At the heart of Cognitive-Behavioral Therapy for OCD and related anxiety disorders is the process of “exposure therapy”. There are numerous variations on exposure therapy, depending on which specific condition is being treated – for example for OCD, the treatment of choice is a specific therapy called Exposure and Response Prevention (ERP). All variations of exposure therapy focus on the same core principle, which is that those suffering from these conditions will experience the greatest reduction in their symptoms by repeatedly doing the very thing that most terrifies them, without responding with any behaviors that are meant to reduce or control their anxiety.
For someone with OCD focused on contamination fears, exposure therapy will likely include purposely touching doorknobs or other allegedly “dirty” items without then washing. For those with variants of Pure Obsessional OCD (Pure O), effective treatment will almost certainly include imaginal exposure, in which the client purposely and repeatedly thinks the very thoughts that they would prefer to avoid, such as thoughts of being a pedophile or a murderer. A person with Body Dysmorphic Disorder (BDD) may be asked to go out for a walk without the hat they usually wear to hide their face, or to go to a brightly-lit restaurant with a group of friends. For those with Panic Disorder, exposure might mean driving on the freeway or taking a plane flight. And an individual with Social Anxiety may be urged to go to the mall to initiate conversations with strangers.
As a treatment center specializing in Cognitive-Behavioral Therapy (CBT) for OCD and related anxiety conditions, we regularly implement exposure therapy with our clients. When we first broach the subject, it is not unusual for a client to be taken aback by our suggestion that they directly face their fear. Some variation of “why on earth would I want to do that” is not an uncommon reply.
When beginning therapy with clients struggling with OCD or a related anxiety condition, we explain that the basic principle of exposure therapy is that one will become less afraid of just about anything if they are exposed to it frequently and regularly. Simply put, the goal of treatment is to desensitize to the feared situation by habituating to it through repeated exposure. For example, if a young boy has a phobia of dogs, the exposure would be to purposely and repeatedly spend time with dogs until such time that the child’s fear is eliminated or reduced to a minimal level.
The question that often arises is “how does exposure therapy work?” Here is a simple, non-clinical explanation of the four ways in which exposure therapy helps to diminish anxiety.
First, by doing exposures, the client discovers that the feared event almost never occurs. The person who touches doorknobs without washing afterward discovers over time that they don’t get sick and die. The individual with Social Anxiety learns that people at the mall don’t respond as if he is an idiot or a freak. The woman with BDD discovers that nobody points at her in horror. And the boy afraid of dogs learns that he doesn’t get bitten.
The second benefit of exposure is that the sufferer learns that, if they don’t do their customary compulsive or avoidant behavior, the anxiety almost always go down all by itself. If the person who is afraid of germs touches doorknobs without then washing their hands, they will at first experience some anxiety. But that anxiety eventually goes away – and almost always for a longer period of time than if they had washed their hands, which provides only short-term relief. Likewise, if a person with BDD goes out without their usual camouflage of a big hat, their initial anxiety will diminish over time – again, often for longer than if they had worn the hat.
The third way in which exposure works is by helping people see that even if a feared situation or event actually does come to pass, it is not necessarily catastrophic. Everybody gets sick sometimes, and virtually everybody is negatively evaluated at some time or another. Likewise, some people do actually experience panic attacks, and dogs do occasionally bite. But if by chance these events do occur, you have an opportunity to learn that it isn’t so bad after all. I personally have been sick more times than I can count, have been evaluated negatively on numerous occasions, have had panic attacks, and have been bitten by a dog. I have never liked these experiences, but they were not catastrophic.
The fourth, and perhaps most important benefit of doing exposures, is that the person learns an incredibly valuable lesson – that they are capable of tolerating the anxiety that they have avoided for so long. Those suffering with OCD and related conditions often spend years doing compulsions and avoidant behaviors in an effort to avoid the feeling state of anxiety. In fact, the fear of anxiety is the single thing that relates all anxiety-based conditions. And when one does repeated exposures, without responding to the subsequent anxiety with compulsions or avoidant behaviors, they learn that, lo and behold, they are far more able to tolerate this feeling than they realized. What they thought would be unbearable turns out to quite bearable after all. Less than ideal perhaps, but hardly unbearable.
