By Paul R. Munford, Ph.D., Cognitive Behavior Therapy Center for OCD and Anxiety
People with checking compulsions share an exaggerated fear of uncertainty that makes them doubt their abilities to perform ordinary tasks of daily living correctly or avoid making social blunders. Being unsure of themselves, they’re constantly beset by thoughts and feelings of being irresponsible, careless, and seriously messing up that cause disasters that incite blame and scorn from others. Ironically, their negative self-assessments are actually directly opposite of their true character.
People with checking compulsions can be overly conscientious and careful and therefore no more prone to making mistakes and having accidents than people without OCD. Nevertheless, their obsessions dog them with thoughts and images of being criticized and condemned if they don’t perform excessive, repetitive mental and physical actions — compulsions — to prevent imagined mistakes and accidents. Try as they might, they never feel that they get it right. Yet they persist in their pursuit of perfection despite the frustration from never achieving it.
This article describes a treatment that works: a form of behavior therapy that I call exposure, ritual prevention, and awareness (ERPA). It essentially requires sufferers to face their fears while refraining from doing rituals, and instead notice the emotional and physical distress that follows. This is absolutely necessary for recovery because doing so causes habituation. That is, the fear and anxiety triggered by the obsessions will naturally diminish if there are repeated and prolonged exposures to the triggers for the obsessions. The fear cannot persist unless it’s reinforced by the occurrence of actual physical or emotional injury. The fear and anxiety threatened by obsessions are always unrealistic or highly improbable and therefore cannot inflict actual emotional or physical injury. Thus they wither and disappear. I’ll describe the treatment experience of an actual person to show you how this works.
Brad’s Fear of Making Mistakes
Brad’s severe obsessive-compulsive disorder caused him to worry about the correctness of just about everything he did. He had obsessions that he was inherently irresponsible and careless, and being so, would cause harm to himself or others. In reality, Brad was exactly the opposite of the kind of person he feared that he was. He was very careful, and never lost anything nor had accidents. In fact he was overly responsible. Before his OCD had taken its toll, he had been a first-rate attorney in a major law firm where he worked 50 plus hours per week. When he wasn’t in the grip of obsessions, Brad realized that his fears were irrational. However, when he was caught up in them, the anxiety from mental images of catastrophic disasters made them seem real.
Brad had a history of occasional, mild OCD symptoms from his teenage years. However, it wasn’t until his late twenties that the obsessions and compulsions intensified and eventually reached a level that disabled him. His self-esteem, much of it based on his professional success, took a major hit when he finally had to go on disability leave. This harsh change in circumstances worsened his, by now, depressed mood.
The extent to which OCD impacted Brad’s life will be evident by recounting but a few of the many compulsive rituals he practiced daily. For instance, after taking his morning medications, he would align the pill bottles in a special arrangement and then proceed to visually examine the arrangement to ensure he was taking the right pill at the right time. Then he would scrutinize them for as long as three or four minutes to be sure that he had returned them to their proper place, in a perfect row. Essentially his every act of daily living was accompanied by similar ritualistic checking and rechecking. For example, after putting out a cigarette, he would lower his face to within three or four inches of the ashtray and stare at the crushed butt for as long as twenty to thirty seconds to be sure it was really extinguished. Occasionally he would be flooded with images of the cigarette bursting in flame and causing a horrible fire. He then redoubled his checking behavior. Another example was great difficulty in discarding trash. He found it almost impossible to throw out empty containers, food wrappers, or even banana peels for fear that he might accidentally be discarding something important or valuable. He would check the items for four to five minutes, and still being unable to dispose of them, he would put them on the kitchen counter until he could try again later.
As you can see Brad’s OCD was at the severe level in terms of the high anxiety and frequency of the obsessions of compulsions. What follows, is a description of his treatment by means of exposure, ritual prevention and awareness exercises.
Exposure, Ritual Prevention, and Awareness Exercises
It is important to understand how the exposure, ritual prevention, and awareness (ERPA) exercises are related to the way the symptoms work. So let’s review the series of events that takes place during a cycle of OCD symptoms, commonly called an OCD spike. First, there’s a trigger, something that is noticed in the physical or mental world or both. Second, it instantly activates an obsession — thoughts, feelings or impulses that are distressful. Almost simultaneously, fear, guilt, apprehension, dread, anger or any number and combination of distressing emotions are provoked. These three events: exposure to a trigger, activation of an obsession, and feelings of distress are sensed as happening together, as a single event. Therefore, the terms, trigger, obsession, and distress are used interchangeably to refer to this seemingly single event, the OCD spike. The natural reaction is to turn it off as quickly as possible. Finally, by trial and error, people find out that by repeating certain actions and/or mental gyrations that they get temporary relief, but only until the next inevitable cycle of obsessions and compulsions.
ERPA exercises address each of these events. First, a trigger for a particular obsession-compulsion combination is selected and then exposure to this trigger is practiced. During the exposure, the next step is to refrain from rituals and instead practice acceptance of the distress. When this is successfully done, the distress fades. The anxiety-producing obsession being neutral is therefore insignificant, making it intrusive and repetitive no more, which negates the need to do compulsions. The exercises have changed the brain, which in turn changes behaviors and emotions. Desensitization has occurred. The exposure exercise is the clinically proven treatment that delivers this outcome.
