Advanced ERP for OCD: how subtle rituals can limit your progress


OCD is often characterized by subtle, hidden rituals.

As any good psychologist experienced in treating OCD can tell you, the most effective treatment for OCD is exposure and ritual prevention (ERP).  You may also see this type of therapy referred to as exposure and response prevention.  In this case, the semantics are immaterial; the concepts are exactly the same.  ERP is a type of cognitive behavioral therapy (CBT) that is based on the premise that the best way to reduce your symptoms is to practice activities designed to trigger your anxiety and then resist any urges to ritualize.  ERP has two main components:

  1. exposure – purposely doing activities that are designed to elicit your anxiety
  2. response prevention – actively resisting the urge to complete a ritual

For example, for someone who worries about germs, an exposure might involve purposefully touching a trashcan and then resisting the urge to wash.

Both the exposure and response prevention elements are critical for effective ERP.  Exposure without response prevention (or with poor response prevention) will not decrease your symptoms.  In fact, in some cases, exposure without response prevention can actually make your OCD stronger because you are reinforcing the idea that the only way to escape from OCD-related anxiety is to ritualize.  In essence, the more you practice your rituals, the stronger and more debilitating your OCD will become.  For most people with OCD, ERP is pretty scary at first.  You are intentionally doing the very thing that the OCD part of your brain has been warning you about.  Fortunately, that fear diminishes with repetition.

As you practice ERP and gain confidence in your ability to resist rituals, the process becomes easier and your symptoms become more manageable.  Therapists who specialize in treating OCD can help you learn to practice good ERP and deal with the anxiety you may feel before (and during) an exposure.  Well-trained therapists are also experienced in being able to recognize a wide variety of rituals and avoidance behaviors, some of which you may be less able to notice yourself.  As a psychologist in Palm Beach, Florida, I work closely with kids, teens, and adults throughout the greater Palm Beach, Fort Lauderdale, and Miami areas on strategies for recovering from OCD.

With consistent ERP that emphasizes both exposure and response prevention, most individuals with OCD experience a significant reduction in their symptoms. However, sometimes you can be practicing regular exposure and still not get the results you want.  If you have experienced this, it is possible that you might be performing more subtle rituals that you haven’t recognized.  Here are some strategies for stepping up the RP in your ERP.  These strategies assume that you already have a basic working understanding of ERP and are looking to increase the effectiveness of your exposures.

  • If your exposure involves touching an object, make direct, sustained contact with the object.  Do not limit contact to your fingertips; apply direct, firm pressure with  your whole hand.  Obviously, refrain from washing, using hand sanitizers, changing clothes, etc. after your exposure.
  • Don’t limit contact to hands.  Ideally, any touch-based exposure should involve touching the object to other parts of your body as well.  Try touching the object to your legs, face, and other body parts.
  • After completing a touch-based exposure, go about your day doing whatever activities you would have normally done.  Don’t let ERP change your routine.  Continue to interact with other people, touch things as you normally would, etc.
  • Pay attention to your body position.  If your exposure involves looking at a feared object, are you orienting your body directly toward it?  If not, try facing the feared object directly.
  • Make eye contact.  Again, in cases where exposure involved interacting with a feared object, try to focus your gaze directly on the object itself.
  • Are you performing any mental rituals?  If, after touching something that looks dirty, you find yourself mentally trying to convince yourself that you’re clean or that the object wasn’t dirty, you are performing a mental ritual.
  • Avoid reassurance seeking behaviors.  Do not ask other people if they think you’ll be okay if you don’t ritualize.  If your exposure involves thinking about harm coming to other people, do not call them to make sure they’re okay.
  • Do not mentally distract yourself while doing an exposure.  This decreases the effectiveness of the exposure.
  • Individuals with harm obsessions frequently over-control their bodies in order to keep themselves from “losing control” and acting on their thoughts.  If your obsessions involve harming others, avoid over-controlling your body.  Keep your hands out of your pockets, and keep your arms uncrossed and open.
  • Never terminate an exposure before you have experienced some resulting  habituation.  If you terminate an exposure while your anxiety is increasing, you may sensitize yourself to the exposure.

In general, remember that the goal of an exposure is to stay with the situation long enough for habituation to occur.  By incorporating the above strategies into your regular ERP sessions, you will make more rapid progress in reducing your symptoms.

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