Response Prevention In ERP For OCD

What is response prevention, and how do you actually do it? Kristina talks with a therapist about the RP in exposure and response prevention (ERP), which means not doing compulsions, or delaying them at first, and how that looks for physical rituals and for mental ones such as rumination. They cover building up step by step, learning to sit with not knowing instead of chasing certainty, and aiming for good enough rather than perfect. It suits anyone who lives with OCD or supports someone who does. This content is educational and is not a substitute for one to one professional care.

Transcript

So let's talk about what is response prevention. Very basically response prevention is not doing your compulsions. The compulsions are the response and the RP piece of ERP is stopping preventing those compulsions and sometimes in early stages delaying the compulsions. Got it. Okay. So it sounds simple, Right? When people hear like, Yeah, Okay, Sure. If I could just do that. So I guess let's break this down. How would somebody do this? How would they design it? How would they figure this out? So it very much depends on what your compulsions are. So if they're mental compulsions and they're intrusive mental compulsions, Like rumination can sometimes be, It gets a little trickier. We have to learn some mindfulness techniques. When it's some physical compulsion, We are sometimes trying to first practice not having access to the physical compulsion. Not actually being able to, For example, If your physical compulsion is that simple one of hand washing, We might remove the soap from the environment. If your physical compulsion is avoidance, Then just doing the thing, Doing the exposure is the full ERP arc. For people who the compulsion is something that they're able to delay but not entirely stop, That at some point they're going to end up doing it, Like showering, Then we're going to practice first waiting an hour, Then three hours, Then four hours, Then overnight. But obviously at some point they will do the compulsion of showering. We just want to extend it so long as to the brain noticing longer sees it as linked to the exposure. Got it. So we really are building out kind of like a ladder here almost so that we're starting with wherever the person's at, Because I've certainly had people where the best they could do is like 30 seconds to a minute. And that's fine. There's no right or wrong. The only thing there is, Is learning and kind of staying the course, If you will. So start, Even if it's a minute, It's a minute, And then get to five, And then get to half an hour, Get to an hour. And so on, So that you're progressively. Showing yourself that you can, In fact, Not do something about it and see what actually happens and what you actually get to learn. So physical ones, I know you said that you can, Cause you see them, Right? So you can kind of, It's a little bit easier, Right? To say, Okay, I'm going to maybe, Let's say if it's a knife and I'm scared of it, I might be, Maybe start by being in the kitchen for a little bit and not immediately leaving. But let's talk about some of the things people do in their head. Cause you know, Mental rituals are kind of a big thing. And I think they're harder. I certainly, That was one of my biggest compulsions. Example, Like I had no idea that that even was a compulsion. I really thought I was thinking and analyzing and. Constantly was having guilt and anxiety and just distraught and almost panic attacks. But like, You know, I've learned now, Obviously, But what would you say? How can somebody even identify what is a mental compulsion? Yeah, So this comes at the beginning side of the work. So when we're actually designing the the treatment plan, We're we're really analyzing all of the different things that we do in response to our fears, Mental and physical. We're creating as robust of a list of all of the safety behaviors. In order to do inhibitory learning, Which is basically learning that the thing you fear is not that scary, We have to find out what the brain is doing to feel safe so that we can interrupt that cycle. So I would definitely do a lot of the work on identifying mental compulsions before we even started ERP. Okay, And so let's say somebody identified that they do a lot of mental analysis, Mentally reviewing, Mentally re-questioning things over and over and over because they have this need to figure this out. They have to know. They have to know now. They have to know yesterday. What could they do? Well, That's also an example of needing to get hearts and minds on the same side, On team fighting OCD. Because if our client or if the OCD experiencer is thinking of those thinking patterns as productive, If they believe that and analyzing their fear is going to actually benefit them, Then there's no way we can get them to not do it in response to an exposure. I would definitely take a step back. Maybe do some act some acceptance and commitment therapy to really identify whether or not this analysis or these mental rituals or this whatever it is is in line with their value system and if it is helping them to move on or if it's keeping them stuck and so it takes a lot of self-reflection at the beginning stages before we can really do the exposure and correctly or helpfully do