By Dr. Christian R. Komor
OCD Recovery Center
Obsessive Compulsive (OC) Disorders including OCD, Asperger's Disorder, Tourette's Disorder, Hypochondriasis, Compulsive Hoarding, Trichotillomania, and Body Dysmorphic Disorder are chronic and often debilitating neuropsychological problems. OCD itself is genetically hard-wired in the brain (specifically the cortical-thalamic-striatal pathway of the basal ganglia) and can be affected by personality factors, immune system changes and hormonal fluctuations. For most patients a variety of practices and procedures are needed in order to reduce intrusive obsessive thinking and compulsive behavior, heal depression and restore self-care, relationship and other life skills. Such a broad-based program is outlined in our Obsessive Compulsive Disorders: A Comprehensive Program for Recovery (2001) that provides different areas of treatment for obsessive compulsive disorders.
While a broad-based recovery program is essential, the core of OCD recovery remains Exposure and Response Prevention (ERP), usually conducted in the form of Cognitive Behavioral Therapy (CBT). In ERP the individual comes into contact with the thought, situation, person, or object they fear and remains in contact with the feared stimulus long enough for the brain to habituate to the stimulus. This is much like jumping in a cold lake of water and staying in the water long enough to become accustomed to it. Without taking the risk of exposure to feared situations it is impossible to really progress in the healing process. By doing so, on the other hand, brain imagery studies have shown us we are actually healing the cortical-thalamic-striatal region of the brain - something that is impossible to do through any other method - including medication.
Success with ERP-based treatment is dependent on the following Five Principles (which are then reflected in the Five & Five Steps, the focus of this article): (1) Safety - choosing exercises that, while they may seem so, will not bring actual harm to the person, (2) Intensity - keeping anxiety levels between the levels of 25-75 on a scale of 0-100, (3) Neutralization - refusing to "undo" the exposure with rituals or compulsions. (4) Saturation and (5) Duration - finding creative way of ensuring the feared stimulus is encountered on a regular basis for long enough to cause healing in the brain (which could be measured via a SPECT scan). These are referred to as the Five Principles of ERP. We use these Five Principles like a recipe to design ERP exercises. When we include all five factors the exercise is almost guaranteed success!
But once we have designed an exercise using the Five Principles how do we get ourselves through the simple and yet terrifying act of turning to face fearful obsessions and remaining with them while not ritualizing. Frequently OCD sufferers will report that car accidents, public speaking, near plane-crashes and the like are not nearly as frightening as confronting an obsession! It is precisely because it is so difficult to refuse to perform obsessive-compulsive rituals in the face of the feared obsession that it is important to have a set procedure for doing so. OCD Recovery Center has developed a specific "Five & Five" Step procedure for walking through the fear of Exposure and Response Prevention. These Five & Five Steps, if followed closely, will take the OC sufferer step-by-step through the flames of anxiety that can seem so intense.
These Five Principles of behavior therapy with OCD form the basis for the Five & Five Steps which we will now discuss. Note that steps 1-5 are essential to the process, Steps 5-10 are employed only when the person is unable to resist the urge to neutralize the anxiety (via a ritual or compulsion) or to lend additional support to the exercise. Some of the additional steps should be used sparingly and with caution because they can become rituals in themselves and therefore develop into secondary problems.
It is recommended that, after making whatever modifications are needed to tailor the procedure to one's own situation, the Five & Five Steps should be applied consistently day after day so that they become second nature. The steps have been given short labels to make them easier to remember in practice.
Most OC sufferers have a variety of compulsive behaviors they perform on a daily basis. Some, if stopped, would result in very intense anxiety leading to panic, and an increase in future compulsive rituals. Others carry with them only mild anxiety and can be fairly easily eliminated without undue stress. In choosing which OC rituals to confront it is wise to make a list of all rituals and then rate them from highest ("100") to lowest ("0") in terms of the anxiety that would be generated if the behavior were stopped. Then rituals achieving a rating of 25-75 are selected for ERP.
This is the most important step in the process. People with OCD will have primary and backup rituals for relieving anxiety. They can wait for long periods of time before performing a compulsion so that they can fool themselves into believing it is not connected to the initial stimulus exposure. Neutralizing strategies can be very, very subtle such as a blink, a head shake or thinking about a color. It is essential to realize what neutralizing strategies are being employed and to stop them. Neutralizing strategies will always short-circuit the treatment process if allowed to continue. It is better to choose an exercise that fosters less anxiety and is manageable without performing a compulsion than choose a more difficult ERP exercise and later give in and neutralize the anxiety.
It is not necessary to obsessively focus on the anxiety that is naturally generated when refusing to perform a compulsive ritual. The key in Step Three is to be aware of the anxiety, to see it for what it is and then do something else - go on with life as it were carrying the anxiety with you. The optimal procedure is to say to one self "Yes, I am anxious because of the ritual I am refusing to perform. Now I am going to go on and do something that I choose to do." There is an exciting element of risk here. It can be unsettling to step out and assert one's own choices and desires after being a slave so long to the compulsive behavior.
