When Doing ERP is Too Tough

There are patients who would like to do exposures and practice ritual prevention, but find the exposures are too tough, too anxiety-provoking to get into it, but still seek relief from the treatment. So, what to do?

Well, usually we would need to look at one’s value system. For example, if a patient is having trouble with Scrupulosity, it might be important to understand why they feel that this is wrong or that is wrong or that is okay, and why? Why is it okay to be impolite to a family member but devastating to them if they visit a friend’s home without a gift of some sort?

For someone with HOCD, why is it so wrong to find a man attractive even if they are not into men? For people with contamination obsessions, why is it okay to shake a sick person’s hand, but wrong to touch a toilet seat? Helping people untangle these things, will usually help them to face their fears and do the exposures (the ERP). Basically, this is akin to doing a SUDs hierarchy – listing which triggers are the most alarming and which ones can be tolerated. And, in discussing which triggers are impossible to overcome, in time that (the discussing with a therapist) will help to ameliorate much of the fears.

This all comes down to what I have spoken about for years, that OCD therapy is not just about doing ERP, though that is still the first line of defense. But sometimes, to get to that point, a deeper history and understanding as to how someone became the way they are is crucial. To deny that point is to deny the very person in the patient – that each person is very different. All people with HOCD or POCD or Scrupulosity, Religiosity, etc., are not the same. They certainly may share interrelated points, or agree on certain criteria, but there are nuances that need to be explored.

And in addition to looking at one’s value system, it is usually important to evaluate and understand one’s reward system; that is, behaviorally, to understand what one has to gain from doing this or that? It’s not dissimilar to a psychodynamic drive theory model. If one can understand what motivates them and what brings them to a halt, they can start to unpack the blocking points to a happier life; and in time, push past and thrive.

In conclusion, if you are too afraid to do exposures, you may not be completely ready (yet). But there are theories and techniques which can help to resolve the fear(s), to have some control of them by understanding them better. Insight can often be a very good thing. Sometimes we get lost in the language – Insight, Support, Commitment, Acceptance, and more, all work together to help a person who is stumbling at the starters gate.

Douglas Zimmerman