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.