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OCD Checking and Washing

You think you know about ERP for OCD? Guess again!

"Exposure Therapy/Exposure and Response Prevention." Anyone who does any reading about OCD comes across these terms all the time. Most people (including professionals) THINK that they know what ERP is, and, to a degree, they do: For washing, expose yourself to "contaminated" things and then don't wash. For checking, when you get the urge to check something, well...don't.

Simple in concept but extremely difficult in execution, ERP may defined by the above, but the definition doesn't really get at HOW TO MAKE IT HAPPEN. Hierarchy exposure, going from easier to harder exposures, tends to be used by lay people and many professionals as an intervention across different situations—for instance, touch the chair which is less "contaminated" first, and then work you way up to the bathroom doorknob. But this still doesn't hit the mark.

Exposure has "rules" that should be followed to ensure success, and should be applied within each and every exposure experience. Here are a few of those rules:

1. FREQUENCY: Whatever you exposure yourself to, and at whatever level you are in your hierarchy, it is essential that you engage in that exposure behavior frequently and regularly. Practicing leaving the house without checking the stove, or not washing your hands after touching the landline phone once a week, or even once a day, probably won't do the trick. These exposures have to be done frequently, often many times a day, to allow exposure to properly have its effect of desensitization, or, the lowering of your anxiety.

2. DURATION: Hand and hand with how often you do exposure is how long you do it for each time you do it. The rule of thumb is that you must engage in the exposure experience at least until your anxiety drops to 50% of what it was at the very beginning of the exposure experience. This, of course, gives you the time necessary to experience desensitization. If you leave too early in the process, you are actually reinforcing the "escape" response, training yourself to run from the anxiety, which in fact strengthens the OCD. Give yourself plenty of time each time you engage in an exposure exercise- it is an essential part of applying the technique successfully. Best though to not let the clock tell you when you are done, rather, let your anxiety be your guide. When it has dropped enough, your exposure will have an effect.

3. INTENSITY: How strong of an exposure experience should you be looking for? For the most part, this is a personal decision, but here again there are some basic guidelines. Start too low on your intensity level, that is, expose yourself to a thing or situation which does not create much anxiety (say, a "2" on a 1-10 scale, where 10 is the highest imaginable anxiety), and you won't get much payoff from the experience. On the other hand biting off more than you can chew (going for that 9 or 10 right away), may be so overwhelming and strenuous that you may decide to give up the whole effort and drop out of therapy or just stop trying on your own. We suggest shooting for something between 4 and 7 on that 1-10 scale as a place to start, and shoot for dropping it down to a 2 by the end of exposure (NOT zero), before moving to the next level.

4. METHODOLOGY: There are many ways to manipulate the intensity described above, depending on the methodology you use. Say the challenge is to leave the house without checking that the range is on. If you presently have an elaborate ritual of touching the range knobs a certain number of times and/or in a certain order, you might first change the order, the number of times you touch them (sometimes even increasing to 5 if you always have to check an even number of times), or a combination of the two. Then you can graduate to shortening the amount of time you touch them, just waving your hand across the burners as a check, and next just visually inspecting them. Next, look at them for shorter periods of time, and from further distances from the range. In all these ways, you are constantly "pushing up against" the OCD, loosening its grip on you, and strengthening yourself.

5. MONITORING: Along with all the above is the idea of observing, recording, and reporting (to your coach or therapist) your progress. Nothing helps motivate and encourage, and also help to clarify the progress that has already been made, then good record keeping. This is an essential aspect of just about all cognitive behavioral interventions, and it has its special place here with ERP.

6. POSTPONEMENT: A sort of particular kind of methodology is the concept of postponement, or "delay." Here, the focus is not so much on changing what you do, how you do it, or how often you do it, but when you do it. Say I expose myself to a contamination source, and my standard response is to take a very ritualized 2 hour shower where I repeat certain behaviors and have to follow some very specific rules. In postponement, you might practice jumping into the shower for a quick rinse and then out again in just 30 seconds, drying yourself off, and then go right back in and take your 2 hour shower- no changes. It is less difficult to do this when you have every intention of going right back in the shower and engaging in your full ritual. Next time you would do the same thing again, but wait 60 seconds after drying off from your 30 second rinse before beginning your 2 hour ritual. Next time you wait 2 minutes before going back in, then work yourself up to 10 or 30 minutes, or even a few hours. Ultimately you find that you don't feel the need to go back at all. During this process, you could experiment with adding a few seconds and a few actual washing activities to the original 30 second rinse.

We do the same kind of thing with checking the doors at bed time. Go up and into bed first, under the covers with the lights off. Wait 10 seconds before you come back downstairs to do your door checking ritual. Next night, wait 30 seconds, and so on.

7. One last ERP concept is perhaps the most overlooked—the cognitive part of the exposure. Too often when people do exposure and then don't wash or check they reassure themselves mentally that everything is ok. This does not help the process. Best to do cognitive exposure as well as behavioral. So the person should be thinking "yes, I didn't check the locks and burglars are going to come into the house and steal everything and torch the house!," repeating this over and over again on purpose, ultimately eliciting desensitization. This concept gets a little tricky, and sometimes requires a hierarchy of its own and the use of scriptwriting. I will follow up on this concept in more detail in a future blog.

For now, you have a blueprint of the nuts and bolts of how to actually implement an exposure strategy. Following the rules above provides you with a much better chance of quick, successful results.