"I just had an unwelcome sexual thought—I'd better say a prayer for forgiveness."
"I might have touched that person's coat. I should probably wash my hands."
"I'm not 100% positive that the door is locked. I have to go back and check it one more time."
Obsessive-compulsive disorder (OCD) is driven by doing—repeating, washing, locking, looking, feeling, asking, repeating (again), reassuring, checking. All this doing is meant to prevent bad things from happening.
As active as exposure therapy is, in a real way it is a kind of non-doing. Exposure invites us to approach our fears and then do... nothing. Simply face them. It is in the nature of our nervous systems to get over our fears if we stay with them. All we have to do is stay—nothing easier, or harder, than that.
Conquering fear is in many ways like falling asleep. How hard do you have to work to fall asleep? We need to create the conditions that lead to sleep, climb into bed, and our bodies and brains do the rest. In fact, effort gets in the way of falling asleep. In a similar way, the work of facing our fears comes from confronting them—our bodies and brains take care of the rest.
If we're not careful, we can infect the exposure process with a need to do something in addition to the exposure. One way this excess doing happens is when ERP therapists tell the person with OCD to use distraction during exposure. For example, while the patient is handling a "contaminated" object, the therapist might instruct her to "think about something else," or may strike up a conversation about recent movies. This type of distraction generally needs to be avoided in ERP.
Why? Because full attention to the scary stuff works better than distraction. If we distract ourselves during exposure we can be left with the belief that we couldn't have made it through the exposure if we'd paid full attention to it.
Using distraction is like watching a scary movie through our fingers. When we truly let down our guard, we can get the full benefit from facing our fears. In the process we learn that we are enough to get over our fears—we don't need props or gimmicks or subtle ways of protecting ourselves.
Therapists who encourage distraction send a mixed message, suggesting that exposure is necessary on the one hand, but that the person can't tolerate "undiluted" exposure on the other.
It's also the therapist's job to make sure that the person in treatment isn't doing subtle forms of avoidance during the exposures—for example, by thinking about things besides the feared situation. Therapists need to encourage the person to focus on the exposure exercise, to allow the uncomfortable feelings to be there, and to imagine what he's afraid might happen as a result of the exposure.
Doing exposure in the most effective way possible can involve less doing and more being present, and riding the wave of one's anxiety as it peaks and falls all on its own.