2.2 ERP: Three Kinds Of Exposures

This unit is part of a guide. To see all units in the guide, click here.

This is may be the most important unit in this guide. Doing exposures is really at the heart of recovering from any OCD, and its particularly the case with sensorimotor OCD. The key is to do the exposure without doing any kind of compulsion or ritual; either sitting with the awareness or carrying on with whatever you were doing. I recommend three kinds of exposures, all of which you should do every day initially:

1) Mindful Exposure

This kind of exposure is a form of mindfulness. Essentially you will schedule some time out (at least 10 minutes), sit down, and consciously focus on whatever sensations are troublesome, without doing anything else. It can be helpful to keep repeating in your mind something like ‘I’m conscious of my blinking’, but the main point is to keep focused. It’s a kind of meditation in that you are trying to keep focus on your bodily sensations and will keep having to bring your mind back to it every time you get distracted.

While you do this, you MUST NOT do any kind of ritual or compulsion (ideally you know which compulsions to avoid from 2.1). The aim is in fact to expose yourself to as much discomfort as possible. For example if I’m someone who feels urges to swallow, I’ll try not to swallow, and just feel as uncomfortable as possible. Perhaps a lot of saliva will build up in my mouth, or perhaps some will dribble out; that’s fine. Perhaps my eyes will feel dry or uncomfortable if I don’t blink; that’s the idea. You actually want it to feel as awkward as possible and then not do the ritual. Don’t worry about the fact that you’re not doing things ‘normally’ right now. No matter how much of an urge you feel to swallow, blink, breathe, scratch or whatever it is; don’t do it, nothing bad will happen. Embrace the discomfort. You can actually ‘enhance’ the exposure here by making it as uncomfortable as possible for yourself; for example if saliva in your mouth makes you uncomfortable, generate as much of it as you can and then don’t swallow.

This is where you learn a key skill; the skill of doing nothing in response to discomfort, where you don’t do any compulsion. You learn not to engage in any kind of ritual, physical or mental, and just let it be there. Try be a casual, dispassionate observer; just observing how it feels, without judging the experience (e.g. saying this is bad or good). And keep in mind, this is a skill, so it takes a while to get used to.

You may feel a lot of anxiety doing this, perhaps more than you are used to. This is okay, and isn’t a sign that it’s not working. This is because you are exposing yourself to the fear. Ideally do not stop doing the exposure until there’s some decrease in anxiety, ideally significantly. Sometimes this can take quite a while, so hang in there.

Exercise 2.2.1: Schedule a time daily to do mindful exposure. It should be at least 10 minutes a day, but 20-30 minutes is ideal initially. Do this every day until there’s absolutely no anxiety. After about a week, you should notice this becomes much easier, but keep going.

2) General exposures (aka consistent reminders)

This is where we expose ourselves to the thought, but continue on with whatever activity we are doing. Like in the mindful exposure, we are trying to expose ourselves to the awareness without doing a ritual, but here we are carrying out with our daily activities.

What this means in practice is that you’ll place reminders and notes in your life such that you are constantly reminded of whatever sensation you fear. For example if I’ve got an issue with breathing, I can put a post it note on my desktop monitor or to do list with ‘Breathe :)’ on it, or set an alarm 4-5 times a day to remind me of my SOCD with breathing. The idea is you are constantly exposing yourself to this thing you are fearing. Just doing this has a significant effect; it’s like facing it head on instead of running away. I like to think of this as smashing the OCD over the head with a hammer; it won’t be able to handle this onslaught of exposure.

The key here is just focus on what you are meant to be doing after you are reminded of the sensation. If you are working, keep working, if you are watching a movie, keep watching it. It may feel uncomfortable, but that’s the idea. Don’t turn this into a mindful exposure by continuing to focus on it though instead of doing your task though; just resist from doing any of your compulsions. Also, don’t worry about how you can’t do things ‘normally’; just do it to the best of your ability with the awareness there.

This kind of exposure is important as it helps you in normal life. You will get triggered every so often, and you’re learning to just get on with your life. Your mentality should be to embrace the SOCD; every time you remember it thinking “Great, welcome back; I’ve been wanting you to be here”. Each exposure is an opportunity to become stronger, so you should be welcoming it. You can periodically make sure the awareness is still there.

You should also again do all you can to ‘enhance’ the exposure, and make it as uncomfortable as possible. For example, if a compulsion you have is with blinking, you can perhaps deliberately not blink initially for a minute so your eyes feel a bit dry, and then carry on with your activities. You can also use sarcastic scripts (potentially based on thoughts you know you’ve had) to enhance the exposure like “Oh well, you’re right OCD, looks like my life is going to be ruined because I’m conscious of my nose”. If you can make a bit of a joke out of it, that’s good.

