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.

14 Comments

  • Hi Dr Grayson, but one thing difficult with self help ERP for OCD is not the couragement to apply ERP, but the confusison on the method of doing it. Like for the pushing up glasses problem, I’m really not sure if my constantly pushing up glasses is a ritual or not, so in that case how can I do ERP to that?

    • The issue with glasses is usually that it feels like you will continue to notice the feeling forever and it is interfering with everything you do. If this is the case, the goal is to find a way to do two things: 1) decide that you want to learn to live with the feelings — to get used to it. If you actually make this decision; then 2) taking the steps to do this. Most often we would have you leave the glasses wrong or maybe even make them wrong on purpose. Along with this, make an MP3 that just says the word, “Glasses” once every 3- seconds to 90 seconds. The idea of the MP3 is to make sure your attention doesn’t accidentally wander from the sensation. The delay between the word is to help keep the word noticeable. We would have you listen to it as continuously as possible. This may fall under the category of neutral obsessions. Feel free to e-mail me for a copy of an article about neutral obsessions.

  • What a wonderful, thought-provoking post! I’m planning on writing about responsibility on my blog in the near future, and will definitely quote you. Thank you for your insights, Dr. Grayson.

  • You said rightly that OCD hurts the dear ones as it hurts the person who is conditioned to it. Can you explain the role of anger in case of person suffering from OCD pure ‘o’. Is it not true that manifestaion of anger becomes a sort of rumination/compulsion with such persons? or whether angery outbursts are nothing to do with OCD pure ‘o”? Whether angery outbursts are not in response to accute obsessive fears as a sort of defense mechanism/ escape ruite? Please clarify.

  • As a psychiatrist, I am concerned that this article will reinforce avoidance of doing exposure therapy, the single psychotherapy technique that has the best data for relieving obsessions and compulsions. No one should be forced to do behavior therapy, because that is generally not effective. OCD suffers should be provided with a good understanding of the technique and its pitfalls so that they choose to do it and understand the trial and error process involved in making it work. On the other hand, therapists should be required to be expert at behavior therapy and know to refer patients for ERP if they don’t get results. I have seen so many patients in the course of my 30 year career who have had 20+ years of psychotherapy without even being informed about what ERPis. They generally enjoy co-obsessing with their therapists and making the problem worse, not better.

  • Why does this article say no one SHOULD do ERP? Isn’t it recommending it?

    I went against my OCD and now I feel doomed like no matter what I’m going to force this thought on me and never let it go and ultimately force myself to act out this thought.

    It’s the last thing I’d ever want to do and terrifies me, but I can’t and won’t let it go… when I get distracted I purposefully bring it back up. The fear of forcing myself to think it and act out is keeping it going. How does one deal with this or do ERP for this?

    It’s not about triggers, hiding weapons, or wondering if I’m a bad person or want to. I know I’m a good person and would never want to hurt anyone or anything. It is the fear that just because I said I have to do something , I will do it or force myself to think about it until I can no longer take it. No mattee what I do, i just come back to the thought “it doesn’t matter, you made up your mind, you have to act out, there is no escape, you will force yourself to think this and act out…” Please, anyone. I need help. No one accepts my insurance and I can’t afford help. My job, marriage and life are on the line right now…

  • I’m not using compulsions to alleviate the anxiety and they wouldn’t even help anyway. I went against my OCD and now I feel doomed like no matter what I’m going to force this thought on me and never let it go and ultimately force myself to act out this thought. It’s the last thing I’d ever want to do and terrifies me, but I can’t and won’t let it go… when I get distracted I purposefully bring it back up. The fear of forcing myself to think it and act out is keeping it going. How does one deal with this or do ERP for this?

    It’s not about triggers, hiding weapons, or wondering if I’m a bad person or want to. I know I’m a good person and would never want to hurt anyone or anything. It is the fear that just because I said I have to do something , I will do it or force myself to think about it until I can no longer take it. No mattee what I do, i just come back to the thought “it doesn’t matter, you made up your mind, you have to act out, there is no escape, you will force yourself to think this and act out…” Please, anyone. I need help. No one accepts my insurance and I can’t afford help. My job, marriage and life are on the line right now…

  • You are correct that suffers with severe OCD (for over 30 years) do not enjoy any quality of life. And that it causes major harm to their loved ones. However, some of these suffers do not see the harm. OCD is like a parasite that deludes the brain, the suffer is sadly unable to see the harm it causes themselves or others. The OCD even indulges the suffer and allows the sufferer not to act on impulses when the situation arises (such as no washing facilities or emergency situations). But they immediately go back to rituals when they can.
    To them the fear of CBT and ERP is so profound that they would rather stick with the OCD (which they see as harmless).

  • Hi Dr. Grayson! I now know that I have had Reassurance Ocd, abandonment issues, and the anger issues it causes, most of my life. I am lucky to have a decent job, but these issues show up at work with sometimes devastating shame. I have been in psychotherapy forever and now know it’s not really effective. I’m wondering if a) ERP works if I am seeking reassurance from a person and b) are there any ERP treatments in Connecticut that you know of? Thanks a lot! Chris

  • I’ve been in ERP Therapy for severe OCD for the past six months, almost all my compulsions have decreased immensely, I don’t bloke that the thoughts, I allow them to remain without responding or doing an compulsion.

    My Anxiety has greatly reduced most of the time, however the thoughts and feelings are still there and they feel more Real THAN EVER, it’s utterly frightening, many of times I cannot even distinguish between my wants and desires and OCD thoughts, what do you advice Dr.?

  • Thanks for this article. I’m just starting ERP for my Pure O OCD and this actually made me a lot more confident about this course of treatment. It’s true, OCD steals everything from you, and giving in to its demands only feeds it. I need to start taking back control of my life from this disorder and this seems like the way with the best chance of success.

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