🔼: [[💡 Therapy|Therapy]], [[🛡️ Obsessive-Compulsive Disorder (OCD)]], [[🛠 Exposure Therapy]] ##### Exposure and Response Prevention (ERP) > [!note] This is still very much a work in progress. It’s published because what’s here may still be useful, even if it’s incomplete and a bit messy. The most recommended [[💡 Therapy|Therapy modality]] for [[🛡️ Obsessive-Compulsive Disorder (OCD)]]. Like [[🛠 Exposure Therapy]], it involves creating an Exposure Hierarchy (a progressive list of ways to incrementally work up to exposing ourselves to what triggers our [[💡 Anxiety|anxiety]]) and then deliberately and voluntarily exposing ourselves to them over and over again *without* a [[💡 Reactive Protectors|Reactive Protector]] using a [[💡 Compulsions|compulsion]] to soothe the anxiety. This is why we create a hierarchy, we start with an exposure mild enough that the [[💡 Reactive Protectors|Reactive Protector]] doesn't feel like they absolutely must do their job to keep us safe. With time, we learn to tolerate the uncertainty, become less and less anxious, our [[💡 Window of Tolerance|Window of Tolerance]] expands, and we can accept more and more risk. We allow the fear to wash over us, maybe for hours or days, until our mind and body really understand that there is no danger. In a sense, this is a [[Practices 🕯️|Practice 🕯️]] – we don't logic our way out of the anxiety and we don't soothe it, we wait until the sense of safety is "figured out" physiologically. - You can do exposures even when you're not anxious, our bodymind is still learning - The more we practice this, ideally every day, the easier it becomes to resist our [[💡 Compulsions|Compulsions]]. It becomes a [[💡 Habits|habit]], our normal way of engaging. There is no safety in trying to figure out what can’t be figured out. 1. [[🔑 All Parts are welcome exactly as they are|🔑 Greet and welcome these thoughts]] - “I hope these thoughts stay forever.” - We don’t want to suppress thoughts; it doesn’t work and not all thoughts are related to OCD 2. Embrace uncertainty and accepting risk - “Maybe, maybe not. Maybe I do want that, maybe that will happen. You know what, you’re probably right, I hope it does happen.” 3. [[🕯️ Self-Stewardship]]: If the thing happens, I'll handle it. ###### Responding to [[Intrusive Thoughts]] and [[💡 Obsessions|Obsessions]] - “That might happen.” - “I guess we’ll find out.” - “I dunno, we’ll problem solve when the problem gets here, if it does.” - “Maybe, maybe not.” - “Neat thought!” - “Thanks for telling me.” - “Cool story, bro.” - “You might be right, I’m not sure.” - “I don’t know. ” - “I really enjoy having these thoughts, I hope they stick around forever.” (Even if we don’t.) - Don’t seek reassurance or reassure yourself. Go the opposite direction. “It’ll happen. It’s happening. It’s already happening.” Reassurance is a [[💡 Compulsions|Compulsion]]. It’ll prevent us from improving. - Exaggerating the thoughts to comical degrees. - Anything that isn’t problem solving or figuring out. It seems odd, but the idea is to only respond to real problems and present dangers. If something bad happens, we’ll handle it or [[⭐️ Community Care#🦮 How to know when you need help, and how to ask|🦮 ask for help]]. We’ll go to the doctor, we’ll put the fires out, we’ll attend to the consequences. We’ll cross that bridge when we get to it, we’ve got it. [[💡 Anxiety|Anxiety]], [[💡 Shame|shame]], or [[💡 Guilt|guilt]] might arise — greet them with friendliness. The thing that inspired these feelings doesn’t matter, but we and our parts do. It’s okay to feel things. We don’t have to change or fix them, just to let them know we see them and they’re allowed to be here exactly as they are. Lean into [[⭐️ Self-Care]] and [[☀️ Compassion#Self-Compassion|self-compassion]]. %% How do you make sure we aren’t using ERP to [[💡 Gaslighting|Gaslight]] ourselves? %% [[🕯️ Dropping Hot Coals]] ###### ERP and Parts [[🔑 Most therapy modalities are Protector trainings]]. I’ve not been through ERP with a therapist myself, though I have a hunch that traditional ERP trains [[💡 Protector Parts|Protector Parts]] in feigned acceptance, friendliness, indifference, or liking [[Intrusive Thoughts]] or [[💡 Obsessions|Obsessions]]. ERP recommends responding to thoughts in particular ways *even if we don’t believe or mean what we say*. This can make it more difficult for there to be a direct relationship between [[💡 Presence|Presence]] and the parts involved in an [[🛡️ Obsessive-Compulsive Disorder (OCD)|OCD]] constellation; we might consider this a form of [[🛡️ Presence-ing]]. This is not a bad thing, sometimes [[🔑 we need Protectors]] and ERP has not only reduced suffering and changed lives for the better, it has *saved* lives. It just also means that these parts might answer [[F4 — Feel Toward|Feel Toward questions]] with “Yeah, this is fine, I don’t mind it being here,” to blanket over the parts of us being protected by them. So long as that’s happening, there *might* not be enough [[Qualities of Presence ☀️]] to offer to the parts involved in the constellation — though it’s tough to say because [[🔑 we only need a critical