not responding to your OCD.
Response prevention truly shows how important it is to have a therapist and a plan you can trust. Clients often feel lonely and hopeless when first starting, and a great therapist can help you feel confident, comforted, and in as much control as is healthy, ready to take on your next exposure.
Here is an example of response preventions that may be a part of the client’s plan with Contamination OCD:
SUDS 3: Being around a sick person
Delay hand washing for 5 minutes
SUDS 5: Shaking the hand of someone who is sick
Delay hand washing, showering, or changing clothes for 30 minutes
SUDS 9: Shaking the hand of someone who is sick and then shaking another person’s hand (thereby spreading it)
No hand washing, showering or changing clothes
In this example, the person must delay certain or all compulsions for a set amount of time, until the last one when they are tasked to not engage in the compulsion at all.
If they feared just being around someone sick would cause them to lose control or harm someone else, you can imagine how difficult it would be to also shake the person’s hand and then not engage in their safety behaviors. The goal, however, is to help them balance their fears with reality, and sit in the uncomfortability of the unknown. They can then start to enjoy other people’s company again and stay in the moment, rather than getting lost in panic and repetition.
Mindfulness and Somatic Practices
As mentioned in the beginning, ERP is most helpful when combined with mindfulness and somatic work. Mindfulness helps you to differentiate between OCD thoughts and thoughts coming from your true, wise Self. And somatic work helps you to differentiate between panic you should listen to (i.e. a bear stalking towards you) and panic that is not so useful (i.e. worry that your family will be harmed if you do not count your steps) and then sit with it as it lessens.
Mindfulness
Mindfulness will most often come into play when beginning the Psycho-Education and Exposure Hierarchy steps. Through this practice you will learn how to see your thoughts as just thoughts. Instead of immediately reacting to each thought, you can filter through them and decide which ones are important and which ones are not. That way you can identify the OCD thoughts, minimize them, and throw them out. It sounds much easier than it is, but many people will find after OCD therapy that they don’t even notice their OCD thoughts, and if they do, they can more easily let go of them.
The Flowing River is a mindfulness practice you can try on your own. You can start by finding a comfortable seat, closing your eyes, and taking deep breaths. Then bring to mind a flowing river, maybe one you know or one that seems peaceful and calm. Spend some time just sitting by it, enjoying the sounds around you, and even dipping a foot or toe in if you’d like. After you begin to feel more relaxed, imagine your thoughts descending down the stream as fallen leaves, rocks, bugs, or any other natural object. Notice how your body reacts to them, but try not to stick to any for very long. Watch them continue to flow away as you bring your attention back to the river and the next thought.
Somatic Practices
Somatic work will come into play when beginning the Psycho-Education and Response Prevention steps. These techniques help you to tune into your body’s sensations and emotions. You can then learn how to identify what sensations seem to accompany OCD thoughts. For instance, you may feel your gut sink, head race, and throat tighten when an OCD thought arises. It may feel more intense and prolonged than sensations that accompany other thoughts or fears. By learning how to relate these sensations to OCD, you can more easily identify them as useless and misplaced, and then direct your attention to activities or experiences you know are true.
In Summary
This three-part series was meant to provide you with information about what OCD is, how to know when it’s time to seek help, and what types of treatment to look for when you do. It can be life changing to tell your story to someone who is familiar with the monster who follows you and isn’t afraid of facing it with you.
If you’ve read these posts and are thinking that now might be the time get support to get unstuck from OCD anxiety and compulsions, please reach contact us to schedule a consultation with one of our therapists. Separation from you OCD Mind is possible.