Although exposure therapy works for reducing the symptoms of OCD, many people decline exposure therapy out of fear and misunderstanding. However, if you break down OCD exposure therapy step-by-step, you will discover that it is simply a tool for unlearning unhealthy associations and is a process that you are in complete control of.
- Before conducting exposure therapy, the first step is to build what is referred to as an "exposure hierarchy." This means ordering the things you are afraid of from least distressing to most distressing. For example, while touching a door handle without washing your hands may low on your list, touching a toilet seat and then touching your face might be the highest item on your list. The exposure hierarchy helps guide your progression through the exposure exercises. Your therapist will usually help you construct your hierarchy.
- Once you have constructed your hierarchy, the next step is to select your starting point. It is usually best to begin exposure therapy with items/activities on your hierarchy that are distressing enough to cause anxiety, but easy enough for you to complete successfully until you gain more confidence. Your therapist will work with you to select your starting point.
- After having selected your starting point, you and your therapist might first complete a thought record. A thought record is a tool for identifying the trigger of your anxiety, the automatic thoughts generated by the exposure, and the cognitive distortions that may be shaping your thinking/emotions. Most importantly, thought records are a tool for generating rational alternatives to distorted "OCD thinking." Completing a thought record prior to undertaking an exposure can be very helpful for coping with the anxiety experienced during the exposure.
- Once the thought record has been completed, you will then complete the exposure exercise. This step does not have to be complicated, but needs to be carried out correctly. For example, if the starting point on your hierarchy was touching the rim of a contaminated garbage can, you and your therapist would simply find a garbage can that you believed to be contaminated and you would touch it. If you and your therapist have selected your starting point correctly, your anxiety should be fairly high leading up to and immediately after touching the garbage can.
- Your therapist might use a scale called the Subjective Units of Distress, or SUDS, scale to rate your anxiety that ranges from 0 (completely relaxed) to 100 (the worst anxiety you can imagine feeling). Good exposures generate anxiety in the 60 to 100 range.
- After touching the garbage can, you would be asked to not engage in your usual compulsions or rituals, such as hand washing. This will require you tolerating your anxiety being higher than usual, for longer than usual. However, by not engaging in your usual rituals you are teaching yourself that you can cope with distress and that you do not need rituals to keep yourself safe. This is the essential lesson of exposure therapy.
- As a general rule of thumb, your anxiety should be reduced by 50% before stopping an exposure. For instance, if you started the exposure with a SUDS rating of 100, it would be important to wait until your SUDS rating had fallen to at least 50. For this reason, your therapist will likely ask you your SUDS rating throughout the exposure. Sometimes this process of habituation can take 45 minutes to an hour (or even longer).
- This process is repeated in weekly sessions until you no longer experience anxiety when exposed to a particular item on your hierarchy. Once you have mastered an item on your hierarchy, you move on to a more difficult item. You continue this process until you have met your goals.
- In between therapy sessions, you will be expected to do homework assignments where you undertake exposures at home and at work. Family members can help you with these exposures.
A final note: Exposure exercises should always be voluntarily. While your therapist should certainly push you out of your comfort zone, you should never be pushed out of your safety zone.