The second pillar of recovery is ERP. ERP stands for exposure and response prevention. It is also sometimes referred to as Exposure and Ritual Prevention and/or notated as Ex/RP, and there is really no difference in the two. For the purpose of this course book, we shall refer to it as ERP. ERP is still the treatment of choice for all forms of OCD, including ROCD, 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 the triggering events for the purpose of triggering the obsessive thoughts. Why in the world would anyone want to get exposed to his triggers by choice? It is bad enough, as it is that you get exposed to them all day anyway, right? Wrong!
There is a strong purpose in getting exposed to your triggers deliberately. The purpose is to desensitize oneself to the fear by facing it continuously. The purpose is to render the fear extinct, through habituation. Like the analogy of a horror movie not remaining scary 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 by watching a romantic movie. This may give rise to obsessions, which may give rise to the urge to do the compulsions. You may want to stop watching the movie. You may want to compare physical attributes. You may get the urge to neutralize the thoughts, by telling yourself that your partner’s nose is not too long. Or, you may get the urge to seek reassurance from others if your partner looks good.
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 stop watching the movie, you continue to watch the movie. Since the compulsion is to compare physical attributes, you would learn how not to do it. 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 to 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.
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 ROCD, not doing the compulsion may increase the anxiety in the beginning. But if the compulsions are resisted, the anxiety will eventually subside by itself.
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 7 to understand how capable you are at learning new things.
The idea behind filling this worksheet is for you to recognize once again that if you put your mind at 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 ROCD gives up on you because you are not giving in.
The process of recovery through ERP seems difficult, and it is. But what is expected of you is not superhuman strength. You are not expected to handle snakes or walk on fire. You are merely expected to replicate the average action of average people.
If you pick out one hundred people at random either on the street or out of the telephone directory and question them on their relationship behavior, you will have an understanding of what average relationship behavior is. This course book will expect you to be able to replicate that average behavior. Nothing more, nothing less.
In the next chapter, I shall be discussing the third pillar of recovery in ROCD, and the first one of the MAGIC acronym, which is mindfulness.
Fill WS7 – things you got good at with practice