Facing Fears
By Deborah Osgood-Hynes, PsyD.
Obsessive Compulsive Foundation
There are not many people who like to feel the body sensations and emotional discomfort that go along with high levels of anxiety: racing thoughts, increased heart rate, rapid shallow breathing, feeling dizzy or faint, sweating, shaking, nausea, fear, doubt and uncertainty. Whether this discomfort is triggered by external situations, places or objects, or whether the distress is due to internal triggers such as thoughts, images, memories, or anticipation of future events, emotional and bodily distress are something most people would rather do without. It’s understandable why someone would avoid situations that trigger the anxiety or would do whatever they could to reduce the stress. Though understandable, this becomes problematic.
While OCD symptoms have a neurobiological origin, learning factors also contribute to symptom growth and maintenance. Anxiety and discomfort are aversive. Most of us will do whatever we can to avoid discomfort. However, any action that is done to reduce discomfort gets reinforced and strengthened because it made the discomfort temporarily go away. Avoidance and/or compulsions (both mental and physical rituals) reduce discomfort, albeit only temporarily, thereby strengthening the compulsions or avoidance behavior. It’s as if you are teaching your mind and body that the only way to reduce discomfort is through ritualizing or avoidance.
Behavioral treatment follows a fairly simple principle. To reduce a fear you have to face a fear. This applies to all types of fears. If you fear flying, you need to start taking plane trips. If you fear public speaking, you need to give more lectures and presentations. If you fear open spaces, you need to go gradually to more open-feeling locations. If you fear elevators, you need to practice taking elevator rides. If you fear surfaces that you believe are contaminated, you need to touch those very surfaces. If you fear intrusive unwanted violent and/or sexual thoughts, then you need to deliberately think and face those thoughts. If you are afraid of the physiological experience of the anxiety itself, then you need to practice doing actions that trigger these feared body sensations. With repeated practice at facing what you fear, your fear will gradually be reduced (habituation). The way to reduce the fear, anxiety, distress and doubt is to face the fear, anxiety, distress and doubt. Keep in mind the phrase: “No pain, no gain.” Short term pain (albeit sometimes very intense emotional pain) can lead to long term gain (OCD symptom reduction and reduced anxiety, fear and discomfort). Treatment can be set up so that you face fears gradually (systematic exposure and response prevention using a hierarchy of increasingly difficult feared situations) or done more rapidly through flooding (facing the highest fears on your fear hierarchy first instead of last). Treatment can be effective either way. Despite which method you choose, it can be a difficult journey that requires a lot of dedication, courage, persistence and support.
The two main treatments for OCD are: a) medication and b) exposure and response prevention (ERP) tasks. Cognitive therapy and dialectical behavior therapy can be useful adjuncts to supplement ERP work. If you are not familiar with exposure and response prevention treatment methods or with commonly prescribed medications for OCD, I would recommend you look to the many wonderful books on the market currently that can elaborate on this further as it is not the goal of this article to explain these treatment methods in detail. Suffice it to say that the goal of ERP tasks is to face your fears (exposure) and try not to do what the OCD is telling you to do (resist rituals and reduce avoidance behavior).
Facing your fears through exposure and response prevention tasks is more useful the more practice you can give to it. I know this is not easy but you can potentially reduce your symptoms faster. If you face a feared situation or thought once a week for 30 minutes, while it may be a very good “behavior therapy moment” as I like to call them, you will get much more momentum and gain out of your therapy if you could face your fears more often. After facing that same fear every day for 30 minutes a day, you will be that much further along. Remember that behavior therapy is about repeated practice at facing a fear. If you only face a fear once in a blue moon, your OCD has all that time in between to build and maintain its strength. Every time you realize or avoid, your OCD fears and symptoms are reinforced. There are different 1evels of practice intensity and I leave it up to you and your individual therapist to discuss the pace of therapy that is right for you.
