When exposure for OCD is misunderstood
The aim of exposure is not to create as much discomfort as possible, but to work at the point where change can happen. In OCD, a poorly planned exposure can easily become part of the OCD cycle. Effective exposure depends on good technique and a clear understanding of how OCD works.
Planning the exposure is the difficult part. Once the plan is right, carrying it out is often much more straightforward.
When we use exposure, we deliberately approach a trigger to weaken the learnt alarm response. We are teaching the anxiety system that this trigger does not call for action. The alarm response is not merely unwanted; it is unnecessary.
Don’t worry
It is easy to feel alarmed when you first hear about exposure. You may quickly imagine that everything will go badly, or that you are taking a risk that can never be undone.
Some therapists say: “You just have to throw yourself into it and do everything you are afraid of. Then you will quickly learn that OCD was wrong.”
Although there is some truth in that, I doubt the therapist would find it so easy if they were living with something as complex as OCD themselves. OCD is not the same as a straightforward phobia, where direct experience can quickly show that the feared situation is not dangerous.
If someone is afraid of a rabbit, they can sit quietly near it and discover that nothing happens. That may be the therapist’s model of exposure, but it is a considerable oversimplification of how OCD works.
When you have OCD, you are already busy working out how to avoid the consequences of having been close to the rabbit: how to wash afterwards, and how on earth to get home in the car without contaminating it with “rabbit mess”.
It is only one example, but you probably see what I mean.
Designing exposure properly
Exposure for OCD therefore has to be designed differently. Getting it right demands much more of the therapist, who must look beyond the tip of the iceberg.
When we work with exposure, we always work at three to four out of ten on the anxiety and OCD scale. At this level, there is room to stay with the discomfort without becoming overwhelmed or feeling pushed too far afterwards.
As we continue working at this level, the “dangerous” situations higher up the scale gradually move down into our sweet spot. None of us functions well in the red zone. We are not built for it, and fortunately we do not need to be.
We do have some strategies that can help, but that is for another time.
“I’ve tried that before”
You may be thinking: “I’ve tried that before, and it only made everything worse.”
That may well be true. But if it made everything worse, the exposure itself was not designed properly. Many therapists do not understand how to design exposure for OCD.
For example, I worked with a client who had been admitted to a psychiatric ward. She was unable to live independently or hold down a job. She feared that chemicals in her surroundings could impair her cognitive abilities, which might then lead her to harm someone.
In hospital, the staff tried to expose her to what she feared. She was instructed to sit for three hours on a chair that she feared might contain traces of a harmful substance. They believed this would teach her that the chair was not dangerous and make the problem disappear.
Unsurprisingly, the exercise failed, and she was discharged with her OCD described as incurable.
But once we began working with her OCD and using exposure properly, she moved back into her own flat and found a job she truly enjoyed.
She was not chronically ill. She had received inadequate treatment.