Question: I know about ERP, and I understand that OCD symptoms can be reduced by resisting rituals and then habituating to the anxiety brought on by obsessive thoughts. However…what if an obsessional thought requires no ritual? Confused!
Great question. I think that in all cases of obsessive-compulsive disorder (OCD), there is some type of ongoing ritual that maintains the obsessional thought. This is because OCD is caused by threat misappraisals that are perpetuated and negatively reinforced by compulsive behaviors. As long as your compulsive behaviors remain in place, you are prevented from having the type of corrective learning experiences that are necessary for you to recover from your OCD. The reason that ERP is so effective is because it allows you to build these types of corrective learning experiences into your daily life.
Sometimes a person has very obvious rituals; other times, rituals are more subtle. If you’re struggling with identifying your rituals, take a look at this list. With your example, the ritual might be mental rather than behavioral, which can make it more difficult to identify. I would ask yourself, “When my obsessive thought makes me feel anxious, what do I then do in order to escape/reduce this anxiety?” The answer is your ritual.
This is the reason why trying not to think about an obsession can (for some people) become a mental ritual.
Fortunately, there are multiple solutions to this problem:
Strategies for Responding to Spontaneous OCD Triggers
1. Do a thought exposure (imaginal exposure) in which you sit with the thought and focus on it purposefully. If you allow enough time to do this, you will eventually habituate. Note: you may need to do this multiple times but the process of habituation should accelerate as you get more practice. Some people use recorded audio loops to hear the thought again and again; others write the thought over and over again; still others say it out loud. This is a good example of ERP (exposure + response prevention).
2. Allow the thought to be there and don’t try to squelch it…but continue to go on with your day while allowing the thought to be there. This is a good example of response prevention. Many people may also include an exposure element by elaborating on the thought, giving it more detail, taking it to extremes…with the express purpose being that of habituation to the thought.
3. Another example is taking the obsession and turning it into an in vivo exposure. For example, if the obsession is something like, “I might have an unwanted bodily fluid on my hands,” an exposure might involve touching one’s hands to other parts of the body (face, legs, etc.) or touching other surfaces (toilets, etc.) to make sure that the unwanted contact has actually occurred. One would then go throughout the day without washing.
With all these strategies, anxiety will increase in the short term (i.e., the time subsequent to the exposure). However, ultimately, you will become less and less bothered by your obsessions as you get more practice.
The ultimate goal is to learn, “I can be okay even if I’m not as clean as my OCD tells me I should be,” “Dirty isn’t dangerous,” or some other such thought.
I think you already know these things logically. ERP is the means by which you can learn to believe these things experientially.
Questions? Comments? Other challenges when implementing ERP? Share below.