Key Barriers to OCD Recovery: Barrier 1 - Using ERP for controlling obsessions

In this series of posts, I will explore some of the key barriers to OCD recovery that I have seen in the last few years. Through my connection to Stuart and The OCD Stories podcast, (including sharing my experience of my own struggles and subsequent OCD recovery, see episodes 158, 282, 334, 362, 393) I have been fortunate to work with many wonderful, compassionate and intelligent OCD clients. Many of these clients reached out because they were having difficulties with exposure and response prevention therapy (ERP). These clients have been my teachers. I have used their experiences to develop a 10 week ‘ACT Skills for OCD Recovery Course’. A significant number of these clients benefited from including Acceptance & Commitment Therapy (ACT) and Compassion Focused Therapy (CFT) into their ERP process.  

Many of these clients had already had a number of rounds of ERP, often with good OCD treatment centres/clinicians, and were still struggling. Some of these people could not engage in ERP because their feelings and thoughts were so overwhelming. For others, as they started things got worse and became too much to bear. Some clients were frightened to begin ERP, having built their lives around avoiding OCD and anxiety. A number of these clients had experienced benefits from ERP in the past, but had suffered major relapses and were disheartened or not happy with the end result of their ERP therapy. Others had comorbidities such as trauma, eating disorders, addictions, major depression, interpersonal difficulties, autism, ADHD and more.

It’s painful to say, I could not help everyone and I continue to learn from reflecting on the experiences of those clients that left therapy with me early. But the people I have seen get the strongest recoveries all were able to implement the ‘antidote’ ideas in this blog series.

These ideas are not all new. I am drawing from the ideas of many great clinicians and advocates in the OCD community. Hopefully you will find benefit in them. You might want to apply them to the courageous recovery work you are doing. You may want to discuss them with your clinician to see what advice your therapist can provide. These concepts have helped me think about these barriers and how to respond. I am definitely not saying I have the magic bullet; this is just what I have observed to help and hinder clients. There are clients out there who have struggled with my approach too. OCD recovery is a process of skill development. In skill development there is no escaping the need for deliberate and conscious ongoing practice. Often, we need external feedback to spot the things we are missing from the first-person position. It can take much longer than the research studies state. If you speak to people in the OCD community about their recovery, seldom do you hear 16 sessions and done. There are less studies on long term outcomes and what helps people maintain recovery 5, 10, 20 years and on.

I have also drawn from my own experiences in my journey with OCD. I have experienced almost every one of these barriers and have found things that support and help me with them. At times my mind would seem to resist everything I tried. Later I realised it was frightened about change and the threats it believed were still out there. But with ‘gentle relentlessness’ the ideas in this series helped me.

 All the client examples are made up, using combinations of clients that I have worked with (and my own experience) and I have attempted to anonymise them. If you recognise yourself in these stories, it likely points at the common experience of OCD and how much our symptoms overlap with others.

Barrier 1 - Using ERP for controlling obsessions or the ‘I hate white bears and I want them out of my house’ barrier

Katie had experienced OCD since childhood. She had experienced multiple OCD themes. Her mind had worried she might hurt others; she might take her own life; that she might accidentally hurt people through missing something; and, that she might secretly want to have sex with children, animals and the relatives she loved so deeply. She had engaged in various forms of talk therapy. Katie had at first talked about the general anxiety, panic and low mood she had experienced. She had talked about her historical trauma experiences. It had been nice to be heard, but she felt that her intrusive thoughts were as bad as ever. She stumbled upon an article about ‘Pure OCD’ and she related to all the things she was reading. Katie read about a type of therapy called ERP. This therapy was the ‘gold standard’. Gold was good she thought. ERP had been shown to be highly effective in treating OCD. It was far superior to other forms of therapy and this filled her with hope. She read that she would need to confront these abhorrent thoughts and start reconnecting with the people she was avoiding. This was terrifying as she believed she was avoiding these people under the guise of keeping them safe. She started to sweat and feel nauseous thinking about this, but she was willing to do this work to get her life back. She was ready to be brave.

