For people with obsessive compulsive disorder (OCD), intrusive thoughts and urges can be anxiety-inducing, frustrating, frightening, confusing, exhausting: in a word, overwhelming. Without guidance and support, people with OCD will try to reduce the distress and overwhelm of OCD by performing repetitive ritual behaviors they feel driven to do.
These behaviors can be observable, like arranging things, cleaning and re-cleaning, checking over and over, saying things out loud, specific movements or behavior patterns, strict routines that get done over and over until they’re “right”, etc, or they can be “invisible” compulsions, like ruminating, repetitive thoughts or mental arguments, replacing thoughts, avoiding people, places, or situations, etc.
OCD is painful, but treatable, especially when you combine DBT and ExRP
OCD can be incredibly disruptive to your daily life, and not everyone in your life is willing, or able, to understand what you’re experiencing, making it feel very lonely and isolating as well. Without the right kind of support, it can be very difficult to effectively manage OCD, and your rituals and avoidance behaviors can be reinforced and will often escalate. When they’re the only thing that feels safe among the uncertainty and anxiety of intrusive thoughts, you’ll turn to them again and again.
People with OCD don’t have to stay stuck in the obsessive-compulsive cycles, however. Exposure and response prevention, or ExRP therapy, has been shown for decades to be the most effective form of therapy for helping people with OCD to stop compulsive behaviors from disrupting their lives.
Combining ExRP with dialectical behavior therapy (DBT) can be especially powerful at combating the distress and disruption of OCD; ExRP gives you guidance on how to disrupt the OCD cycle by reducing rituals, and DBT gives you ways to cope with the process of ExRP and the challenges of OCD, as you learn how to live life without ritual behaviors.
What is ExRP?
Exposure and response (or ritual) prevention, or ExRP, gives you a structured way to stop performing ritual behaviors. It differs from regular exposure therapy in that you both seek out exposures, AND put effort into ceasing ritual behaviors.
You’ll start with your least distressing obsessive thoughts and put effort into OCD ritual reduction. Your therapist will help you plan ways to halt the behaviors, and will help you plan out exposures as well, so you can expand your ability to resist ritual behaviors while fully engaging in life.
As you succeed in reducing ritual behaviors, you’ll move on to more distressing obsessions, until you’ve developed the distress tolerance to cope with anything OCD brings your way. It might sound impossible when you haven’t had effective help, but even people with taboo, frightening, violent, overwhelmingly constant, or upsetting intrusive thoughts from OCD have had success with ExRP in reducing the influence OCD has on their daily lives.
How can you use DBT and ExRP together for OCD?
DBT can provide structure to help you sustain your efforts in ExRP. OCD ritual reduction isn’t as simple as “just stop it,” so DBT skills can provide structured ways to manage your behavior. DBT also helps you face strong, difficult feelings like shame and fear, which are very common and sometimes very overwhelming emotions that people with OCD often feel.
Mindfulness turns down the volume on OCD anxieties
OCD brings up a lot of difficult thoughts of things you don’t want to have happen, and a lot of feelings that go along with these thoughts, like shame and fear. It can feel shameful to have intrusive thoughts, especially when you don’t understand why they’re happening, and you might feel like you’re a terrible person for having them (even though they are a reflection of what you do not want, not what you do want!).
Mindfulness is a pillar of DBT, and it can help with managing OCD. Being present, here and now, helps you take a step back from your intrusive thoughts, focusing your attention not on combating them with rituals, but simply noticing and letting them come and go. Mindfulness also encourages you not to judge your thoughts as good or bad, and not to judge yourself as good or bad for having them.
Mindfulness takes practice, but by bringing your attention back to now again and again, worry, shame, and fear are less loud, and your intrusive thoughts become less compelling. ExRP is easier to enact when you have a little distance from your thoughts, and mindfulness through DBT can help you create that distance.
Distress tolerance helps you hold out when reducing rituals with ExRP
While mindfulness can help lessen the anxiety and shame of intrusive thoughts, they’re still distressing. Intrusive thoughts often hinge on “what ifs” that go against what the person with OCD wants to have happen. What if I lose control and harm my family? What if I forgot to turn off the stove and my house burns down? What if I ran someone over and didn’t realize it? What if this food makes me sick because it’s contaminated? What if I don’t pray right, and my friends all get hurt as a result?
Even with ExRP, your intrusive thoughts can bring you anxiety; with ExRP, the goal isn’t to get rid of anxiety, but to learn to live with it, and thus help you tolerate it better. DBT offers you multiple ways to tolerate distress, extending your patience and resilience with difficult thoughts and feelings.
Since the rituals of OCD are an attempt to reduce distress, but they don’t work, you need a replacement that does. DBT has been shown again and again to help people tolerate distress instead of trying to run away from it with rituals. Distress tolerance can help you make ExRP work for you, supporting you as you reduce your OCD rituals.
How can DBT skills help people with OCD to reduce common rituals?
When people with OCD start to connect with others, it can be surprising to see how many rituals that you might have performed alone, that made you feel totally isolated, are actually fairly common for people with OCD. There’s one DBT skill that can help you to make ExRP work for you, no matter what your OCD compels you to do: Opposite Action.
Opposite Action helps you reduce OCD rituals and re-engage with life
When you’re compelled to perform a ritual, practicing Opposite Action can help you stop yourself from performing the ritual by having you do the opposite. If you want to re-wash your hands over and over, or you feel compelled to replay conversations in your head, you can choose to walk away from the sink or go have an actual conversation that takes up all of your attention.
Adding Opposite Action to ExRP gives you a structure to lean on when intrusive thoughts become especially distressing, and it works for any compulsions you have. It’s not easy to do when OCD is especially distressing, but it gives you a simple, approachable thing to do when OCD rituals are stopping you from living your life.
Opposite Action reduces avoidance, giving you back your life
OCD can become so distressing that avoidance is an especially common ritual, and one that can become very isolating. It can keep you away from the people, places, and experiences you want to enjoy. Ironically, this avoidance reinforces the anxiety of your OCD, pushing you to avoid more.
The DBT skill of Opposite Action helps you reject avoidance even when OCD is making you anxious. If you want to stay home, stay away, or stay put, Opposite Action pushes you to go out and live your life. You’ll feel distress (and can use other DBT skills to help you tolerate that distress), but you won’t let OCD reinforce itself, and with time, it’ll become easier and easier to reduce OCD rituals.
Suffolk DBT can help you combine ExRP and DBT to counteract OCD
With ExRP at Suffolk DBT, you’re not stuck dealing with OCD alone. You have access to an evidence-based OCD treatment method, an evidence-based behavior therapy method, and you’ll work with a therapist who knows you can change (even if you don’t yet believe it yourself). Taking on the world without ritual behaviors can feel rightening, but you’ll have access to therapy that couples compassion and structure, with support every step of the way.
If you’re ready to start creating a life worth living, no matter what OCD tells you is possible, connect with us today. You are capable, you can change, and you can handle uncertainty, especially with support from Suffolk DBT.