People who don’t have OCD or other anxiety disorders cannot fathom just how terrifying the prospect of exposures can be to someone who has spent years avoiding the very thing we are asking them to face. But to those with anxiety, this fear can control them and drastically diminish their quality of life. In facing their fears head on, they learn these four valuable lessons which help them change their life from one of anxiety, avoidance, and dread, to one in which they can choose to live as they have always dreamed.
•Tom Corboy, MFT, is the executive director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.
Hi! I currently working on overcoming my HOCD and I have a question/worry about ERP. I fear that telling myself things such as: “I am gay” or that “any gay thought I have is actually my true desires”as part of the exposure therapy, might actually make me believe I am gay or make me gay. I really do not want to be gay and I just want to continue enjoying my heterosexual life with no irrational fears. I will appreciate your comment on this.
ERP does not turn people gay. Furthermore, simply saying or writing “I am gay” (or any similar thought) cannot make someone gay. If that were the case, we would all be magicians who could change ourselves or other people just by saying certain things.
Hello… at 24 years old I have never been attracted to my same sex. EVER. I have had multiple same sex friends and we changed our in locker rooms, etc and not even a worry. A few months ago I had a strange feeling after seeing someone in a swim suit and had a dream about a gay character on TV and have been plagued with the worry I suddenly turned gay. I love my Heterosexual relationship and I just want to go back to the time were we would have sex no problem and planned out lives together with no doubt of my sexuality. It’s ruined my sex life for now I’m afraid to have sex and have imagines of same sex people. What do I do? Will this ever go away. I just want to g back to how it used to be. I really don’t want to turn gay.
A few thoughts…
1) People don’t just “turn gay”.
2) Avoiding sex with your partner because of unwanted images is an avoidant compulsion. It is making your OCD worse, not better.
3) The unwanted images are no more important than if you had unwanted images of cars, or boats, or tomatoes or whatever. They are just thought which you are over-valuing.
4) Of course you want this to go away, but it will not go away by itself. The best option for you is to seek treatment with a therapist who specializes in treating OCD.
I’m having exactly the same issue, im really tired of it, for the past 10-15 years or I can say since birth I have never really have any issue surrounds my sexual orientation, I always know what i want, and who I was attracted to.
But recently, especially the last two years i have been troubled with anxiety problems, very often, a small thing can trigger my anxiety, especially something related to my health, and I began to stuck into anxiety mood, where i literally just troubled with anxiety issue 24/7, when anxiety arises, i will begin to look for evidence, checking, to find any sort evidence to relief my anxiety, whenever i could not get the answer i want, I became more obsess with the issue and i just could not shrug it off. And lately, new things happened, because of certain things happened, something has triggered my HOCD, and it all of sudden my past evidences on being in heterosexual relationship become nothing, now every thing is about gay being gay 24/7, and i really dont know what the fxxk i was doing at times, my life all sudden become another story, and I even had symptoms where every same gender I met also can trigger my HOCD. Very tortured.
Hi I Just Want To Be Happy,
Everything you write sounds like textbook HOCD. I encourage you to seek treatment with a therapist who specializes in treating OCD with Cognitive Behavioral Therapy (CBT).
My OCD has done the right amount of damage one could expect from this deadly disorder. When the symptoms started to show up, things quickly went haywire. I was under a sudden attack carried out by an unknown entity. My grades started to go down, and I stopped hanging out with friends. However, with time I have learnt to control it.
While, things appear to be normal at the surface, I am often revisited by the ghost of OCD at my workplace. The fortress of control crumbles before my eyes when I sit in my cubicle and start working. It seems like somebody takes the lid of a container that holds my fears and intrusive thoughts. Will appreciate if you suggest a solution I can use to control my anxiety in situations like these.
It sounds like your symptoms are not as controlled as you report. My suggestion is simple – seek out a therapist who specializes in treating OCD with Cognitive Behavioral Therapy (CBT).
