“On the surface, it looked like I was better,” Anne said, through her tears. “I was going out and doing things that I’d avoided for decades. But even then, my OCD was still calling the shots.”
Anne, my client, had completed what seemed like a successful course of exposure and response prevention (ERP) therapy for her OCD with another therapist roughly five years earlier. She’d graduated from therapy and had gone on to pursue a demanding career. But when she reached out to me, her symptoms were worse than ever.
Anne explained that during her initial course of therapy she’d come to believe that the goal of exposure was fear reduction.
“But my anxiety would often remain high unless I ritualized,” she explained. “So I started swapping out one ritual for another in order to make the exposures work.”
For a long time, Anne didn’t realize that the techniques she was using to reduce her anxiety were simply new rituals. For example, one of her fears was that if she sat in a chair someone else had just been in, she’d turn into that person or take on some of their essence. Under the guidance of her former therapist, Anne had practiced sitting in another person’s seat, including her mom’s desk chair, and it seemed like she was making great progress with remaining seated. But to combat her anxiety, Anne would silently repeat to herself, “Not Mom, not Mom, not Mom, not Mom” the entire time she was in her mom’s chair.
“So saying ‘not Mom’ made it seem less likely that you could turn into your mom?” I asked.
“Exactly!” she said. “But then I had to start doing more rituals when sitting in other people’s seats; or doing other exposures. My therapist never knew about these. He was just interested in my anxiety coming down and told me I couldn’t quit an exposure until my fear decreased by 50 percent.”
To outsiders, Anne’s first course of treatment appeared to work wonders. After decades of awkwardly standing during meetings and social gatherings to avoid turning into someone else, she was finally able to sit in other people’s chairs. But the reality was, rather than help Anne face her fears head-on by inquiring as to whether she was using any rituals while doing these exposures, her therapist had accepted her chair-sitting as success and left it at that. That omission allowed Anne to continue dodging her anxiety by using these new mental rituals.
“You, on the other hand, seem to want me to bathe in my discomfort!” Anne told me, after I described my approach to treating OCD.
“That’s true,” I said, laughing. “But not because I’m trying to be cruel. I want you to learn that you can tolerate being anxious, even if your anxiety stays high for a while. To really see that you can feel anxiety and not need to do anything to try to make it go away.”
Rethinking Habituation
Encouraging anxious clients to face their fears is widely accepted as the gold-standard approach for treating anxiety-related disorders, including OCD. But as Anne’s case illustrates, exposure therapy isn’t always as effective as we’d like. And that reality is often unacknowledged and at times obscured by outdated notions about what drives therapeutic change.
If you’ve been trained in treating clients with ERP, there’s a good chance you’ve learned that successful treatment hinges on habituation occurring (i.e., anxiety decreasing) during repeated, prolonged exposures to anxiety-provoking stimuli and contexts. And it can be very exciting to see this fear reduction process unfold when working with anxious clients. But a growing body of research suggests that our emphasis on habituation can undermine the real goal of exposure therapy.
In cases like Anne’s, when we prioritize habituation, it’s not uncommon for symptoms to stick around or resurface in the weeks, months, and years after therapy ends. The reason? When we aim for habituation, we inadvertently confirm clients’ mistaken beliefs that anxiety is a bad thing that needs to be eradicated. Sure, they might temporarily get relief, but often only because we’ve added another ritual—this time disguised in the form of an exposure—to their toolbox. In other words, when we conduct exposures with the purpose of decreasing anxiety, we inadvertently collude with OCD, and help it grow stronger in the long run.
Instead, when working with clients with OCD, we ought to emphasize that anxiety is a part of life, and that our job is to learn to live our lives to the fullest despite anxiety’s presence. With this in mind, we can pitch exposures as exercises in tolerating distress that will help strengthen clients’ muscles for responding to anxiety in a new, more adaptive manner. And we can be clear that although anxiety may sometimes decline on its own as result of repeated, prolonged exposures, this reduction in anxiety is not the goal of treatment.
