The limitations of ERP treatment for OCD- (and what mindfulness training can offer)

Here are some thoughts on the treatment of OCD that I have developed over the past 10 years of exploring my mind through conventional and alternative/mindfulness based approaches to treating OCD.  I hope that some of these ideas may be of some benefit to the OCD community.  

None of what I write is to deny that exposure therapy can be effective or beneficial to people.  I am simply offering some observations from my own exploration.  In future posts, I hope to propose a mindfulness and compassion centered way of doing exposure therapy that I believe will be effective not only for treating OCD but for offering a sense of holistic healing as well.  

First, let’s look at what’s happening with OCD from the habit loop model of reward based learning as discussed by Brown addiction psychiatrist Judson Brewer.  

The habit loop contains a trigger, a behavior, and a reward.  When we are triggered, the mind wants to DO something!  That’s the behavior.  And, as I have discussed in previous blog posts, the reward lays down a memory and helps the brain remember the trigger and the behavior so that the brain can get more rewards in the future.  The rewards set up this process of repetition and it’s this feeling of craving or anxiety that keeps the process going.  More repetition leads to more anxiety/craving which leads to more behaviors and more rewards and more repetition of the habit loop.  

In OCD there is a triggering thought which produces anxiety in the body.  Then we do a behavior (including mental behaviors) meant to lower the anxiety (called a compulsion).  We then feel better in the short term which sends the message to our brain to remember this habit loop so that we can feel better in the future.  In the case of OCD, however, “feel better” only really means the temporary reduction of this craving/anxiety to do the compulsion.  We get a momentary relief from checking, but ultimately we feel worse because now we have more of these anxiety sensations that are meant to compel us to do the behavior again and get another reward. (even if the reward isn’t rewarding).  

Here are some observations from my own life and from my studies on these topics.  Let me know if you can relate or if you disagree with something!  