By practicing the exercises at least one to two hours per day including weekends and holidays, good progress can be made. When this schedule is adhered to, most people desensitize themselves to the particular trigger they’re working on within five to seven days. This success gives them a big dose of confidence that they can control their anxiety, and increases their motivation to pursue and eradicate it. They now truly believe they can become scared fearless.
To put together an exposure exercise, the steps are to:
- Select a trigger, an obsession-compulsion combination for elimination
- Practice exposure: bringing on the obsession in reality and in imagination
- Practice ritual prevention: refraining from doing compulsions and fear blocking behaviors
- Practice acceptance: fully experiencing the triggered thoughts, images, impulses, and feelings they set off
I’ll explain each of the above activities and illustrate them with examples from Brad’s treatment.
Selecting the First Trigger for ERPA Exercises
Of the many obsessions and rituals that Brad endured daily, he chose to tackle as his first ERPA exercise, “picking up scraps of paper on my daily walk.” I selected this one because it triggered mild levels of fear and would be the easiest to confront. Remember that he worried about accidentally throwing away things of value, because it could mean that he was basically careless. To prevent this, he would compulsively check just about every item that came to his attention before discarding it, and after discarding it, retrieve it and check it again, to be sure it belonged in the trash. One of the most frequent triggers for checking was seeing scraps of paper he came across on his daily two-mile walk. The sight of them — crumpled up tissues, food wrappers, bits of newspaper, and the usual urban litter — triggered fear that they were one of the many reminder notes he habitually scribbled and had unknowingly dropped on his previous day’s walk. This obsession occurred, despite his precautionary compulsions of visually inspecting his hands and arms before leaving the house to be sure that no notes were unknowingly stuck to them. And since that was not enough, he flapped his arms with his fingers widespread to shake off any notes that might have escaped the visual scrutiny. When he was not engulfed in an obsession, he knew these rituals were ridiculous as well as the fear they were intended to prevent. But when he was looking at a scrap of paper demanding to be checked, the fear took charge; so much so that he was starting to skip his daily exercise because fatigue from the checking was increasing.
Practicing Exposure in Reality
Exposure requires having people deliberately face the situations in their physical and social worlds and in their imagination that trigger obsessions. The exposures should be prolonged and repeated until the provoked fear is eliminated. Brad’s first exposure exercise was to do the opposite of checking the paper scraps and instead deliberately look at, but not touch, scraps of paper during his daily walk. He was to not engage in avoidance behaviors of trying to ignore them. Instead, he was to search for the scraps and when he spotted one, pause, look at it on the ground, and pay attention to the disturbing thoughts it triggered; “Is this a note I dropped yesterday, or the day before?” If it was, he feared it was evidence of his basic careless nature. So he needed to check it. He hoped it was just a scrap of paper. But by not checking, he knew he would never know and would continue to doubt his own trustworthiness. He had urges to challenge these thoughts by coming up with reasons why they were untrue, but he didn’t. Instead he deliberately focused on the scraps and didn’t check. He said instead to himself,” This is probably a note I dropped yesterday, or maybe the day before, and it shows how careless I am. Will I ever get over this or is it the way I really am?” He went on and on in this way, dwelling on these fearful ideas, and refraining from taking the edge off his distress with rationalizations or mental maneuverings of any kind. Instead, he paid attention to the distress and was rewarded by its gradual decline and disappearance as he persevered with the exposure. Brad also kept a record of the number of checks he did perform.
Practicing Ritual Prevention of Behavioral Compulsions
For three days before starting the exercise, Brad counted the number of scraps he picked up; the average was three per day. So his first assignment was to pick up no more than ten per day. When he was able to do this, further gradual reductions were to occur until he reached the goal of picking up no scraps per day. When this was achieved, litter would no longer trigger the obsession that he dropped something, thereby eliminating the urge to check, and awakening his awareness that he was no more careless than the typical person.
On the first day, he picked up eleven, one more than he was supposed to. However, for the next ten days he succeeded in keeping the number at ten or less. In the beginning, he noticed mild to moderate tension and then its decline as he continued working. The second assignment was to limit checking to nine or fewer scraps per day. This time he was successful for ten days and was able to avoid any checking during the last two days. He said that his tension and urges to check had dropped remarkably. The next step was to reduce the checking to five or less items per day. He did better than that; he was checking free for all but three days and on those days, he only checked once. There was a spike on the 21st day when he checked five times. This was due to a serious quarrel with his father with whom there was an extensive history of conflict that Brad attributed to his father’s excessive criticism that bordered on humiliation. Most likely the surge in checking was from the stress of this argument. It’s common that stress from any source intensifies obsessions and compulsions.
