Full Exposure: The Sickening Treatment for OCD
How contamination can help OCD sufferers manage their symptoms.
Posted May 21, 2012
People associate repetitive behaviors such as handwashing and counting with OCD. In reality, most of the action is actually happening inside the sufferer’s head. As a victim of this most misunderstood disorder, I’d like to clarify a few misconceptions.
OCD is about fear and uncertainty—the physical compulsions are a way to ward off the demons that torture the poor sufferer. You’d think that if you could eliminate whatever the obsessed person is frightened of, you could get rid of the OCD. But, if you go this route, you quickly start to run into problems.
Consider a patient who is struggling with a fear of contamination—should we seal her in a sterile plastic bubble? Or will a hazmat suit suffice? Or should we play it safe and exterminate every virus and bacterium on the planet for her protection? Imagine someone with religious obsessions—do you think a signed contract from the Pope will be enough to convince him he isn’t going to hell? Or should we get one from God himself? And what if neither party agrees to provide a signature?
You see the problem with trying to fight OCD by destroying what the sufferer fears. Indeed, the urge to get rid of something terrifying is exactly what inspires the ritualistic behaviors. Sufferers may not have access to hazmat suits, but they can wash their hands, and if that doesn’t somehow render them completely immune to all sickness forever then they’ll just have to wash their hands again, and of course, again.
There is a form of therapy that consistently alleviates OCD symptoms, but it’s among the cruelest and most agonizing procedures in all of psychotherapy. And it doesn’t involve protecting the person with OCD from his or her worst fears. In fact, this treatment requires that the sufferer confront them, directly, and without any kind of protection.
The treatment is called Exposure and Response Prevention, or ERP therapy. ERP works when, guided by a trained therapist, the sufferer approaches the object of his or her fear without indulging in any compulsive ritual behaviors. These exposure exercises often involve doing things that would make anyone, even someone without an anxiety disorder, deeply uncomfortable.
A sufferer with obsessions related to contamination and infection, for instance, might have to plunge his hands in a dirty toilet or a bucket of discarded tissues and then sit there, for hours, without exercising his handwashing ritual behaviors. No handwashing. Period.
And there are as many forms of ERP as there are people with OCD. A sufferer with religious obsessions could be asked to curse or desecrate religious objects. A sufferer concerned that she might lose control of herself and hurt someone she loves might be required to record and listen to violent messages, or even to carry a knife as she spends time with her family.
That’s right: there’s a form of therapy that actually requires distributing dangerous weapons to the mentally ill.
But the truth is that, even carrying a knife, someone with OCD isn’t any more likely to snap and kill someone than anyone else might be – and how many times have you, reader, paused while preparing supper to disembowel a loved one or roommate? And as gross as it is, a lavatory manicure probably isn’t actually going to kill anyone; humanity survived for centuries before the invention of lemon-scented dish soap.
By directly facing his or her fear, the ERP patient slowly learns to live with the risk of the catastrophic anxieties that took over their lives. ERP isn’t safe, necessarily: the presence of a therapist is not a magic antibiotic, and the OCD patient with his fists in a toilet is just as likely to contract E. coli as anyone else similarly exposed. But the purpose of the treatment is to teach OCD sufferers that safety isn’t always necessary or desirable, and that they can survive and even thrive while directly threatened by their worst fears.
In Triggered I describe my particular variant of OCD, which involved deeply unpleasant runaway intrusive thoughts. Like the reluctant knife-wielder described above, my symptoms often involved imagining myself doing repulsive things to other people. So while my OCD wanted me to hide in my room, avoiding my worst fears by shunning human contact, my ERP treatment required me to go out and interact with other people, friends and strangers, at home and in shops and coffeehouses.
By confronting my worst fears, I not only learned to manage my OCD—I developed an entirely different method for confronting fear and perceived danger. Instead of finding ways to avoid anxiety, I’ve learned to realistically assess the risks of my actions, and to strive for the things I want to achieve even when I’m scared of the consequences. When I am afraid of something, I take that as a signal not to run but to deliberately approach it, because I’ve learned my obsessions and anxieties almost always point me in the wrong direction.
So, can you “cure” OCD? Not yet. But I’ve learned that it’s possible to manage OCD. ERP didn’t just help me fight my OCD—it changed the way I live my life. I’d recommend it to anyone who struggles with anxiety, whether it’s pathological or run-of-the-mill. When we confront the things that terrify us, we can only become stronger.
You’d be surprised how sticking your hand in a toilet can make you a healthier person.
Copyright, Fletcher Wortmann, 2012.
Author of Triggered: A Memoir of Obsessive-Compulsive Disorder (St. Martin’s Press), named one of Booklist’s “Top 10 Science & Health Books of 2012”.
Visit my website: http://www.fletcherwortmann.com/
Read my Psychology Today blog: http://www.psychologytoday.com/blog/triggered