Is That an Exposure … or a Ritual?

The solved question

Once again, I am fortunate to introduce Dr. Seth Gillihan, who has previously guest-blogged for ocdtalk:

In exposure and response prevention (ERP) for OCD, the OCD sufferer deliberately confronts situations and thoughts that provoke distress (the exposure part), and resists the urge to do compulsive behaviors (the response prevention). This combination eventually makes the situations and thoughts less upsetting and makes it easier to stop doing compulsions.

Most of the time it’s pretty easy to tell the difference between exposure and rituals. In the short-term, good exposures raise a person’s level of distress, whereas rituals lower distress. For example, consider a person with contamination-related OCD. This individual is likely to feel worried and anxious about touching a dirty sink, and probably would feel a drop in anxiety if she were to give in to the urge to wash her hands after touching the sink. In this case the behaviors that we would call “exposure” (touching the sink) and “ritual” (washing her hands) clearly are different.

However, it’s not uncommon for a person in ERP to get confused about whether something is an exposure or a ritual, and for good reason: Sometimes exactly the same behavior can serve as an exposure or a ritual.

Take the example of a person whose obsession is that his bank account will be compromised and he’ll lose all his money. A major trigger for his anxiety is looking at his bank account statements, where he often sees withdrawals that he does not immediately recognize. For this person, looking at his bank statements will be an item on his exposure hierarchy.

Now imagine that the person is working with his therapist on this exposure. At first the man reports strong anxiety during the exposure, and after a few minutes tells his therapist that the bank statement no longer bothers him. It might be easy to conclude that the exposure was successful and that the man quickly learned to tolerate the distress and uncertainty of viewing his bank statement. However, he reports that after he read each item carefully he recognized each transaction, and felt reassured that he needn’t worry. The problem, of course, is that the exposure turned into a checking exercise, with OCD masquerading as treatment.

As always with OCD, we have to ask what the function of the behavior is. Does it raise distress, enhance the sense of uncertainty, and encourage tolerance of negative emotions? If it does, it’s probably an effective exposure. Or does it try to provide a sense of certainty and a short cut to relief? If so it’s a ritual. Other examples include:

·         Looking at one’s clothes or body for suspicious spots that could be blood (exposure) vs. carefully inspecting these spots to make sure they’re not blood (ritual)

·         Watching where one is walking to see ambiguous items that could be biohazards (exposure) vs. staring at an item on the ground to see if it really was a biohazard (ritual)

·         Viewing erotic images to trigger uncertainty about one’s sexuality (exposure) vs. viewing the images to make sure one doesn’t get “inappropriately” turned on (ritual)

·         Feeling one’s car bumper for irregularities that might indicate having hit a pedestrian (exposure) vs. trying to confirm that the bumper has no signs of impact (ritual)

In all of these cases the behavior is easy to label once we consider its purpose. Careful attention to the nature of the exposures can ensure that valuable treatment time is not wasted and that recovery is achieved as quickly as possible.

Questions or comments? Please post them here or contact me by email.

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23 Responses to Is That an Exposure … or a Ritual?

  1. This is an interesting topic. One has to be aware that ERP can develop into a compulsion itself. Great article.

  2. Janet and Dr. Gillihan, Thank you for this post. It really underscores the trickiness OCD can present and how patient and therapist must be very clear about what is being provoked by an intervention.

  3. You’re welcome, Angie. Good description for OCD…..tricky!

  4. Warren says:

    As an OCD behavior therapist, I am asked this question often. For example: If I look in the mirror and see a defect, is it exposure or checking? I tell my BDD clients here on Long Island NY to look ONCE BRIEFLY: that is exposure. Any 2nd look or subsequent looks are rituals for reassurance. The same goes for any other exposure: do it ONCE and stay with the anxiety. Do not repeat to ‘see if it’s ok’ – that would be a ritual. For more on this, ocd.hereweb.com or woodge1@hotmail.com

  5. This article is very pertinent for me right now. I was having this conversation just the other day.. As I progress through treatment my OCD worries have shifted and changed. Right now I have some obsessions about whether I have social anxiety. I have found myself wanting to avoid social situations as I get intrusive thoughts about being anxious in social settings. Of course as exposure I ensure that I confront social situations but equally I find I use it as a checking tool (oh see I don’t feel anxious in this pub therefore I don’t have social anxiety and so on). The article highlights just how complex this condition and treating it can be. Many Thanks for writing such an insightful article. Emily

  6. Emily says:

    This is just one of the reasons why my son and I found ACT (acceptance commitment therapy) much more useful than ERP alone. With ACT, you don’t need to analyze things over and over again, plus since we know with OCD the focus of our obsessions changes, this might result in the sufferer having to build and learn how to navigate the whole ERP hierarchy over and over again for each obsession.
    I know that many OCD sufferers found the ERP approach very helpful and even life saving and for that I am very grateful, just pointing out that there are other ways to tackle this disorder.

