Gut feelings...
Exposures: What to do if your clients are doing exposures as a compulsion
Anya, a 26-year-old, was in charge of organizing the schedule for the annual camping trip with her college classmates. She was excited and ready to make phone calls and gather prices for transportation, camping sites, etc. But in the middle of preparing for those errands, she noticed a red stain on the hardwood floor of her house. Quickly her mind came up with the thought, “Did I step on it? What if it’s blood? What if I get an illness? Is it fresh blood?” Immediately, Anya jumped in the shower and washed her feet as carefully as possible in case her socks got contaminated and touched her skin. Afterward, Anya ended up throwing away her shoes.
Anya had unwanted thoughts about getting contaminated: What if I get an illness? What if I get contaminated?
Indeed, it’s very distressing for anyone to have their mind come up with that thought, but Anya’s mind was playing tricks with her. And because that obsession came along with so much fear, she got hooked on it and took it as the absolute truth. Immediately afterward, she started doing things to avoid getting contaminated or ill.
If you are familiar with Exposure Response Prevention (ERP) or exposure-based treatments, the frontline treatment for OCD and all forms of anxiety, you know that approaching a triggering situation, person, or activity and staying present with that experience is fundamental for treatment to be effective. And yet, at times my clients have started their sessions saying, “I’m doing all types of exposures, hundreds of them, every day, and I’m still struggling.”
What happens when our clients are doing exposures but they’re getting stuck? What if clients are doing exposures as a compulsion?
Here are some questions to unpack those moments of stuckness:
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- What are you hoping to experience or accomplish when doing exposures?
- What’s your experience after completing your values-based exposure exercises?
- Preventing another OCD episode from coming in the future.
- Did you have any agenda, expectation, or hope, when practicing exposures?
Check for the following responses: (a) Making your obsessions go away; (b) Making the anxiety, fear, panic, and other related feelings go down; (c) Answering a question about an obsession - Invite clients to check, when practicing exposures, how would they describe their attitude towards it? For example, using the continuum below, ask clients to mark an “x” where it fits better:
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Feeling better right away Hammering out Pushing through Flexibly choosing
If clients are practicing exposure exercise hoping for one or a combination of the items above, and pushing through or hammering out, chances are that they’re doing exposures as a compulsion.
If that’s the case, here is what you could do:
Ask clients to pause any exposure exercises right away.
Revisit the frame to do exposure work: e.g. why are you approaching this situation, activity, or thought that scares you?
Link them up: practice an exposure as a move towards your values (values-guided exposures).
Mix them up: combine different ways of doing values-guided exposures.
Vary them up: practice values-guided exposures in different contexts.
Tune them up: adjust your values-exposure activities as needed.
Stay with them: watch out for subtle compulsions and avoidance when practicing values-guided exposures.
Be curious of them: watch what shows up when making exposures or W.I.S.E. M.O.V.E.S.
Give another trial to practice values-based exposures, but if they catch themselves doing them as something to completing and get it done, then pause again.
Remind clients that as much as there is an urgency to get the obsession-problem under control, it’s more important to find a rhythm that gets their life back on track, full of vitality, meaning, and presence instead of attempting to get their life back rushing through skills, with exhaustion, a scatterbrain, and full of fatigue.
Our brains are constantly trying to defend us from anything that could possibly go wrong. And by nature, some brains are just wired to be more reactive than others. So much that when a client approaches an exercise towards being the person our clients want to be, the tiny possibility of an obsession showing up makes their brain shout signs of danger at them, alerting them in a high pitch, high volume, and high speed. They end up practicing values-guided exposures as a control strategy to neutralize obsessions.
Our brain is an old device doing its job. However, none of this means that we cannot teach our clients to respond flexibly to those urges to tackle the obsession-problems, leave those obsessions unattended, and show up to their life as it matters to them.
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Based on: LivingBeyond OCD using Acceptance and Commitment Therapy & The ACT Workbook for Teens