Exercise: 2.2.2 Create reminders in places you frequent (desk, computer, car, bedroom etc) and set alarms throughout the day so that you are constantly ‘triggered’ throughout the day. If a certain obsession is no longer giving you a lot of anxiety, change these so it reminds you of whatever obsession is. Get a bit creative with this to make sure you’re being reminded of it. The more, the better.

3) Exposure during trigger activities

You’ll probably have found there’s certain situations where you are triggered a lot or certain activities you struggle with. For some people their OCD with their eyes makes it hard to read, or for others with their saliva makes it hard for them to socialise. Sometimes these are activities you typically enjoy, like watching a movie, and the SOCD is ‘ruining’ the experience.

Once you’ve identified certain situations, repeat the exercise from 1.2 where you challenged your thoughts. For example with reading, someone might say ‘I can’t read properly’, or ‘it’s ruining the enjoyment’. Again, interrogate this. You probably can actually read pretty decently even with the SOCD there, as long as you focus on reading. It might affect you a bit, but not much. The anxiety might be unbearable, but if you could remove that, you probably can read okay.

Then it’ll be about exposing yourself in these situations. Again, just remind yourself of the obsession at the start of the activity, and then go on with it. Embrace any time you brain reminds you of the obsession, but don’t stop to focus on it, carry on with your activity. You can also periodically set up reminders (using an alarm or otherwise) during the activity so you don’t forget it.

It’s generally easier to do this in situations where your mind is stimulated and you have something to concentrate on, e.g. while you are watching a film perhaps or talking with friends. It can be harder in situations where your mind doesn’t have anything much focus on e.g. when you’re lying in bed or when you’re just going for walk. You should ensure you practice exposure in both kinds of situations.

Exercise 2.2.3: Work out what situations/activities are triggering for you. Repeat the exercise from 1.2 where you wrote the trigger, the automatic thought, and how it can be challenged. Schedule reminders at the start and during these activities so that you can be exposed as much as possible while doing them. Finally, do the activities themselves, perhaps more than you usually would if possible.

Feel free to ask any questions about these exposures and any challenges that arise doing them.

Continue to 2.3 What to Expect and Your Mindset

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Akash

Today I had only one problem of breathing but now i have blinking swallowing problem after reading these posts please help i am sad…

Igor Fleury

I do not understand for the mindfull exposure. I cannot avoid blinking for more than 2 min. Swallow for 20 min i can. Is swallowing a compulsion/ritual and the trigger is awareness of saliva? Should i be avoiding swallowing on the mindfull and also the general exposures? Isnt saliva and swallowing the hole obssesion? And the fear , rumminations, trying to figure out the compulsions and rituals i should avoid?

Last edited 9 months ago by Igor Fleury
Igor Fleury

Hi Aadil, thanks for the reply.

The reason I’m asking is that the moment where I swallow naturally is not happening at all. I can let the saliva for as much time as I want, but my awareness is locked on saliva + swallow. Your text presents the the swallow as a ritual for relief. so do you see the swallow as a compulsion? Should I try to swallow less and less, leaving the saliva there as much as I can?

Jasmine chin

Hi, I have a question regarding the mindful exposure. You mentioned that no matter how much the urge to breathe, dont do it. As i am having this problem of breathing, in this case, do you mean that i try not to breathe and hold my breathe? Since the mindful exposure is to focus consciously on the sensation right, why should we be avoiding the urge to breathe consciously when i am doing this kind of exposure?

james

How do I not breathe consciously once I am conscious of my breathing?

YITENG

Thank you very much

Teal

So for swallowing I should try not to swallow? It feels odd because I don’t feel particularly anxious, but I still have this problem.

Teal

I think deep down I want it to go away and haven’t completely accepted it, even though I am not as anxious. I have the breathing too, but less than the swallowing.

Also I feel my throat is sore, could it be because of the swallowing? I was starting to calm down but then I felt my throat being sore and that’s when it worsened again.

Thanks for this guide, it gives me a bit of hope.

Mick Sadler

Ok, So I have the blinking OCD which has semi paralyzed me from engaging in activities – I am actually off sick from work because of this – so my understanding is this, the exposure you recommend is for me to do everything, ie watch a movie, go out, read, go to work, even with the anxiety (even as I type this now with a shaky feeling) keep doing activities with the Blinking awareness banging in the background and basically try not to react to the awareness, even try and humour it? give it no value? or embrace it? go to work with it screaming at me from the background like a child but do not react, instead carry on? is this what you mean Aadil? how long can it be expected to take for your mind to get used to this?