  • The cause of OCD is the mind’s resistance to being with unpleasant body sensations and emotions.  In order to get away from difficult sensations and emotions that are scary, the mind seeks distraction or obsessive thinking.  Both distraction and obsession actually offer temporary rewards in the moment.  We feel better.  With OCD we experience something in the body that is deemed too unpleasant to be with.   When we experience fear or anger or sadness or even pain the mind says “do something”.  This is where obsession comes in.  It offers temporary relief, but the thinking gets us caught in never ending obsessions precisely because it offers a reward of feeling a little better. This doesn’t necessarily mean that we feel good when we do a compulsion, but we have scratched an itch.  There is a seductive relief in giving in to this craving to act.  With OCD, we are not afraid of the triggering thought or the triggering event or object itself.  What we are really afraid of with OCD is the bodily and emotional outcome of the trigger which presents itself as unpleasant sensations in the body.  
  • The reason why the thoughts of OCD seem so scary and important is because of the incredibly uncomfortable sensations that we feel in the body.  We could have the same “intrusive thought” but if it’s not accompanied by an unpleasant feeling in the body, we are not going to worry about it so much.  
  • Once anxiety has been triggered, the mind could really care less what behavior is used to get the reward.  The only reason that the mind turns to the specific behaviors related to the trigger is that there is a history of doing these behaviors to get the reward(and the mind doesn’t like change).  However, I really believe that the mind is open to any reward.  Therefore, if we withhold the reward by exposure therapy with response prevention (ERP), then the mind will simply seek out other rewards to feel better.  In other words, if we prevent the OCD mind from acting out the specific compulsion (which it knows leads to a reliable reward), the mind will be happy enough to seek rewards from binge eating, or other distracting thoughts or anything else.  By doing this we are actually setting up new habit loops.  The key here is that the behavior actually isn’t what’s driving OCD.  The reward is driving OCD.  By doing an ERP we are simply preventing the mind from getting the reward it has linked to the trigger because it’s a reliable reward.  However, we are doing nothing to update the reward values of any of our actions and the mind will simply seek out other rewards.  
  • When we do ERP, we are intentionally bringing on the trigger and then the idea is to resist doing the specific compulsions related to the behavior.  Or more broadly, we resist doing something that’s intended to lower our anxiety.  However, it’s not like life stops after you intentionally create the trigger.   We are still doing something after we have done the exposure.  As I discuss above, our brains just want to feel better by getting a reward.  They are not particularly picky in how they go about getting the reward.  If the specific behavior targeted in the ERP is now unavailable, the mind will just replace that behavior with another behavior that our brain links to feeling better.  Exposure tries to decouple the anxiety from the specific behavior, but we may actually now be coupling the anxiety with distraction behaviors or new thinking behaviors. This is why OCD morphs in my opinion.  After we do an exposure, we are going to seek out external rewards and create new habit loops because the brain still wants a reward, whatever it may be.  It doesn’t care how it gets it. The reward lays down a memory to do the behavior again in the future.  
  • For example, if I have a “need to read”  and I look at the title of the book and am triggered with anxiety and the ERP is to not continue to read the book, maybe I don’t do the behavior but I go to starbucks to get a coffee and distract myself. In this case I am not using reading the book to lower my anxiety and get a reward, but I am using coffee to do the same thing.  Coffee becomes the new behavior in the habit loop that results in a reward and a memory.  Now whenever I’m anxious my brain will remember getting a coffee because that behavior has been linked to making me feel a little bit better.
  • Food and caffeine and alcohol, drugs, sex, compulsive internet searching etc. are obvious rewards that our minds can use as behaviors instead of the typical OCD compulsions.  This is because not only are they rewarding by making us feel better in the context of anxiety, but they have profound effects on the brain.  This is why I was addicted to sugar for most of my life.  What I was triggered with anxiety and the obsessive thoughts became less rewarding, I would simply turn to food to numb my pain and feel better.  I would get a massive, unnatural rush of sugar and  find myself in a new habit loop of feeling anxious (trigger), eating food (behavior), feeling better(reward) which was almost impossible to get out of.  This isn’t OCD exactly, but it’s the exact same structure of doing something to feel better when we are triggered.  If I resist doing my OCD habit loops, but I replace them with something like food, I don’t have OCD in the clinical sense, but I do have a miserable life.  The focus can’t be on simply avoiding doing the specific compsulions.  We must be open to the fact that the brain is seeking out rewards to feel better in any way possible, and whatever we do to feel better can easily create new (and potentially more dangerous in the case of drugs or alcohol) habit loops.
  • It’s not the specific thoughts or objects we are afraid of with OCD.  It’s really the body sensations.  One of the first ERP’s that I did was over a decade ago when I was terrified of being gay.  The obsessions were so strong that I had this core doubt over my sexuality.  I did tons of exposure and really pushed myself and attacked the OCD and made a lot of progress over many months.  After some time, my mind wasn’t worried because the body wasn’t giving it any signals of anxiety.  However, there was always this nagging feeling that the gay OCD could come back at any time.  What was really interesting was that anytime anxiety was triggered in ANY context, I would become worried that the gay OCD may return.  Precisely because I was feeling anxiety, the same thoughts that were less scary from doing all the exposures were now more scary.  I never felt like I was safe.  Doing the exposures helped a lot but never got to the underlying fear of the body sensations and never helped me develop an understanding of how my mind truly works.  
