Obsessive Compulsive Disorder Treatment with ERP

Many, probably most, clients who have OCD are initially ambivalent about getting treatment.  If they have heard about Exposure and Response Prevention, the “gold standard” treatment for OCD, they know that more than talking is involved.  What’s “response prevention”?  It sounds pretty scary.

To understand ERP,  it’s important to learn to distinguish between obsessions and compulsions.  An obsession is what makes the client afraid.  Is he sure he turned off the stove?  If he leaves it on, there could be a fire.  A compulsion is what makes the client feel better.  He will go and check.

This sounds pretty simple so far.  Everyone occasionally has to check something.  The trouble is that in OCD, the very action that makes the client feel better, ends up making the situation worse.

If you don’t have OCD, you check the stove once, and that’s it.  The person with OCD , however, has to make absolutely sure the the house and everyone in it is safe.  Could there be a small possibility that he didn’t look at the switch properly?  He checks again…and again…  The problem is that there is no way to be 100% certain of anything.  The checking behavior is reinforced because he feels better for a few minutes after he checks, but the obsession keeps coming back.

OCD can show up in ways that are less obvious to other people.  The client can’t be 100% sure that she really loves and wants to stay with her partner.  She obsesses about it and has mental compulsions, going over her thoughts about him or her over and over again.  She may worry about getting cancer if she has to visit a hospital or doctor’s office.  If she thinks about a town where she had a bad experience when she is in a different town, both towns may become “contaminated” with negative feelings and she may have to avoid them and all the people that remind her of them.

Some clients have “just so” OCD.  They have to keep vacuuming or organizing until they “feel right”. Work may have to be done on a rigid schedule with no flexibility.  Nothing can be out of place.  Sometimes people without OCD joke about wanting to have a “little bit” of it.  But there is nothing funny about wasting your life on meaningless rituals.

Other  OCD clients are afraid of discussing their obsessive thoughts with anyone.   In OCD,  the brain can get “stuck” on horrific thoughts, such as harming a baby or molesting a child.  The client with OCD is afraid that, because he had the thought that it would be physically possible for him to do such a thing, it means that he really”wants to”.  This is not true.  His brain is equating thoughts and images with actions.  We don’t have control over what thoughts and images pop into our minds, and frantic attempts to make repellent ones go away don’t work.

Exposure and Response Prevention is the effective treatment for OCD.  It is done gradually and collaboratively, with lots of support.  The therapist starts with education, and makes a list of situations the client fears (obsessions), from the easiest to the hardest.  Exposure treatment is facing the obsession, putting yourself in the feared situation.  Response Prevention is refraining from doing any compulsions (mental or physical rituals, or compulsive avoidance).  The client starts with an easier exposure and prevents herself from doing any compulsions during “exposure time”.   During the session, the client may write a story about what she fears or practice touching “contaminated” objects such as doorknobs or faucets.   She will have “homework”.  For example, she might read the anxiety-producing story she wrote during the session every day , or write down that she wishes someone she loves would get hurt, or clean the house in the “wrong” way.  The therapist and client have to work together to define the obsessions precisely so the exposure “fits” and is effective.  Also, it’s important to make the exposure easy enough so that the client can succeed in preventing compulsions.

During “exposure time” the client refrains from distracting herself and just “sits with” the anxiety  without doing any compulsions.  Once exposure time is over she can distract herself by doing other things.  If the client isn’t able to give up compulsions altogether, she is allowed to do them the rest of the time, but not during the planned exposure.  Avoiding feared situations (such as driving if the client fears he may accidentally run over someone) is a compulsion, and the exposure would be to start driving again.

There are two theories about how ERP works.  The client learns that she can tolerate the anxiety of the exposure.  Also, she gets used to the anxiety the situation provokes, and it goes down during the session and with repeated exposure practice.

I offer Exposure and Response Prevention treatment (ERP) and also Acceptance and Commitment therapy, a mindfulness-based treatment that helps clients “defuse” from their thoughts.  ACT complements ERP, and is used with it in treatment centers such as the McLean OCD Institute.