Exposure and Response Prevention: An Analogy

Posted by in ERP, Obsessive-compulsive disorder (OCD) Exposure and Response Prevention (ERP) Exposure and response prevention (ERP) is just like a fitness program for your brain. However, instead of shaking up your fitness level, it’s designed to shake up stubborn OCD symptoms. Let’s expand on this analogy. Reasons for Doing Exposure and Response Prevention (ERP) People don’t adopt fitness routines for no reason at all; physical exercise is not a random activity. We don’t accidentally buy gym memberships or wake up on treadmills. Exercise is always purpose-driven and typically is intended to improve one’s quality of life in some quantifiable way. Common goals for exercising are related to health, aesthetics, or the feelings it evokes. Treatments like exposure and response prevention (ERP) are also intended to enhance your life in a meaningful way. Just like with exercise, your ERP efforts will be driven by your own personal motivators. Maybe you want to spend less time on your rituals so that you can be living more deliberately and less reactively. Perhaps OCD has caused your world to shrink, and you want to take it back. Maybe you’re motivated to fight OCD so that you can be a better parent or spouse. Maybe you simply want your days to be filled with more fun and less panic. These reasons form the basis of your recovery plan. If these reasons don’t exist for you…if you’re doing treatment for someone else rather than for yourself, the road will be difficult. In order to be able to sustain effort through challenges, you will have to identify personal motivators that are meaningful to you. Just like with physical exercise, your ERP has to be purpose-driven or you will lose your momentum. This analogy can be taken even further. Exposure therapy is not a singular activity. Physical exercise is often based around targeting a particular muscle group or certain aspect of health. People who want big biceps do different exercises than people who want to lose weight. This is similar to exposure and response prevention therapy. People who want to be less bothered by unwanted thoughts (e.g., thoughts of hitting someone with your car) do different exposures than someone who is afraid of contracting a deadly disease. The form of the “exercise” reflects a specific therapeutic goal. You can target your OCD symptoms in multiple ways. People who want to work on their abs might consider crunches, leg lifts, push-ups, etc. In ERP,...
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Treatment of Unwanted Thoughts & Sensations in OCD

Posted by in Obsessive-compulsive disorder (OCD) In my post about the treatment of sensorimotor OCD, a reader asked about the ultimate goal of treatment. Should the goal of treatment be to never notice an unwanted thought or symptom? Suppressing Unwanted Thoughts & Sensations in Pure-O & Sensorimotor OCD Let’s explore this idea in detail. Suppose I adopt the goal of being 100% symptom free. After all, this is the endpoint of treatment that most people are seeking. What are the implications of this goal? You will likely slow down your progress. Why? Because every day you will encounter something that violates your expectations. Unwanted thoughts are a normal part of the human experience. Everyone has thoughts that are unwanted, aggressive, selfish, perverse, or deviant at times. For people without OCD, these thoughts tend to be fleeting because the thoughts themselves aren’t treated as significant. They are accepted as normal brain noise. These thoughts may register, but they quickly get buried beneath other more pressing or interesting thoughts. For people with Pure-O OCD, unwanted thoughts may occur over and over again. Often these thoughts are considered dangerous or preventable, or they may be regarded as problems in need of solutions. Many people with Pure-O OCD become emotionally invested in filling their heads with the “right” kinds of thoughts. It is largely the importance we attribute to our unwanted thoughts that determines whether or not they get stuck. As soon as we shift into problem-solving mode via a behavioral ritual or a mental compulsion, we increase the salience and power of the perceived threat. Rituals reinforce and sustain what-if’s, which is why rituals are so good at maintaining OCD symptoms over many days, months, and years. If you read my last post about thought control in OCD, you recognize that never having an unwanted thought is an impossible goal. Our brains just don’t work that way. If you insist on being symptom-free, “normal” body-noise and thought-noise becomes a potential threat. This is because it leads you to characterize something normal as unwanted and dangerous. If you think about it, you’ll realize that it is often not the actual occurrence of symptoms themselves that creates anxiety, but rather the personal ramifications of those symptoms. For people with Pure-O OCD, fear is often based on the possibility that having an unwanted thought means something about you (e.g., maybe you secretly want to harm a family member or maybe you’re...
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School Refusal & Parental Stigma: Am I a Bad Parent?

