Q&A with an OCD Expert
Updated: Aug 17, 2020
For the next few weeks, I'll be sharing one question and response from my interview with Jon Hershfield, the author of the Mindfulness Workbook for OCD and director of the OCD and Anxiety Center, Sheppard Pratt. This interview was audio recorded and then transcribed. Because this is now a text, some paraphrasing was done.
Interview: October 4, 2019 Transcribed: August 2, 2020
What is ERP and Mindfulness and how can the two be combined in treatment?
ERP ERP means Exposure and Response Prevention, and it’s part of behavioral therapy, which is under the umbrella of Cognitive Behavioral Therapy, the gold standard treatment for OCD. What it means is that you expose yourself, meaning that you put yourself in front of or the presence of something that is triggering for you. This could be a thought, an idea, an object, or even just an emotion. In that state, when you have OCD, you want to do compulsions. That's how OCD works. You have an obsession, it makes you uncomfortable, and you do compulsions. Then, you get stuck in this loop. So ERP is where you gradually introduce something to somebody so that they feel like they want to do compulsions to intentionally raise their discomfort level and then they practice resisting the compulsions. That's their response prevention.
Example For example, if you had a fear of causing a fire, you might expose yourself to gradually working your way up to using your kitchen stove and then you would engage in response prevention by not going back to double-check after you turn the stove off and sitting with that uncomfortable uncertainty that “maybe I didn’t really turn it off and maybe something bad will happen.” The goal of ERP is two-fold. One is that through the repetition of exposures, your general discomfort will go down. The other is that your brain will also learn that it doesn't need to flee the scene and make you upset about whatever discomfort is there. The goal is to tolerate the uncertainty, and even if it’s uncomfortable, that doesn't mean that you have to do your compulsions. What that really means is sort of staying in that space between the exposure and the response prevention as long as you can.
Mindfulness Mindfulness basically just means nonjudgmental awareness. It means paying attention to the present moment, exactly the way it is, not trying to change it, not judging it, not wishing it was different, just noticing okay this is what is. The way ERP and mindfulness sort of connect is that when you’re doing the ERP, you’re really practicing mindfulness in that you're putting yourself in a situation through the exposure that’s challenging for you and instead of pulling yourself out of compulsions like you normally would, you’re actually staying in that space and observing it: This is how it feels. These are the thoughts that come with it. These are the emotions that come with it. You're actually willing yourself to stay there instead of fleeing from it. Inversely, mindfulness is also very scary for people with OCD because it involves things like noticing your thoughts, letting go of them, and coming back to the present (even if your thoughts on paper look very, very scary). So there’s an exposure element to mindfulness as well, because it’s exposure to this fear of not being vigilant enough at addressing all of your thoughts and feelings the exact right way but, instead, just experiencing them and letting them come and go.