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  • Exposure and Response Prevention (EXRP)

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    Exposure and response prevention (EXRP) is the evidence-based treatment of choice for learning to manage obsessive compulsive disorder (OCD). In this treatment, individuals with OCD are “exposed” to their fears (thoughts, feelings, sensations) and they learn to tolerate them without engaging in their typical response (checking, asking for reassurance, engaging in a compulsion or ritual, ruminating, worrying).

    When an individual is “wired” for OCD, their brain tells them that certain thoughts and feelings are dangerous. So they learn to “protect” themselves any way that lowers their perception of danger (usually how anxious/nervous/uncertain they feel). For example, you might think, “what if I’m really gay and I’m lying to myself and my partner?” or, “what if I don’t really love them/they’re not ‘the one.’ ” If you have OCD, alarm bells will begin ringing and you will begin thinking of how terrible your life will be and how you’re not really the person you thought you were. You might feel ashamed and guilty for lying to everyone around you. You might even “confess” to your partner that you had these thoughts and worry that they will break-up or divorce you, but you just can’t keep this to yourself. Or, you might be afraid that that’s what would happen if you were just “honest” with yourself and “brave” enough to tell them so you keep quiet and say nothing. You might become detached, jumpy, or avoidant, or you might become overly dependent and pestering.

    If this is you, I would encourage you to speak to an OCD specialist before making any drastic decisions in your relationship. OCD can make you doubt your feelings and what you think you know about yourself and others. It makes you think you need to know for sure. THIS IS A LIE. We can’t know most things in life for sure. Even people who don’t have OCD have doubting thoughts in their relationships. The difference is that their brains do not react to doubt with an overwhelming “danger” reaction (fight/flight) and they are able to make choices in their relationship that are independent of their feelings (see also Choice article). Treatment often incorporates learning to make values-based choices instead of emotion-based ones.

    In EXRP, you gradually expose yourself to thoughts, images, emotions, situations, and sensations that may trigger your “smoke alarm.” This is the part of your brain that detects and tries to prevent potential threats (fight/flight). If you are willing to tolerate the discomfort of the alarm (anxiety, worry, panic, shame, guilt, doubt), you often learn that the perceived threat isn’t actually dangerous, that you don’t need to do anything about it, and that over time it may become less scary/triggering.

    The perceived threat in most of these situations is a thought or an emotion (“I might be gay,” “I may get sick,” “I feel anxious so something must be wrong”). But if you can give yourself the chance to face these “threats” by accepting that you may never know for sure, or that maybe you don’t really know who you are or whether you’re sick, you’re learning to tolerate the feeling of uncertainty. Over time, your brain may stop flagging these thoughts and feelings as “threats,” and you may experience decreased anxiety/worry/rumination.

    NOTE: Decreasing anxiety or stopping thoughts/feelings is not the goal of EXRP. The goal of EXRP is to learn to tolerate the thoughts and feelings without engaging in your typical reactions. You also learn to intentionally shift your attention to those things that matter most to you in life (values), and you practice making these choices over and over, instead of following your automatic desire to decrease your anxiety/distress (usually by “doing something” such as getting reassurance, performing a ritual, ruminating, etc.).

    Many people find that if they stop engaging with the distressing thoughts and feelings, their anxiety does subside. But this can’t be your main focus. It’s like trying not to think of CHOCOLATE CAKE after I tell you not to think about it or picture the last time you ate it or what it would be like to taste it right now. This is thought suppression, and it doesn’t work. What does “work” is accepting that humans have thoughts and feelings, and as a human you may sometimes feel uncomfortable, experience intense emotions, and have thoughts you don’t like or that are inconsistent with your values. If this is the case, you can learn to make room for these thoughts and feelings without needing to do anything about them and move forward with your life.