mass of Self-energy]]. It might be worthwhile to begin by getting to know the part of us who was trained by ERP. Even if they allow us to talk directly to the other parts, they don’t have to stop doing their job until *they* decide to. ###### Exposures There may be some part of us who refuses to do ERP, which makes sense. They consider the trigger and think "Hell no, I'm not doing that." But what can they say yes to? - The easiest exposure is just be aware of our [[💡 Compulsions|Compulsions]] and choose to remove the easiest one. When we're fully comfortable with it gone, we choose another. Then another. - The second easiest is to not do a [[💡 Compulsions|Compulsion]] when life inevitably triggers us. - Use an AI tool to make an Exposure Hierarchy. - Notice small fear-based decisions we make throughout the day, use them as exposures. Pick something up off the floor without washing your hands. - Make mistakes on purpose. Do something badly, on purpose. This helps us tolerate uncertainty, helps with [[🛡️ Perfectionism]], helps with [[🛡️ People-Pleasing]]. This might evoke anxiety, but we can hold the part of us who feels so scared through it. Send a text or email with grammatical mistakes. Go to checkout at the grocery store and change your mind about something you were going buy. Inconvenience someone. [[⭐️ Self-Becoming#Do Hard Things|Do Hard Things]]. - As with [[🛠 Exposure Therapy]], are the parts who hold the fear also the parts who are open to letting us try it? - Imaginal exposures, similar to a [[🕯️ Fire Drill (You-Turn)]]. - [[🧘 Trigger Practice]] ###### Tips from Dr. Penzel[^1] ERP can be difficult, sometimes to the point where people give up and think it won’t work for them. We can use some of these as daily [[🕯️ Remembrances]]. - [[🕯️ Mindfulness]]: - It’s important that those of us with OCD constellations never forget that we have them. This means we can’t always trust our thoughts, which can be painful, but is actually true for everyone — we just experience negative consequences that cause more immediate suffering than most, so we have to learn and embody this lesson more thoroughly than most. Recovering from OCD requires us to achieve and maintain a level of mindfulness that few people have. I like to compare it to a video game. When we’re playing a video game on the lowest difficulty, we can get to the end without much skill or effort and without learnings its ins and outs. If we play on the hardest difficulty, we have to learn the mechanics of the game much more intimately to win. It’s more challenging, but we become *much* more knowledgable and skillful. The same is true for life, and OCD increases the difficulty of certain aspects of our life-game. Especially when we’re treating it, we’re not figuring out thoughts and feelings, especially when they’re about really negative, extreme things. If we’re not sure, it’s often better to treat it as a symptom. It’s better to do a bit of exposure than not enough. Anxiety + Urgency to Fix/Figure Out = OCD. We can say “Okay, I might be wrong, but I’m going to do an exposure anyway.” - We can have [[💡 Obsessions|obsessive thoughts]] any time, anywhere. Don’t be surprised when old or new ones arise, just be prepared to work with them. We want to bring this practice into our everyday. If new ones arise, we’d be wise to take note of them and tell our therapist to keep them informed. There’s nothing they haven’t heard. - [[💡 Black-and-White Thinking|Black-and-White Thinking]]. Slip ups don’t make us start over, starting over isn’t even possible because we’ve already learned so much, it’s not the same. [[🔑 There is no such thing as failure]]. If we accidentally do a [[💡 Compulsions|Compulsion]], we can re-expose ourselves to the thing we did the compulsion for. Even big setbacks aren’t the end of the world, we can always do-over our day or hour or minute. Don’t wait for the next day to start again, just start again. Remember these are [[Practices 🕯️]] — they take practice. We’re going to do this incorrectly sometimes, we’re going to do [[💡 Compulsions|Compulsions]] when we think we’re doing exposures sometimes, and that’s okay. Mistakes are the building blocks of learning, not failures to learn. - Anxiety is not the problem, it’s the [[💡 Compulsions|Compulsions]], the way we try to get certainty that doesn’t exist. If anxiety is seen as the problem, we’re just going to have more [[💡 Reactive Protectors|Reactive Protectors]] doing compulsions to get rid of it, which creates more anxiety. [[🔑 Protectors often accidentally bring about what they want to prevent]]. The anxiety goes away as we practice don’t react to it. - OCD rarely make sense and we don’t have to make sense of it. The things we thought would make us better actually made us worse; the things we thought would make us worse actually made us better. - Be willing to accept the risk. [[🔑 Risk is unavoidable]], and we tend to worry that recovering from OCD is the biggest risk, because what if our obsessions are true? What if my fears are keeping me safe and I actually start acting on those thoughts and feelings? - Don’t analyze, question, or