Let me give you an example of what we do at the OCD Institute at Mclean Hospital in Belmont, Mass. The OCD Institute is a 20-bed residential treatment program for people with moderate to severe OCD or for people who would like to get OCD treatment but do not have access to qualified treatment providers nearby in their state or in their country. Many who come to the OCDI are considered treatment resistant, having been through numerous trials of medication and behavior therapy. The average length of stay is 1-3 months. At the OCDI, in addition to medication treatment, behavior therapy focuses primarily on exposure and response prevention tasks. Each resident is expected to follow through with a minimum of 4 hours of exposure and response prevention tasks every weekday. This includes 2 hours in the morning from 10-12 AM (which may be coached full time) and 2 hours again in the afternoon from 2-4 PM. On the weekends, we ask people to do at least 2 hours of ERP tasks. In addition to these 4 hours of ERP a day, many residents also have additional ERP plans that are specific to their morning wake-up routine, bathroom routines, going out into the community and bedtime routines since they get stuck with rituals at these times. Practicing ERP is very difficult. But therapists and counselors are available to lend support to help coach a person through his/her ERP tasks. We also include specific ERP tasks that are not coached (self-directed) to reduce the dependency on a coach in preparation for facing fears alone, such as, when the resident returns home. While it is important to practice ERP frequently, another important lesson is to live the philosophy of ERP outside of specific ERP practice times. The more you can incorporate a life philosophy of facing your fears and the more you can practice doing ERP tasks when spontaneous life behavior therapy opportunities arise, the more your therapy gains will grow and generalize.
As I said earlier, it takes courage to face your fears on a daily basis. Support to do this is important. First, it is helpful if you learn to praise and encourage yourself for your efforts. Praise yourself for your effort to fight the OCD even if you were not as successful at resisting rituals as you would like. Second, external support can come from many sources: an individual therapist, family, friends or group therapy, to name a few. Keep in mind that support is not asking others to accommodate to your OCD way of doing things nor is it having others offer reassurance to soothe OCD feelings of doubt and uncertainty. Good sources of support give you ideas and encouragement to face your distress and anxiety.
At the OCD Institute, in addition to meeting with a behavior therapist 2-4 times a week, the psychiatrist once a week, the social worker once a week and numerous counselor meetings, we have many types of group therapy for education and support. After a 2-hour block of time doing ERP tasks, residents meet as a group to publicly describe their distress level faced, rituals performed and percent of effort. Symptom specific groups for those struggling with issues of scrupulosity, body dysmorphic disorder, perfectionism and thoroughness, and intrusive violent and sexual thoughts offer specialized treatment and racing fears support. Symptom specific groups allow people to discuss issues that they may not feel comfortable discussing in a larger group context with others that are not experiencing those symptoms. In these groups it is not uncommon to hear people say that for the first time they have met someone struggling with issues just like them and were able to face issues of shame or embarrassment. Some groups focus on teaching coping strategies to supplement ERP tasks such as cognitive therapy or affect management (distress tolerance). Yet other groups focus on methods to maintain motivation, relationship issues relevant to OCD struggles, relapse prevention, support during transition, support for completing behavioral assignments given within the skills groups, and teaching ways to generate small manageable ERP goals above and beyond ERP tasks already established with the behavior therapist.
The first group in the morning helps people track daily appointments and personal goals, and the last group of the day offers a check-in and support regarding daily goals. Outside the OCD Institute, there are not as many OCD support groups available for people as I would like to see. Groups can be a wonderful source of treatment and support. Check to see if there is an OCD support group near you that can help reinforce your efforts to fight your OCD.
There are many modes of treatment intervention, all of which can be beneficial in the effort to reduce OCD symptoms, regain quality of life and increase the possibility of pursuing life goals. Typically, individual outpatient treatment is once a week for a 50 minute session. Occasionally, outpatient treatment offers 80 minute sessions once a week. Some locations offer home-based sessions. Group treatment is typically once a week for 80 minutes. Intensive outpatient treatment varies across locations and can meet from 2 to 5 times a week for 2-4 hours per meeting. Longer sessions provide more opportunity to practice exposure and response prevention tasks. Day treatment typically involves coming to a program 5 days a week for 5-8 hours a day and includes a combination of individual therapy and group therapy. Residential treatment requires living at the treatment facility and includes both individual and group therapy.
Regardless of which treatment modality you choose to pursue, as you work on facing your fears to reduce OCD symptoms, it is important to hang onto your life goals and dreams. OCD treatment is not just about reducing your emotional reactivity to feared situations and reducing your rituals and avoidance behavior. Treatment is also about getting back in touch with who you are beyond your OCD symptoms. Therapy can help you regain your life and self-worth. There are lots of ways to get support to do it. The OCF has Referral Lists that you can ask for. So, face the fear, do it often and get support.