Anand, I have an anxiety disorder which surfaces periodically. I now am aware of the first symptoms and immediately make sure I am doing mindfulness, journaling, etc. With my anxiety I want to “keep it under control”. I have learned that this is not how it works. You cannot control it. You need to be aware and learn to live with the ups and downs. Best of luck.
Wonderful advice! Seeking “control” never works. Thank you for posting.
I’m suffering from Hocd, and I’m interested in ERP, but I don’t know how I can do it by myself. I try to imagine my self killing my angel son ( as a kind of imaginal exposure ). i prevent my self from reassure seeking but i feel like I’m frozen with this nightmare.
I want to ask if can put knife on skin of my son as step of ERP. Or put my hands around his kneck when he is sleep, as step of ERP.
What should i do? plz if there is any book with worksheet for ERP for HOCD ( also gay ocd )
Direct me to it. I found the mindfulness book for ocd, is it helpful for ERP.
Thanks in advance.
ERP is not only helpful for HOCD – it is the key to effective treatment. But I do not encourage you try self-treatment. Simply put, you don’t have the training or experience to treat HOCD.
Also, I want to emphasize that putting a knife to the skin of your child, or putting your hands around his neck while he sleeps, are exposures that should only be done under the guidance of a therapist who specializes in ERP for OCD.
That said, I am happy that you have stumbled across our book, and yes it does address ERP specifically for HOCD. If treatment with a local professional is not an option for you, then hopefully our book will be of assistance.
How could I get the book? Can I order?
You can learn more about our book at https://ocdla.com/mindfulness-workbook-ocd.
Hello I’m 19 and I’ve been suffering from HOCD for a while now, I haven’t exactly been diagnosed with it but one day I wanted to find out what these thoughts were but was scared incase it showed I was a psycho! Then I came across HOCD and felt relief then kept reading success story’s which mad me feel so much better, I learnt myself to deal with it, If I got a harm thought I’d just tell myself yeah I get good thoughts and bad, so get over it and it worked so well but now it’s come back worse! I get really bad urges then I sort of panic, my heart sinks and I feel sick I’m so scared I act upon it!
My partner also wants a baby but I’m so scared in case I get these thoughts and hurt my child as I had this problem when I got a puppy. I got a HOCD thought about it then thought the best solution was to remove him I was so scared! I can’t afford to get professional help as I left my job a couple of week ago due to this, if voices were raised or my boss was yelling at others i would just panic, crumble inside and have to leave! First time I’ve wrote about this, feels good! I also can’t watch anything to do with violence or death it scares me! I used to be so confident and happy :(…
A few thoughts…
1) Having OCD does not make one a “psycho”.
2) HOCD generally refers to the fear that one is gay. The symptoms you describe strongly suggest that you have Harm OCD. You can learn more HOCD at https://ocdla.com/sexual-orientation-hocd-gay-ocd-treatment-1969/. You can learn more about Harm OCD at https://ocdla.com/harm-ocd-1-1982/.
Thanks for a great post, but I would like to ask some questions :
1) I suffer from HOCD and what depresses me the most is groinal responses. How can I avoid them?
2) As I live in a homophobic society ( tho I am not ) , and there are almost not OCD specialists here, I want to get self-treatment. My anxiety really fell down a bit thanks to ERP and No PMO hard mode, but what confuses me is that according to ERP, at the last point for most HOCD sufferers they should densensitize pornography, but on the other hand one should avoid pornography because of No PMO, so ERP should start after 3 months’ no PMO or what?
3) I know It depends on sufferers, but generally how much time do we need to overcome this disorder? Thanks in advance for the answers
1) You can’t avoid groinal responses…nor do you need to. Sensations in the groin are a fact of life. The problem is not the groinal sensations, but the fact that you are paying way too much attention to your groin, and valuing what you experience as being important. Let your groin do whatever it wants, and don’t analyze it.