  • I learned over time that exposure doesn’t necessarily get to the root fear of the physical sensations themselves.  We can do hundreds or thousands of exposures like I did without actually turning towards the sensations in the body.  The root cause remains untouched so we will continue to just be afraid of any thought that produces scary body sensations in the future.  The OCD will continue to just morph and we will have to endlessly do exposures forever while never feeling quite like we are in control.
  • Furthermore, exposure teaches us to focus on the big scary terrifying obsessions but it completely avoids all of the subtle habit loops that perpetuate OCD and experiential avoidance in general.  If we do exposures for only the big scary obsessions but we are driven to numb the unpleasant sensations of anger or we can’t turn be with the craving to eat when we are no longer hungry, we are subtly perpetuating the core fear that drives OCD.  Namely the fear and avoidance of unpleasant body sensations and emotions.  It doesn’t matter if it’s anger or sadness or fear or pain.  If we are unable to be with these sensations then we will turn to our minds or other numbing behaviors.  We are creating a mind that resists with every little action of avoidance we take, so if we focus on big exposures yet do subtle avoidance of everything else in life, we are not making any progress.  In other words, a mind that craves feeling better in any sense will crave feeling better in every sense more and more.  If we focus on specific exposures while our mind craves doing mini compulsions in other aspects of life, we will not make progress. 
  • Focusing on one’s values and moving towards living one’s life accordingly is a very powerful tool for healing, but I believe that we must be careful it doesn’t turn into subtle avoidance.  I found that I could live my life and start facing some of my fears, but I was still terrified of certain thoughts.  Living my life was almost another way to avoid the sensations in the body.  We can learn that the body sensations are not safe and that we can just keep returning to our values as a way to avoid them and run from them.  OCD becomes that bad guy and the enemy that we always have to be on our toes to avoid.  We have to really live our values otherwise OCD will catch up to us.  
  • Here is a story from my own life that illustrates this point:  For about two years until fairly recently I suffered from severe panic.  The panic was unrelenting and nonstop.  I gained the courage over time to start living my life and doing more and more things with the panic, but I never felt any freedom whatsoever.  I was, however, able to function more than I could before.  I now realize that this was because it was more rewarding for my brain to do those functional societal behaviors than to actually face the panic which was incredibly unpleasant.  Social things that I was otherwise scared to do in the past were now easier because the alternative was a moment with my panic.  Living my life just became a way to avoid feeling the panic.  As I understand it, by living our life we are supposed to be doing bigger and more complex exposures which have been proven to be effective with the inhibitory learning theory.  This was not my experience.  After months of living in the world and taking all sorts of actions and exposing myself to all sorts of situations, I realized that what I was doing wasn’t working and the panic was actually getting worse.  
  • For me, healing was very hard and very difficult, but it only came when I started to slowly explore the sensations in my body and investigate them with mindfulness and compassion.  Over time I gained the courage to be with them for longer and longer periods and to see what thoughts were causing the sensations and how I reacted to the sensations.  It was only when I finally turned towards panic and fear and sat with it without trying to get rid of it that I realized I was ok.  This courage to turn towards let the panic unwind itself over time on its own schedule.  Now it comes less and less frequently.  
  • During the pandemic I was at home and terrified with the fear of getting sick.  I decided to trust mindfulness and compassion practices.  What I would do was whenever I felt the panic coming on I would go with it and use the RAIN practice that I teach on this blog.  I got curious about the panic and offered myself care.  At this point I had the courage to turn towards because some inspiring teachers and mentors had made me believe it was possible, and I had a better understanding of how the mind works and how we can ride out anxiety by turning towards it.  I understood that anxiety, panic, and OCD are like a fire.  First, we need to stop fueling the fire.  We stop feeding the mental rituals that add fuel to the fire.  The panic will still rage even after we stop fueling it.  Eventually, however, the fire and the panic and OCD will be less and less, but this lags behind us changing our behaviors just like a fire still burns after we remove the fuel.  In just 4 days of sitting with the panic whenever it came up, I made more progress with my panic than in the two previous years.  I went from being terrified every second to feeling some real freedom.  
