Exposure and Response Prevention
In this week’s episode our hosts Lauren Rosen, LMFT, and Kelley Franke, LMFT, discuss exposure and response prevention which is the gold standard treatment for OCD recovery.
What is exposure in exposure response prevention?
Lauren: Exposure is the process by which we face down the things that give us anxiety, we face down our triggers. So this is going to look really different depending on the theme of your OCD. If you’re interested in learning more about the different subtypes, we do talk about exposure and response prevention within the context of each of them in past episodes.
But if for example, you have harm OCD, you might find knives to be very triggering. And you might find yourself avoiding knives. Or you might find yourself using knives but then asking for reassurance that you won’t stab somebody. Or saying a prayer while using the knife in order to prevent the worst from happening.
So the idea is that if you’re avoiding something, of course, we want you to not be avoiding things because that’s going to limit your life. But then also, we want to have you do the response prevention piece as well.
In Vivo Exposures
Kelley: To piggyback off the exposure piece, there are lots of different types of exposures.
There are incidental or in vivo exposures that happen in real-life stuff. These typically aren’t planned, they aren’t in your exposure log… they’re just happening as life happens… And that plays a big role in ongoing recovery. Because that’s ultimately what we have to do. There are going to be triggers that are just going to pop up as life happens and your OCD will say to you, “Don’t do it” and your job is to DO IT. Whenever OCD tells you not to do something, effective exposure means doing it!
Lauren: Especially when it’s something that is important to you, right? Because don’t have to do everything that is scary 100% of the time. But when it’s interfering with something that you want to do you have to tell it say, no, bite me.
Lauren: Generally, imaginal exposures mean writing through this scary story of the worst-case scenario that could come to pass. Many clients will say they are already doing this in their mind, so why would they need to do this? But what happens is they then get to the end of this story and try to figure out how to avoid it or fix it, or ruminate on how awful it would be.
We’re not going to do any of that. You’re going to get to the end of the story and just sit with it. Allow the anxiety to come up and resist the urge to resolve this story.
Written Word Exposures
Lauren: Let’s say you have POCD. Likely the word child or pedophile is anxiety provoking for you. So these might be words you can play around with. You may write them down or practice saying them in your mind, and allowing the anxiety while resisting the urge to engage in compulsive behaviors.
Kelley: A lot of times people come in and they’re ready to do these gnarly exposures when a lot of the time we’re going to work more on the reducing of compulsions, the response prevention, and the exposures themselves aren’t so gnarly.
Exposures without response prevention
Lauren: It’s really important to know how to do Response Prevention from the beginning because otherwise, you’re just going to trigger yourself and do compulsions without knowing how to respond in a helpful way which just adds insult to injury really.
You end up doing the very thing that reinforces the cycle.
Kelley: That said when you’re first starting out doing exposures you will do compulsions. It’s when we see a huge flare of compulsions that we need to re-evaluate the intensity of the exposure.
Lauren: Absolutely. Oftentimes we start by delaying compulsions or reducing compulsions. It’s not an all-or-nothing thing. You don’t have to stop cold turkey.
Kelley: When we are doing these active exposures, we’re bringing up uncomfortable feelings and thoughts. We are not going to do anything about it. We’re not going to do what we typically would do, which is convulse. Depending on the person, we are going to start by delaying the onset of compulsions and reducing them. Or we can go cold turkey, depending on the person.
Ultimately, the response prevention is 85% of it. That’s a random number. There’s no research to back that.
Lauren: Really, it’s 100% of it. Because otherwise you’re just triggering yourself and doing compulsions so finding some way to do some degree of response prevention is all of it. In fact, it’s funny because if you could only do one of the two things in treatment then it’s response prevention, 100%. Because when you’re going throughout your daily life, the most important thing is that you’re not capitulating to the behaviors that are keeping you stuck and limiting your life.
Kelley: And that’s actually what makes it a disorder. It’s not the intrusive thoughts or the obsessions, it’s the compulsions because even after treatment, you will still get intrusive thoughts, unfortunately,
Response prevention with behavioral compulsions
Lauren: So what does response prevention with behavioral compulsions look like?
Kelley: So we could break it down into a few different types:
- Reassurance seeking
- Mental compulsions; mental review, rumination, counting
- Physical compulsions; checking, counting, washing, locking
So if we’re doing exposure and response prevention for hand washing (and just to mix things up, it’s not contamination, it’s emotional contamination). So say someone sees another person and it triggers them to think about the possibility of them taking on their personality trait. And because of this they feel compelled to wash their hands.
What we have to do is find what is anxiety provoking and expose ourselves to that. So, let’s go find the person. Or let’s write down all of their personality traits. And what we’re going to do is delay the compulsive behavior just a bit, we’re just trying to break up this cycle a little bit at a time.
ROCD and ERP
Lauren: Let’s take ROCD. Something that comes up a lot in the context of ROCD is, what if I’m not attracted enough to my partner? So you think about what triggers these thoughts.
For many, it’s scrolling through instagram.
They scroll online and see a good-looking person whom they find very attractive and wonder whether that means they aren’t really attracted to their partner. So instagram can be a great exposure for this.
So what you’re going to do is purposefully expose yourself by scrolling on instagram for ten minutes each day. And when you see an attractive person, those thoughts will arise and you will begin to feel anxious. You’re going to wilfully tolerate that anxiety. You aren’t going to go reassurance-seeking to your friends asking whether it’s normal to feel this way. You’re going to breathe, make space, and carry on scrolling.
Kelley: I won’t go into too much detail because we have other episodes on this but say a person’s obsessions are saying profanities, racist slurs, or homophobic comments and offending someone. Something that’s completely out of line with who they are. A mental compulsion is done inside our mind to try and solve that uncertainty.
So they may think:
Did they seem alarmed?
I need to remember what I said.
Did they seem alarmed?
What was their facial expression?
They bring it up in their mind as a form of self-reassurance to be sure they didn’t offend anyone.
Lauren: In general, put a big label of rumination on mental compulsions. Rumination is the act of trying to figure it out. As if there’s an end date, there isn’t. Rumination keeps going, keeps on, and it just gets worse and darker. And the hole gets deeper… abort mission!
Kelley: We like to talk about problem-solving, which is time limited. It can be solved because there’s an actual deadline for something.
Lauren: Right! So if we go back to the problem of obsessing over whether we offended someone with racial slurs or homophobic comments, for example. The exposure piece would ask you to go out in public and think about those comments in your head as you’re walking around. The response prevention asks for you to resist the urge to figure out whether or not you said those words aloud, whether or not you offended someone, and simply allow the uncertainty of whether or not you said these things out loud.
Lauren Recommendation (13:26) – The mindfulness workbook for OCD