Katie had some money saved up and decided to go to one of the therapists that she had heard talking about OCD on various podcasts. He spoke with precision and clarity and was very convincing. It was expensive but it would be worth it. The therapy room was filled with calming colours and abstract art. She felt frightened and scattered and that she couldn’t articulate how difficult OCD was. He was kind, if a little like a school teacher. He helped her articulate OCD. Obsessions, compulsions both mental and physical in form. It was starting to make a bit more sense. She decided to do exactly what he said. She wanted these thoughts and feelings to go.  

After discussing her OCD and life, he described ERP. Katie had read and listened to so much material on OCD online. She was well aware of everything he told her. Katie wanted to get going. She wanted to feel better. Katie followed the ERP by the book. She wrote her thoughts and scripts about her fears and read them over and over. She watched documentaries about all kinds of abhorrent killers and abusers, movies and TV shows about serial killers. Katie worried about her YouTube algorhythm and what anyone might think. She read newspaper articles. She was determined to beat this. Her therapist had said she would win if she kept going. He told her all about mental compulsions and when she noticed herself ruminating just to stop. Katie was less sure about this. She felt like her mind would automatically start analysing and debating the thoughts. Sometimes she would ‘come to’ from a daze and notice it was happening. It was one thing to stop her physical compulsions of avoiding knives, physical contact and other threats. But to stop ruminating just seemed impossible. She kept trying and her therapist also said to alternate just stopping with agreeing with the thoughts and at other times answer them with the statement ‘maybe, maybe not’. Some days she would be doing these techniques all day long.

She practiced religiously. Katie would have a better few days and then notice and the intrusive thoughts would start intensely again. Sometimes the thoughts would come with no feelings and be a minor irritation. Other times they would hit her like a huge wave of panic and she would try to respond as she was told to. To ‘just sit with’ the distress. She felt nauseous for large parts of the day and was finding it hard to engage with the people she loved. She was losing weight as it was hard to stomach food. Her mind was a constant battle of these thoughts. Alongside this she started to track whether it was working and worrying why she seemed to keep having these intense bouts of thoughts and feelings. She should be getting better by now. She read more OCD books and listened to more podcasts. She doubled down on her practice and sometimes she would feel slightly numb to the experience.  Then she would have another intense bout. She would check whether she was still having the thoughts and would notice a cascade of thoughts and impulses. She would get the occasional hour of relief and then as she noticed that she was feeling better, this would seem to trigger her into the thoughts again. It felt like her OCD would switch form as well. At times it was intense intrusive images. At other points she would feel physical contraction and like she was beginning to move (impulses). Sometimes it would be inner monologue that she could hear and then at other times just an intense feeling. It was exhausting.  

Katie raised this with her therapist. He said it sounded like ERP was working. She just needed to keep going with the ERP and make further attempts to stop her rumination. Katie started to feel resentful but it was difficult to raise this with her therapist. He was so intelligent and convincing. Katie started to feel hopeless and self-critical. She must be broken. She must be doing it wrong.

After 16 weeks, her therapist suggested that as her symptoms had improved, she might be in the place to continue her ERP on her own. Katie hadn’t been able to tell him, just how bad she was still feeling. He was so impressed with her discipline and hard work. Katie expressed some agreement with him in the session, but when she walked out the door in a daze she couldn’t quite work out what had happened. Therapy had ended and she still felt awful. Why had it not worked? Katie thought it must be something wrong with her. She thought that maybe it was a sign this wasn’t OCD and she should go back to making sure she did not hurt anyone. She told herself ‘maybe, maybe not’ and felt another bolt of fear run through her body.

Katie had understandably approached ERP with the agenda to make her symptoms go away. For control and avoidance. She had experienced short periods of relief and at times numbness, but then OCD had switched form or crept back in. Why wouldn’t Katie approach therapy this way, given what she had read about therapy?

Of course, we all come into therapy with this agenda, I certainly did. When I first had ERP, I was experiencing a debilitating period of sensorimotor OCD. I wanted my mind to get off these sensations and I was willing to do ERP to achieve this. I tried hard to and yet it didn’t help. Later when I was experiencing health anxiety and existential OCD after having had ERP a couple more times, I had the realisation that I couldn’t remove the fear of dying of cancer or the confusion, doubt and despair in the face of existential uncertainty. But what I could do was get more comfortable in the fear, doubt and despair and pursue valued life directions. I could develop the ability to connect and pursue my goals with these difficult feelings in the background. When I approached ERP together with ACT skills, I experienced the improvements I was looking for. This was paradoxical. I wasn’t chasing symptom reduction, I was trying to get better at functioning with the symptoms.