By Deborah Osgood-Hynes, PsyD.
Obsessive Compulsive Foundation
There are not many people who like to feel the body sensations and emotional discomfort that go along with high levels of anxiety: racing thoughts, increased heart rate, rapid shallow breathing, feeling dizzy or faint, sweating, shaking, nausea, fear, doubt and uncertainty. Whether this discomfort is triggered by external situations, places or objects, or whether the distress is due to internal triggers such as thoughts, images, memories, or anticipation of future events, emotional and bodily distress are something most people would rather do without. It’s understandable why someone would avoid situations that trigger the anxiety or would do whatever they could to reduce the stress. Though understandable, this becomes problematic.
While OCD symptoms have a neurobiological origin, learning factors also contribute to symptom growth and maintenance. Anxiety and discomfort are aversive. Most of us will do whatever we can to avoid discomfort. However, any action that is done to reduce discomfort gets reinforced and strengthened because it made the discomfort temporarily go away. Avoidance and/or compulsions (both mental and physical rituals) reduce discomfort, albeit only temporarily, thereby strengthening the compulsions or avoidance behavior. It’s as if you are teaching your mind and body that the only way to reduce discomfort is through ritualizing or avoidance.
Behavioral treatment follows a fairly simple principle. To reduce a fear you have to face a fear. This applies to all types of fears. If you fear flying, you need to start taking plane trips. If you fear public speaking, you need to give more lectures and presentations. If you fear open spaces, you need to go gradually to more open-feeling locations. If you fear elevators, you need to practice taking elevator rides. If you fear surfaces that you believe are contaminated, you need to touch those very surfaces. If you fear intrusive unwanted violent and/or sexual thoughts, then you need to deliberately think and face those thoughts. If you are afraid of the physiological experience of the anxiety itself, then you need to practice doing actions that trigger these feared body sensations. With repeated practice at facing what you fear, your fear will gradually be reduced (habituation). The way to reduce the fear, anxiety, distress and doubt is to face the fear, anxiety, distress and doubt. Keep in mind the phrase: “No pain, no gain.” Short term pain (albeit sometimes very intense emotional pain) can lead to long term gain (OCD symptom reduction and reduced anxiety, fear and discomfort). Treatment can be set up so that you face fears gradually (systematic exposure and response prevention using a hierarchy of increasingly difficult feared situations) or done more rapidly through flooding (facing the highest fears on your fear hierarchy first instead of last). Treatment can be effective either way. Despite which method you choose, it can be a difficult journey that requires a lot of dedication, courage, persistence and support.
The two main treatments for OCD are: a) medication and b) exposure and response prevention (ERP) tasks. Cognitive therapy and dialectical behavior therapy can be useful adjuncts to supplement ERP work. If you are not familiar with exposure and response prevention treatment methods or with commonly prescribed medications for OCD, I would recommend you look to the many wonderful books on the market currently that can elaborate on this further as it is not the goal of this article to explain these treatment methods in detail. Suffice it to say that the goal of ERP tasks is to face your fears (exposure) and try not to do what the OCD is telling you to do (resist rituals and reduce avoidance behavior).
Facing your fears through exposure and response prevention tasks is more useful the more practice you can give to it. I know this is not easy but you can potentially reduce your symptoms faster. If you face a feared situation or thought once a week for 30 minutes, while it may be a very good “behavior therapy moment” as I like to call them, you will get much more momentum and gain out of your therapy if you could face your fears more often. After facing that same fear every day for 30 minutes a day, you will be that much further along. Remember that behavior therapy is about repeated practice at facing a fear. If you only face a fear once in a blue moon, your OCD has all that time in between to build and maintain its strength. Every time you realize or avoid, your OCD fears and symptoms are reinforced. There are different 1evels of practice intensity and I leave it up to you and your individual therapist to discuss the pace of therapy that is right for you.
