For many people, managing OCD over the long haul means learning to bounce back from relapses. In terms of OCD, a relapse means a significant increase in intrusive thoughts and compulsions following a period of relatively mild symptoms. If you’ve been through this cycle of symptoms, you know it can be frustrating and demoralizing. At the same time, building resilience is not about having a perfect, symptom free experience for the rest of your life but instead learning from your experiences and taking steps to get back to recovery.
The five steps below will guide you through the process of regaining your progress with ERP for OCD (exposure and response prevention).
Step 1: Practice self-compassion.
It doesn’t help to beat yourself up. You are probably your own worst critic, saying mean things to yourself about how you ended up in this place after having made progress in the past. Maybe you think being cruel will help to motivate you to get back on track with ERP. In my experience, making people feel terrible about themselves does not inspire motivation for change. In fact, it tends to have the opposite effect, increasing feelings of hopelessness and decreasing inspiration to do hard things.
Try instead to treat yourself with kindness. Imagine what you would say to a friend experiencing a relapse. You would not tell someone you care about that they are weak, lazy, or unacceptable. Instead, you might tell a friend that no one is perfect and that it’s normal for symptoms to ebb and flow. You might remind your friend that they’ve done hard things before (including ERP, among many others!). You might identify their personal strengths and other resources they have working for them. When talking to a friend you might also remind them of reasons to be hopeful about their symptoms getting better. Practice saying those things to yourself.
Step 2: Understand what happened.
First, think back on what led up to your relapse and try to identify any stressors. We don’t want to encourage rumination about what exactly happened or a need to figure it out perfectly. However, a brief period of self-reflection might be helpful in recognizing early warning signs of relapse in the future.
For example, were there stressors that happened before you noticed that your symptoms started to worsen? These could be directly related to your OCD themes but often they’re not. Stress in relationships, at work, a move, world affairs, sickness, feeling socially isolated, not sleeping well, and not feeling well physically are all common stressors that can make people vulnerable to OCD’s tricks. Stress tends to make intrusive thoughts stickier. Stress also tends to deplete resources that help us disengage from urges to do compulsions. Even if stressors don’t seem related to your OCD, they may be relevant.
Next, think about early warning signs. In hindsight, were there any early warning signs that OCD was getting worse? Sometimes people notice that they are more likely to slip up with certain compulsions, like reassurance seeking, googling, or an extra handwash. Knowing where OCD is most likely to get its foot in the door before barging in can help alert you to times you may need to make response prevention more of a priority. These little slip ups or a “one time won’t hurt” kind of thinking can quickly spiral into more and more compulsions.
Step 3: Identify your current compulsions.
As a first action step toward getting back to recovery, work first on decreasing compulsions with response prevention. Compulsions are the engine that drives OCD. When you cut back on compulsions, you stop giving gas to the engine.
Sit down and make a list of the current compulsions you’re engaging in. Review previous therapy notes, response prevention guidelines, or other plans you have from work in therapy. Ask yourself what behaviors, physical and mental, you find yourself getting stuck in when you’re feeling anxious. Be sure to consider both physical compulsions and mental compulsions, like ruminating, mental review, comparing, rationalizing, or figuring it out.
Once you have a list, write down guidelines that will start to help you reduce these compulsions. Think of these as guardrails that will help you limit or eliminate your compulsions. Some examples of response prevention guidelines are below.
- Handwash only after using the bathroom and before cooking.
- Limit googling about health conditions to 5 minutes per day.
- Do not ask family or friends for reassurance about safety.
- Resist urges to body scan for physical symptoms.
- Check locks and the stove only once before bed.
Step 4: Develop your exposures.
Now that you’ve addressed the RP portion of ERP, think about the E (exposures). There are a few questions you can ask yourself to generate exposures.
- How has your world become smaller since your relapse? Are there things that you were doing before that have become too difficult? Write those things down.
- Are you avoiding people, places, or situations because of your OCD? If you were avoiding avoidance, what would you be doing with your time? Write those things down.
- Are your daily behaviors in alignment with your values? Are you doing more of something (time on social media) or less of something (spending time with other people) because of your OCD? Write those things down.
- What are your current triggers? Triggers can easily be turned into exposure opportunities. The major difference between a trigger and an exposure is not the thing itself but how you respond to it. A show might be a trigger if you do compulsions afterward to cope with distress. That same show can be an opportunity to practice an exposure if you use your response prevention skills. Write your triggers down.
Below are some examples of exposures that might target themes related to relationships, contamination, hit and run, and health anxiety.
- Watch The Bachelor and resist comparing the relationships to your own.
- Pet your dog. Allow the dog to lick your hands. Touch your dog’s paws.
- Drive an unfamiliar route to work.
- Watch a medical show on a streaming service. Resist urges to google or body scan.
- Place outside items like a purse, bag, or luggage on your bed.
Step 5: Make a plan and take action.
Now it’s time to take your response prevention guidelines and your exposure list and make a plan.
The RP (response prevention) in ERP is just as important as the exposure. Review your response prevention guidelines at least twice a day. Here are some examples of how you could do this. Increasing your awareness of when and why you do the compulsion can help you make a different choice next time.
- Create a quick checklist of all the compulsion you’re working to prevent. Review it first thing in the morning. At the end of the day, check the box if you’ve done the compulsion. Try to reduce the number of checks you have over time.
- Download a counting app like Trivit. Create a category for each compulsion. If you do the compulsion, give yourself a tally mark.
- Download a reminder app like Yapp on your phone. Program random reminders for encouragement.
Next, tackle your exposures. Choose at least one exposure to practice each day. Before you begin, remind yourself why this exposure is important to you.
- How does this exposure connect you with your values or move you forward in life?
- How would life be different for you if you were able to do this thing without compulsions?
If your exposure is short, consider doing several per day. Try for around 30 minutes of exposure per day. Remember that exposure has to be paired with response prevention in order to see results. If you do an exposure and engage in compulsions, you are not doing ERP. You are just living with OCD.
Finally, remember that you can do this! If you’ve done ERP before and got to a place of recovery, you have great evidence that you can do this again. You know you can do it because you already have done it!
If you have had an OCD relapse and need support, please don’t hesitate to call our care coordinator at 314-462-2965 or send a message through the website.