How I work with exposure and response prevention for OCD

I've noticed that sometimes, clients can feel apprehensive about working with exposure and response prevention (ERP). This may be because they have researched the process beforehand and it sounds quite scary. Other times, they have experienced therapy using ERP in the past and this has been quite an overwhelming experience for them. They may not have been given the option to have much input into this process.

ERP in the therapy room

In my therapy sessions, I work with my client at their own pace. We are all individuals and the time it takes to learn how to manage OCD varies from client to client. We create a hierarchy of triggering situations together, which I ask my client to rate on a scale of 1 to 10 to show the level of anxiety they feel in each one. We then create exercises from the hierarchy, starting with something on the lower rungs and working our way up to the higher ones over time.

We often also practise exposure work in our sessions. This gives us a chance to see what happens at the moment for the client in terms of thoughts, images, feelings, sensations or urges. This helps us to get a clearer idea of the level of anxiety experienced by the client in this moment - often, this is lower than the anticipated level. ERP exercises in sessions help to clarify exactly what the client needs to do at home when they begin to engage with this work.

In the following session, we'll discuss how the task went, looking at what went well and what didn't go so well. This gives us an opportunity to see how we can tweak things to improve their next attempt. And although ERP work is definitely challenging (especially at the very beginning), as the client begins to face scary situations rather than avoid them and to practise not engaging with their usual compulsions, over time, this process begins to feel less anxiety-inducing. When this happens, it usually motivates the client to move on to work with other triggers, which ultimately results in a reduction of their overall anxiety, too.

We also use illustrations to encourage the client to focus on unhelpful safety behaviours, which maintain their OCD cycle, as well as on more helpful behaviours which maintain good management of OCD.

My sessions are very much a collaboration between myself and the client. I never ask a client to engage with work they don't feel happy to try out. The tasks should feel challenging, but not overwhelming. The effect of ERP work is to 'retrain our brain' to understand that we are not facing multiple threats every day and that we, therefore, don't need to be protecting ourselves with the help of repetitive compulsions. This process takes time and requires some patience, but it has the potential to significantly change our lives for the better.

Understanding OCD

I find that typically, clients feel motivated by gaining an increased knowledge about how their OCD operates in their lives. This helps them to separate themselves from the condition. It's true to say that OCD sufferers are generally extremely sensitive, compassionate people who experience high anxiety in their daily lives. Because of this, we are some of the least likely people on the planet to cause harm. Unfortunately, we are also some of the most likely to worry about causing harm.

OCD can manifest in many different ways and clients come to me with a variety of themes. Some examples of these are fear of being a paedophile, fear of causing violent or sexual harm, fear of having a different gender or sexual orientation to your true one; fear of not loving your partner or your partner not loving you, fear of being immoral or offending God, magical thinking (believing we can affect situations by performing an unrelated physical or mental compulsion), issues with contamination or order, health anxiety, sensorimotor OCD (monitoring bodily functions such as breathing or swallowing). There are many other manifestations of OCD besides these.

OCD is very good at making us doubt who we are or making us feel that we are going mad. It's a liar and it specialises in telling us that we are the opposite of the person we truly are. It likes to attack areas of our lives which we care deeply about, and sometimes also the people who are important to us.

Finding support

Exposure and response prevention is the gold standard treatment for OCD. This method has been researched over many years and is evidenced to work extremely well with this condition.

In my own experience, I have noticed that clients feel greatly helped by the fact that I have OCD myself, which I have managed well for a number of years. Please feel free to get in touch via my profile or my website if you would like help with managing OCD.

OCD Action is able to provide information and support for OCD sufferers and their families/carers.