2) I do not recommend self-treatment. If you would like to discuss online therapy with one of our staff therapists, we can be reached via the contact page of our website at https://ocdla.com
I find the hardest part of ERP to be the commitment to not respond. As someone suffering from health-related OCD, the intrusive thoughts can seem very real and they often urge me to take actions (e.g. seeing a doctor). At times like this, I lose the ability to live with the thoughts without responding to them.
Yes, the response prevention component of ERP can be difficult. If it were easy, nobody would have OCD. That said, if you do structured ERP under the guidance of a therapist who knows how to implement ERP appropriately, you should develop an improved ability to resist the urge to respond to our anxiety with compulsions or avoidance.
A constant battle.
I live with two gay roommates, been to the gay bars, have even considered myself bi curious. However, I begin to obsess over me being straight? It consumed my life. For my entire life, I have always wanted to be with women and it’s all I ever thought of. Living with a gay male roommate, he helped convince me even more that I could be living in a state of denial, so my gay thoughts became more intrusive. I thought of the male anus, it was gross, but now I have thought about it so much that its no longer gross but I can’t sit through gay porn. I try and every time I end up puking. I don’t understand it. I can handle the thoughts, fine, but I can’t watch it – something seems violent and sickening about it. I was able to the other night fantasize about a man I know of but could not get an erection – I spent an hour trying to get fully hard and I couldn’t – then the thought of women creeped in my mind and I begin to feel safe and normal, but I wanted women out of my mind so I can know. One day, I even came twice to a gay fantasy, but I didn’t get an erection – I had just finished having sex with my girlfriend and it was from delayed ejaculation. Still, no…
A few thoughts…
What you are doing is NOT exposure therapy – you are compulsively checking to see if you are gay.
Puking from revulsion when watching gay porn sounds like pretty good evidence that you are not gay. But the bigger issue is that you are watching gay porn. This sounds like something you are doing to test your response, which is a compulsion that will make your OCD worse. Step #1: stop watching gay porn.
Likewise, if you were unable to get an erection during an hour of masturbating to the idea of a man, then I doubt you are gay. And as with the gay porn noted above, I am guessing you were masturbating to the idea of a guy to test yourself. Step #2: stop masturbating to the idea of guys.
Your gay roommate may have an ulterior motive in trying to convince you that you are gay. And I am guessing that discussing your sexual obsessions with him is a compulsive effort on your part to get some clarity. Step #3: stop discussing your sexuality and your obsessions with anyone other than a therapist trained and experienced in treating OCD with Cognitive Behavioral therapy (CBT).
My counsellor suggests I have something that seems like harm OCD. The description of obsessive violent thoughts all fit … but in my case they 98 percent self-directed and in my case I do actually harm–I beat and scream at myself myself–often quite hard or tear out my hair.
Certainly the violent thoughts, involving very violent punishment/torture/killing of myself by far exceed the actual acting out.
However, as I am actually already physically acting out the compulsions to beat with several episodes of varying frequency a day, then would a fear that exposure therapy might exacerbate this seem a little more prescient?
While self-harm obsessions are quite common in Harm OCD, the fact that you are actually harming yourself several times a day suggests that you would be best served by seeking treatment with a therapist who specializes in self-harm. Your self-harming behavior would not be appropriately addressed by treatment that focuses on exposure therapy for OCD.
I bought your book and really love it I am also seeing a therapist now I’m not exactly sure if I actually have OCD or not, mine is regarding clothing I am constantly uncomfortable with clothing it’s always either too tight even when it’s not or it touching me or rubbing, even so much that I fixate on it and feel anxiously even just thinking about the clothing, I get very fight or flight feeling. I’m constantly thinking about it and avoid it but I’m beginning to avoid more and more types of clothing… I’m starting to do some ERP with my current therapist I’m not sure how much knowledge she has in that type of therapy though! Do you think ERP is something that could help me??
