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.
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