September Q&A
Earlier in September I had made a post requesting any questions or thoughts (via my blog or through other social media that I’m active on) that I could help answer in a dedicated Q&A topic. I’d like to make this a regular part of my blog - perhaps a monthly feature - where I can aggregate some of the queries that I’ve received from readers and provide my thoughts/advice on them.
Here are some of the questions that I’ve received from readers during the month of September - the people are anonymized for privacy, but my intent with publishing these to my blog is to underscore:
How many people struggle with OCD, and often with various different types of fears and triggers
Helpful tips and advice that can be applied not just to the person asking the question, but for general readers of my blog as well
Without further ado, here are the September questions.
“Even practicing ERP, it all just seems so pointless, I still have intrusive thoughts, and it just feels like I’m in denial and not making progress.”
This perspective may imply that the person is still doing some compulsions/ruminating on their thoughts, even though they are practicing ERP. If intrusive thoughts still bother and upset you, it implies that at some level you are still reacting to the thoughts by "judging" them as bad and associating your value and worth with these thoughts. It also sounds like you might be hoping ERP will eventually cause the thoughts to go away.
The important thing to realize is that the thoughts don't go away, and the goal of ERP therapy isn’t to eliminate the thoughts. It is to eliminate your reaction to the thoughts.
Whenever you react to a thought (by judging it as “bad” or trying to chase it away or do some action to prove the thought isn’t true) you are reinforcing to your brain that these thoughts are dangerous and need to be fixed. Through ERP, you gradually teach your brain (by not reacting to the thoughts) that there is nothing to fear and you don’t need to do anything about them. Then, your fear/anxiety decreases as your brain begins to learn this new behavior.
I still have the same thoughts pop up in my mind that used to bother me. So does everyone else. Studies show that even “normal” people have weird and messed up thoughts; they just don’t obsess over them or attach any meaning to the thoughts like OCD sufferers do. So I still get the same thoughts, but I don’t really care about them anymore and they don’t cause me any anxiety. That is the endgame of ERP. Once you make peace with the idea that the thoughts may not go away, but you can learn to live with and accept them without letting them control your behavior, is when you’ll really start to make great progress with ERP.
“Any tips for doing ERP for real event OCD?”
I believe the important thing to understand here is that regardless of the "sub-type" (real event OCD, contamination OCD, pure O, relationship OCD, false memories, etc...) ERP ultimately boils down to the same approach:
Identify your triggers
Understand the compulsions you perform in response
Refuse the compulsions
Things like false memory and real event OCD are tricky, because they're primarily mental, so it's not always easy to identify the compulsions (and hence, not easy to know what you're supposed to be refusing).
For example, maybe you realize that you spend a lot of time in your head doing things like:
Replaying memories and conversations over and over again in your mind to reassure yourself nothing bad has happened (which ironically will just make you doubt the memories even more)
Looking for evidence to "prove" nothing bad could have happened, since you can’t remember it with 100% clarity
Logically trying to reason out or argue with your brain as to why something you fear couldn't possibly have happened
Once you realize that all your mental rumination is just a compulsion, the ERP technique is to simply not ruminate. If you catch yourself doing any one of those compulsions or behaviors, practice gently bringing yourself to focus on the present moment rather than being stuck in your head. And you might feel incredibly anxious when you’re not analyzing or ruminating, but you can learn to sit with the anxiety and accept the uncertainty through complementing ERP techniques with ACT (Acceptance Commitment Therapy) techniques as well (and ACT will be the subject of a future blog post). ERP teaches you to prevent your response to the thoughts and eliminate compulsions, and ACT teaches you to accept and move on without tying your self-worth or perception of your value to the thoughts.
“Would you mind explaining what “ERP” is exactly?”
This will be the topic for a future blog post in and of itself, because it is such an important and vast subject, but at a high level Exposure Response Prevention (ERP) is a Cognitive Behavioral Therapy framework that focuses on exposing yourself to things that trigger your anxiety and obsessions, and purposefully not doing the compulsions.
For example, if you have an OCD fear of contamination, a classic compulsion is excessive hand washing. An ERP exercise might be purposefully touching something you deem as contaminated (dirty clothes, unclean surfaces) and then not washing your hands. This works because if applied correctly, it gradually habituates yourself to the anxiety and you “teach” your brain that it has nothing to fear by not doing the compulsions. In turn, over time the urge to do compulsions lessens and the anxiety response decreases as well.
IOCDF.org has a great overview on ERP. I also go into a bit more detail here on this post.
One thing I wanted to add which I feel is very important: ERP is all about eliminating the response to your triggers. It is focused on eliminating your compulsions. Note that ERP is NOT focused on eliminating your anxiety, and that is key to understand when you first begin ERP. So many people go into ERP expecting that it will help reduce their anxiety, when in reality, your goal should be solely focused on eliminating your compulsions while accepting any anxiety that comes along with it.
“What is Acceptance and Commitment Therapy? (ACT) Is it different than ERP?”
