OCD Triggers in Daily Life? Don’t Ritualize. Be Strategic! 3 Tips for Fighting OCD.
Exposure and response prevention (ERP) for OCD involves willingly habituating to your triggers. When spontaneous triggers occur, don’t ritualize; be strategic.
Question: I know about ERP, and I understand that OCD symptoms can be reduced by resisting rituals and then habituating to the anxiety brought on by obsessive thoughts. However…what if an obsessional thought requires no ritual? Confused!
Great question. I think that in all cases of obsessive-compulsive disorder (OCD), there is some type of ongoing ritual that maintains the obsessional thought. This is because OCD is caused by threat misappraisals that are perpetuated and negatively reinforced by compulsive behaviors. As long as your compulsive behaviors remain in place, you are prevented from having the type of corrective learning experiences that are necessary for you to recover from your OCD. The reason that ERP is so effective is because it allows you to build these types of corrective learning experiences into your daily life.
Sometimes a person has very obvious rituals; other times, rituals are more subtle. If you’re struggling with identifying your rituals, take a look at this list. With your example, the ritual might be mental rather than behavioral, which can make it more difficult to identify. I would ask yourself, “When my obsessive thought makes me feel anxious, what do I then do in order to escape/reduce this anxiety?” The answer is your ritual.
This is the reason why trying not to think about an obsession can (for some people) become a mental ritual.
Fortunately, there are multiple solutions to this problem:
Strategies for Responding to Spontaneous OCD Triggers
1. Do a thought exposure (imaginal exposure) in which you sit with the thought and focus on it purposefully. If you allow enough time to do this, you will eventually habituate. Note: you may need to do this multiple times but the process of habituation should accelerate as you get more practice. Some people use recorded audio loops to hear the thought again and again; others write the thought over and over again; still others say it out loud. This is a good example of ERP (exposure + response prevention).
2. Allow the thought to be there and don’t try to squelch it…but continue to go on with your day while allowing the thought to be there. This is a good example of response prevention. Many people may also include an exposure element by elaborating on the thought, giving it more detail, taking it to extremes…with the express purpose being that of habituation to the thought.
3. Another example is taking the obsession and turning it into an in vivo exposure. For example, if the obsession is something like, “I might have an unwanted bodily fluid on my hands,” an exposure might involve touching one’s hands to other parts of the body (face, legs, etc.) or touching other surfaces (toilets, etc.) to make sure that the unwanted contact has actually occurred. One would then go throughout the day without washing.
With all these strategies, anxiety will increase in the short term (i.e., the time subsequent to the exposure). However, ultimately, you will become less and less bothered by your obsessions as you get more practice.
The ultimate goal is to learn, “I can be okay even if I’m not as clean as my OCD tells me I should be,” “Dirty isn’t dangerous,” or some other such thought.
I think you already know these things logically. ERP is the means by which you can learn to believe these things experientially.
Questions? Comments? Other challenges when implementing ERP? Share below.
Related posts:
Imaginal Exposure vs. In Vivo Exposure for OCD
OCD Treatment Group Using ERP
Contamination OCD – Long Shower Exposures
Pure-O OCD Rituals: Starting Over, Resetting, & Undoing
Treatment for Body-Focused Obsessions & Compulsions in OCD (e.g., Swallowing, Breathing, Blinking)
Sensorimotor OCD & Social Anxiety Differential Diagnosis: “Obsessive Swallowing”
OCD: Screaming, Blurting Out Obscenities/Cursing/Profanity, & Other Unwanted Impulses
OCD Treatment: Back to Basics
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Dr. Steven Seay is a licensed psychologist in Florida & Missouri. He is the Director of the Center for Psychological & Behavioral Science and provides treatment & therapy throughout South Florida, including Palm Beach Gardens, Jupiter, West Palm Beach, Boca Raton, Boynton Beach, Fort Lauderdale, & Miami.
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Another excellent post….easy to understand and full of helpful information for OCD sufferers and their loved ones. To me, the most helpful piece of advice in this post is “Allow the thought to be there and don’t try to squelch it.” Such an important part of treatment for OCD!
Thanks for reading, Janet!
