For people with Obsessive-Compulsive Disorder (OCD), it can feel like their mind and reactions are playing tricks on them. People with OCD get in a stuck pattern after they are triggered, overestimate the threat of the trigger, and then engage in avoidance or compulsions to try to get rid of their distress. This process wreaks havoc on their ability to function and can impact their relationships, roles, and jobs. For instance, someone with obsessions about being contaminated by germs and getting sick may not be able to go out in public for fear of contracting those germs (a type of avoidance). If this person fails to avoid germs when a neighbor comes over and starts coughing, s/he may then excessively clean themselves or their home to decontaminate (a type of compulsion). This highly debilitating disorder can be quite common, with 2.5% of the U.S. (or 1 in every 40 people) meeting criteria for the disorder during their lifetime.
OCD has two main components: the obsession with possible threats, and the compulsion to neutralize the obsession. There are many types of obsessions or fears, such as:
- Contamination of self or others
- Harming others or being responsible for harm
- Unwanted sexual thoughts
- Believing that thoughts will lead to actions
- Discomfort when things are not “exactly right”
Compulsions can come in a number of forms, as the brain is highly creative in trying to neutralize anxiety. Compulsions can look like, but are not limited to:
- Checking behaviors or thoughts
- Confessing “bad” thoughts
- Mental compulsions such as preventing harm by using “safe” numbers or ending all interactions with a “good” thought
- Washing or cleaning
- Repetitive behaviors
The good news is that there is hope for those struggling with OCD, through an evidence-based treatment called Exposure and Response Prevention (ERP). ERP is considered the “gold standard” in treating OCD and is the preferred treatment prior to talk therapy.
ERP therapy is effective because it addresses both the obsessions and the compulsions that keep the brain stuck and behaviors habitual. During exposure, the client and therapist work together to put the client in situations where the distorted fear is triggered but the client stays with the situation instead of avoiding it mentally or behaviorally. With exposure practice, the anxiety goes down to more manageable levels, and the client can tolerate more exposure. During response prevention, the client practices new behaviors or thoughts instead of the typical compulsions. For instance, if a client’s compulsion is to tap their fingers a certain number of times to eradicate “bad” thoughts, then the client will put their hands in their pockets instead.
In summary, ERP teaches new learning. With exposure, the client learns that the fear is distorted and that they can tolerate it. With response prevention, one learns how not to make the anxiety worse and how to stop the cycle of compulsions.
ERP can sound counterintuitive at times, especially for someone who has been entrenched in OCD patterns. Here are some guiding concepts about ERP therapy:
- Exposure work should be connected to addressing the core fear. If a client becomes overwhelmed with the uncertainty that their family member might have died or had an accident since their most recent contact, then exposure is about situations that bring up that fear of the uncertainty.
- Exposure is done with the client’s permission and agreement, and the client is active in coming up with scenarios that will address the core fear.
- Some clients fear that they will be forced to endure the most extreme example of exposure at the start of ERP therapy. For instance, if a client has a fear of germs, they may fear that they are going to have to sit in a dumpster or touch the inside of a toilet bowl at a busy public restroom during early sessions. This approach can be too overwhelming, could reinforce the original fear, and may lead the client to view ERP as a failure.
- Instead, the client and therapist work together to list out a hierarchy of exposure activities, and the list is based on how distressing the task feels to the client. The most distressing task on the hierarchy only needs to be as extreme as needed for the client to complete the goal of therapy. The client can opt to move from the easier exposure tasks up to the more challenging, gaining confidence over time. Research also supports jumping around the hierarchy so that the brain can learn to handle the element of surprise.
- Many clients may believe that they should not feel any distress in an exposure or response prevention situation, and so they either wait for the distress to go away entirely before moving on, or may give up, in the belief that the therapy is not working. Instead, the idea is for the client to be in the presence of the fear and learn that the distress will peak and then lower substantially.
- Response prevention techniques are not the same as distraction. Distraction is a very valid way of getting through a difficult, anxiety-provoking situation. However, distraction does not encourage new learning, so it is not a recommended skill to use during ERP therapy.
The encouraging news is that ERP can be highly effective in helping the brain to unlock from the patterns of OCD. If you or a loved one are looking for help with OCD treatment, please ask potential therapists about their familiarity with ERP therapy.