Acceptance Commitment Therapy (ACT) is another form of Cognitive Behavioral Therapy (CBT), just like ERP is a type of CBT as well. ERP is often viewed as the Gold Standard for OCD treatment (and for good reason), but in my opinion, ERP is really strengthened by ACT. The two frameworks complement each other well. At a high level, ACT is all about accepting thoughts, feelings, and uncertainties. It's about recognizing that you can observe feelings of anxiety, fear, doubt, guilt, etc... that are occurring in your brain, but also realizing that these feelings are separate from who you actually are and what your values are. ACT is all about acting in accordance to your values while you have any thought or feeling. So you may be feeling anxious or uncertain while practicing ERP, but ACT would tell you that these feelings don't control your actions. You can still do things you enjoy, and spend time with people you love, and live a happy life even while these feelings bounce around in your head, because at the end of the day, you are not your thoughts or feelings - you are your actions.
To me, the two frameworks complete each other wonderfully. ERP is how you handle the trigger/compulsion, and ACT is how you move on from it. People will often be confused when getting into OCD recovery and try to figure out: should I do ERP? Should I do ACT? My response: why not both?
“I have terrible thoughts and fears that make me think I’m an awful person, or that my thoughts reflect who I really am. Is it true?”
Asking yourself "is this true?" or "did it happen?" is a compulsion and just what OCD wants you to do. The thing is, you will never know the truth and will never get that 100% certainty that your brain is craving. It sounds horrible but that is the way OCD works. The more you ruminate and try to "figure it out," the less certain you become and the more you are convinced you've done something horrible.
The key to beating OCD is to understand that you need to accept uncertainty. At some fundamental level, you know this is OCD talking and not your logical brain. Disregard the compulsion to ruminate, disregard the urge to try and figure it out, and instead just accept the uncertainty and decide to move on with your life.
Consistently making this choice whenever OCD uncertainty rears its ugly head will help retrain your brain and make it easier and easier in the future to refuse compulsions and eventually recover from OCD.
“How do I help my family member who has OCD?”
The key to beating OCD is first understanding OCD and how it works. Your brain craves the sense of relief it gets from performing compulsions, no matter how temporary that relief may be. So, in order to get that "high" of feeling relief, your brain throws up more compulsions for you to do. By doing the compulsions, you normalize this behavior and reinforce to your brain this is how you should act.
In reality, the key to beating OCD is to break the cycle. Whenever your brain tries to get you to do compulsions, refuse. Choose to sit with the anxiety instead of chasing relief. If you make this choice over and over again, you break your brain's dependency on doing OCD compulsions to fuel its sense of relief. This is fundamentally how Exposure Response Prevention (ERP) works, by refusing the response, you are changing the way your brain engages with the OCD compulsions. ERP is THE Gold Standard for OCD recovery.
If you are not suffering from OCD but your loved one is, it's still important to know how OCD works so you can help them break the cycle. Sit down with them and discuss what their triggers and compulsions are. Explain how OCD functions and that refusing the compulsions is critical to their recovery, no matter how anxious it makes them feel. Be their accountability partner - if you observe them performing compulsions, gently remind them to sit with their anxiety and refuse the compulsions. Or, if the anxiety is too much to bear at first, help them take it in phased steps. Instead of instantly washing their hands whenever they may feel contaminated, tell them: "Hey, how about this time, wait 15 min before washing your hands. Sit with the feeling of anxiety. Then the next time you feel contaminated, try waiting 30 min before washing your hands. Then 1 hour. Etc..."
The worst thing you can do if your loved one is suffering from OCD is to provide reassurance. DO NOT DO THIS. This is a HUGE mistake that many people (even therapists) make when they try to help people suffering from OCD. Reassurance is something like "Oh don't worry, you're clean" (if they're afraid of contamination and do excessive washing/cleaning as the compulsion. Or saying something like "Oh don't worry, I closed and locked the door." (if they have a compulsion of checking locks and doors). Reassurance only feeds OCD. To break away from OCD, you need to help your partner habituate to the sense of uncertainty and anxiety that comes from not performing compulsions. Eventually this anxiety goes away, but they have to actively practice refusing compulsions and acclimate to the feelings of anxiety first.
Help your loved one find good recovery resources. There are plenty of great resources online - I have some free ones listed here on my blog. If you think therapy is warranted, find a therapist who specializes in ERP and ACT. OCD is still a fairly niche mental disorder and sadly I feel a lot of psychologists aren't well trained in proper techniques to address OCD. Finding a trained and experienced ERP/ACT therapist is the best road to recovery; finding a therapist who has no idea what they're doing may actually make the OCD worse! (if the therapist does things like reassurance to make them feel better)
I think that about wraps it up for the September Q&A. Hopefully reading through some of these questions, and my responses/answers, is helpful to viewers of the blog. My intent is to show that even though OCD can take many forms, ultimately recovery still boils down to the same ERP and ACT techniques that I am highlighting in my other blog posts.
I’ll be doing a similar Q&A post for October, so please feel free to send me any questions (via email, or by leaving a comment on this post) and I will do my best to answer them in next month’s Q&A post!
Eric