What Exposure Response Prevention Therapy For OCD is Like
Over, over, and over again
I’ve momentarily forgotten how to breathe. There’s a claw around my chest, and it’s tightening by the second. I’m sweating, and it isn’t because it’s hot.
My brain tries to run away from the intrusive thought and think of anything else, literally anything, but I pull it back. Focus, I remind myself.
My brain tries to remind me that I’m safe, I’m on my couch, I’m not my thoughts, I’m not a bad perso-
I stop. It’s the slippery slope of reassurance. No compulsions, I remind myself.
The anxiety is nearly unbearable. Today, it takes a long time for the anxiety to pass, but eventually, it does. I get up and continue with my day.
This is my life. Almost every day, I set aside some time to think up some horror-movie-like storyline in my head and repeat it until my brain no longer perceives it as a threat.
Exposure response prevention therapy: terrifying, hellish — but it works.
Pure-OCD: Not about germs, cleaning, and ordering
In August last year, I had a mental breakdown was diagnosed with obsessive-compulsive disorder. In those hazy few months, while my mental health deteriorated, the exact moment I was diagnosed has stuck with me. It took place in a bleak living room of a mental health respite, and I was with the crisis team. I’d spent 45 minutes trying to convince the psychiatrist that I was ‘dangerous’ because of these looping, unspeakable thoughts that had left me barely functioning. I was so scared of my brain that I’d lost the will to live.
When she told me I had OCD, and that I wasn’t a threat to society (despite what my brain was telling me), I was floored. Like many, I had no real understanding of OCD.
The IOCDF describes OCD as a mental health disorder where a person gets caught in a cycle of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings. Compulsions are behaviors an individual engages in to attempt to get rid of the obsessions and/or decrease his or her distress.
I live with the sub-type known as ‘Pure-O.’’ ‘Pure-O’ as a term itself is considered by some as a misnomer, as it implies that a person only has obsessions, but has no compulsions. This is not true — it’s just that my compulsions are not visible.
For example, someone with contamination OCD may share the same fear as me (that they might hurt someone), but their obsession is that they’ll catch germs from a surface, and their compulsion might be to clean surfaces ritualistically to prevent contamination of themselves and their loved ones.
My OCD primarily shows up as Harm-OCD. My obsessions manifest as unwanted intrusive thoughts around the idea that I might lose control and hurt someone, which of course, is the last thing I want to do. My compulsions are largely internalised — sorting through my memories like a filing cabinet, looking for evidence that I might be “bad,” or self-soothing by repeating phrases. There are external compulsions too — avoiding people, places, and objects out of fear; or seeking reassurance by asking people to validate my “goodness.”
Unfortunately, engaging in a compulsion is like scratching an itch. It temporarily provides relief, but the problem never goes away. In fact, the OCD just gets worse.
Exposure Response Prevention Therapy
The most effective treatment for OCD, irrespective of sub-type, is exposure response prevention therapy (ERP), where one exposes themselves to situations where they face their fears and/or obsessions, without engaging in compulsions. The idea is that over time, the anxiety level drops once your brain realises that it’s not in danger. The IOCDF states that ERP has about a 70% efficacy rate when combined with medication.
In New Zealand, finding a practitioner who is skilled and experienced in ERP is difficult. It took me a few goes, but in February this year, I found a clinical psychologist with experience in ERP. With her support, I started the gruelling task of tackling my OCD.
For a person with contamination OCD, ERP might take the form of gradually exposing yourself to objects that you consider “dirty,” increasing in difficulty over time.
For Pure-O, or tackling violent and sexual harm-related intrusive thoughts, exposure isn’t as straightforward as interacting with a physical object, surface, or real-life situation. Simply put, my OCD fixates on topics that are so taboo that the only things that exist in real life that can help with ERP are crime news articles (which have been part of my treatment), or imaginal exposure — that is, working with my therapist to create scripts around my darkest, scariest thoughts to expose myself to.
Going to brain-gym every day
ERP is the hardest thing I’ve ever done. On the regular, I have to deliberately induce my latest ‘worst nightmare scenario’ — which is often highly vivid, disturbing, and terrifying. I have had to learn to just sit with, and tolerate the anxiety until it passes, understanding that my thoughts are just that — thoughts. Eventually, the anxiety does pass.
It’s like doing a daily workout to work on a muscle, to re-wire the neuropathways in my brain. Some days are so exhausting that I end up curled up on my couch, crying. Some days, I’m left feeling nauseous. Some days, it’s doable, and I can just feel the anxiety creeping around the edges.
My latest theme is so challenging that I’ve been working on variations of the same scenario for over a month, and only now can I sense some progress. But even as I type this while thinking about it, I can feel a tightening of my chest. It’s extraordinary how much power OCD has.
The traps of ERP
ERP takes commitment. It’s not as simple as ‘tackle your fears head-on,’ and I wouldn’t recommend doing it without the support of a professional who knows how to do ERP properly.
There are pitfalls of ERP I’ve had to navigate through with my therapist:
- Going too hard, too fast —ERP should be a challenge, but not impossible. Going straight to an extremely challenging exposure without working up to it can be likened to flooding therapy — which can overwhelm and exacerbate the anxiety. I’ve experienced this when the imaginal script we created was just too much when I tried to do it by myself at home. I failed to make progress after multiple attempts, and we had to work together to tone it down a bit.
- Pesky compulsions — I’ve become acutely aware that one of the first things my brain does during ERP is to distract and/or thought-stop due to discomfort. I automatically try to convince myself repetitively that I am not my thoughts, which of course, is a mental compulsion. I’ve also had to work on making sure that the ERP exercises themselves don’t become a ritualised compulsion in response to my OCD.
- Rebound OCD when the intrusive thoughts go away — OCD has a nasty way of biting back. One of the first things that happened when I overcame a harm-related theme was my brain defaulting back to what if this reduced anxiety is because I actually enjoy these thoughts? This created a lot of additional anxiety, and again, I had to work with my therapist on skills to handle this.
What has made ERP particularly effective for me so far is concurrently working on my underlying anxiety; as the anxiety and OCD feed into, and strengthen, each other. It’s a chicken and egg situation, but it doesn’t matter which comes first. Both OCD and anxiety are horrible, but working on them simultaneously has been crucial to my progress.
Life: one giant exposure
ERP has been life-changing. It has enabled me to function and live again, without my fears getting in the way. And in many ways, engaging in daily life again has just been one giant, exposure exercise — dealing with intrusive thoughts coming out of nowhere.
Because of ERP, I can now cook again without giving a second thought about all the dangers of the kitchen (read: knives). I can go outside without worrying about the irrational fear that I could ‘harm’ others. I’m able to look at pictures of friends and family again without intrusive thoughts looping incessantly, generating waves of panic and nausea. The unwanted thoughts still pop up — they haven’t magically gone away. But I’m now a lot more skillful — I’m able to notice the thought, and not give it as much weight or meaning as I once did. And over time, some obsessions have disappeared.
As my therapist describes it: “It’s like watching a scary movie. Watching it the first, second, or third time is scary, but eventually, your brain gets bored. And then the OCD loses its power.”
Cruelly, OCD has a tendency to fixate on things that you care about. Sometimes, just as I’ve tackled one theme, another scary variant shows up. However, I’ve noticed that with practice, it’s taking less time to overcome the intrusive thoughts.
So for now, the movie is still going. But because I’ve seen parts of it before, some of it is getting boring, and it’s way less scary. And to me, that’s a huge win.