Dear Dr. Seay,
What happens when one practices ERP and then the ERP becomes a ritual in of itself? My OCD morphs the ERP into the idea that I am not doing ERP correctly. If I rearrange an object once and anxiety ensues, then I repeat it several times to lose track of doing it the “right way”. Eventually, I find myself in a loop and feel depressed for not exposing myself the correct way. Does that craziness make sense? The images that pervade my mind is that of the projects where I grew up and one person who haunts my thoughts. He represents my fear of being poor and being a bum.
Good ERP is usually less about doing the “perfect” exposure and more about doing whatever feels “wrong.” With certain rituals, ERP works best when it results in a lack of closure. If you’re finding a lack of closure after your first response prevention effort, that’s probably where you should terminate the behavior. For some individuals with perfectionism issues, it’s also helpful to do ERP imperfectly, imprecisely, or partially.
Hello Dr.
I tought about this method before reading this article, but i understand that you only refere to the compulsionists and not just the obsessives. I have unwanted sexual thoughts and it’s very hard to allow them, and developing like you mention, my mind already does that but causing inner conflict. Any help, please?
If you haven’t seen it already, read my post on unwanted sexual thoughts in OCD. ERP is always the treatment of choice for OCD, even in cases of Pure-O. Rituals can be behavioral OR mental. With mental rituals, response prevention is absolutely essential for treatment to be successful.
How can I use those techniques for thoughts of fear of becoming violent, go crazy or lose control? Thanks!
People will often use imaginal exposures to address these types of thoughts. They will also intentionally put themselves in vulnerable situations that will trigger the thoughts, so that they can work on habituating to them.
Thanks man!
Your posts are very helpful.
Thanks for reading!
But Steve isn’t it paradoxical when you intentionally think those OCD thoughts , you start believing them, like if the OCD says you have done something wrong and you sit with that , won’t you start believing them and be doomed with guilt all your life . Please help me with confusion . Any answers will be highly appreciated
With mistakes, you will never be able to sufficiently “prove” to yourself that you didn’t make the mistake. Thus, you have to learn to cope with the possibility that the mistake was made.
When individuals practice thinking an unwanted thought on purpose, they initially experience a large “spike” in their anxiety. If they stick with these thoughts long enough, the anxiety gradually dissipates…and with practice, they become “immunized” to anxiety associated with the thought. However, if one is ritualizing while thinking the thought, the immunization effect does not occur.
I have this weird obsession or thought.. And.i know.its.totally irrational but this. Thought is everyday, the thought tells.me that my kids are fake that my whole family.is.imaginary, its so dumb because i know its not true but then i start thinking.what.if…. What do u think
I want to do ERP very badly but in doing so I feel I that what I compulse about is going to be true then I worry about my son If I resist compulsions then the first feeing I get is that I have to then believe he is going to get hurt etc. And thinking it means it is true I want to do ERP and think I am doing because it doesn’t mean he is going to get hurt or die and that my thought are silly I want to stop compulsions thinking positive things and that my son will be fine. Not negative things
What if your 13 year old child refuses to participate in ERP? He says it won’t work for him. We tried it the other day and he shut himself in his room for 8 hours afterwards. His obsession is that he will kill himself and his compulsion is avoidance. Thank you.
Hi,
I’m not sure if misophonia counts as OCD, it’s less action I’m taking and more just intense, unbearable cognitive dissonance at the sounds of other people eating. It only happens when presently exposed, and de-sensitization does not work. My ritual is closing my ears or avoidance, but in situations where I can’t escape I have no coping mechanism and it’s unbearable. Please I’d love suggestions.
Misophonia is distinct from OCD, although some people with OCD can also have misophonia. Unfortunately, at the current time, misophonia has been understudied and under-researched, and effective treatments have not been well-articulated. Although some people do find that exposure therapy can be helpful (and yes, I’ve seen straight ERP work for some people with misophonia…although it’s important to carefully craft your hierarchy), I think that mindfulness practice–or ERP fully embedded in a mindfulness-based approach–is probably a better option. This would be somewhat similar to what I would suggest for someone with sensorimotor OCD.
Dr. Seay,
I am a 15-year-old female and I have been having what I have described as “intrusive sexual thoughts” for about the past 6 months. These thoughts are very unwanted and my psychologist suspects that I have “pure O”, as seems consistent with what I’ve read on the Internet.
