OCD Treatment: How to Preserve Agency during ERP (Exposure Response Prevention)

Exposure Response Prevention, the gold star treatment for OCD, can be a challenging process of facing our fears, experiencing our triggers, and resisting our compulsions.  The key for successful exposure response prevention is client buy-in.  

The individual with OCD has to want to get better, just as much as their family members and their therapist.   

Usually with severe OCD, the family is the first to contact the therapist.  The conversation wherein family and friends try to convince their loved one to get treatment can almost feel like a substance use intervention.  Severe OCD is addictive.  It is a force that our loved one must be ripped out of, sometimes initially against their will.  This process is sensitive and tricky, as individuals with OCD can be highly rewarded by non-family members for their perfectionism, precision, or fastidiousness.  Some individuals may be highly functional even though they may be spending 7+ hours a day on compulsions.  

For many of us with OCD, we have trouble with finding the intrinsic motivation to get better.  

Our OCD feels safe.  Our OCD is predictable.  In order to break away from our OCD, we must truly trust and believe that a better life lies on the other side of uncomfortable treatment.  

In therapy, we must be able to visualize what “better” looks like.  We must be able to imagine a world wherein our OCD voice is no longer commanding our lives.  

Sadly, many of us have lived with our critical inner voice for so long, that it is difficult to even distinguish the OCD from our true selves.  

The most important first step in OCD treatment is creating a treatment plan that has the client’s full buy in.  We start by asking the questions: What are your motivations to continue as is? What are your motivations to change? 

Why would you challenge yourself to go outside your comfort zones; what are the benefits of experiencing the distress of ERP?

Often we must create a motivational inventory that the client returns to when they are feeling less positive about the process.  It is not enough for family members to be invested, a person with OCD must have an internal motivating force that is strong enough to override the disorder’s intrusive voice.  

When OCD treatment plateaus, we must ask ourselves, how much do we really want it? Who is really spearheading the process?

In therapy we have a saying: “Never work harder than your client.”  ERP can really push this saying to its outer edges, because an individual with OCD often needs the strength and immense effort of both a coach and therapist supporting their recovery.  However, it is very important that the client not feel dragged along in the process. 

A client is able to claim agency in the process by structuring their own Fear Hierarchy (a treatment plan tool used in OCD to decide on when to do which exposure), choosing their own external motivators (such as rewards or praise), and having the power to click back into a lesser exposure or de-expose themselves.  

A client’s agency is a factor in treatment that must be assessed on a continual basis.  If our client feels like they have lost agency, it is much more likely that they will drop out of OCD therapy.  It is our responsibility as clinicians to build the trust to communicate directly when treatment isn’t working and be willing to workshop the process at all stages of therapy.  

For more info or for help with your mental health journey, please reach out to Kairos Wellness Collective.