The “Exposure” in ERP can be one of two kinds: imaginal or in vivo. Read more about how therapists can determine which form of exposure is called for.
In this post I expand on the notion of doing “extreme” exposures as a part of exposure and response prevention therapy, or ERP. It’s the second in a series on therapist errors in ERP.
I will be reposting some entries from my PsychologyToday.com blog and wanted to start with an early post on exposure and response prevention therapy. The full post is available here.
Earlier this month I wrote my first blog entry on PsychologyToday.com. You can view it here:
On the eve of the new year I wanted to take some time to reflect on the year that’s ending and to look ahead to 2015.
One of the biggest changes that I look forward to is being in full-time clinical practice. When I left the University of Pennsylvania in 2012 I took a visiting assistant professor position in psychology at Haverford College around the same time that I opened my practice. It’s been a wonderful place to teach and do research, and the faculty in my department have been unfailingly kind and generous.
As my practice has grown over the past couple years I’ve realized that as much as I enjoy academia, my heart is in the clinical work. On a daily basis I have the privilege to work with individuals who are determined to get their lives back. Whether it’s sleeping better, finding new ways to cope with stress, facing fears, fighting addictions, strengthening relationships, healing from trauma and loss, or anything else, I get to be witness to the courage that allows us to make tough changes. I couldn’t ask for anything more than to be a part of that process.
This fall I made the final decision to leave Haverford College after the 2014-2015 year, and to focus my efforts on being a therapist. I’m excited to see what lies ahead.
This year also saw the birth of our baby in November. I was grateful for her safe arrival and for the strong support from so many who shared in our joy.
Early 2015 will also bring the publication of Overcoming OCD: A Journey to Recovery which Janet Singer wrote about her son’s recovery from severe OCD through exposure and response prevention (ERP) therapy. I provide commentary throughout the book on topics related to OCD. I also plan to start blogging on PsychologyToday.com in the new year.
I wish you health and happiness in 2015, and many moments of feeling fully alive.
Recently I was invited to join the roster of bloggers at PsychologyToday.com.
I plan to write posts for PsychologyToday.com that are similar to what I’ve been doing here, so many of my future entries on this blog will be re-posts from things I’ve written for Psychology Today.
The general page for blogs at PT.com is here.
Once my page is set up I’ll share the link.
Today marks the beginning of OCD Awareness Week. According to the International OCD Foundation (IOCDF) the goals of this awareness week are to “educate the public about what it means to have OCD and related disorders, to fight stigma of mental health issues, and to help people find the resources and treatment they need.”
My friend and co-author Janet Singer works constantly toward these related goals. I’d like to share the blog entry that she posted most recently, which talks about a common response when the topic of OCD comes up: “I’m a little OCD myself.”
Thanks to Janet and others who are engaged in similar work, more OCD sufferers can find the kind of help that makes life livable again.
Ambrose Redmoon is credited with saying that “Courage is not the absence of fear, but rather the judgment that something else is more important than fear.” A recent article and video on NYTimes.com beautifully illustrated this truth. The piece features Attis Clopton, who had an intense fear of water. He decided he wanted to conquer his longstanding fear, and so worked with a swim coach to do just that.
Many things stood out to me from watching the video, given the work that I do. First, Attis Clopton had had traumatic experiences with water, and his solution was to avoid water and the fear that came with it. Like Attis, we’re all wounded during our lives in various ways, and we make compromises to keep going. We might avoid certain situations, guard ourselves in relationships, use drugs or alcohol to cope, or cling to a sense of control. These compromises can work, and then at some point may stop working, or not be worth what they cost. Attis finally reached a point where he realized he was alive but wasn’t truly living his life. He knew he had to change.
This need to change provided the motivation that Attis needed. Whenever we make big changes in our lives there inevitably comes a point when we think that maybe the old way, the “safe” way, really wasn’t so bad. At these times we can remind ourselves of why we wanted to change in the first place. Why were we not content to leave things as they were? And what’s on the other side of our fears? For Attis, facing his fear was a huge challenge, so there had to be compelling reasons to stay in the water when he really wanted to flee.
Attis also needed to experience the water, and it was his experience that changed him. It wouldn’t have been enough simply to be told that “water isn’t always dangerous.” That intellectual understanding could only take him so far. What got him over his fears was moving through them. Nothing is more powerful than our actual experience of successfully doing what we’re afraid of.
In many ways Attis’s instructor was like a good exposure therapist. She seemed to understand and empathize with his fear, and at the same time wasn’t willing to let him stay there. She also had a program of exercises that were gradual and systematic, with later steps building on earlier ones–just like we do in exposure therapy.
Once Attis had overcome his fears, he still had a lot of work to do. Even though he was no longer afraid, he didn’t know how to swim. I often find something similar in my clinical work–after the symptoms are under control, there’s still the task of creating the kind of life that the person wants. For example, overwhelming social anxiety can lead to a stunted career in addition to impoverished relationships; after successful treatment, a person has the challenge and the opportunity to build a better life.
Every time we decide it’s worth it to face our fears, we allow our lives to expand. And with that expansion comes freedom–the freedom to live lives that we value, to share love with close others, to face life with all its beauty and uncertainty. The image of Attis Clopton swimming in the ocean perfectly captures that sense of freedom in letting go. We can decide as often as we need to that freedom is worth more than our fears.
The article and video are found here.
A common compulsion in OCD is checking to make sure that something was done correctly: turning off the stove, copying an address, shutting the refrigerator, locking the door, and so forth.
We can never know with absolute certainty that we’ve done something right, so many people with OCD end up checking repeatedly, sometimes for hours. The lost time is bad enough, and most people find that they actually feel less certain that they’ve done it right.
How can it be that more checking yields greater uncertainty? A recent study addressed this paradox by having participants perform a computerized task and then check to make sure they’d done it correctly. The study authors predicted that repeated checking would lead to quicker, more automatic checking as well as less confidence in one’s memory of having done the task correctly.
The study’s results did show that repeated checking resulted in faster checking and less memory confidence. It was unclear whether the faster, more automatic checking caused the greater uncertainty, and more work remains to be done to understand how checking leads to uncertainty. Additionally the participants were undergraduate students, not necessarily individuals with OCD, which calls into question the applicability of the findings to checking in OCD.
What’s the bottom line for OCD sufferers? As most people with OCD-related checking have found, the best solution is not to start checking in the first place. Generally it’s easier to walk away from an urge to check than to “check a little” and then walk away.
Of course, it’s easier to say “don’t check” than it is to resist the compulsive urges. Exposure and response prevention (ERP) for OCD is designed to assist a person’s efforts to break free of compulsive behaviors. Over time it typically gets easier not to check, leading to less distress and more time to do the things a person actually cares about.
Elaine C. P. Dek et al. (2014). Automatization and familiarty in repeated checking. Journal of Obsessive-Compulsive and Related Disorders, 3, 303-310.