This is the final post in the series on obsessive-compulsive disorder (OCD)—a psychological disorder associated with obsessions (recurring thoughts, urges, etc) and compulsions (repetitive behaviors in response to obsessions).1 Today I conclude my discussion of exposure and response prevention (ERP), which is one of the most effective treatments for OCD.2
Last time I used the example of someone named Charlie who had germ-related obsessions; for instance, Charlie found taking out the garbage highly anxiety-provoking. After creating a fear hierarchy (see picture), Charlie began his gradual exposure to anxiety-causing situations on his list.
Exposure and response prevention (ERP) requires one to stay in the obsession-related stressful situation until anxious feelings dissipate. During and after exposure, the individual must refrain from engaging in compulsions and other forms of avoidance (e.g., distractions).
But what if, unlike for Charlie’s obsessions, there are no exposure exercises for your obsession? For instance, if you obsess about running over an animal when driving, or going to Hell for being a bad person, how can you practice real-life exposure?
One solution is imaginal exposure.
To illustrate, consider Jessica obsessions. Often when Jessica feels very angry and enraged, she obsesses about the possibility of one day becoming a murderer. The thought makes her highly anxious. Various treatments have not helped, so her therapist has suggested imaginal exposure. Because the thought of murder is so upsetting, Jessica creates a hierarchy for her imaginal exposure, and begins with exposing herself each day to anxiety-provoking thoughts lower on the hierarchy first.
For instance, Jessica spends 45 minutes each day imagining that, in a fit of rage, she punches a stranger in the face at a bus stop.
Before she begins practicing imaginal exposure, Jessica writes a script in which she includes her feelings, thoughts, and behaviors at the scene. Jessica’s script is very detailed. For instance, she tries to visualize the scene as she punches the person at the bus stop, the victim’s look of horror and pain, the pouring of blood from the victim’s nose and mouth, the faces of bystanders who are terrified and shocked, the sound of sirens approaching, two police officers approaching her with their guns drawn, being pushed into the police car while crying, and so on.
Jessica uses this script to create an audiotape, and listens to the tape each day until her anxiety about the situation dissipates. In the coming weeks she will move to more anxiety-provoking situations, and eventually to visualizing murder. No matter the step, Jessica needs to focus on those aspects of the situation that makes her most anxious, and stay with those feelings for as long as necessary.
The logic of ERP
It is important to remember that ERP makes no promises; bad things (be they murder, suicide, catching a rare disease, etc) may occur. But the likelihood of such events is very low. So with the help of ERP we can learn to live our lives not in constant fear of rare events. The goal is experiential learning; that is why we need not an intellectual lesson but repeated exposure to our thoughts, feelings, bodily sensations, etc.
Refraining from performing the rituals and compulsions during exposure is necessary because if you perform your usual rituals you will not learn that the thing that triggered your fear (e.g., imagining yourself as a notorious killer) is not really dangerous. Nor will you learn that you have the ability to manage your feelings of anxiety, and that your anxiety will go down on its own even without you performing the compulsions.
If you are receiving therapy, you probably know that your therapist is not going to force you to do the exposure portion—or physically prevent you from doing the compulsions. Your success depends on your willingness to face your fears. You need to really believe this form of therapy is the way toward lasting change. You need to make a commitment.
OCD can gradually tighten the circle around you until your life is extremely limited. This happens gradually enough that you may not see all that you have lost. Therefore, one way to motivate yourself to face your fears or to try ERP, is by comparing the consequences of being disabled by OCD versus having it under control. To do so, try brainstorming about negative consequences of OCD—its effects on work, intimate relationships, choice of activities, etc. Then think about positive consequences of not being limited by OCD:
Where would you go? What activities would you try? How would you spend your day?
And when live a fuller life, what feelings might you experience? Will you feel happier and more confident? Well, try and find out! But there is a high likelihood that when you are able to think about your fears logically, you will have more experiences and many of them will be positive.
**Please note that this information is meant only for educational purposes, and is not intended to be a substitute for professional medical advice or treatment.
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
2. Strauss, C., Rosten, C., Hayward, M., Lea, L., Forrester, E., Jones, A. M. (2015). Mindfulness-based exposure and response prevention for obsessive compulsive disorder: study protocol for a pilot randomised controlled trial. Trials, 16, 167.