The symptoms you describe suggest some degree of what is commonly called Sensory Integration Disorder (SID), or Sensory Processing Disorder (SPD). In fact the symptoms you describe related to your clothing are textbook examples of SID/SPD. The good news is that this condition is quite similar to OCD in many respects, and responds quite well to ERP. You can read an article for which I was interviewed that discusses the overlap between OCD and SID/SPD, as well as how ERP works for both, at https://ocdla.com/Uncovering-OCD-Advance-Magazine.pdf.
Lately I’ve been having thoughts about brutally harming people and its leading me to think I’m legit going to become a murderer. Most of the time its about family.
This sounds like classic Harm OCD to me.
I’ve been reading your book on Mindfulness for OCD, and it’s helped me quite a bit. I’ve started doing exposure exercises, but now I’m wondering, can exposure become compulsive?
Among others, I have the (irrational) obsession of being watched by people in cars when I cross streets while they have a red light. This has led to hyper-awareness of normal things I do outside of this type of setting, too. But I started doing exposure exercises where I’d make myself cross streets, feeling the eyes aimed at me, feeling super conscious of every move I made, but ultimately not engaging those thoughts and emotions.
I’ve started to realize, however, that I keep having an “urge” to do the exposure exercise, like I need to prove myself that I can carry out the activity in the most frightening settings and locations. It’s like I am now reacting to something, and doing it to seek reassurance. I feel like it’s now a way of testing myself, or more so, “playing the game” as with any other obsession.
Could it be possible that doing ERP has turned into a compulsion of some sort? I have no idea if I should keep doing it…
Any advice would be highly appreciated 🙂 Thank you so…
Yes, exposures can become compulsions. In fact this is a fairly common problem. Remember, the goal of exposures should be to experience the anxiety. If you are doing exposures to seek reassurance, then you are doing a compulsion. I encourage you to read our article “Reassurance Seeking in OCD and Anxiety”. Other than that, my best advice is to seek treatment with a therapist who specializes in treating OCD with Cognitive Behavioral Therapy (CBT).
I’m having a hard time with the ERP obsession theme. Its quite awful. I’ll give you an example. For an exposure, some therapists have pictures on a wall hang crooked. That patient is supposed to habituate to crooked pictures. Well, now, if my picture is hanging straight on the wall, I feel like a horrible human being because the picture is hanging straight. My head screams, “You better make that picture crooked or else you have failed exposure therapy!” And what is so confusing is that, yes it would make me anxious to make my picture crooked, but the thing is, I like pictures hanging straight on my wall. So, would it be a compulsion to make the picture crooked or an exposure??? It’d definitely still make me anxious to make a picture crooked on the wall, but really I just want to keep it straight & leave it alone. This is hell.
The average person without OCD would not spend nearly as much time and mental energy as you thinking about about whether a picture is hanging straight on the wall. In fact, they would likely not spend any time whatsoever thinking about it. And if you think that a picture hanging crooked (or straight) on a wall is “awful” or that you are “a horrible person” because a picture is crooked (or straight), then I posit that you would well-served by doing ERP. And since your primary discomfort in this case appears to be the possibility that the picture is crooked, I encourage you to make the picture crooked, and to live with the secondary discomfort about doing ERP incorrectly. Hang it crooked, and get on with your day. Pictures being crooked are not worth this much analysis (actually they’re not worth any analysis at all).
Okay, but what if I want to just leave it hanging straight? That’s a crime. I’m confused. You say there is no difference between a straight and crooked picture. How is this logical? There is a difference.
My fear is this:
Because my picture is straight, this means I’m mentally ill.
No, I did not say “there is no difference between a straight and crooked picture”.
What I said was “pictures being crooked are not worth this much analysis (actually they’re not worth any analysis at all)”.
Of course there is a difference between a picture being crooked or straight. But it is an unimportant difference. This is not peace in the middle east – this is a picture hanging on a wall. It is unimportant. In fact, I can’t think of too many things in this world that are less important than whether a picture is straight on the wall.
And no, a picture being straight does not mean you are mentally ill. A picture being straight means a picture is straight. Nothing more.
I’m having a situation where I’ve realized that not doing an exposure exercise, aka facing a fear, leads to me feeling terrible, even more anxious than actually doing ERP itself.
