By Joan Davidson, PhD
Co-Director, San Francisco Bay Area Center for Cognitive Therapy
Many people feel hopeful after reading about OCD and learning that treatment may help them. At the same time, as they learn about what exposure and response prevention (ERP) entails, they often feel caught between a rock and a hard place. As awful as OCD is, therapy that involves facing your worst fears may also sound awful. Deciding to start treatment takes courage. Practicing ERP during treatment takes commitment. Choosing to embrace ERP as a life-long goal takes determination. Knowing why it’s worth it can make a world of difference.
ERP, the gold standard of treatment for OCD, involves facing obsessions and situations that trigger them without using compulsions. By changing your responses to obsessions, you break the OCD cycle. The concept is rather straightforward. There are many resources available to learn about ERP. Skilled therapists can guide you through the process. Yet the thought of facing obsessions head-on and not using compulsions can seem terrifying and beyond reach.
If you’re beginning treatment, you may question if it will work for you or if you’ll be able to do it. Of course, no one can provide you with certainty (an underlying theme in OCD!), but you can work with a therapist to consider the potential advantages and disadvantages of committing to treatment. What do you have to gain? What do you stand to gain or lose if you don’t try?
Taking time to discuss why ERP is worth it not only helps clients get started, but it also helps when the going gets tough during and after treatment. Jeff Bell, news anchor, author, and mental health advocate, writes and speaks about the importance of finding your “greater good” goals when facing the challenges of OCD. Exercises like those used in Acceptance and Commitment Therapy (ACT) help clients identify what they most value across various life domains, which helps them commit to taking actions (like ERP!) to live a life that that is consistent with their values. Answers to questions like, “How does OCD interfere with living true to my values?” can help clients identify their “greater good” and pave the way toward committing to treatment.
Challenge: Handling “choice points” every day. It’s one thing to have the “big picture” perspective about what you value more than giving into the OCD cycle, but remembering those values and choosing to act in accordance with them can be extremely challenging in the moment when faced with an OCD trigger. Those “choice point” moments are where the action is.
When faced with an obsession, remind yourself exactly why on earth you’re choosing to lean in toward your fears and not use compulsions. I ask my clients to do this all the time. We choose obsessions and situations to face, behavioral responses to change, uncertainties to accept and embrace, and “greater good” reasons to do it. The more you practice “calling out” your greater good reasons for facing obsessions without using compulsions, the more likely you’ll remember them and call upon them when faced with unexpected challenges.
Keep a “Positive Log” of victories, meaning decisions to take steps in the service of greater good values when facing OCD triggers. These victories can be small steps. Review your log regularly and remind yourself about the progress you’re making.
Challenge: Remembering the treatment goal. At some point during treatment, you might feel discouraged if new obsessions pop up or if old obsessions resurface. You may feel like you’re failing.
The content of obsessions can morph and change over time. That’s the nature of OCD. What you’re changing is how you respond to obsessions, whenever they occur and whatever form they take. What you’re challenging is how you deal with themes such as trouble tolerating uncertainty or things not feeling “just right/just so.” The goal is not to rid yourself of obsessions or anxiety forever; the goal is to change your responses. Writing down your treatment goals (i.e., changing how you respond to obsessions and the anxiety they provoke) when monitoring your progress helps you stay on track, even when new or old obsessions may catch you off-guard.
Challenge: Feeling like it never ends! No matter how much great work you do in treatment, it can feel disheartening when you think about how this work never truly ends. You may want to forget about OCD for a while. You may feel like you deserve a break! Unfortunately, if you stop using the ERP tools you’ve learned, you’re likely to backslide.
Remembering how you want to live your life and why this ongoing work is worth it can be especially important when you finish treatment. Keep reminders of your values and goals visible and easy to access. Continue reviewing and updating your Positive Log. Challenges will arise, and some of them may be difficult, but remember, you’ll be armed with new skills to respond to obsessions and you’ll become quite adept at using them.
Seek support! You don’t need to feel alone after treatment ends. Consider meeting with your therapist for follow-up sessions. Participating in or starting a local OCD support group, joining an on-line support group, attending talks and local workshops about OCD, and of course, attending the IOCDF conferences are all great ways to find support, stay motivated to challenge OCD, and remember why it’s worth it.