the response prevention piece. Got it. So like, Here's an idea that I have that I wanted to ask you. So one thing I know is like Greenberg talks about rumination focused ERP, For example. Anybody who doesn't know, You know, This is where we're putting response prevention on the front end. So we're saying, Hey, Before we even do any exposure, Let's make sure we're really targeting any and all avoidances, But also any mental rumination. What is rumination? Well, It's dwelling, Right? We're dwelling on something. We're kind of mulling it over in our head a thousand different ways. We don't ruminate on good and happy things. We develop things that are uncomfortable to us, That bother us. So understanding what that sounds like, What that process looks like, Realizing that it's a loop, That you're not essentially getting any new answers from this. And then really understanding also the distortions that go into our thought process. Um, And, And once we see that, I think also understanding kind of the internal, I call them objections, But it's like the internal rationalizations and justifications that we start to use to keep holding on and gripping to this thing. That get in the way and kind of unpacking all of that and then saying, Okay, Now let's put this in practice. Like, What does it look like if I start with something minimal that's not as intensive that I can be in front of? And what is it like to not answer that question? What is it like to not chase it, To not continue solving it, Right? That's really kind of the predominant way that he proposes to do the work. And that if you do that, You're not inciting more anxiety, And then you can move towards now engaging with different. Triggers because you're not going to go in your head and start to create something about it. What's your thought on that? So I think it's it's an excellent addition to the. To the OCD conversation and the OCD specialty, His work, I think that I am a big fan of individualized OCD treatment. So I use ERP and then I'm bringing in a lot of different other elements. And one of which is, As you mentioned, Understanding the mental distortions that we are making during analysis. So that is oftentimes, CBT is oftentimes what I need to do with clients when they believe that their mental analysis is healthy and helpful. So we would go through that classic list of 12 distortions, Personalization, Catastrophization, Mental filter. All of it and analyze whether or not these distortions are really making it unhelpful. You know, Anxiety provoking to really think about these issues and overthink your fears. Yeah, And so then what would you say would be part of response prevention for something like that? Like there's different things we I know we both know things like non-engagement statements or responses Choosing to do something more meaningful in that moment or like we engage with whatever is actually in front of you But what would be some of those responses? I guess what could somebody else then say because we don't want them to obviously go in and Argue with it like okay. Well, It won't be that bad. Like that's not what we're talking about you Right, So how could they. If they notice like, Oh, I'm getting sucked in and I feel urgent about this and I have to figure this out. What could they say instead? Yeah, So I mean, There's a lot of different opinions about this. There is, Of course, The classic ERP. You have to say, Well, Maybe, Maybe not. Those of us with hormone CD really struggle with that because if someone told me, Well, Maybe you will murder your baby. Like, No, I can't sit with that maybe. That's not an okay maybe. And so I think that for me, At least, And for some of my clients, The better response is just to sit with the not knowing. And rather than trying to actually say, Like, Maybe I'm a murderer, Rather than actually really going there being like, I don't know. There's so much uncertainty. In my life, There's so much that I can't control and I'm gonna sit with this feeling of not actually being fully in control. Yeah, I think that's a really big one to be honest. And for me similarly, I will say that in doing this work, I think the whole maybe, Maybe not, I've personally had a, Yeah, Just kind of a shift in terms of my own internal understanding, Just from all the clinical practice. I think the reality is it's a doubting disorder and I think that in the moment when you are triggered and things are up and your system is firing on all cylinders and your physiology is completely off and you're maybe sweating or your mind is racing or your stomach is clenching or your heart is going to fly out of your chest, Whatever those things are, Right? I think it's true a more accurate responses right now. I'm doubting and I'm doubting everything but really probably that one specific thing And I don't right now feel like I can grasp it or have clarity or have that answer And I think what is more accurate is what you said. It's like yeah, I don't know right now so let me let me allow that and I and I think there's a lot of It's interesting but a lot of fighting that we internally go through because because we start to create a lot of, We interpret things a certain way. Like, Well, But if I allow that, Right, Then that's going to mean. Fill in the blank that, Oh, I want it, Maybe I like