OCD says that a person has to avoid things that cause obsessions and do compulsions to prevent bad things from happening. "If you use that toothbrush now, your dad will die." "Walk far away from that spot--it could be HIV-contaminated blood." "Your hands don't feel clean enough--wash them again so you don't get someone sick."
The goal of ERP is to defy the OCD--to do the opposite of what it commands. By facing obsessive fears and not doing rituals, the person stops fearing the triggers and learns that the rituals are part of the problem rather than the solution.
The most powerful learning in ERP comes when the person faces the scariest OCD triggers: Nothing rewires the brain like facing our worst fears. Sometimes in OCD treatment a person naturally will want to stop short of the most difficult exposures. The problem with not tackling the toughest items on the person's exposure "hierarchy" is that it makes relapse more likely.
By way of analogy, imagine if a person had a dog phobia. Treatment would involve gradually working up to being close to a dog and then petting the dog, or even letting a small dog sit on one’s lap. The treatment wouldn’t be complete if the person weren’t willing to “go all the way” and actually touch the dog. The person might be left with the belief that “if I’d touched that dog he might have bitten me,” or, “I’m not brave enough to let dogs get that close to me.” Fully facing one’s dog fears makes it much more likely that the person will conquer the phobia. In the same way, ERP is most effective when the therapist encourages the person to confront her fears as directly as possible.
What this means in practice is that the top OCD exposures will often go beyond what's considered "normal." For example, it would not be unusual in ERP for someone to eat food that's been placed on a clean napkin on a toilet seat. This kind of exposure truly "takes the fight to OCD." It says, "I'm not content to make peace with OCD--I want it out of my life." When we deliberately resist OCD's directives, we maximize our chances for success.
Hopefully you're thinking, "But that's disgusting! Nobody wants to eat from a toilet!" It's certainly gross, and it's not normal. At the same time, it's probably cleaner than eating off your desk at work. In fact, it's not actually worse than things we do all the time without thinking about it, like touching a dirty door knob between washing our hands and eating.
The truth is, we often have to take extreme measures to combat serious conditions. People don't normally put things in their bodies that make them violently sick and make all their hair fall out--but if they have cancer, they'll need to do something “abnormal” to beat it, like taking chemotherapy. In the same way, ERP is a non-normal and effective treatment for OCD.
I should note that exposures are not designed to be extreme for the sake of being extreme. There seems to be a bit of a trend toward a "more extreme is better" approach in OCD exposure. The point is to maximize recovery. Yes, licking a toilet seat would be more extreme than eating food from a napkin on the seat, just like sticking your head in a dog's mouth goes beyond petting the dog; the question is whether being more extreme is necessary. For most people with OCD, stopping shy of toilet licking is still plenty to conquer the fear.
Exposures at the top of the hierarchy are probably going to trigger a lot of anxiety, and may lead the person to want to avoid the exposure. The therapist has a crucial role to play in these moments. The challenge is to be compassionate without being indulgent. Compassion says, "Yes, this is a really hard one--of course there's a part of you that doesn't want to do it." Non-indulgence says, "... and you can do this. You're strong enough. Here's a chance to really stick it to OCD."
Therapists make a mistake to do one of these approaches without the other. Being angrily insistent doesn't tend to be helpful, nor does throwing in the towel too quickly.
When the desire to avoid is strong, that's when we know the OCD is threatened. Thus the difficulty in doing the exposure can be highlighted as a sign of how important it is.
If the person truly isn't willing to do the exposure, the therapist should work with the person to find a suitable substitute, with the goal of working up to the top exposure. Some days the steps forward will be small and sometimes they'll be big--the most important thing is that the person is moving forward.
My next entry in this series will address the different kinds of exposures used in ERP therapy.