When we approach ERP with the agenda of control and reduction of obsessions (and overwhelming feelings) this causes paradoxical effects. We get increases in the thing we are trying to reduce. This happens in many domains of life, for example, we can’t sleep better by trying harder to sleep. This is in part, because the agenda causes us to monitor, check and resist the intrusive thoughts and difficult feelings. This threat focus increases the detection and amplification of these thoughts and feelings. Like Harvard Psychologist Daniel Wegner’s studies showed, if I try not to think about a white bear, I will have more intrusive white bear thoughts. If I track my mind for white bears, or suppress white bears I get more of them as well. If I use ERP to try not to feel anxious, or check if I am feeling anxious or other emotions I will feel more anxiety, confusion, doubt, numbness etc. The judgement of the thoughts and how therapy is working, is the spark that lights all the other mental compulsions, like analysis and rumination, and leads to physical compulsions like avoidance and checking.

Worse still, like Katie, this can cause us to ruminate on the question: if it is not getting better predictably with ERP then it must not be OCD. This then causes further rumination and monitoring and checking for obsessions and feelings.  This thought can start the process of ruminating about treatment and recovery, self-criticism and hopelessness as we saw with Katie.  

Like a headache we can struggle, check, monitor, resent and judge the pain and it only makes the headache worse. Or we can accept the pain as best we can, and live life and pursue our goals. If we do this, more and more the headache fades from awareness. Or if we are aware of it, then it is less troubling.

Antidotes – what can we do about the white bears?

Katie found my work through The OCD Stories podcast. She wanted to try a skills-based approach and she resonated with the ideas on self-compassion given how much she was blaming herself for ERP not working. We went back to basics and explored how she was interacting with her thoughts and feelings during ERP and life. It became clear to me that she had a strong agenda to get rid of OCD and she had been using ERP to try to do this. I explained that we would use ERP to train psychological skills and flexibility. This would mean she would be able to allow the intrusive thoughts to come and go without responding, making room for these feelings to rise and pass and stay present and engaged with what mattered to her. We would probably use many of the same ERP practices but we would spend more time developing these skills before doing them during exposure. We would then apply these skills throughout the ERP practice to learn how to let go of mental compulsions. We would also regularly connect to her core values and meaningful life goals. Connecting the exposure to who and what mattered to her and building life actions around this.  

I also found she had some difficulties in her work and relationships alongside OCD and we would take time to look at these and work on them too. She said her last therapist had forbidden her to talk about anything other than OCD and ERP. 

We spent time trying to reduce the agenda of control. To see from her experience, that she could not control other difficult thoughts and feelings outside of OCD (I asked her, could she completely relax next time she felt stressed about a deadline for example). That this agenda was costing her a lot and that it would be more workable to learn to handle these intrusive thoughts. We needed to come back to this regularly as the old agenda tried to creep back in.  

Once we had ACT skills in place and started increasing Katie’s self-compassion, we developed an exposure hierarchy and started to work through many of the exposures she had worked on before. Katie said in the past, she had been told to ‘just sit with the emotion’ and not ruminate, to agree with OCD or say ‘maybe, maybe not’ in response to the obsessions. When she tried this, she had felt herself tightening up and her mind was still ruminating automatically. She was left analysing and ruminating for hours after the exposure, with many of the intrusive thoughts and feelings coming back to her. She couldn’t just drop it. With the skills-based approach we were training, she knew what to do in the moment. If she couldn’t stop ruminating, she could defuse or mindfully step back and observe her thoughts. She could use the ACT tools to help with the difficult feelings and she was getting more able to be present to her values and goals.

She didn’t need every trace of OCD to disappear now to live her life, she was comfortable with these thoughts and could live her life with the obsessions in the background. As she deepened this skill-based approach, paradoxically her symptoms got better. She no longer felt nauseous for much of the day and her mind wasn’t firing these thoughts so intensely. She told me that even if it did get bad again, she could handle it and live purposefully. When she used her skills like this, these difficult periods came and went much quicker and were getting less frequent and intense over time. She had trained herself to change the control agenda of ERP to a willingness and values-based one. She had committed and been very disciplined in her daily practice and response to difficulty in the moment.

