Exposure Response Prevention (ERP) for HOCD

When you have Homosexual Obsessive-Compulsive Disorder (HOCD) you are consumed with thoughts and images that somehow your sexual preference has changed. I have been working with people with all forms of OCD (HOCD is a sub-type of OCD) for twenty years and want to take time to talk to you today about a particular type of therapy that research has consistently shown will help. It’s called Exposure and Response Prevention or ERP for short and in my clinical experience I have personally found it very effective with people with HOCD. Before discussing treatments it is important you understand HOCD properly; I shall outline the condition briefly, but I recommend you read my guide to HOCD.

Common Obsessions in HOCD:

• Fear of Becoming Gay/Lesbian: A persistent worry that one might “turn” gay or lesbian, despite having no history of same-sex attraction. This fear often stems from misinterpreting ordinary thoughts or sensations.
• Doubt About One’s Sexual Orientation: Constant questioning and scrutinising of one’s feelings and attractions, searching for “evidence” of homosexuality. This can lead to a distressing sense of uncertainty about one’s identity.
• Intrusive Thoughts or Images: Vivid, unwanted mental pictures or intrusive thoughts about same-sex encounters, often accompanied by intense disgust or fear.
• Fear of Others’ Perceptions: Anxiety about being perceived as gay or lesbian by others, leading to hypervigilance about one’s behaviour and appearance.
• Sensory Obsessions: Misinterpreting normal bodily sensations or reactions as signs of attraction to the same sex. You might have come across the phrase of the Groinal Response in relation to HOCD, and this is a classic example of misinterpretation of a sensation.

Before I start talking about ERP Therapy, it is important for you to know that what you are feeling is as a result of OCD and not some sort of denial due to homophobia, to be clinically correct HOCD, is not confined to the heterosexual community, just the same as contamination OCD is not confined to a specific community. A more unto date term is sexual orientation OCD, but like all forms of OCD, it is not about the content of the thoughts, but rather how you react to them that is causing your suffering.

How ERP Works for HOCD

Exposure and Response Prevention (ERP) is part of Cognitive Behavioural Therapy (CBT) and is widely regarded as the most effective treatment for OCD, including HOCD. It involves a two-pronged approach:

1. Exposure: Gradually and systematically confronting the feared situations, thoughts, and images that trigger anxiety.
2. Response Prevention: Resisting the urge to engage in compulsions, those repetitive behaviours or mental acts aimed at reducing anxiety and seeking reassurance.

ERP’s effectiveness lies in the principle of habituation. By repeatedly exposing yourself to anxiety-provoking stimuli without resorting to compulsions, your brain gradually learns that the feared situation is not actually dangerous. This leads to a decrease in anxiety over time, breaking the cycle of fear and avoidance.

Research has consistently shown the effectiveness of ERP for OCD. For example, a meta-analysis by Abramowitz (2006) found that ERP was significantly more effective than other forms of therapy in reducing OCD symptoms. While dedicated studies on ERP for HOCD specifically are limited, clinical experience and expert consensus strongly support its efficacy. The National Institute for Health and Care Excellence (NICE) guidelines recommend ERP as the first-line treatment for all forms of OCD, including HOCD (NICE, 2005).

Types of Exposure in ERP:

• In Vivo Exposure: Directly confronting real-life situations that trigger anxiety. For HOCD, this might involve:
  • Going to LGBTQ+ friendly spaces or events.
  • Having conversations with LGBTQ+ individuals.
  • Looking at pictures or videos depicting same-sex intimacy.
• Imaginal Exposure: Confronting feared thoughts and images in your mind. This can be helpful for addressing obsessions that are difficult to replicate in real life. Examples include:
  • Visualising a scenario where you develop feelings for someone of the same sex.
  • Imagining yourself coming out as gay or lesbian.
• Interoceptive Exposure: Deliberately inducing physical sensations associated with anxiety, such as increased heart rate or dizziness. This helps to build tolerance to these sensations and reduce their power to trigger anxiety.

How to do ERP for HOCD

In my main page on ERP you can see how to make your own exposure hierarchy.

Building an Exposure Hierarchy:

• Start with a list of feared situations, thoughts, and images, ranked from least to most anxiety-provoking.
• Use a Subjective Units of Distress Scale (SUDS) to rate your anxiety level for each item on the hierarchy (0 being no anxiety, 100 being the highest level of anxiety imaginable).
• Break down exposures into smaller, manageable steps. For example, if looking at a picture of a same-sex couple for 5 minutes feels overwhelming, start with 30 seconds and gradually increase the duration.

Example HOCD Exposure Hierarchy:

Exposure:

• Begin with the least anxiety-provoking exposure on your hierarchy.
• Stay in the situation until your anxiety decreases significantly (ideally by at least half).
• Repeat exposures regularly to reinforce the learning process and build long-term habituation.

Response Prevention:

• Resist the urge to engage in compulsions during and after exposure. This is crucial for breaking the cycle of OCD.
• Response prevention techniques for HOCD might include:
  • Delaying compulsions: If you feel the urge to check your feelings, wait 10 minutes before doing so.
  • Reducing the frequency of compulsions: If you typically check multiple times a day, limit yourself to checking only once.
  • Modifying compulsions: If you usually seek reassurance from your partner, try expressing your anxiety in a different way, without asking for reassurance.

Example ERP Exercise:

• Exposure: Watch a 5-minute YouTube video about a same-sex couple.
• Response Prevention: Resist the urge to check your feelings, seek reassurance from others, or engage in mental rituals. Focus on accepting the uncertainty and anxiety, allowing them to subside naturally.

Tips for Success:

• Be patient and persistent: ERP takes time and effort. Don’t get discouraged if you don’t see results immediately. Consistency is key.
• Seek support: A therapist can provide guidance, support, and accountability throughout the ERP process.
• Challenge your thoughts: Learn to identify and challenge the unhelpful thoughts that fuel your HOCD. Cognitive techniques, such as thought records, can be helpful for this.

Finding a Therapist

ERP is most effective when conducted under the guidance of a qualified mental health professional with expertise in OCD and HOCD. You can find a therapist through:

• OCD Action: https://www.ocdaction.org.uk/
• The International OCD Foundation: https://iocdf.org/

Frequently Asked Questions About ERP for HOCD

• Will ERP make my HOCD worse? Initially, ERP may increase anxiety temporarily. However, with consistent practice, anxiety will decrease over time.
• How long does ERP take for HOCD? The duration of treatment varies depending on the individual and the severity of their OCD. Most people see significant improvement within 3-6 months of consistent ERP.
• Can I do ERP for HOCD on my own? While self-help resources can be helpful, it’s generally recommended to work with a therapist for guidance and support.