Learning to Tolerate Distress
I’m not saying that habituation is necessarily a bad thing. It often happens during in-session exposures and it can be incredibly empowering for clients to experience this reduction in anxiety when they approach rather than avoid their fears. It’s also reinforcing for us, as therapists, to see our clients habituate to their fears. But I suggest that rather than celebrate when our clients experience habituation, we try instead to de-emphasize its significance while stressing the importance of distress tolerance, which, according to inhibitory learning theory, is the more critical ingredient of exposure therapy.
This reframe regarding the goal of exposure therapy is equally helpful when (as is often the case) habituation doesn’t unfold. As noted above, Anne’s anxiety often remained high throughout her exposures and we had many difficult conversations over the course of her treatment about this.
“This is so hard,” she’d say. “I just don’t want to have to feel this way anymore. I hate being so anxious all the time.”
“I get it,” I’d say. “Trust me, if I could wave a magic wand and make your anxiety go away now and forever, I would. But since I can’t, our best bet is to learn to live with anxiety when it shows up, rather than to try to chase it away and keep it from coming back. We’re rewiring your brain to respond differently to distress moving forward by going out of our way to bring on and feel this intense anxiety so that you don’t have to run whenever it surfaces down the road.”
In other words, I encouraged Anne to see painful emotions—particularly anxiety—as adaptive experiences that need not be fought. After all, we all have unwanted emotions at times. The key to navigating them is not to figure out how to make the feelings go away in the moment, but rather to feel them without letting them derail us. With this in mind, the goal for treatment then becomes helping clients build their muscles for tolerating these emotions, rather than making these emotions disappear.
Although perhaps counterintuitive at first, when we practitioners prioritize distress tolerance in this way, we reframe our own views of anxiety. Instead of seeing our clients’ distress as problematic, we welcome it when it surfaces and praise our clients for persisting with exposures and not ritualizing their anxiety away.
With this framework, we can also confidently prompt our clients to stretch themselves by increasing the difficulty of their in-session exposures, rather than aim for habituation. And when our clients tell us that they want to stop a challenging exposure, we can acknowledge their struggle and confidently tell them that we know they can stick with it.
What’s more, when we do this, we have a chance to learn to tolerate the discomfort that we ourselves can feel when our clients are distressed, thus growing right alongside them.
Getting Client Buy-In
At first glance, this might seem like a hard sell to clients. But I’ve found that an honest and compelling rationale is usually all it takes to get them on board. Here’s how I pitched this approach to Jason, who feared that he might be a pedophile.
“Rationally, I know that I’m not really attracted to kids and that I would never harm a child,” he told me. “And sometimes when I remind myself of that, and it helps for a little while, but never for long. I just can’t let go of this doubt and the anxiety and need to know that comes with it.”
“Ah, well you just hit the nail on the head.” I replied. “Of course, you’d want to reassure yourself that you aren’t a pedophile given how scary this thought is for you.” Then I told him directly how his attempts to minimize distress could end up as new rituals, setting him back in the long run.
“Yeah,” he said. “The rituals don’t seem to help that much anymore. But I don’t know what else to do. I truly can’t imagine anything worse than being a pedophile.”
“For sure,” I replied. “It would be pretty terrible if it turned out that you actually were a pedophile. And yet, we have no way of knowing for sure that you aren’t, right? There aren’t any blood tests – at least not that I know of – to tell us whether you are or aren’t a pedophile.”
Jason laughed and said, “If only there were, that would make this so much easier.”
“Yes,” I replied. “But since there aren’t, the only real path forward is to accept this uncertainty and to carry on despite it. Think about it, acknowledging that you could be a pedophile, as we are going to do in our exposures, is very different from actually being a pedophile who molests kids.”
Jason looked skeptical. He said, “I’ve got to be honest, I don’t think I could bear the anxiety that I would feel if I were to tell myself that I could be a pedophile.”
I acknowledged that his skepticism made sense given that accepting the possibility of being a pedophile would of course stir up intense anxiety. I reminded him that coping with the anxiety was the goal of exposure work.
“I know,” Jason said, sighing. “I know it’s what I need to do. It’s just hard to wrap my head around.”