Part of what I struggle with is feeling like I’m completely alone. I do not know any other teenagers who experience the same symptoms I do. Other high schoolers may experience sexual thoughts at times but I don’t know any others who have OCD or pure O or are plagued with unwanted sexual thoughts almost constantly.
Another major concern is that my thoughts possibly are indeed not intrusive but actually normal. Something my psychologist told me this past week is that all teenagers experience sexual thoughts, boys more than girls. Being a girl, I found this much more distressing than helpful. I know that my psychologist was trying to help, but what she actually did was increase a fear or uneasiness about my male peers. I’m afraid that the “intrusive” thoughts I’ve been having for months have been nothing more than a normal part of growing up. Yet as I research OCD or sexual obsessions, it seems that my symptoms match those of pure O rather than “normal” teenager maturing. I am very confused and I feel lost, especially since my psychologist knows that the thoughts are repetitive and unwanted, and she has even agreed that I probably have OCD, but continues to introduce the concept of “normal” sexual thoughts.
Additionally, I may have tried a form of ERP back in August and September, although I didn’t know at the time that that was what it was. When I would think of the sexual thought, which would occur nearly constantly, I would face it directly instead of trying to push it away. I would “say” to the thought, “You can’t hurt me. You are a lie.” This might have been ritualistic (?) but it seemed to help in the moment. Either way, it was a temporary help, and the thoughts because worse later on.
Thank you for taking the time to read this essay of a comment. 🙂 I would appreciate any feedback you would have for a confused teenager such as myself.
Are you local? There are a number of teenagers who come to our teen OCD support group who have sexual obsessions like the ones you’ve mentioned. It’s important to know that you’re not at all alone in this. RE: what to do, ERP can be incredibly beneficial for dealing with unwanted sexual thoughts, and your willingness to face and deal with your thoughts head-on is commendable. Just be careful about starting a conversation with your OCD. The more you argue with your OCD and try to convince yourself that the thoughts are a lie, the more you subtly give them power. This is where mindfulness comes in. Mindfulness helps you recognize the process of how OCD infiltrates your thought process and gives you the ability to make a choice about how you want to respond (or NOT respond). Although standing up to your OCD and arguing with it can sometimes mobilize you, it’s also lot like trying to argue with a bully. Bullies don’t care how many facts you have on your side. Sometimes any response on your part keeps the attack going.
Thanks for the great article. I have a related question. When doing written imaginal therapy, to what extent is it helpful to insert yourself as actively responding to the consequences of a “worst-case scenario” ? In writing up a script for my harm OCD, I was surprised that one of the first feelings I had after anxiety was one of anger. I imagined someone confronting me that I had ruined their life, and other people telling me that I’m a terrible person. Though I felt anxious about the scenario, I also realized, “Wait a second. What an awful thing to lay at someone’s feet, that they accidentally ruined your life.” Instead of wanting to run and hide, I wanted to stand up for myself. I’ve never felt that kind of power of hypothetical, terrifying scenarios before. Would adding a “response script” be entirely counterproductive–ritualization in another form? Or could it lead to increased feelings of self-efficacy and an improved ability to cope? I’d love to hear your thoughts on and experiences with this. Thanks again for all the help you provide those of us suffering from OCD.
Dr. Seay,
OCD is pretty common in my family. No surprise why I’m having it. I believe ERP is the best cure for OCD. This time I’m experiencing an awful & ridiculous OCD thought which is about sleeping. it keeps telling that I will never sleep!!. If I sleep , I worry about the next night . I have noticed that If I allow the thought to be there and not try to squelch it…but continue to go on with my day while allowing the thought to be there, I don’t feel anxious when I go to bed . Exactly doing what you said in strategy #2.
Right now I feel afraid of the thought and wish to get my sleep back . any help or advice would be appreciated.
Thanks
So, if I wipe after going #2, but I wipe “too hard” or too much, to the point my bowel movements have bright red blood in them, what do I do? Stop wiping after i go #2. ? Or??
This is one of those situations where it is probably more helpful to shoot for “good enough” rather than “perfect.” You might also want to talk with your doctor to see if there are any medical issues in play, which could certainly contribute to the situation.