The second pillar of recovery is ERP. ERP as you know stands for exposure and response prevention. It is also sometimes referred to as Exposure and Ritual Prevention and/or notated as Ex/RP, but it is one and the same. ERP is the treatment of choice for all forms of OCD, including Harm OCD, as it is evidence based and effective (Khodarahimi, 2009) and is associated with a long-term remission rate of 32% to 70% (Burchi et al., 2018). ERP has two key terms – exposure and response prevention.
Exposure involves getting exposed by choice to events that trigger obsessive thoughts. Why would anyone want to get exposed to his triggers by choice? It is bad enough that you get exposed to them all day anyway, right?
Wrong!
There is a strong purpose in getting exposed to your triggers deliberately – to desensitize yourself to the fear by facing it continuously. To make the fear extinct (kill the fear), through habituation (getting used to the trigger). Like the horror movie losing its edge after being watched repeatedly, your triggers will also lose their edge if faced repeatedly. But – you need to face your fears and not do the compulsions that your mind asks you to do in the moment.
For example, you may choose to expose yourself to the anxiety of holding a knife in your hand while being around your child. This may give rise to obsessions, which may give rise to the urge to do the compulsions. You may want to run away from the situation. You may want to keep the knife far away from yourself. You may get the urge to neutralize the thoughts, by telling yourself that you love your child and do not want to harm him. Or, you may get the urge to seek reassurance from others if you are a good person.
These compulsions are the usual responses you provide to your obsessions. The response prevention portion of ERP requires you to not counter an obsessive thought with the usual compulsive response. In this case, since the compulsive urge is to run away from the situation, you continue to stay right there. Since the compulsion is to keep the knife far away from yourself, you continue to hold the knife in your hands. You would learn to not neutralize your thoughts or seek reassurance from others about this. In short, you would learn to not do your compulsions as a response to your obsessions and let the anxiety reduce on its own.
You may wonder why you would feel less anxious if you don’t do the compulsion. Wouldn’t your anxiety actually rise? The reason is fairly simple to understand, but difficult to implement. Think of an alcoholic who wants to give up drinking. When he tries to give up drinking and stays away from alcohol, his body demands alcohol, as the body is used to having alcohol in the system. The body will protest and he will have withdrawal symptoms like headache, nausea, anxiety
or even hallucinations. He will have an intolerable craving of alcohol. That is, his anxiety WILL rise in the beginning.
But eventually, if he resists it long enough, despite the increasing urges, the need for the alcohol begins to diminish and soon, he does not feel the need to drink any longer. Similarly, in the case of Harm OCD, not doing the compulsion will definitely increase the anxiety in the beginning. But if the compulsions are resisted, the anxiety will eventually subside by itself. This is important to understand because if you think you are doing something wrong when you do your exposures and find your anxiety increasing, you may stop doing your exposures altogether. You may miss the point that for the anxiety to go down, it has to go up as much as it can first before subsiding on its own.
Also think of learning a new skill. When you first want to learn driving, and you sit behind the wheel, there is fear – of losing control of the vehicle, getting into an accident, hurting people, and damaging property. All these are valid concerns. Yet, if you decide not to get behind the wheel to learn driving, you will never overcome the fear. However, if you persist in spite of the fear, you not only get better at driving, but you also begin to lose the fear, as you get habituated to it by facing it often enough.
Can you think of other examples where you did not know how to do something in the beginning, were bad at it, but with repeated practice, you got better at it? Hint – your childhood. Even activities like brushing your teeth followed that process. There was no fear, but there was difficulty, which you managed and at which you got better. Fill in Worksheet 2.4 to understand how capable you are at learning new things.
The purpose of this worksheet is to recognize that if you put your mind to something, you can achieve it. You may not master it, but through repetition you can do it well enough to put it on your resume. The same principle works with anxiety. If we face the obsession without doing the compulsion the anxiety goes up in the beginning. But after some time, through repeat exposure, the anxiety begins to fall. It is almost as if your Harm OCD gives up on you because you are not giving in.
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