Practicing Exposure in Imagination
For the first time in years, Brad had controlled his compulsive checking, and found it easier than he had expected. This initial achievement physically energized him and boosted his mood. He was convinced that he could overcome the rest of the symptoms, which he did. Brad was basically a conscientious and responsible man — characteristics commonly found in people with checking compulsions — who used these traits in facing his fears. Notice that he did the exposure exercises daily, including weekends. Even though he clearly demonstrated himself to be forthright, trustworthy and careful, he had doubts about these qualities and continued to worry that he was the opposite: careless and irresponsible. These catastrophic obsessions went so far as his envisioning himself abandoned and alone at near end of his life. These ideas were not with him all the time, but would flare up during bouts with obsessions, and activated compulsions. To tackle these imaginary fears, we used audiotape exposure exercises.
We wrote the following scenario, and recorded it on an endless loop audiotape that automatically replayed the scenario over and over simply by turning the tape recorder on.
You have been grappling with OCD for years and its getting worse. You worry about everything you do for fear that it will go wrong. No matter how hard you try, it seems that you’ve always missed something. It takes you forever to do even the simplest thing because you have to keep checking it. If you don’t, you know it won’t be right. Maybe it’s more than OCD. Maybe this is just the way you are. Your father might be right, you can’t do anything right. Even when you do well, you figure it should have been done better. You never can satisfy yourself with anything that you do. So maybe you should face it and listen to the nagging doubts that you’ve had. That you just can’t get it together. That what’s holding you back is more than OCD. It’s the way you really are and always will be, some kind of a flake.
Brad listened to the tape every day for as long as 90 minutes at a time, and after about two weeks, he reported little or no anxiety from it. During the day, the thoughts of being irresponsible and careless were becoming less frequent and when they occurred they were without feeling. Losing their impact, he was beginning to regard them as unreasonable and began to wonder why they ever bothered him in the first-place. Additional tapes were made about his fear of being shunned and abandoned, and they produced the same good result as the first one. By these means, he freed himself of what had been catastrophic expectations. This is a common example of how changing behavior by contacting feared situations rather than avoiding them eliminates fear and anxiety and permits rational thought processes to replace irrational ones.
Practicing Ritual Prevention of Mental Compulsions
Brad’s ritual prevention started by having him refrain from doing the behavioral compulsions of inspecting his hands and arms, and flapping his hands before the start of his daily walk. During it he was to refrain from picking up paper, or litter of any kind. On learning that he did mental compulsions, he was instructed to refrain from them as well. He was to stop trying to convince himself that he couldn’t have possibly dropped any notes, and if so he would be able to recall whatever he had written anyway. He also reasoned that if he did, it wouldn’t really make any difference because he would be able to recall whatever he had written anyway. Finally, Brad called his mother daily, often more than once, to get her reassurance that various activities, even insignificant tasks, had been done correctly. When he fretted over a perceived mistake or shortcoming, he would go over it in great detail to get her assurance that nothing really went wrong. Over the course of treatment, this was a compulsion that Brad had the most trouble giving up. He did agree, however, not to discuss this first exposure exercise with her at all. His progress with reassurance seeking was slow because of his difficulty resisting it and his mother’s difficulty withholding it. It seems only natural to offer sympathy and support to people in pain. But with regard to OCD, reassuring them that they are safe from irrational fears only prolongs their suffering because it blocks exposure.
While facing the fear, the task is to pay attention to the uncomfortable thoughts, and emotional and physical sensations while dwelling on the scary thoughts and images, and accept them as being possible, and imagine the dreaded future events happening. Concentrate on the prospect of living in a world of uncertainty, of never knowing if and when something bad is going to happen, of never getting over the anxious condition.
During his first ERPA exercise, Brad had mild to moderate anxiety, some muscle tension, and felt slightly warm. He was definitely feeling uncomfortable but it was tolerable. Knowing that he had only ten permissible options to check during his two-mile walk, he used them sparingly, giving in only to the strongest impulses. When he practiced ritual prevention, the anxiety grew, stimulating thoughts that he was careless on the previous day for dropping the notes, and was being irresponsible now for not checking. He recognized these thoughts as the irrational symptoms of OCD and began focusing on them and the feelings they cause instead of fighting them. As he did so, and as time passed, their impact weakened, making it easier for him to continue holding these irrational thoughts and emotions in his awareness. Near the end of the walk, he found he wasn’t so concerned about using up his checking options because the threat from the litter was becoming less real as were his concerns about being careless. He noticed that his distress was definitely decreasing. This recovery trend continued each day and he moved smoothly through all the steps of progressively eliminating the number of scraps checked per day and essentially put a stop to it in three weeks.
The benefits derived from this initial exercise spread to his other obsessions and compulsions, reducing their strength and making them more readily responsive to ERPA. Brad was ultimately able to reduce his symptoms to a level that permitted him to function normally, and return to work at his law firm; and as he continued to practice ERPA he benefited from further symptom reduction.
For more information on this topic you are referred to the book from which this article was abstracted with permission by New Harbinger Publications, Inc., Overcoming Compulsive Checking: Free Your Mind from OCD, by Paul R. Munford, Ph.D. Dr. Munford is a clinical psychologist and director of the Cognitive Behavior Therapy Center for OCD and Anxiety. He is also the author of Overcoming Compulsive Checking: Free Your Mind from OCD, New Harbinger Publications.