2.2 ERP: Three Kinds Of Exposures

Note: All parts of the guide have been updated as of Sep 2022 after much discussion from those suffering from SOCD and my own experience. In particular I have considerably adjusted the ERP approach, as I now believe that is better to simply avoid doing any explicit rituals, rather than trying to literally do nothing, which seems to have been causing some issues for people.

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 idea is to do the exposure without doing any particular 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) Conscious Exposure

This is where you will schedule some time out (at least 5 minutes) and invite the awareness of whatever sensations are troublesome, without really doing anything else. You can do this while going for a walk or a drive or just sitting outside, but it should be something where your mind isn’t too occupied. Doing nothing in particular will give you the best chance to have a more intense exposure, whereas if you are busy doing something else you won’t notice the sensations as much. One thing you can do is set an alarm every minute during this period so you keep getting reminded of it.

Previously I said you should focus on the sensations during this in a mindful kind of way, but I believe this can become a kind of ritual. Instead, just encourage the awareness to be there as much as possible so you can get a good quality exposure in. You will forget it from time to time during this period and that’s fine.

While you do this, you should not do the rituals or compulsions you were doing previously. (ideally you know which compulsions to avoid from 2.1). For example if swallowing is my issue and my ritual was to always monitoring and try swallow every 20 seconds, then I would not do that. Instead I’d just sit with the awareness without having a particular strategy to ‘deal’ with my awareness. I might swallow sometimes if there’s a lot of saliva, I might not, but it doesn’t really matter. The point is just to avoid any particular ritual you were doing to ‘solve’ the problem earlier, and get comfortable with that awareness there without needing to ‘solve’ or avoid it.

At this point, don’t worry about the fact that you’re not doing things ‘normally’ right now. That doesn’t matter. Get used to having these sensations without having a particular strategy to deal with it. This is the skill of learning to do nothing in particular in response to your trigger. But don’t stress about perfectly doing nothing; it’s not about that, it’s just about avoiding the rituals you were doing previously (and it should be pretty clear if you are doing them or not).

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. Sometimes it may last for quite a while, even for hours after the exposure. Don’t be surprised if this happens; it’s part of the process. It should get easier.

Exercise 2.2.1: Schedule a time daily to do conscious exposure. It should be at least 5 minutes a day. Do this every day until there’s absolutely no anxiety during and afterwards. 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 conscious exposure, we are trying to expose ourselves to the awareness without doing any rituals, but here we are carrying on 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 carry on what with 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 or not the same as usual, but that’s the idea. Don’t unnecessarily continue to focus on it 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.

One side tip here is to 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. Often you might have avoided these situations because of the anxiety involved.

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 are reminded of it.

This applies to both 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), as well as where your mind doesn’t have anything much to 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.

One thing to be aware of is that you may have very little anxiety in general, and even think you don’t have much of a problem, but then a certain situation or environment will really trigger you out of the blue. Until you do repeated exposures to that situation in particular, the fear will not be removed. So pay special attention to what situations affect you the most.

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