Research has shown that the most effective treatment for individuals with Obsessive Compulsive Disorder (OCD) is Exposure and Response Prevention (ERP) Therapy. With ERP, the therapist supports the person in identifying the things that OCD is making it difficult to do. We then work on developing a range of 'exposures' that will allow you to practice doing these difficult tasks without performing your usual rituals. What this means is that you will have to feel anxious and/or uncomfortable on purpose at a level that you feel you can tolerate. And there's no doubt about it. ERP therapy is not easy. In fact, I've had clients tell me that it's the hardest thing they've ever done in their life. And yet, the reason they've stuck with it is because they realize early on that it works, and that the more you work on it the easier things get.
Avoidance Strengthens Fear
A basic principle that explains how anxiety disorders like OCD, Phobias, and Panic Disorder worsen over time is that Avoidance Strengthens Fear. The more rituals you perform, the more you avoid specific situations, the more you try not to think certain thoughts or feel certain feelings, the worse your fears become, and the more you need to avoid your triggers. Exposure therapy is about reversing this trend. And proving to yourself (and to your anxiety disorder) that the opposite is also true; that Exposure Weakens Fear.
What is an Exposure?
An exposure is a brief therapeutic experience, during which you “expose” yourself to your feared situation and/or thought on purpose. Identifying exposures that are effectively targeting your fears, but also not overwhelming is a key part of treatment. For an exposure to be effective, it typically includes the following:
Exposure to your trigger: This is your feared situation. It is called a trigger because, when you are exposed to it, it “triggers" the thoughts and feelings that you are currently trying to avoid. During an exposure, you are actually going to think those thoughts and feel those feelings on purpose at a small dose in a safe environment.
Ritual Prevention: While being exposed to your trigger, you must resist doing your usual rituals or safety behaviors. No asking anyone for reassurance. No positive self-talk. No counting. Just focusing on the trigger, and sitting with any thoughts it brings up.
Habituation: For most exposures, the process of habituation occurs. This is a big word for a pretty simple concept. Habituation refers to the process of your anxiety going down all by itself, without you needing to do any rituals or any other behaviors to make that happen. The truth is that our body's are not meant to stay anxious for long periods of time. Once your body is in a feared situation and nothing bad happens, your mind will eventually readjust and let off of the anxiety pedal.
Course of Treatment
We begin with a full assessment of your OCD symptoms as well as any co-occurring anxiety issues such as Generalized Anxiety, Tics, Hair Pulling and Skin Picking. I will ask a lot of questions about your current symptoms, your history, and your overall life situation. I may also consult with any other providers/professionals you think it would be important for me to contact. I will then provide you with my clinical impression of your situation, and provide you with the treatment options that are most appropriate for your particular mental health issue/s.
If we proceed with ERP treatment, I will provide some initial treatment readiness, which typically lasts from 1-3 sessions (but in some cases can become a more substantial component of treatment). This may include some education on your particular mental health issue and how ERP treatment can help, some discussion aimed at expanding insight (yours and mine) into your symptoms and what in your life is maintaining them, and some exploration of the reasons why you may want to work on your OCD, which you can keep in mind throughout treatment. We will also identify any other issues in your life, such as Autism, ADHD, PTSD, or Depression, which may impact how we proceed with treatment. Finally, we will want to identify the coping skills and social supports you have available to you, and to which you can turn when things are difficult.
As we begin ERP treatment, we will first develop a fear ladder with a long list of exposures that will guide us through your treatment. We will then begin practicing exposures in the therapy office and assigning things that you can work on between sessions. Treatment length can vary from a short term course of 8-10 sessions to longer courses when symptoms are more severe and complex. As you gain mastery over your symptoms, we may also space out your appointments so that you can spend more time living life while still having appointments to keep you on track.