it, Or I'm not doing enough to protect or. Whatever it is, Right? How then, What would you say about that? I mean, I think that sitting with that fear and allowing for there not to be certainty about whether or not, You know, Listening to my imaginal exposure and getting desensitized to it means that I'm a bad mom, Right? Because that was one of my big doubts. I should be upset when I hear this imaginal. I should be fearful that I'm going to do something bad. Once I started to get more comfortable with you know, With myself and the fact that I had to be okay with horrible things potentially happening, Then I started to feel like, Well, But does that make me a bad mom? I think that it's all about having distress tolerance for the not knowing. I'm going to keep going back to that because the compulsions, Mental and physical, Are all about certainty. It's all about checking a box and making yourself feel like you did something that is certain, Even if that's imaginary. Yeah, That need to know, That need to have that answer. And the truth is like, Hey, We don't have OCD all the time, Right? So the reality is we do know things and we do have certain, I'd say like functional certainty and knowing, Right? Like there's also things we truly don't know. Like I don't know when it's gonna be my time to not be on this planet, Right? Like we don't know some of that stuff. Or if I'm waiting for a doctor to give me back results, Like I don't have to wait. Like I don't know that stuff. But other stuff, You know, It's true that when OCD kind of clicks in, It puts us right into this kind of state where we just feel so doubtful and not knowing things. And it feels like, Well, I have to know to solve this instead of recognizing, Well, No, This is part of the disorder. It's OCD, D, The disorder, Right? I just have a. Little something that pops in my head and I move on with life. It's like, No, This is how this works. And to your point, Understanding better. How and what OCD really is and how it functions in your body, In your feelings, In your brain, In your thought processes. And so then if you're doing effective response prevention, Kind of what would you say is the idea there generally? Is it that. . . Like, Would you say you kind of want to live out of that place and kind of make that almost like a lifestyle where you're learning to do like the opposite? Urges ur. What's your take on that? Side of a lab, We are probably going to be doing sort of good enough response prevention. We're going to be most of the time not doing our compulsions and that's great. That's what I consider to be success. You're allowing yourself to be exposed. Most of the times you're preventing responses and that healthy balance is a way to just move forward with your life. Yeah, I mean, I love that you've made that clarification for sure, Right? There's the like reading material and lab work. And then there's like, Here's what actually looks like in daily life. And I agree. I think that there's. There's got to be room and flexibility for the humanness of it all, Right? We're not going to be perfect at things, But can we get to that good enough where we have enough functioning and everything back that we're good, We're happy with it? And then we do our best, Right? We're not purists, Because we're also not robots. So what would you say if somebody, Let's say, Is making progress and then they think they're doing response prevention, But then let's say things start to get bad again? Um, Where should they, Where should they look? What should they do? Yeah, So whenever we feel like the OCD is gripping us again, I always say like back to basics. Go back to something easier on your fear hierarchy and repeat an exposure. Repeat the response prevention. Remember that you habituated your brain once to not doing the safety behaviors and you can do it again. It's incredibly important not to consider ERP as like a past tense, Like, Oh, I did ERP already. ERP, Honestly, It's like a lifestyle. At this point, Like it is, It has become part of my behavior in a lot of different aspects of my life. So I am doing the harder thing and preventing the safety behavior more often than just in the narrow world of my OCD. So I would say go back in to your work and try it again. And remember that once you do the ERP once, The next iteration will be easier. Like that's the way our brains work. We have learned the new skills and we just need to tap back into them. Got it. And so what would you say then in terms of like response prevention? I know you said earlier that, You know, If you did an exposure, But then you, You'd somehow then afterwards avoided or checked or mentally started to reassure whatever you did, Um, That that would be a compulsion and you kind of canceled it out. So, So what's important then about maintaining that response prevention piece? Like what, What does it do for the person, Uh, For the longterm? Yeah, So that's the habituation that needs to happen, That when you do your compulsion in response to your exposure, You're actually reinforcing the brain's fear cycle. So you are actually teaching your brain when you do a compulsion, Yes, This was a dangerous, Bad thing, And it needed to be neutralized with this compulsion. So all you do is re-expose. You try again. I actually believe that exposures need