argue with them [[💡 Obsessions|Obsessions]] — agree with them. They aren’t real questions with real answers. Just say they’re true and real, even if they’re scary or inappropriate. Agreeing just means we don’t care about the thought. - Don’t waste time trying to prevent or not think thoughts. It doesn’t work and tends to make [[💡 Obsessions|Obsessions]] worse. “If you want to think about them less, think about them more,” sounds risky. [[🕯️ Titration]] and [[🕯️ Pendulation]] can be helpful, but if we jump into the pool we get used to it more quickly. - [[🕯️ Self-Stewardship]]: - This is our responsibility. We don’t involve others unless our therapist recommends it, they’re willing to help, and we can accept their help. - If you don’t feel ready to do it, speak up and say something. This is more [[🕯️ Self-Stewardship]]. This journey is ours, claim it. - Don’t wait for the perfect moment to start working on this. It’s never going to happen, motivation comes from action and [[🛡️ Procrastinating]] is a part of many people’s [[🛡️ Obsessive-Compulsive Disorder (OCD)|OCD]]. The intention is to change the way we behave. The perfect moment is now. - Review homework daily, even if you think you know them. - Be patient. Progress, not perfection. [[🔑 Progress accumulates]]. Stay away from [[💡 Comparison and Competition|Comparison and Competition]], don’t even try to figure out how long it took someone else to get over a particular fear or topic. [[🔑 Go at your pace]]. One day at a time, on our own time. - Be proud of yourself and acknowledge your successes. Write it on the bathroom mirror, put a sticky note somewhere and add to it to see it grow. Eventually we’ll be able to look back and say “Wow, I can’t believe that used to bother me.” [[🕯️ Self-Stewardship]]: authentically encourage yourself, the parts of you facing their fears. - Always go toward the anxiety. The only way to overcome a fear is to face it, not to run from it. If we want to get better, we have to do it. - When faced with two possible choices of what to confront, choose the more difficult one. Some may need to go up the exposure hierarchy linearly, but it’s important not to assume that the higher ones are necessarily more difficult. If you have the choice, do the more difficult one. Do it with a therapist. - Don’t be perfect or get sidetracked by [[🛡️ Perfectionism]]. Don’t try to do the homework perfectly at the perfect time, that can be a compulsion. Do it imperfectly on purpose, do it whenever we can throughout the day. The point isn’t to ruin our schedule, but to have a life, to live. - Read over homework at the start of each day. Don’t assume you already know it. Start you day deciding you’re someone who’s going to risk getting dirty, hurting someone, losing their relationship. - When doing the assignments, be careful not to give yourself reassurance. “It’s only homework, it’s not a real thing,” “My therapist wouldn’t ask me to do this if they thought I was in real danger,” “I’m only doing this because I was told to, so I’m not responsible if something actually happens.” We’re taking all the logic and reassurance seeking out of it. We’re doing it because we want to. We want to risk the anxiety and fear so the [[💡 Parts|parts of us]] involved in the [[🛡️ Obsessive-Compulsive Disorder (OCD)|OCD]] constellation can learn something new. - Give your homework your full attention, focus on what you’re doing. Let yourself feel the [[💡 Anxiety|anxiety]]. We can live our life, but we don’t have to distract from the anxiety or do something to stop us from feeling it. Don’t let the homework become an automatic routine, which can be another way of [[🛡️ Avoiding]]. The intention is to build tolerance for [[💡 Fear|fear]] and for what might happen. - Hold challenging assignments or unexpected challenges as opportunities for practice. This reframe might feel phony for a while, but eventually it becomes true. Challenges are not just unfortunate things happening to us, they’re opportunities for us to practice, get better, grow. - Don’t rush exposures. The goal isn’t to race to the top of the hierarchy, it’s to practice until we embody new learnings. - If your exposure homework doesn’t give you any anxiety, it’s not going to help us much. Tell your therapist. Challenge yourself. Sometimes it takes a while for the anxiety to happen. Sometimes what gave us no anxiety one day gives us anxiety another day. - OCD can make us doubt ourself, doubt our homework, that we’re not in the right place for this treatment. That we should try x other things because it’s better than feeling anxiety, but they don’t help us embody new learnings, they’re quick and temporary fixes. OCD is “the doubting disease” — it makes us doubt anything that’s important to us. If it tells us our OCD will be made worse by this, agree with it (see: [[#Responding to Intrusive Thoughts and 💡 Obsessions Obsessions|Responding to Intrusive Thoughts and Obsessions]]) “Yep, it is going to make it worse. If it’s gonna get worse, cool.” [^1]: [OCD and Anxiety | 25 Tips for Succeeding in Your OCD Treatment](https://www.youtube.com/watch?v=fPtjx2ysxa8)