Once a ritual is selected for elimination and the individual refuses to perform the ritual behavior or thought in spite of the urgings of the OCD, a surge of anxiety will be experienced. This anxiety surge will eventually dissipate within minutes to hours (often in 15 to 20 minutes). The OC sufferer is encouraged to maintain awareness of the anxiety by doing "anxiety checks" every five minutes until the anxiety has dropped by 50% from its initial strength. At that point the individual can go on about their daily activities without needing to maintain awareness of the anxiety. It is important to remember that anxiety may show itself in thoughts, feelings, physical reactions and, or behavior. Each individual will be unique in their pattern of anxiety reactions and it may help to identify one's specific anxiety symptoms prior to engaging in ERP.
It is necessary to persist in refusing the ritual until the anxiety dissipates - however long this may take. Like aerobic exercise, which must be done for a certain length of time in order to have cardiovascular benefits, one's anxiety level must have decreased by at least 50% before any positive benefits will accrue. Of course, once the anxiety has dissipated the individual will feel no need to perform the compulsive behavior! Time is a key factor in the healing process. Many people with OC disorders will refuse a ritual, but then go ahead and do it in a little while. This will only provide the OC disorder with what is known as "intermittent reinforcement" - a strong reinforcer to continue generating obsessive and compulsive demands. It helps greatly for the patient to take note of their anxiety level (0-100) every ten minutes or so along the way. Observing the anxiety level decreasing provides strong encouragement.
In Step Six the individual then reminds him or herself that the urge to perform the obsessive ritual is in reality a faulty brain message. Usually this means actually stopping all activity and concentrating one's awareness on what's happening, on the obsession or ritual, long enough to truly and clearly see and feel it is just OCD and not a "real" danger or issue. Armed with this awareness it is then possible to be aware both mentally and experientially that the compulsion is not a real choice, but rather an expression of the obsessive compulsive disorder. Various slogans and other forms of self-talk can be used to achieve this end. It also helps, at this Step, to have a working awareness of one's mental, physical, and emotional symptoms of anxiety. This allows the patient to say, "This is just anxiety caused by the obsession or compulsion I am refusing to give in to." Again, however, one must be cautious as both Steps Six and Seven can easily turn into neutralizing compulsions. They should only be used if the anxiety is so strong that it is impossible to accomplish the exercise without their assistance.
We might think of Step Seven as the "spiritual step". Here we are developing trust which usually means trust in a higher power, the universe, destiny or life itself. The well-know "Serenity Prayer" exemplifies this Step: "Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference." The key is in reminding oneself that compulsive rituals are designed to try to control what cannot be controlled. Yes, one may choose to brush one's teeth in order to prevent cavities, but replacing the toothbrush seven times in the toothbrush holder will not prevent AIDS. So while riding out the anxiety arising from ERP, the OC sufferer is encouraged to again and again remember to let go of what cannot and should not be controlled.
When creating an Exposure and Response Prevention exercise, or inadvertently encountering a exposure stimulus in daily life it is important to make the experience of the stimulus (e.g. the level of anxiety it generates) manageable. This may not always be possible, and it is preferable to face down an very high anxiety situation rather than avoid or ritualize it. If possible, however, it is always desirable to make the situation manageable in terms of anxiety (e.g. targeting a 25-75 range on a 0-100 anxiety scale). This can be accomplished by manipulating the situation in some of the various ways listed above. For example, one could spend only a few minutes but a trash can instead of an hour, or wear gloves while pumping gas, or ask someone to do the behavior first. All of these are "mediators" which will titrate the exposure to a manageable range - much as medication is titrated so that the patient will not get too much or too little. This allows us to hit the "therapeutic window" at wish the exposure does the most good without overwhelming the individual.
While not always the case, often after following through successfully with an ERP exercise feelings of grief, elation, anger, etc. will arise. It is well to give these feelings some attention, allowing oneself to vent or express them with another person, listening to expressive music, or even hitting a punching bag. The idea is not to obsess on the feelings, but simply to let the flow. Sometimes this will lead to additional realizations and insights which can then be notated in Step Five & Five. Unlike Steps Six and Seven, Steps Eight and Five & Five will not lead to neutralization so they can be used without reservation.
It is generally helpful to most people with OCD to keep a journal in which they can keep track of therapeutic recommendations and homework assignments, chart progress, notate problems with procedures, and make observations. This material can be brought back to the treatment sessions and will vastly increase the effectiveness of the treatment process.
Finally, keep in mind that if one gives in to an OC ritual it is still possible to make it a "win" by clearly acknowledging that one has had a "slip" and that the OC has won but that nothing real has been accomplished. A helpful statement here would be "I gave in to the OCD and its meaningless!" instead of "I protected myself (or accomplished something) by doing the OCD compulsion." Also, if one gives in to a ritual a healthy choice would be to find another similar challenge to do right away so that the OCD doesn't feel it has had a victory.
There are, of course, many other aspects to OCD recovery - Special Characteristics such as increased needs for reassurance or symmetry, neuropsychological and physical differences, etc. OCD recovery is not simply confronting rituals and compulsions, but undertaking this courageous task leads to all kinds of positive downstream effects such as reduced depression and increased feeling of self-sufficiency and spontaneity and free-will. Without ERP other important self-help measures (e.g. learning relaxation training, aerobic exercise, taking vacations) will likely eventually be overwhelmed by the compulsions and rituals. The freedom gained through ERP is a precious gift that only a recovering OCD sufferer can appreciate fully and the self-love which develops along the way is worth the effort.
Copyright 2005 by Christian R. Komor, Psy.D. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission from the author except in case of brief quotations embodied in critical articles and reviews.