If you are reading this and you have Harm OCD, I really do appreciate how difficult it is to come forward for therapy and even more difficult when you read about ERP. Some people may find it difficult to come back after their first session when they realised they will be ‘exposed to their fears’ but this is where psycho-education comes in – explaining clearly to you what is involved and show you the controlled manner in which it is done. In terms of psychoeducation it is also important that you fully understand Harm OCD before moving on. I decided to write today’s article to encourage those of you who may be afraid of therapy to seek treatment. As a psychologist specialising in OCD and Exposure and Response Prevention (ERP), I’m going to break this down into (hopefully) manageable bits of information. In this article, I’m going to break down exactly how ERP can help you overcome Harm OCD, step-by-step.
Before discussing anything in any depth I want to take a moment to expand on the topic of psychoeducation as it will help to calm some of your fears. When you begin ERP therapy, one of the first things we’ll do is spend some time on psychoeducation. This might sound a bit formal, but it’s really just about understanding how OCD works and why ERP is such an effective treatment. Think of it like getting a map before you set off on a journey. Psychoeducation helps you understand the terrain of your OCD and how to navigate it effectively.
We’ll explore the OCD cycle in detail, breaking it down into its key components:
- Obsessions: Those intrusive, unwanted thoughts, images, or urges that trigger anxiety. In the case of Harm OCD, these might be thoughts of hurting yourself or others, even though you have no desire to do so.
- Anxiety: The intense distress and fear that obsessions provoke.
- Compulsions: The mental or physical actions you take to try to reduce anxiety and prevent the feared outcome. This might involve avoiding certain situations, seeking reassurance, or performing mental rituals.
- Temporary Relief: Compulsions might provide temporary relief from anxiety, but they ultimately reinforce the OCD cycle.
Understanding this cycle is crucial because it helps you see how your compulsions, while intended to help, are actually keeping you stuck. By avoiding your fears and engaging in compulsions, you’re inadvertently teaching your brain that the obsessions are truly dangerous and must be avoided at all costs.
This is where ERP comes in. By gradually confronting your fears and resisting compulsions, you’re essentially rewiring your brain. You’re teaching it that the obsessions are not real threats and that you can handle the anxiety without resorting to those unhelpful behaviours.
Psychoeducation also helps you understand why ERP can be so effective. We’ll explore the science behind it, including the role of habituation (getting used to anxiety-provoking situations), extinction learning (breaking the association between obsessions and anxiety), and cognitive restructuring (challenging unhelpful beliefs).
Think of psychoeducation as laying the groundwork for successful ERP. It empowers you with knowledge, helps you understand the rationale behind the treatment, and motivates you to embark on this journey of recovery.
ERP for Harm OCD – how it works
ERP is the most effective treatment for OCD, and it’s based on a simple but powerful principle: by gradually facing your fears and resisting the urge to perform compulsions, you can retrain your brain and break free from the OCD cycle. It’s like building a muscle. At first, lifting a heavy weight might seem impossible, but with consistent practice, your muscles get stronger, and the weight becomes easier to lift. ERP works in the same way. By repeatedly confronting your fears without giving in to compulsions, you strengthen your ability to tolerate anxiety and uncertainty. If you are thinking right now, well, it’s not the same for someone who is afraid each time they cook dinner that they could lift a butter knife and stab someone. I can assure you that someone with POCD or contamination OCD will feel the same as all forms of obsessions that exist with OCD are so frightening that you are compelled to do things, ritual, compulsions to keep you and everyone else safe. But you do not start off with the things that terrify you; it is controlled and managed by your therapist. You won’t get anywhere near the stage of exposures – the facing your fears bit until you have been taught ways to manage your anxiety; fully understand the process and then you shall start with something that only causes you a modicum of of anxiety.
When you begin ERP therapy, we’ll first work together to understand your specific obsessions and compulsions. You might be tormented by vivid images of accidentally harming your child, fear that you’ll lose control and hurt a stranger, or worry that you’ve contaminated someone with a deadly illness. These thoughts are incredibly distressing, but it’s crucial to remember that they are just thoughts – they don’t reflect who you are or what you’re capable of.
Once we have a clear picture of your OCD, we’ll create a “fear hierarchy” – a personalized list of feared situations, thoughts, or images, ranked from least to most anxiety-provoking. This is where the real work begins. I remember one client who was terrified of knives, convinced that she would lose control and hurt her family. We started by having her simply hold a butter knife, then gradually worked our way up to sharper knives and eventually to using them in the kitchen. It was a challenging process, but with each exposure, her anxiety lessened, and she began to reclaim her life in the kitchen.
