Monthly Archives: August 2010

No one should do exposure and response prevention!

Exposure and response prevention (ERP) is the first line treatment for OCD, but no one should do it!  I do believe that any sufferer with OCD who would like to be free of this problem would be well advised to choose ERP for treatment.  Many sufferers of OCD find their decisions and actions guided by shoulds, by what is right and wrong.  They would say that this is being responsible.  Wrong. Responsibility is not a matter of what you should do.  Responsibility is taking the steps to accomplish the things you want to do.  The responsibility of shoulds involves some authority shaking a finger at you demanding you to be good or to do the right thing or else.  This is neither thoughtful nor helpful.  When we are working with an individual, we emphasize that we don’t want them following the treatment we are proposing simply because we are experts who are supposed to know, we would like them to follow our treatment if we have convinced them that this is the best way.

The responsibility of taking the steps to accomplish what you want puts the power in your hands.  With regard to OCD, this makes the decision to do ERP a matter of thoughtfully looking at what treatments and evidence for them is available.  However, it does impose an additional requirement.  It makes you responsible for possible outcomes.  I often ask someone, can an individual be a responsible criminal and if so how?  Many want to say no, because they confuse responsibility with right and wrong.  Others will say yes, but if I ask how, they suggest by carefully planning their crimes.  This would be part of it; however, in making a choice, I also need to consider the possibilities of what might happen.  I used to work with drug addicts on probation and parole and I ran into responsible and irresponsible criminals.  The responsible felons were those who had accepted the possibility of landing in jail, since most of the people they knew eventually were caught.  They may not have liked prison, some went straight following their incarceration, but they accepted the consequence.  The irresponsible felons complained about how unfair it was that they were in prison and why the system should be changed and so on.  All of that might be true, but it was true, that regardless of what they feel, the law was the law and they apparently weren’t willing to accept prison as a real possibility.   A similar example would be someone who would like to become an actor.  It is fine to hope to become a Hollywood star, but if failure isn’t acceptable, then acting makes no sense to try, since this is the most likely outcome.  If on the other hand, you want to devote a number of years trying before moving on, or if you are willing to accept not getting further than community theater, then attempting to go into acting is responsible.

Anyone suffering from a problem would wish the problem to be gone quickly.  But at this moment in time, ERP is the most researched treatment and the only one that all of the experts and professional organizations (both the American Psychiatric Assoc and the American Psychological Assoc recommend ERP as the first line treatment for OCD as well as the International OCD Foundation).  The possible feared consequences that most sufferers face are horrible, but consider a few facts.  First, what have you lost to OCD and I don’t mean in general, but in detail, humiliating experiences, being late for important events, lost relationships and so on.  Second, how have you hurt your loved ones – forcing them to do rituals, endlessly asking for reassurance, being angry at them for not giving in.  If you have children, would you do anything for them?  If you say yes, and I don’t mean to be offensive, but you are lying to yourself.  You put your OCD fears in front of their welfare.  You run the risk of having children who won’t respect you or who will live in fear of the world.  There is a 1 in 4 chance your children may have OCD and your behavior teaches them that OCD is something to cope with or not.

And there is a third reason.  At this point your OCD steals everything from your life and hurts your loved ones.  Even if you were to leave them, they would just be hurt more by your abandonment.  And you are willing to have all this happen because of a possibility of something bad happening.  Whatever decision you make there is risk. However, the saddest thing about your rituals is that they don’t work.  You never get the safety or reassurance you wish for.  And if you described your rituals to me, I would be able to find flaws – reasons you are still at risk.  So the saddest thing about your rituals is that for all of your pain and efforts, you never get the prize, all of your fears may happen anyway.

I have written elsewhere that the only thing we have is the present.  Those you love are only there when you are with them.  So when you are alone, there are past good memories and hopes for a future, but that isn’t now.  And with your OCD, you don’t even have the present, because you are trapped in OCD land.  Responsibility is taking the actions to achieve what you want and accepting the consequences.  To give into your rituals is to decide to have a difficult life, hurt the ones you love and have not guarantee that what you want to avoid will be avoided.  To fight OCD is to want to learn to live in the moment and enjoy it and to learn to cope with possible risks.  Working on your OCD helps you and those you love.  Not working on it hurts everyone.  Running away hurts everyone.  If you really would do anything for those you love, be responsible and take the steps to achieve your goals.