  • The person with OCD needs to believe it’s safe to turn towards their OCD and body sensations.  If the therapist views OCD as this big, bad, monster that we need to not feed then they are going to project fear of the sensations of OCD onto the client.  Alternatively, if the therapist does not understand how the mind works, then they are not going to believe the client has the skills and ability to ride out OCD with mindfulness and compassion.  For example, OCD is an urge to do something, but it’s like a wave. It doesn’t last forever.  If we understand how our mind works we can ride that wave to shore.  If the therapist doesn’t trust or understand this process they will not give the client the courage to turn towards the OCD and ride out the wave.  They will think that the client isn’t able to do that or that it’s not possible.  If we believe OCD is just something we have that’s an unchangeable part of our brain chemistry then we will not trust our ability to ride out our habit loops.  OCD may be a big wave or a compilation of many waves, but it’s still a wave that arrives at the shore like all others.  
  • It’s important to remember that OCD is not trauma where it’s unwise to turn towards it.  Panic is also not uncontactable trauma.  What I found from my own experiences is that when I got messages from my therapists that viewed panic as this scary trauma that I could not turn towards or else I might be retriggered, that absolutely 100% changed how I related to the panic.  It made me believe it was unwise to turn towards it or I could make things worse.  Alternatively, when I came across the work of Dr. Jud Brewer, and the inspirational books and lectures of Mingyur Rimpoche who had himself suffered from panic as a young boy, and the work of psychiatrist Kelly Brogan, I found that they all offered a sense of safety and courage that it was possible for me to turn towards the OCD and ride out the waves.  It was only with this inspiration and courage that I felt fully resourced to feel the unpleasant sensations and not panic because I trusted that I would be ok.  Only then did the real healing start.  With this being said, however, it’s important to find a balance between resourcing and turning towards.  Between mindfulness and compassion.  Between investigating and safety.  This is something we all have to learn, but it’s something that I believe is possible for someone with OCD to come to understand for themselves with practice.  
  • With a mindfulness based approach we try to help our brains to see the lack of rewards in the old OCD behaviors compared to the nice, new rewards of curiosity and compassion.  We do this by making our brains aware of how the OCD behaviors and the mindfulness behaviors actually feel in our bodies.  Body sensations, not thinking, drive behavior change because they let us actually see from our own direct experience what we are really getting from any given behavior.  
  • One of the problems that I encountered with ERP therapy is that we are exposed to the trigger, but traditional ERP offers no tools for how to work with and contact the anxiety in the body after being triggered.  This leaves us open to experiential avoidance AND replacing old behaviors with new distraction or thinking behaviors.  
  • We can come to view mindfulness as its own exposure therapy.  In this way, the exposures are all about exposing ourselves to what we truly fear at the root of OCD, namely our emotions, unpleasant body sensations, and thoughts.  The response prevention part of mindfulness based ERP isn’t about not doing the compulsion or not distracting ourselves from the anxiety that’s coming up.  It’s really about getting curious and turning towards the unpleasant sensations inside of us.  When we do this we learn that the sensations actually are not as scary as we thought and they are not permanent.  The sensations actually change as we investigate them.  We can actually ride out the sensations by just turning towards them with loving awareness.  So not only do we not do the compulsion as is the goal in regular ERP, but we also are offering ourselves the rewards of curiosity and kindness that are more rewarding in the moment and over time.  
  • The OCD mind is not operating under some different criteria than the “normal” person’s mind.  It’s simply that the habit loops are stronger and more ingrained.  We can take solace, however, in the fact that the process is still the same.  It may take longer to untangle the habit loops, but the ability to do so remains unchanged.   
  • The way out of the anxiety habit loop isn’t to focus on the behavior.  The way out is actually to focus on the reward value since that’s what motivates our behavior.  Just doing exposures and not doing the compulsion is great, but it doesn’t get to the root of the reward value.  We need to see for ourselves what we are getting from the compulsion in our bodies so that we start to become disenchanted with the OCD behaviors.  Then we can search for something more rewarding like curiosity and kindness.  Reward value is all about how something feels in the body.  If we are not in touch with the body sensations we are going to have a skewed reward value.  
  •   
  • With RAIN we simply recognize that OCD has come, allow the thoughts to be there, notice the urge to do a compulsion and then go into the body to investigate the sensations themselves.  We get curious about what these thoughts actually feel like in the body.   With RAIN We learn to ride out the anxiety and we start to see that the thoughts are so scary only because the body sensations are scary. We start to see that curiosity and compassion actually feel better than doing a compulsion.  What’s fascinating is that often when we are investigating the anxiety we will have absolutely no idea what the thought was that caused us to get anxious and call upon the RAIN practice.
  • This shows us that the thoughts are completely irrelevant.  If they were so important then how could one forget them while investigating the fears in the body.  We start to see that we can get curious about what anxiety actually feels like.  This curiosity becomes rewarding because it’s a game.   As we get familiar with anxiety through investigation then we are not caught off guard when OCD thoughts come.  We go into the body and notice similar sensations to the ones we were exploring in the past.  We start to see a cycle.  An ebb and flow. We also see that these sensations are similar to other cravings. 
