Can ERP Become a Compulsion?
I was inspired to write this blog post based on a conversation I had with someone about ERP, particularly when it comes to forcing yourself to face triggers/exposures (the “Exposure” part of ERP) so that you can then practice eliminating the compulsions tied to those triggers (the “Response Prevention” part of ERP). When first starting therapy and practicing ERP, this is a pretty typical exercise. You sit down, identify your triggers (sometimes ranking them in a hierarchy from “most” to “least” triggering), identify the compulsions you would typically perform in response to those triggers, and then try purposefully putting yourself into exposure situations so that you can work on preventing those compulsions.
As a practical example, you might have an obsessive fear of contracting a life-threatening disease. Exposures or triggers would include things like touching public toilets, touching door handles, or shaking hands with a stranger. Compulsions you might perform in response to these situations could include things like washing your hands, taking a shower, or perhaps even more seriously, using chemical agents to “clean” yourself to ensure you’ve killed off any life-threatening germs you may have contracted. When performing ERP, the goal is to eliminate the compulsions so that you learn to sit with the resulting anxiety and gradually acclimate your brain to the feeling of “wrongness.” If you consistently practice ERP, eliminate compulsions, and get your brain comfortable with anxiety, the obsessive fear eventually reduces as your brain “learns” that these triggers/exposures are not actually real threats. So using this example, a therapist might tell you: “OK - to practice ERP, go out and shake the hands of five random strangers. Then, refuse the urge to wash your hands or take a shower, no matter how strong the urge becomes or how bad the anxiety feels.”
This is a pretty standard example, and it’s quite common and often necessary for OCD sufferers to have to “force” themselves to face triggers/exposures, otherwise they might just avoid their exposures altogether in order to avoid the anxiety these situations bring. So it’s quite common - and even recommended - that when initially starting ERP, to identify your triggers and purposefully put yourself in exposure situations so that you can learn how to refuse compulsions and learn how to sit with your anxiety.
This is all well and good, and it’s a proven method that works. There’s a reason why ERP is usually regarded as the gold standard for OCD recovery. However, I do believe that ERP can be taken too far, and like many things, can be twisted by OCD into becoming a weird compulsion of its own.
Speaking from my personal experience - I noticed that after several months of practicing ERP, I was actually going out of my way to expose myself unnecessarily to old triggers and exposures so that I could “practice” my response prevention. As an example, one of my oldest fears/triggers was thinking negative thoughts about someone/something, and believing that my thoughts would come true.
For example, before I ever started ERP, I might get a random intrusive thought like “I wish my parents were dead!” and then, horrified, I would have to spend hours “undoing” the thought by thinking to myself “No, of course I would never want that! It’s not true! It was just a thought!” etc etc…
After starting ERP, I would “force” myself to think such terrible thoughts, and subsequently refuse the compulsive urge to think “counter-acting” thoughts to negate the initial negative thought. This was good and the proper way for me to start practicing ERP, since this was quite early in my recovery journey.
However, after several months, I noticed that “forcing” myself to think negative thoughts was becoming a compulsion in and of itself. I was so eager to beat OCD that I would force myself to think negative thoughts and proclaim negative statements probably hundreds of times a day. I was scared that if I stopped exposing myself to these triggers, then I would stop making progress in my OCD recovery, and hence I doubled-down and continued to expose myself to more and more triggers.
It was at this point, in hindsight, where I should have realized that practicing ERP had become a compulsion. OCD had taken my recovery practice and twisted it into a compulsion in order to keep itself alive in my head. I realized that the negative thoughts themselves (e.g. “I wish my parents were dead!”) no longer actually caused me any anxiety. However, the fear of missing out on a trigger or exposure practice opportunity instead caused me anxiety - “If I don’t think this negative thought, it means I’m not trying hard enough in ERP, and it means I won’t recover from OCD!” As soon as the focus of my fear shifted from the intrusive thoughts to the fear of “not doing ERP correctly,” that should have been my primary clue that practicing ERP had become a compulsion.
For some of you reading this, it may sound confusing and even disheartening. “How can I beat OCD if I don’t even know if I’m doing ERP correctly? If OCD can turn ERP into a compulsion, how can I ever get over this disorder?” Don’t fret. My intent with this blog post is not to scare you or demoralize you, but just to share my learnings and advice on how to get over this hurdle. And my recommendations are these:
1) If you are just starting ERP - DISREGARD THIS POST. When you are brand new to ERP and learning how to eliminate compulsions, it is required and necessary to purposefully expose yourself to triggers and fears. At this early stage in your recovery journey, don’t even worry about whether or not ERP is a compulsion. It’s not applicable.
2) If you have been performing ERP for some time and your old fears/triggers/thoughts are no longer causing you much distress, then it may be worthwhile to step back and evaluate your ERP practice. Ask yourself the question: “Am I putting myself into exposure/trigger situations because I still need to learn how to eliminate compulsions? Or, am I only putting myself into exposure/trigger situations because not doing so makes me afraid of “missing out” on opportunities to practice ERP?” A good check is to evaluate where the anxiety is coming from. If the exposure/trigger itself is what is causing you anxiety, then it may still be necessary to perform ERP. However, if the fear of missing/avoiding the exposure/trigger is giving you anxiety, that may be an indicator that your ERP practice could be at risk of becoming a compulsive behavior.
3) If you are at the point where your ERP practice is becoming compulsive, don’t get discouraged, because it actually means you are close to the end of your recovery journey. At this point, your old thoughts/fears/triggers no longer cause you anxiety. Rather, the fear of missing opportunities to practice ERP causes you anxiety, because you desperately want to beat OCD and the fear of “losing progress in your recovery” is what is driving the compulsive urge to put yourself into more exposure situations. This is OCD’s last ditch effort to retain its hold on you. It knows that at this point, the old fears/triggers/intrusive thoughts no longer hold any power or control over you. And thus, OCD tries to turn ERP into a compulsion as a last ditch effort to keep itself alive in your brain. At this point, recognize what is happening - ease back on your ERP practice and don’t purposefully create or seek out exposures or triggers. Know that, if a random exposure or trigger pops up in your every day life, you have the tools, skills, and mindset to handle it and refuse compulsions - but at this final stage of recovery, there is no longer any need to artificially manufacture or seek out extra triggers.
I know this topic and concept might be very confusing, and it can be a gray area to determine whether or not your ERP is actually helping you or becoming a compulsive urge. In general, I would still say “PRACTICE ERP!!” The intent of this blog post is NOT to dissuade you from ERP or to stop you from seeking out exposures/triggers to practice with. In general, the advice I have in this post is only applicable to those OCD sufferers who are nearly at the end of their recovery journey and no longer really need to be practicing ERP quite so rigorously. To everyone else, I would still advise you to practice ERP and put yourself in as many exposure/trigger situations as possible, so that you can continue to learn how to refuse compulsions and sit with anxiety.
As always, happy to answer any questions, especially given that this can be a very nuanced topic. Hope this post has helped bring some insight to those of you who are nearing the end of their OCD recovery journey!
Eric