People with Obsessive Compulsive Disorder (OCD) perform compulsions to temporarily relieve themselves of the anxiety associated with their obsessions. A person with contamination fears, for example, may wash their hands repeatedly throughout the day and perform other cleaning rituals. While this temporarily reduces their anxiety about germs, in the long run it causes their OCD to get worse.
One approach shown to be effective in helping people overcome their cycle of obsessions and compulsions is called “Exposure and Response Prevention” (ERP). Considered the “gold standard” for OCD treatment, ERP is fairly straightforward: The person with OCD exposes themselves to situations that trigger obsessive thinking and doesn’t allow themselves to perform a compulsion in response. While this sounds simple, it does require the OCD sufferer to face their fears and tolerate a fair amount of anxiety to overcome their OCD.
There are several ways to go about Exposure and Response Prevention treatment:
Imaginal Exposure: With this approach, the person with OCD imagines in detail any thought or situation they find distressing. A person who repeatedly checks the locks on their front door, for example, might imagine a scenario in which they accidentally leave the door unlocked and their house is robbed. Many therapists will ask their clients to make a short recording describing the situation (1 – 2 minutes) and have them listen to it over and over again. While listening to the recording will trigger the client’s anxiety initially, the more they listen to it, the more they’ll learn they can tolerate the ensuing distress. As the client becomes habituated to their fear, their anxiety level and need to perform a compulsion in response will drop.
“In vivo” Exposure: With this approach, the client confronts situations that trigger their obsessions in real life. A person who has to have their desk arranged in a certain way, for example, may be asked to keep their desk in disarray. A person with fear of germs may be asked to use a public toilet or keep their hand on a dirty doorknob for an extended period of time. As with imaginal exposure, “in vivo” exposure may cause the client’s anxiety to increase initially, but with time and repetition, the client’s distress level and urge to perform a ritual (compulsion) will decrease.
Fear Ladders: Many therapists ask their clients to create a “Fear Ladder”, listing all situations or thoughts that cause them distress. The client rates each situation/thought on a scale from 1 to 10, with a 1 being the least anxiety-provoking and a 10 being the most anxiety-producing. After reviewing the list with their therapist, the client starts at the bottom of the ladder, facing their least-anxiety provoking fears first. Once they’ve learned they can tolerate the distress associated with those situations, they slowly move up the ladder, exposing themselves to increasingly challenging thoughts and situations.
Delaying the Response: Rather than telling the client they cannot perform a compulsion at all in response to their obsession, the therapist may start out by asking the client to simply delay their compulsion for 3 or 5 minutes. With time and practice, the client should be able to delay their compulsion for longer periods of time, until they reach a point where they don’t have to perform a compulsion at all.
Processing: It’s important for the client and therapist to talk about the exposure after it’s over. This helps the client gain insight about the experience that will be useful as they continue to work to overcome their OCD (e.g., “My anxiety was very high for the first 10 minutes, but I noticed that it dropped after that.” or “It wasn’t as bad as I expected it to be.” or “The more I did it, the less frightening it became.”)
Mindfulness: Mindfulness means being aware of and accepting what’s happening right now in the present moment. This can be very useful during exposure exercises. By acknowledging and accepting the distress you feel when facing your obsessive fears, the easier it can be to resist performing your compulsions. This is one of the great paradoxes of anxiety: The more you fight it, the stronger it gets. By accepting and inviting your anxiety in, the less intensely it’s likely to affect you. There are a number of ways to practice mindfulness including meditation, noticing what’s happening in your body, and paying attention to your five senses.
John “Andy” Bradshaw, Associate Marriage & Family Therapist #101517 (supervised by Dino Di Donato, MFT #39831) focuses on the treatment of OCD and anxiety at Market Street Center for Psychotherapy. You can contact him at (510) 599-9845 or firstname.lastname@example.org.
- Foa, E.B., Yadin, E., & Lichner, T.K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder (2nd edition). New York: Oxford University Press.
- Hershfield, J., & Corboy, T. (2013). The mindfulness workbook for OCD. Oakland, CA: New Harbinger Publications, Inc.