    • Warren says:

      I teach my clients a technique for relapse prevention so they won’t have to do the whole ERP process for each new-found obsession. Based on Jeffrey Schwarz’s “BRAINLOCK”, it’s a four-step process:
      1- Identify the new obsession as just another OCD symptom.
      2- Remember that OCD is just a ‘trick in my brain’ and is not a real threat.
      3- Become aware of the new obsession and rate its position on the Hierarchy scale (how much anxiety would you feel if this new obsession was allowed to exist and you couldn’t do anything to stop the anxiety?) Then compare its level of anxiety to the hardest obsession you’ve worked on successfully before in therapy.
      4- If the new obsession’s hierarchy position (level of anxiety) is less than your previous most difficult but successful item in therapy, feel how proud you were of that success, that you now can handle that level of anxiety without ritualizing, and feel the confidence that you can allow yourself to risk ignoring this new one!
      This relapse-prevention technique takes only a few minutes. and means you will probably never have to return to therapy for a week of ERP – or 6 months of old-fashioned suffering!
      (PS I tell my clients they may want to look at BRAINLOCK to further understand the background of this relapse prevention, but I do not encourage them to read it until they have finished ERP, and are no longer afraid of anxiety. I do NOT use BRAINLOCK as a first therapy for OCD – because it teaches you how to ‘just say no’ to a new obsession, and that would be extremely difficult if you have never done ERP.)

    • Thanks for your comment, Emily; I’m glad that your son found ACT to be helpful. There’s growing evidence that an acceptance-based approach can be very effective in treating OCD (for example, a 2010 article in the Journal of Consulting and Clinical Psychology, DOI: 10.1037/a0020508). I appreciated Warren’s comment (below) and agree that once ERP is practiced there generally are “short cuts” to recognize obsessions and respond to them appropriately, and so a person doesn’t have to do new exposure hierarchies for each obsession domain. Thanks again.

  7. Very interesting and informative article. The differences between exposures and rituals can be very fine indeed. I find myself lapsing into rituals in one of my checking issues–checking that the lights in the bathroom are off. If I look at them once and then walk away, I feel the distress that gradually subsides. But if I keep looking at them, what I’m really doing is trying to feel that “relief” that comes from “knowing for certain” that the lights are out.

    • Great description, Tina. Thank you for your comment. Two words you used stood out to me. First the distress *gradually* subsides when a person refrains from rituals. The gradual relief from ritual prevention tends to be markedly different from the quick relief that rituals can bring. And second, “knowing for *certain*” is a giveaway that it’s OCD up to its tricks! Best regards to you.

  8. Emily says:

    Thank you very much Warren and Dr. Gillihan!

    Yes, we found “Brainlock” very helpful as well and discovered many parallels between Dr. Schwartz’s approach and ACT.
    It seems like the first two steps (relabel and re-attribute) become somewhat automatic after a while and the other two – refocus and revalue are very much in line with the ACT principals.

    Dr. Gillihan, thanks for the reference to the study, I remember coming across it but couldn’t find any articles on the direct comparison of ERP vs ACT. I remember my son’s therapist mentioning that many people drop out of the ERP studies and are not included in the total number of participants thus inflating the success rates somewhat..

    But honestly, as long as the approach works for someone, the statistics might not even matter so much. I like the saying I heard when researching the possible benefits of taking Inositol – “nothing works for everybody but everything works for somebody”.

    Thank you very much again!

    Emily.

    • I would definitely agree with you, Emily, that recognizing obsessions becomes more automatic with practice. I should also mention that I’m a big proponent of mindfulness- and acceptance-based approaches when there’s evidence that they work for a given condition, and it’s encouraging to see the newer studies showing that they can be effective for OCD.

      In terms of ERP vs. ACT for OCD, there aren’t any big studies that I’m aware of. There is a study (in the same journal as the other study I referenced) that compared more traditional cognitive behavioral therapy vs. ACT for the treatment of “mixed anxiety disorders” and found pretty comparable outcomes. It looks like there were only 3 participants with OCD, though. The first author is Joanna Arch ( doi: 10.1037/a0028310).

      There’s a 2012 study in the International Journal of Psychology & Psychological Therapy that reviewed and meta-analyzed ACT vs. traditional CBT but I’d be cautious in interpreting the findings. For example, the author included the Twohig et al. (2010) comparison of ACT vs. progressive relaxation training, counting the latter as a form of CBT. Relaxation has been used as a control task vs. ERP, and I doubt any ERP therapists would consider relaxation a form of CBT for OCD!

      In the end the important thing, as you said, is finding something that works for each individual. In my view the statistics give us an idea of the best place to start. Thankfully there are some options if the first approach isn’t successful for someone!

      Thank you for your thoughtful comments.

  9. willitbeok says:

    This is a great post! Something new that I haven’t thought about before. I guess it’s always good to apply mindfulness and make sure that our exposures do not slowly morph into rituals.

  10. This is really funny! The exposure exercises I do, which since my OCD is very disorganized/non-repeating is usually more like ignoring compulsions as they arise or doing the opposite, have become ritualistic. At some point I become really confused. For example, if I *was* arranging my socks so that someone I love will not die, and then I wilfully stop doing this and refrain from arranging socks, I can easily see this trying to turn into “ignoring compulsions will keep this person safe.” I hardly even notice it happening.

    • Wow, Carolyn, that is so interesting, and shows just how tricky, and confusing, OCD can be. It’s great that you realize some of your exposures have the potential to turn into rituals. I would guess a good therapist could help you sort it all out and figure out how to proceed.

      • Thanks, Janet. I’ve been enjoying your posts and comments today. For me, the biggest thing is reducing fear in my life. Once I become anxious about something, OCD gets a chance to take over. I find that accepting the worst case scenerio is a good way to stop worrying, as well as dealing with issues around taking too much responsibility in life. For me that was something that got started in early childhood due to family dynamics. I don’t know if this is similar for anyone else, but I hope to learn more in the future. Thanks 🙂

      • Hi Carolyn, Hyper-responsibility can be a huge issue for those with OCD, as you can see from comments I received on this post: https://ocdtalk.wordpress.com/2012/06/18/ocd-and-hyper-responsibility/
        I’m so glad you are tackling all these issues and wish you all the best as you move forward!

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