Posted by in School Refusal Like any other behavior, school refusal does not have a singular cause. This is pretty self-evident, but in the heat of the moment when your child is having a tantrum, this fact is quickly forgotten. It is simply too easy to conclude that you have raised a “bad child.” Sadly, much of society might wrongly agree with you. For many, the term “school refusal” has automatic negative connotations. Although school refusal is a behavior that has many different potential causes, it often gets lumped together with rebelliousness, conduct problems, and oppositionality. This is unfortunate because many cases of school refusal do not actually involve any of these factors. Am I a Bad Parent? Parent Social Stigma in School Refusal. Regardless of the origins of your child’s school refusal, it is important to consider a separate parent-related factor that maintains school refusal: your fear of being perceived as a “bad parent”.  Although parental stigma does not cause the development of school refusal, it can certainly feed the problem.  Your fear of how others might perceive you or your parenting skills might unwittingly cause you to reinforce your child’s school refusal. Because many parents value education and pride themselves on having well-behaved, well-adjusted children, it can feel embarrassing when your child is refusing to go to school.  Parents of school refusing children often feel isolated and frustrated and may attribute school refusal to their own parenting failures rather than to outside factors that may be contributing to the situation. For many first-time parents (or even “experienced parents” who have younger children who are temperamentally different than their older siblings), school refusal can cause one to question his/her own fitness to parent.  Shame, guilt, and fear of personal embarrassment then leads parents to be less-than-forthcoming with school staff about the true reasons for their child’s excessive absences.  On school refusing days, they may call their child in “sick” in order to avoid contributing to academic difficulties (e.g., receiving zeros on assignments). Many parents also errantly assume that all other households are more harmonious than their own, and they often won’t disclose school refusal issues to other parents and friends for fear of being viewed as incompetent. The fear of being perceived as a bad or ineffective parent can cause many parents to make poor in-the-moment decisions that ultimately backfire. If your child’s carpool is waiting outside, desperation can lead to the use of ineffective strategies like...
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One Panic Treatment Basic that Even Your Therapist Might not Know

Posted by in Panic If you have panic disorder or suffer from panic attacks, chances are you might be inadvertently doing one simple thing that is making your panic attacks and anxiety worse. You might have even learned this strategy from your therapist.  Although beneficial in many different contexts, when used inappropriately, this technique has the potential to dramatically increase symptoms of anxiety and panic. The technique in question? Deep breathing. What is deep breathing? Deep breathing, or diaphragmatic breathing, is a core coping skill taught by many excellent therapists of diverse theoretical orientations. It is a technique that has a long and revered history in the field of psychology due to its anxiety-reducing (anxiolytic) effects. Used alone or when combined with other strategies, such as visual imagery or progressive muscle relaxation (PMR), deep breathing can be a potent aid to relaxation. It is applicable to a wide range of stressors, requires no equipment aside from what you carry around with you in your head, and can be brought to bear quickly and discretely at work, school, or any other place you might need it. As such, deep breathing is a powerful technique to have in your coping toolkit. In addition to being useful for managing anxiety, proficiency in regulating your diaphragm also increases your vocal control, which helps you sound more confident when speaking. It is this vocal control that gives public speakers and opera singers alike the ability to better regulate vocal tone, exert vocal power when needed, and (in the case of the opera singer) sustain notes over long intervals.  Prior to being formally trained in diaphragmatic breathing (deep breathing), most people have only a limited sensory awareness of how to properly control the diaphragm muscle and regulate their breath. When asked to breathe deeply, most untrained individuals intuitively raise their shoulders in an effort to draw in more air. This strategy actually results in shallow, inefficient breaths because it doesn’t allow the diaphragm to lower properly and create room for lung expansion. For deep breaths, your belly should expand downward and outward (rather than upward and inward).  This is the type of breathing you naturally use when you’re sleeping or lying on your back.  For additional guidance on deep breathing, ask your therapist (or vocal coach!) to teach you the basics; remember, however, that lots of practice is necessary to gain greater breath control. As always, I am available for consultation...
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Exposure & Response Prevention (ERP) for OCD: Treatment Mechanism

Posted by in ERP, Obsessive-compulsive disorder (OCD) Question: How does ERP work?  What mechanism underlies it? Obsessive-compulsive disorder (OCD) is characterized by obsessions and compulsions.  Obsessions are disturbing thoughts, images, or impulses that increase feelings of anxiety. Compulsions (also known as “rituals”) are the strategies that individuals with OCD use to reduce the anxiety associated with obsessions.  Rituals are effective coping strategies in the short-term, in that they lead to fairly rapid decreases in anxiety.  However, rituals are considered maladaptive, because the anxiety relief they bring is short-lived.  Engaging in rituals ultimately increases the likelihood that obsessions will be re-experienced in the future.  This can be thought of as a positive feedback loop, in which compulsive behavior indirectly reinforces obsessions.  This is depicted in the bottom half of the included figure. The treatment of choice for OCD is exposure and response prevention (ERP), which not surprisingly, has two main components: 1) exposure, and 2) response prevention.  Response prevention refers to purposefully inhibiting one’s rituals, whereas exposure refers to willingly entering situations that are likely to trigger obsessions.  Both exposure and response prevention elements are necessary for making meaningful treatment gains. Response prevention is the critical component in “short-circuiting” the positive feedback loop in OCD.  When one implements regular response prevention, obsessions are no longer reinforced and ultimately decrease in frequency and intensity.  This is represented in the upper half of the included figure.  Purposeful exposure provides further opportunities to break this cycle.  The more exposures you complete, the more the positive feedback loop degrades.  Eventually, with enough practice, you will become immunized to many of your triggers. Some people get very stressed out at the prospect of completing exposures.  They think, “How could I possibly do an exposure? I’m anxious enough as it is!”  This sentiment is most common prior to initiating treatment and quickly fades once the individual begins practicing regular exposure.  If you feel this way, keep in mind that if you complete structured exposure according to a hierarchy of feared situations (e.g., using subjective units of distress [SUDs] ratings), the process is less likely to feel stressful and overwhelming. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
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