“Of course, it is, yes,” I told him. Then I told him about how the more he practiced sitting with this distress, the stronger his muscles for doing so would become, until he realized that he didn’t need to give into his urges to ritualize anymore. Instead, like a marathon runner who keeps running despite feeling exhausted and wanting to quit, he’d learn that he could feel his anxiety in full, including the uncertainty that comes with it, without needing to neutralize it in any way.
Although Jason remained somewhat skeptical for a few more sessions, this brief conversation was enough to get the ball rolling so that we could begin our exposure work together and watch this corrective learning slowly but surely begin to unfold.
Staying the Course
One of the most effective strategies for maximizing new learning is to have clients acknowledge the possibility of their feared outcomes. This “leaning in” process makes it harder for mental rituals to hijack exposures and gives clients practice sitting with and tolerating anxiety-provoking thoughts.
During one of our sessions, Anne sat in her mom’s chair while saying out loud, “because I’m sitting in my mom’s chair, I could turn into my mom,” again and again, for roughly 30 minutes. Boring as this may seem, the prolonged repetition was incredibly useful for Anne as it made it harder for mental rituals to sneak in, and helped Anne accept that her feared outcome could—not necessarily would—happen.
Another useful strategy for increasing distress tolerance is to simply remind clients that our goal isn’t to eliminate their discomfort, since fear is necessary for growing courage. Viewed in this light, clients are often able to see the value in their distress, which can, in turn, enable them to begin developing a new relationship with it.
It’s worth mentioning here that it’s not uncommon for clients to leave my office feeling intensely anxious after our sessions. Indeed, Anne often said goodbye to me while in tears and shaking. Obviously, this was not easy for me, as I cared deeply for Anne and only wanted to help her. Reminding myself of why we were doing this work was critical and helped me hold space for her distress.
In fact, over the years, I’ve come to think of my confidence in exposure as the wind in my client’s sails. If I’m shaky in my convictions about whether my clients can tolerate distress, they likely aren’t going to get anywhere. However, if I can exude nothing but confidence in their ability to handle even the hardest exposures, it’s almost as if there’s nothing they can’t do.
Living with Anxiety
Thankfully, although her distress was not easy for Anne to sit with, after years of trying to avoid and minimize her anxiety, she was willing to give this new, counterintuitive approach of living with her anxiety a try.
Given that Anne’s OCD often morphed and changed throughout her treatment (as is typical for OCD), we spent a number of weeks targeting each of her many obsessions by doing exposures designed to trigger these obsessions and thus make her feel anxious. These obsessions included not only fears of emotional contamination, but also fears of harming herself and others, as well as “just right” concerns. Although what we targeted varied from week to week, our welcoming approach to distress remained consistent.
Whether sitting in her mom’s chair, chopping vegetables with knives, or doing things the “wrong” way at work, Anne’s job was to intentionally bring on her anxiety as often as possible without doing anything to make it go away. And when her anxiety would begin to decline on its own during an exposure, she’d up the ante by making the exposure harder in some way, when possible. In fact, I instructed Anne to see each moment of anxiety as a critical choice point. She could either give in to her urges to ritualize or avoid and fuel her OCD, or she could lean into her discomfort with exposure statements aimed to increase (or at least maintain) her anxiety and strengthen her muscles for tolerating distress.
A New Kind of Freedom
As you might guess, Anne’s treatment was anything but easy, and included many great gains followed by steep and disappointing backslides. On some days, coming to session and doing exposures was the last thing that Anne wanted to do. And at times, accepting that her feared outcomes could happen seemed too overwhelming to bear.
Thankfully, Anne’s determination to overcome her OCD was strong enough to carry her through just about all of those toughest of days. With time, she learned that she could tolerate whatever OCD threw her way, and eventually anxiety played less of a role in her life, becoming like the background noise of a fan blowing in the distance. She’s very much aware that her OCD will never be gone for good, and she also knows that she now has the tools to effectively respond to it, regardless of when or how it shows up in her life.
Photo © iStock/Ponomariova_Maria
