Working with the OCD population, it’s common for therapy members to ask me, “Why does my OCD seem to be getting worse?” There can be several different answers to this question.
Often, when a member begins exposure and response prevention (ERP) therapy, things can seem to get worse before they get better. By falling behind on exposure homework or management techniques, going through stress or change, or when new OCD themes take hold, symptoms may get worse at any point. And at the beginning of treatment, symptoms can increase because a person is successfully resisting compulsions and not feeling the short-term relief they are accustomed to.
Regardless of the reason for an increase in symptoms, it is always possible to get back on track with ERP therapy. Having a good therapist by your side during this recovery process is key for accountability and continued success. As a therapist, my hope for all my members is that they eventually “become their own therapist.” To do this, a person with OCD must be dedicated to recovery, take time to practice ERP techniques, and most importantly work to accept the uncertainty that exists around their obsessions and fears.
Let’s look at an example of someone experiencing an increase in OCD symptoms to illustrate some possible contributing factors:
Jerry has been in ERP therapy for a little over a month. He sought help due to repeated intrusive sexual thoughts about younger family members. His therapist educated him about how OCD works, and how his thoughts didn’t mean anything about himself or his values. Gaining this understanding made Jerry feel immense relief in the first few sessions—he found hope. It felt good to be talking to a therapist about his fears and not being judged.
Jerry’s therapist also explained that he would need to attend sessions twice a week for at least 3 weeks to ensure the best possible outcome. Together, they built a hierarchy of exposures, designed to begin with exposures that triggered a small amount of fear and anxiety, working up to more difficult exercises over time.
The first exposure involved Jerry writing down his family members’ names on a piece of paper. For homework, in between sessions, Jerry was supposed to keep the piece of paper with him in his pocket wherever he went to continue practicing exposures. Jerry tried this for a few minutes the day after therapy, but when he noticed anxiety beginning to creep in, he took the paper out and threw it in the garbage. Before long, he worried that someone would find the paper, so he took it out of the garbage and shredded it.
In their therapy session a few days later, Jerry’s therapist explained that destroying the paper was a new compulsion that only reinforced his fears—together, they decided to repeat the exposure. He wrote the names down on the paper in session and this time his anxiety got even higher. Immediately, Jerry felt like he couldn’t keep the paper in his pocket at all. He feared that he would become overwhelmed by anxiety.
For the next few weeks, Jerry only did exposures in sessions, but consistently avoided facing his fears in everyday life—he hoped that this would be enough to help him get better slowly, without needing to face spikes in anxiety.
As time passes, Jerry’s intrusive thoughts seem to be getting worse, and he engages in more and more compulsions. His therapist explains to him that it is necessary to practice ERP homework consistently and commit himself to difficult work if he wants to make progress—avoiding his exposures is only strengthening his symptoms, and OCD is increasingly interfering in his daily life.
Recovery isn’t linear
As I said, there are many things that can get in the way of recovery and make your OCD symptoms. No matter what the reason, there’s always hope to get back on track. Whenever you encounter setbacks, small or large, here are some things to keep in mind:
Consistency is important
Like Jerry, many people with OCD who begin ERP therapy have a hard time making progress at first. Many feel that it will be “just too hard” to do the ERP practice on their own. However, this is an important part of the recovery process. Remember: the ultimate goal is to become your own therapist. By practicing on your own you can build lasting ERP skills, and accept the uncertainty despite uncomfortable feelings. But it takes a lot of practice.
Sometimes effective practice makes it feel worse at first
People in ERP will sometimes notice they are feeling worse in the beginning, even when they are doing their homework and resisting compulsions. Remember, those very compulsions that make OCD worse over time often bring temporary relief from anxiety—they allow you to feel better in the moment. When you reduce or eliminate compulsive behavior, your short-term anxiety might spike. But it will go away in time, and you’ll learn to accept it while living life on your own terms. If you stick to your ERP plan and continue to practice, your hard work will lead to long-term relief.
Stressors are going to happen. A loved one may die, an illness may present itself, or a friendship may end. Stressful events and life changes can trigger OCD, allowing it to inch its way back into your life. Expecting to live in recovery free from triggers and stressors is not realistic. In times like these, it is important to remember your ERP skills and recognize that setbacks happen—and that’s okay. If your OCD relapses and you can’t manage it on your own, reach out for help. Nothing is a point of no return, and there is no shame in needing a refresher!
Stay on course
Sometimes people are feeling great after initially going through therapy and think: “I don’t need to practice anymore.” Often, this is OCD speaking. As someone who has OCD, I have found that I won’t ever stop practicing my ERP skills. Sure, my symptoms are less intense and I might not need to use them as much—but I’ve always got my tool box on hand. When an intrusive thought pops into my head, I can immediately use my Response Prevention Messaging (RPM) to ensure that I don’t slip up and engage in a compulsion. ERP may always be part of your life, but it makes you stronger—embrace it!
Will OCD ever go away completely?
OCD will never go away completely. We don’t have control over intrusive thoughts—remember, people who do not have OCD have them, too! However, we can choose how to respond to them, and we can learn healthy responses to use long-term.
OCD certainly can go into remission. Some people may be asymptomatic for years at a time. However, remember there is uncertainty in everything, and in any mental health disorder—a period without symptoms doesn’t mean they won’t return in the future, in one form or another. However, if you practice your ERP, embrace uncertainty, and learn that you can handle feeling anxious, you will remain prepared for any time OCD shows up again, and you can truly live free from the suffering you once felt.
Should I be worried if my OCD gets worse?
If OCD gets worse, take inventory of what is going on in your life. What triggers have shown up lately? Have you been practicing your ERP? Are you in the beginning stages of treatment? Are you paying attention to your values and the things in your life that are important to you? How you answer these questions can tell you a lot about why OCD is getting worse.
Should you worry? I won’t answer that question, to avoid providing false certainty or reassurance. Instead, I will ask you this question: has worry moved you in a positive direction in your life? Has worry helped you to accomplish your goals? What has worrying done for you lately?
If OCD gets worse, you can always get back on track
If OCD symptoms are increasing and you’re struggling to manage them, starting or returning to treatment can get you back on the road to living in recovery. Recovery is not linear—returning to treatment is not an admission of defeat, but another opportunity to live life according to your values.
If you think that you could benefit from doing ERP therapy with a qualified OCD therapist, we can help. NOCD has the largest network of licensed therapists with specialty training in OCD—book a free 15-minute call with our team to learn more about working with a NOCD Therapist.