If you get out there in the OCD community and hear the brave stories of recovery you will hear similar themes. People in recovery may not have learnt these skills through ACT, but the robust long term recovery stories typically have the qualities of:

1) people learning different responses to intrusive thoughts, a more mindful, detached and non-reactive approach to obsessions;

2) more acceptance of the thoughts and feelings we can’t control and ability to make room for difficult feelings to rise and fall in their own time;

3) more self-compassion to the pain of OCD; and

4) a deeper connection to values, to who and what matters in that person’s life.

That’s what I hear in the recovery stories. The stories are not people predictably controlling symptoms with ERP in 16 sessions, like a dial to turn down OCD. They are stories of people developing a different relationship with their human minds and a deepened connection to meaning and purpose. Go out there and find those stories and learn from those people.

Other principles I have found helpful in switching from the avoidance and control agenda, to the willingness agenda (willing to have the obsessions without responding with compulsions and avoidance and to focus on who and what matters in action):

·      Reflecting on the ‘workability’ of this control agenda. Has trying to control thoughts and feelings worked in the long run in any other area of life? What has it cost you to trying to control intrusive thoughts and feelings? What values and goals do you want to move towards instead?

·      Set your goal to improve your functioning with symptoms. Set the intention each day, to get better at focusing on your goals and the things you value even with the obsessions and feelings. Use self-talk to set the goal of reducing struggle and resistance with OCD (increasing acceptance of the obsessions) and to let go of compulsions whilst pursuing a meaningful life.

·      Emphasising ERP as Skills practice not symptom suppression – emphasising the defusion of thoughts, acceptance/making room for difficult feelings, urge surfing compulsions, refocusing on what you value in the present and applying these skills in exposure work. You may need to pause regularly and run through a practice like ‘Dropping Anchor’.

·      Work on the resistance – use the same ACT skills to work on mental resistance like ‘I can’t handle this, it’s unfair’ and the resistance of feelings, monitoring and checking feelings etc. Also, secondary tension in the body, tensing up around difficult feelings. Relax your body around emotional feelings as best you can, use acceptance self-talk like ‘I can practice accepting this’ or ‘accept, allow, willing’ and refocus on values.

·      It can help to coach yourself with kind self-talk (compassionate inner coach) – instruct, motivate, support yourself in applying the skills and improving willingness.

·      Connect this willingness/making room for intrusive thoughts and feelings with engagement in valued actions. It is not passive acceptance; it is an active process all with the agenda of making life richer and fuller and being able to live aligned with values and important goals.

·      Use the symptoms as a ‘pain alarm clock’ to come back to life, goals and values. Almost everyone these days feels they are distracted and missing much of their life. Use this difficulty to focus your attention on what you choose to do in the moment. If in doubt make a choice or continue with a choice and keep refocusing onto what you are doing.

·      Remember this is one ‘silver lining’ of OCD – it is like focusing with ‘weights’, other things get easier, handling these difficult thoughts and feelings, other experiences will be easier. If you can detach from these intrusive thoughts and focus on what you care about then everything in life will get easier.

·      We can extend self-compassion to our grief to what OCD has taken away. Feel the feelings of grief and defuse the ruminative thought loops like resentment, judgment, worry etc. This allows the active feeling of the emotions of grief without getting stuck in rumination. Talk to yourself like a good friend and help the grief to be an active process.

·      Connect to others for support but don’t get caught in co-rumination – other people and community can be one of the greatest OCD supports. The key is to make sure that connection isn’t focused solely on OCD, watch out for excessive co-rumination/ruminating out loud, other difficult thought loops like resentment and hopelessness. Instead try to connect about a wide range of topics, keep discussions recovery focused with some expression of pain being met with empathy and validation (co-support).

·      Values and goals – who and what matters – the key tool to increase the willingness agenda is to keep coming back to values and goals. These are the key reasons behind willingness, the motivator and power source and the essential reason for practicing willingness with obsessions.

Changing the ERP agenda to willingness and skill development is arguably the most useful change you can make for your OCD recovery. I will continue to cover the other key barriers I have seen in my work in this series. Feel free to share your thoughts and questions on any of the ideas in this series. If you want to explore these ideas with a skilled therapist then reach out to us and we can connect you with a clinician to work through these barriers.

Check out barrier 2 in the series: Automatic Compulsions, ‘my mind just ruminates’