Another client, a new father, was convinced he could have harmed his baby in the past and forgotten about it, or could harm him in the future. He made up various excuses to avoid changing nappies or bathing his child, or even holding him for fear that he might somehow cause harm. We started with imaginal exposures, where he would write and read scripts about these feared scenarios. Gradually, we moved to in vivo exposures, starting with simply holding his baby , then progressing to changing nappies and eventually to bathing his son alone.
Here’s how a fear hierarchy for this fear might look:
- Looking at pictures of babies in the bath. (This might cause minimal anxiety.)
- Touching the bathwater.
- Sitting next to the bath while your child is in it. (Anxiety might be increasing here.)
- Helping your partner bathe your child.
- Bathing your child alone while your partner is in the next room. (This might be quite anxiety-provoking.)
- Bathing your child alone. (This might be the most challenging exposure.)
We would start with the first item on the hierarchy, exposing you to pictures of babies in the bath while helping you resist any compulsions. We would stay at that level until your anxiety decreased significantly. Then, we would gradually move up the hierarchy, confronting each fear one by one, always ensuring that you have the skills and support to manage the anxiety.
This gradual approach is crucial because it allows you to build confidence and mastery over your fears. It’s like learning a new skill – you start with the basics and gradually build up to more complex tasks. By starting with less anxiety-provoking exposures, you’re giving yourself the best chance of success and ensuring that ERP is a positive and empowering experience.
Why ERP Works
At the heart of Harm OCD lies a fundamental misunderstanding of how thoughts relate to actions. Your brain becomes fixated on the possibility of harm, however unlikely, and interprets these intrusive thoughts as a genuine threat. This triggers a cascade of anxiety and a desperate need to neutralize the perceived danger, leading to compulsions.
ERP works by breaking this cycle. Through repeated exposures, you learn that:
- Your thoughts are not facts. Just because you have a thought about harming someone doesn’t mean you’ll act on it. In fact, people with Harm OCD are often the least likely to cause harm, precisely because they are so distressed by these thoughts.
- Anxiety is not dangerous. It’s uncomfortable, yes, but it’s not harmful. By learning to tolerate anxiety without resorting to compulsions, you’ll discover that it eventually subsides on its own.
- You can handle uncertainty. Harm OCD often thrives on the need for certainty and control. ERP helps you embrace the reality that you can’t control every thought or prevent every possible harm.
The Neuroscience of ERP
From a neurological perspective, ERP helps to rewire your brain. When you repeatedly confront your fears without engaging in compulsions, the neural pathways associated with fear and anxiety begin to weaken, while new pathways associated with safety and tolerance are strengthened. This process, known as neuroplasticity, is the key to lasting change.
ERP in Practice
Let’s imagine you’re struggling with intrusive thoughts about hitting someone with your car while driving. These thoughts are relentless, flooding your mind with terrifying images every time you get behind the wheel. The anxiety is overwhelming, leaving you feeling trapped and terrified. To cope, you find yourself constantly checking your mirrors, driving below the speed limit, and even avoiding certain routes altogether. These are all compulsions – attempts to neutralize the anxiety and prevent the feared harm. But they only serve to strengthen the OCD cycle.
In ERP therapy, we would gently guide you through a series of exposures designed to challenge these fears and help you break free from the compulsions. We might start by having you read accounts of car accidents or watch videos of driving simulations. This might sound counterintuitive, but by confronting these feared stimuli in a safe and controlled environment, you begin to learn that you can handle the anxiety without resorting to compulsions.
As your anxiety starts to decrease, we would gradually move towards real-life exposures. Perhaps we would start by driving on quiet roads together, with me in the passenger seat offering support and encouragement. Then, as your confidence grows, we might venture onto busier roads, gradually increasing the level of challenge. We might even drive past a pedestrian crossing when the lights are changing, allowing you to experience the anxiety without giving in to the urge to check your mirrors or slow down unnecessarily.
Throughout this process, we would work together to resist the compulsions that have been keeping you trapped. This might involve resisting the urge to check your mirrors constantly, driving at a normal speed, and taking those routes you’ve been avoiding. We might also use mindfulness techniques to help you stay present and grounded in the moment, rather than getting lost in the “what ifs” of your anxious mind.
I think for me, the most important thing for you to know, is that as a psychologist who has been doing this for 20 years, to me, they are obsessions; they are part of OCD, that is how I will see it if I met you. I would not be alarmed or fearful of the thoughts as they are obsessions and can be worked with and understood in ERP.