Sometimes, for whatever reason, I don’t carry out exposure (maybe logical, like having other responsibilities or priorities at that exact moment) and then I feel disappointed and like I didn’t perform well or achieve “perfection.”
My question is… Since I feel so terrible whenever I don’t attend to potential ERP opportunities, does that mean that maybe I should expose myself to THAT anxiety more and learn to desensitize myself from not being perfect and maybe doing things incorrectly (not facing the fear when maybe I should have)?
Again, both doing ERP and not doing it make me anxious, but not doing it wins in that regard.
Many people with OCD report that they get anxious about not doing ERP “correctly” or “perfectly” or “enough”. This is just another obsession. I encourage you to discuss this with a therapist who treats OCD with ERP. If you don’t have training and expertise in ERP, you are likely going to continue running into situations like this.
I am currently struggling with Harm OCD. This isn’t my first rodeo as OCD manifested itself this way before. Now I am having thoughts of hurting my room mate.
My therapist doesn’t seem to understand OCD but seeing someone else isn’t an option.
Getting treated for OCD by a therapist who “doesn’t seem to understand OCD” sounds to me like a complete waste of time. If you broke your arm, would you have it set by a doctor who doesn’t understand broken bones? Would you take a French class from a teacher who doesn’t understand French?
I encourage you to re-think your position that seeing another therapist is not an option.
My best friend is diagnosed with dermatilimania, separation anxiety and OCD. She has recently opened up to me about these feelings, things she’s never told anyone. I wanna help her with all of it without seeming like I’m trying to change her. She manly needs help with the picking that she’s been doing sence she was 7 I think it’s getting worse. Please help me
You are asking for help, but you are not the one who needs help – your friend is.
The best thing you can do is to steer her towards resources that can help her. You can start by referring her to the Dermatillomania page of our website at https://ocdla.com/compulsiveskinpicking/.
Any tips for erp for partner-focused ROCD on physical flaws? I started watching pictures of my boyfriend on his triggering body parts but it does not work. I’m a bit lost.
Moreover, (my obsessions on) his physical flaws prevent me from getting aroused which depresses me a lot. I keep having unwanted images (or it may be that I don’t like his body and never will…). Any advice? I feel so depressed
Thanks a lot
Yes , I have two tips.
1) Paying attention to your thoughts is not helping you.
2) Don’t try to manage your OCD on your own. Simply put, you are not trained in this, and you will be far better served by seeking the guidance of a therapist who specializes in treating OCD with Cognitive Behavioral Therapy (CBT).
Hi! My current OCD symptom has to do with stress and fear that the wi-fi radio waves will affect my thought. I face this symptom especially when I need concentration. I understand that this will not happen, it’s irrational, but I am not 100% sure. I cannot tolerate this uncertainty… My therapist consists on having the wi-fi device all day ON, without reassuring myself that it will not do me bad. Is this the right method? I am constantly wondering why not to turn the device off when I do not need it and be calm…My therapist says that it is a symptom and has to be treated…I would appreciate your scientific opinion. Thanks in advance and congratulations for the precious help you provide in your center.
You asked for my opinion, so here it is…
Your therapist is right. Turning off your wifi would be a compulsion that serves no purpose other than to provide you with a false sense of comfort. You say you cannot tolerate your uncertainty, and I disagree. It may be unpleasant, but you are stronger than you think. If you tolerate your uncertainty, you will be undermining OCD’s control over you.
In the past, I suffered from panic attacks and was diagnosed with panic disorder. I was treated and have been doing well for years. However, I now find myself absolutely obsessed with the concept of panic attacks— “What if I have one tomorrow” “If I have one, I’ll never recover”, watching videos about panic attacks, reading articles, etc. I recognize the signs of catastrophizing and obsessing. But have you ever heard of this? Can you have OCD about something as nebulous as panic attacks? I feel like a hopeless case!
Excessive worrying about the prospect of having a panic attack is an extremely common symptom of panic disorder.
Also, the line between various anxiety-based conditions can at times be gray.