Written by Dr Ben Sedley
Ahead of our ACT for teens with OCD workshop, Dr Ben Sedley has written us a short piece about how exposure and response prevention (ERP) can work alongside acceptance and commitment therapy (ACT) to enhance outcomes for clients with OCD.
The brave but cautious knight came to a fork in the road. One path led her east, the other path west. Facing the knight was a stone with directions engraved on it. “To the east,” the stone said, “is a life filled with adventure, creativity, fun, family, friends, and learning”. The knight read this and nodded with excitement; those are all things she wants in her life. But the stone’s inscription continued, “to the west is a life with filled with certainty”. Again, the knight nodded. This was also a life that she craved. Each day she would spend hours checking that she has got all the details correct, reviewing all she’d done that day to make sure that she hadn’t said or done anything that might cause offence or harm someone. She’d reassure herself that she was doing the right things. She would ask reassurance from her loved ones so she could be more certain that she had not done anything wrong, she would hate to feel like there was a chance that she might be responsible for anything that could even possibly cause hard. She sometimes even retraced her steps to make sure that she had not hit anything along her path.
The problem was that the knight valued being brave and moving towards the life she wanted. But at the same time, she also felt a strong need to be completely and utterly certain at all times, 99% certain wasn’t enough because the cost of it not being ok felt like too high a price to pay.
So, she pushed herself to take a step east by doing something she cares about.
Then she took a step west by checking that she hadn’t hurt anyone while taking her previous step.
Then she bullied herself to take another step east by helping a friend.
Then another step west by reviewing all she’d done in her mind to make sure it was all ok.
Then reluctantly took another step east by doing something fun.
Then another step west by giving herself reassurance that what she had done was safe.
Then another step east…
Then another step west…
And at the end of the day, she was exhausted but still in the same spot. Still trying to move east and west at the same time.
As a clinical psychologist who works with OCD, I frequently meet teens who find themselves in a similar situation to this brave but cautious knight. They know that the treatment plan involves exposure and response prevention (ERP) so they tentatively push themselves to take a step in that direction, whilst still trying to also move in the opposite direction by doing compulsions that no one else can observe. Compulsions such as self-reassurance, history checking, bargaining with their OCD (e.g I’ll do this now and then later I can do some more checking) and more. At the end of this ERP, they are exhausted because they have pushed themselves really hard but still feel no closer to beating their OCD.
That’s why it is important to do ERP with curiosity and precision. You can do this by noticing that you’re having thoughts (defusion) and worries (acceptance), notice where you are right now (present moment) and that you’re more than your OCD (self as context), and choose to take wholehearted steps without any observable or non-observable compulsions (committed action) towards the life that really matters to you (values).