When you have decided to get into ERP for getting your Harm OCD under control, you should also know the correct way of doing your exposures. Doing your exposures incorrectly will make you feel like you are working towards your recovery but your OCD will continue to stay strong. Following are some pointers.
Make time for other activities around your exposures: Have you heard of the financial advice ‘save first, spend later’? Exposures need to be considered like the saving part of your time. Do your exposures first. Do anything else around it. If you have two activities planned, one of which is ERP and you have time for only one, do ERP. If you must lose sleep, lose sleep. If you do not get time to eat, don’t eat. If you don’t get time to bathe, don’t bathe. But do not do these activities when you should be doing ERP. So, make time for other activities around your exposures and not the other way around.
Plan your exposures: Pre-planning actions to avoid triggers is a compulsion. However, pre-planning your exposures is not. Provided you plan your exposures appropriately. You have to anticipate the compulsions for a particular trigger and have a response prevention strategy chalked out. When you spend a couple of minutes planning that, you may be able to catch yourself before or while doing a compulsion and provide the right response.
If you miss doing an exposure today, do it twice tomorrow: Despite the best of intentions there will be days when you may not be able to do your exposures on a given day. The good thing about ERP is that you can do it as many times as you want in a day. So, if you have missed doing your exposures yesterday, do them today. Think of it as your salary. If you got half your salary last month, you will demand the other half this month. Just because it was not paid last month does not mean you will let it go. Learn to treat your exposures like that. Non-negotiable. Compulsory.
Don’t pick up only simple exposures: Simple exposures are those that do not cause you enough anxiety for you to stay with. Simple exposures may be ones with anxiety levels of three or four. Doing them may seem like you are working on your Harm OCD, but they really create a false sense of action as they do not amount to much. Think of lifting five-pound weights at the gym for a month and considering your workout done. Ineffective! Pick up exposures that are both difficult and manageable. They should be difficult enough to make an impact, but not so difficult that the overwhelming feeling makes you give up. Do 1.2x of what you think you can. Don’t try to do 10x of what you can.
Do not engage in compulsions mid-exposure: When you engage in compulsions mid-exposure, you need to start with the exposure again. The value of an exposure is in the response prevention that follows. Doing your exposures and providing compulsive response in between is similar to wanting to quit alcohol but taking a few sips to take off the edge of the abstinence. You need to reset the counter to zero as soon as a compulsive response is provided.
Do not expect the anxiety to dissipate immediately: One of the biggest reasons why ERP fails for some people is that they expect results immediately. When they don’t, they panic that they may be doing something wrong, or worse, give up. Being non-striving when learning a new skill is critical to mastery. Being non-striving means not expecting immediate results and continuing to practice regardless of results. The results do show up but eventually. A mango tree does not bear fruit for 10-15 years. If one were to stop nurturing the tree in the first few years, one would not get the mangoes. One continues in a non-striving manner to nurture the tree, not for immediate results but for eventual gains.
Do not prematurely declare a trigger handled: After ERP has begun people come for subsequent sessions and tell me that they were able to complete the exposure and that they would like to move on to the next few items on the hierarchy. But they may have completed the exposure only a few times and not given it sufficient time to get habituated to it. The desensitization process is not complete with a specific number of exposures. Repeated exposures are required to make the anxiety come down and for us to get desensitized.
Decide on the scale of exposure: The scale of exposure is the level to which you want to take your anxiety as per SUDS. If you start with an exposure at a SUDS score of 5 and stop when it gets to 6, it doesn’t work. Decide that you would take it to say, a 9 and then wait for the anxiety to come down to half that is, 4 or 5. If you manage to bring it down to half quickly enough, move on to another exposure. If even after 45 to 60 minutes of exposure, the anxiety is not reducing, you may have picked an exposure that you may not be ready for. It is okay to drop it then and start with the same exposure when you are more ready.
Stop leaning on your compulsions: Before you realize you have Harm OCD, you begin to get obsessive thoughts that you do not pay attention to, but discover quirks that help deal with the thoughts. Soon, you begin to look at your quirks as your friends. Get an obsessive thought, do a quirky action. Feel an obsessive thought coming up, do a pre-emptive quirk. The quirks soon become compulsions. You just have to do them to make the thoughts go away. That is when they become compulsions, with you summoning them the minute you feel anxiety coming on.
But the process of recovery requires you to treat your compulsions as your enemy, your last resort, in case you are just not able to tolerate the anxiety. And when you do do your compulsions, do them with reluctance, knowing that you have to try again the next time and not do them.
Let some compulsions happen: This is a controversial point and seemingly contradictory to everything else. When you get into therapy, the best thing to do is to not do any compulsions when you do your exposures. However, it is only theoretically possible to not do any compulsions at all during the exposures as you begin your recovery process. Most times you do not even know when a compulsion slips in while you are trying to do your exposures.
Of course, that is wrong, but it happens. If you end up doing compulsions, be okay with that too. Do not beat yourself down because you could not manage something that no one else with Harm OCD can either. But don’t consider this allowance as a carte blanche to do the wrong thing. It is just an allowance to be kind to yourself for the slip.
Do the compulsion if you must: Again, this is an even more controversial point. When you are doing an exposure and even after say, 60 minutes of exposure your anxiety does not come down, you probably have taken up an exposure that you may not be ready for yet. To bring down the anxiety that you are feeling, if you need to do a small compulsion, do so. I am going out on a limb here to suggest doing a compulsion but this too should not be taken as a carte blanche, a green signal to do your compulsions as you please. You are allowed this only under extreme circumstances.
For example, if you are expected to do a harm exposure by holding a pair of scissors in an attack position and sit close to someone you have urges of harming. This can be (or will be) highly anxiety inducing and hence, exhausting. If the anxiety does not abate even after having exposed yourself for 60 minutes and you feel the need for an outlet, and if you ask for a lone reassurance, it is not correct, but understandable.
I repeat, do the compulsion only if it gets too overwhelming. You have probably bitten off more than you can chew and you need respite. This respite will help you continue your efforts and not give up because the whole ordeal seems unmanageably overwhelming. If by doing one small compulsion, you are still in the game, it is worth the minor slip.
Do not give up: Exposures are difficult and I will say this again and again. You will not succeed right away at everything. It will take time. You will stumble and fall. But as the Japanese proverb goes ‘Nana korobi, ya oki’, which means ‘fall down seven times, get up eight’. So, all you need to do is to not give up. Keep pushing yourself to your limits, but in the journey, be kind to yourself. What you are attempting to do is difficult for most people. So, be kind to yourself while doing your exposures.