Obsessive compulsive disorder - OCD treatment and therapy from NOCD

OCD treatment Plan Part Two

Aug 31, 20186 minute read

This is a continuation of our first post about making an OCD treatment plan. If you haven’t read that one yet, be sure to start there. Otherwise, read on! 

Last time, we talked about why you should plan out your OCD treatment so that you can face your discomfort in a useful way. Then we looked in some detail at the first two steps in the creation of such a plan: identifying the bothersome symptoms, and putting them in order.

Now we’ll go through steps three and four, where these lists are put to work. As with the last post, the suggestions here are not meant to replace a clinician. If you’re able to look for a therapist, please do so. And if you already have one, make sure to take their advice first. Here goes!

From plan to practice: doing ERP

Step Three: Making your hierarchy

Once you’re face-to-face with a list of things that scare you a lot, you can start to rank these things. Psychologists, always interested in finding fancier words for things, like to call this ranking a hierarchy. For the obsessions, you might rank them according to the amount of distress they cause you (on a scale of 1-10, for example). It can also be useful to write down the triggers that usually precede those obsessions; this helps you decide how to create the exposures in the next step.

Compulsions are usually tied to one or more obsessions. It’s not as useful to rank compulsions, because they usually give you a temporary sense of relief, not distress. So if you have multiple compulsions for one obsession, try not to fret about ranking them. You’ll probably get to experience the job of confronting them all. Still, writing compulsions down is essential, because you can only do the response prevention part of ERP if you know which responses (compulsions) to prevent.

Following the above example, here’s a possible hierarchy:

Do I really not want to be alive? (9/10)

Triggers: Standing near the train tracks, driving a car, seeing a police officer’s gun. All bring on an intrusive thought of hurting myself.

Could I have done something really bad that I just can’t remember? (7/10)

Triggers: Hearing people discuss a recent crime, seeing police cars nearby, reading a newspaper.

Is it possible there’s someone else out there who is better for me than my current partner?

Triggers: Passing other couples who seem really happy, reading about signs that a relationship is unhealthy, when we argue or don’t enjoy things that were supposed to be fun.

Step four: Planning exposures

Things get a bit more complicated after this, and even more than the previous steps this next one is best done with the help of a clinician. But now that you have your hierarchy (probably a bit longer than the example above), you have some idea of what’s been bothering you, and which things to prioritize.

Although it can be tempting to go after that 9/10 symptom first, clinicians often suggest you start somewhere in the middle. This allows you to get the increase in anxiety that’s necessary to do exposures, without pushing things too far and putting yourself through too much distress at the start.

This is the place where you’ll rank the different triggers for each obsession, creating another layer to your hierarchy. ERP relies on a gradual progression from less difficult to more difficult exposures; going too far, too fast, drastically increases the risk that someone will be unable to prevent their compulsive responses. And if there’s one single thing to take away from this blog post: exposures are only worth doing if you can successfully (but not perfectly) resist doing compulsions.

Things get more microscopic here, but don’t be too overwhelmed: this kind of therapy takes a while, and requires repetition of each exercise. You won’t be doing all of your exposures at once!

Now, continuing with one of the obsessions from the example above, let’s see how this might look. You’ll see the obsession, and under it are some exposures. They’re pulled from the list of triggers above, because exposures are simply exercises in intentionally triggering the chain of obsessive-compulsive symptoms. For each exposure you’ll find an expected difficulty rating, with 1 being easiest and 10 meaning it’ll be excruciatingly difficult.

Could I have done something really bad that I just can’t remember? (7/10)

Tell myself repeatedly that I’ve done something bad (2)

Write down all the bad things I could’ve done (5)
Watch a show about serial killers on Netflix (7)
Talk with someone about a recent shooting (8)

Listen to the local news, record a crime segment, and watch it repeatedly (9)

At this point, self-treatment gets especially difficult. ERP can be very effective in a relatively short amount of time, but it’s a specific protocol that is hard to manage on your own. A general course of treatment would be to proceed through each exposure until it no longer bothers you, and repeat the exercise a few times. But our minds are complicated, and learning to interact differently with the things that bother us is too. Making your plan is one of the most important steps in OCD treatment, and if you’re able to master these steps you’re well on your way.

We’ll be back soon with more. If you have questions, we’re @treatmyocd on Facebook, Twitter, and Instagram.

If you or someone you know is struggling with OCD, schedule a free call today with the NOCD clinical team to learn more about how a licensed therapist can help. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP. At NOCD, all therapists specialize in OCD and receive ERP-specific training.

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