to be repeated at least five or six times before the brain really gets it. You think about how many times you did a compulsion, It might be in the thousands, And so not doing the compulsion at least five times in order to retrain your brain. And so how would you then design RP? Like, So, Okay, One thing I know that I was taught or I learned a while back is for example, Thinking through like, Okay, What behaviors are you doing? Are these behaviors that are kind of like adaptive daily things that we do, People do, Because then we want to create kind of, You know, An average, Kind of amount or baseline of how much of that behavior would be reasonable, And what are the things that we're doing that really serve no function, No purpose at all, Because those behaviors, We want to bring them down as close to zero as possible and really give them up, So that we have kind of a way to start to guide ourselves and understand, Okay, People, When they close doors, Sometimes they do kind of check or tug once, Usually. That would be an example of where like, Yeah, If you did that once, That's still within a reasonable range. But if you're doing it now five, Six, Seven, 10, 20 times, Or now you're half an hour late or you're leaving, You're coming back. Well, Now we're entering the OCD realm so that we have a way to kind of distinguish what and where is it appropriate or not or reasonable or not. What's your approach? So I approach it using reality anchoring. So that is where you use a family member a friend or your therapist and utilize their behavior as an anchor an anchor to a non OCD reality. So for example, I have currently I have like a very activated anxiety about money. And so I find myself checking my bank account twice a day. So that is definitely getting in the realm of compulsion. There's not really anything necessary about that. However, I don't want to go to never checking my bank account. Like that might be problematic. I might bounce some things, Burn some checks. So I, You know, Ask a trusted friend that doesn't have OCD around this and said like, How many times does a person without this OCD check their bank account? And she told me she'll check it twice a week. And I was like, Okay, I just have to trust that, Right? I have to trust that this person is financially stable and responsible. And until I get my own behavior under control or my OCD under control, I'm going to anchor to her reality to study myself. Oh, That's interesting. Yeah. So it's not a reassurance piece. It's more like I'm using that as a, As a way to kind of measure and gauge what seems reasonable. And I have a real life kind of example of that. And I, I trust it, Like you said, I, And, And so then that will become my, My kind of goal until I can get there and then. And then you might move on from that, Or you might keep it, Or you might adjust it. But you're definitely going to use it to help you get off doing it twice a day, For example. Exactly. Exactly. Yeah. Well, I love that you're, You know, What I'm hearing from you too, Is again, The individualizing it, Right? Because I think there are guidelines and there's things you learn when you go through training, Like through the IOCDF, You know, And when you're initially doing this work, But I think when you've been doing this for a while, Just clinical experience, You start to notice and see patterns as well. Right. And, And like you said, Real, Real world. Yeah. What's actually going on there for folks. So can you give us an example, Um, Maybe of like something that you've done before, Like how you help somebody build some, Some response prevention into their practice. Like it could be literally anything, Nothing overly complicated, Obviously don't share, You know, Deep client details, But, Um, Yeah, Anything you can share with us. Yeah, So I'm thinking about one particular case where there was like a deep fear of eyeballs being cut with knives and also paper cuts. And so we ended up going deep into some classic horror movies with Luis Buñuel and a lot of like artistic horror that was not only experimental, Exposing my client and their compulsion was to cover their eyes. And so we worked on preventing that response But actually ended up being like a newfound passion. So, You know whenever we are designing exposures and preventing the response we're actually opening a door that might end up being something that really inspires our client and that's so fun to see I Love that. That sounds awesome. And it's it's really also great to hear that you know, There is some creativity and also like a new discovery or a passion. I think we don't talk about that enough that, You know, Part of this process too, Not only do you get to get some pieces back for yourself that, You know, You've missed, But also you can discover something new or you can also, As you get through it, See kind of what are some other interesting ways how you can kind of challenge your OCD, If you will, Because, You know, As you're getting stronger, And not feeding OCD cycles, Then you get more autonomy and say and the kind of things you get to do and the creativity or the life that you get to have. Absolutely. And I think one of the biggest issues is that OCD makes our life smaller. And so part of all you know, Healthy, Productive ERP is about making your life bigger.