  • Every time we do a compulsion, the nature of the OCD habit loop means that 1) we get a reward of feeling slightly less bad AND 2) this reward creates a memory AND 3) The thinking compulsion doesn’t actually solve the situation so the anxiety trigger is still present AND 4) now our brain is more likely to send us more triggering thoughts which will lead to stronger anxiety sensations and more behaviors and more rewards and more and more thoughts as we feel worse and worse.  That’s the nature of the habit loop.  Only by understanding how the mind works can we see that just following our triggers with behaviors only leads to us feeling worse and worse and more and more stuck in OCD.  
  •  We can use the sensations of OCD that we are investigating and getting familiar with, not the thoughts themselves,  to tell us which behaviors are causing us suffering.  We learn which thoughts are causing us suffering because they come with the biggest charge to do something.  What we learn is that these thoughts may not fit the classic OCD mold.  In fact for me I have lots of what I call “need to say” and “need to eat” and “need to research” etc.  Only by working with these urges can we be with the urges of OCD. They are not different.  It’s the same craving mind. This is where exposure therapy misses the mark.  It doesn’t teach us to hone in on the craving in our life that’s perpetuating the OCD. 
  • The brain has a thinking mode and a being mode.  Anytime we feed the thinking mode mindlessly, we are going to get more ingrained into thinking mode.  Anytime we step out of thinking mode into being mode aka being with our sensory experience, then our minds will be more inclined to live in being mode.  Wherever we direct our awareness whether it be to thinking or being, that’s where our minds will tend to go in the future.  With OCD we are constantly directing our mind into thinking mode and creating endless suffering.  This is thinking created suffering that only exists in thinking mode and doesn’t exist in being mode.  The more we do compulsions the more we instruct our mind to stay in thinking mode.  
  • Are we mislabeling our emotions?  For so long what I thought was anxiety was actually anger or sadness.  I thought I was obsessing because of anxiety, but it was really anger or sadness that I did not know how to cope with.  I could not tell the difference between fear and anger.   If someone does something and I get really angry and I don’t know how to process the anger, then of course it’s reasonable I may go into my head to obsess.  There is nothing else to do with this strong feeling.  I never learned anger was ok.  So I would think something’s wrong and to do something I would go into my head.  It’s the same for sadness or any difficult emotion or sensation that we don’t want to feel.  
  • This is really important because I think it shows that OCD is really a response to the mind’s natural craving tendency to move away from the unpleasant and towards the pleasant.  The Buddha taught that this craving and attachment was at the root of suffering.  It’s the suffering that we add on top of the natural suffering and dis-ease that’s part of being human.  The Buddha taught that the human mind has a tendency to wander and get stuck craving for things and craving to be rid of things.  OCD is merely a response to not knowing how to deal with these cravings.  It’s an inability to tolerate the unpleasant sensations that come up through craving.  OCD is merely a coping strategy to the unpleasantness of craving.  Alcohol, drugs, sex, etc can all be different responses to the same unpleasantness from craving for or against something. 
  •  If the trigger for what eventually turns into OCD is actually anger or sadness, then exposure therapy makes no sense anymore for these emotions.  You don’t do an exposure for anger or sadness.  In order to process these emotions, you have to feel them and then act in a way that respects the particular emotion and message your body is sending you.   Anger and sadness require their own emotion specific responses.  
  • Awareness is how we update the reward values of different behaviors.  Awareness lets us see how rewarding a behavior actually is right now in the present moment and resets the reward value and moves better behaviors into automatic mode.  The problem with ERP is that it doesn’t replace the compulsive behavior with a better reward. 
  • Tonight I was triggered by something and then I felt a lot of anxiety.  My mind wanted to Do something!  What I consistently notice is that anything I do with a searching,clinging mind actually perpetuates the anxiety and grooves it into my mind.  When I feed this craving this is what turns into what feels like OCD.  For example, the mind’s endless need to go in circles and search for more information online.  These behaviors can have absolutely nothing to do with the initial trigger.  Any behavior that sends the mind into this craving, doing mode is actually a behavior that perpetuates the habit loop of anxiety.  The only way to step out of this never ending cycle of doing is to find a place where the mind can go into being mode.  Being mode includes internal rewards like compassion and mindful awareness liked I have discussed in this blog.  Interestingly thought, I believe it also includes doing what otherwise might be a distraction behavior but doing it mindfully.  This is really challenging though because there is much more of a chance for the mind to wander.  With this in mind, we can use the RAIN practice to step out of our habit loops and enter being mode.

In contrast to traditional exposure therapy, a mindfulness based exposure therapy actually makes mindfulness itself the new exposure.  The exposure is now actually exposing oneself to the thoughts and emotions and body sensations that are so scary.  

The benefit of this type of exposure is that with awareness we are able to see the unrewarding nature of our old OCD behaviors AND offer our brains an updated reward that actually feels better.  At the same time we are learning to be with the sensations of OCD as they live in the body.  We are learning that when we trigger these unpleasant feelings we can gain trust in offering ourselves internal rewards to ride out the OCD habit loops.  These new skills can then be applied to all aspects of life to live in a more fulfilling and rewarding way.  

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