Let me give you an example of what we do at the OCD Institute at Mclean Hospital in Belmont, Mass. The OCD Institute is a 20-bed residential treatment program for people with moderate to severe OCD or for people who would like to get OCD treatment but do not have access to qualified treatment providers nearby in their state or in their country. Many who come to the OCDI are considered treatment resistant, having been through numerous trials of medication and behavior therapy. The average length of stay is 1-3 months. At the OCDI, in addition to medication treatment, behavior therapy focuses primarily on exposure and response prevention tasks. Each resident is expected to follow through with a minimum of 4 hours of exposure and response prevention tasks every weekday. This includes 2 hours in the morning from 10-12 AM (which may be coached full time) and 2 hours again in the afternoon from 2-4 PM. On the weekends, we ask people to do at least 2 hours of ERP tasks. In addition to these 4 hours of ERP a day, many residents also have additional ERP plans that are specific to their morning wake-up routine, bathroom routines, going out into the community and bedtime routines since they get stuck with rituals at these times. Practicing ERP is very difficult. But therapists and counselors are available to lend support to help coach a person through his/her ERP tasks. We also include specific ERP tasks that are not coached (self-directed) to reduce the dependency on a coach in preparation for facing fears alone, such as, when the resident returns home. While it is important to practice ERP frequently, another important lesson is to live the philosophy of ERP outside of specific ERP practice times. The more you can incorporate a life philosophy of facing your fears and the more you can practice doing ERP tasks when spontaneous life behavior therapy opportunities arise, the more your therapy gains will grow and generalize.
As I said earlier, it takes courage to face your fears on a daily basis. Support to do this is important. First, it is helpful if you learn to praise and encourage yourself for your efforts. Praise yourself for your effort to fight the OCD even if you were not as successful at resisting rituals as you would like. Second, external support can come from many sources: an individual therapist, family, friends or group therapy, to name a few. Keep in mind that support is not asking others to accommodate to your OCD way of doing things nor is it having others offer reassurance to soothe OCD feelings of doubt and uncertainty. Good sources of support give you ideas and encouragement to face your distress and anxiety.
At the OCD Institute, in addition to meeting with a behavior therapist 2-4 times a week, the psychiatrist once a week, the social worker once a week and numerous counselor meetings, we have many types of group therapy for education and support. After a 2-hour block of time doing ERP tasks, residents meet as a group to publicly describe their distress level faced, rituals performed and percent of effort. Symptom specific groups for those struggling with issues of scrupulosity, body dysmorphic disorder, perfectionism and thoroughness, and intrusive violent and sexual thoughts offer specialized treatment and racing fears support. Symptom specific groups allow people to discuss issues that they may not feel comfortable discussing in a larger group context with others that are not experiencing those symptoms. In these groups it is not uncommon to hear people say that for the first time they have met someone struggling with issues just like them and were able to face issues of shame or embarrassment. Some groups focus on teaching coping strategies to supplement ERP tasks such as cognitive therapy or affect management (distress tolerance). Yet other groups focus on methods to maintain motivation, relationship issues relevant to OCD struggles, relapse prevention, support during transition, support for completing behavioral assignments given within the skills groups, and teaching ways to generate small manageable ERP goals above and beyond ERP tasks already established with the behavior therapist.
The first group in the morning helps people track daily appointments and personal goals, and the last group of the day offers a check-in and support regarding daily goals. Outside the OCD Institute, there are not as many OCD support groups available for people as I would like to see. Groups can be a wonderful source of treatment and support. Check to see if there is an OCD support group near you that can help reinforce your efforts to fight your OCD.
There are many modes of treatment intervention, all of which can be beneficial in the effort to reduce OCD symptoms, regain quality of life and increase the possibility of pursuing life goals. Typically, individual outpatient treatment is once a week for a 50 minute session. Occasionally, outpatient treatment offers 80 minute sessions once a week. Some locations offer home-based sessions. Group treatment is typically once a week for 80 minutes. Intensive outpatient treatment varies across locations and can meet from 2 to 5 times a week for 2-4 hours per meeting. Longer sessions provide more opportunity to practice exposure and response prevention tasks. Day treatment typically involves coming to a program 5 days a week for 5-8 hours a day and includes a combination of individual therapy and group therapy. Residential treatment requires living at the treatment facility and includes both individual and group therapy.
Regardless of which treatment modality you choose to pursue, as you work on facing your fears to reduce OCD symptoms, it is important to hang onto your life goals and dreams. OCD treatment is not just about reducing your emotional reactivity to feared situations and reducing your rituals and avoidance behavior. Treatment is also about getting back in touch with who you are beyond your OCD symptoms. Therapy can help you regain your life and self-worth. There are lots of ways to get support to do it. The OCF has Referral Lists that you can ask for. So, face the fear, do it often and get support.
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