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The San Mateo CBT Clinic provides therapy for anxiety disorders in children, teens, and adults. Jonah Lakin PsyD is a licensed clinical psychologist specializing in Cognitive-Behavioral Therapy (CBT) for Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agorophobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

San Mateo CBT Clinic blog about anxiety treatment

Anxiety Blog. Describes CBT principles involved in treatment for anxiety disorders in children and adults. Conditions discussed include: Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agorophobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

The Role of Uncertainty in ERP for Harm OCD

Jonah Lakin

The treatment for all anxiety disorders is exposure therapy. Exposure therapy varies slightly for the different anxiety disorders but the essential components are always the same.

  • Exposure always involves gradually facing anxiety provoking situations. People typically start with the least anxiety provoking and work their way up towards harder and harder situations. 
  • Exposure always involves abstaining from actions that temporarily reduce anxiety. 

In essence, for exposure to be effective a person has to repeatedly trigger anxiety, fully allow the anxiety in, and resist efforts to get rid of it. After doing this several times, people get to learn directly that anxiety will gradually reduce on its own.

In the treatment of OCD, exposure therapy has a special name “Exposure with Response Prevention”  (ERP) which means that people intentionally put themselves into situations that trigger anxiety (exposure) and then they practice resisting their urges to engage in compulsive behavior (response prevention).

Effective exposures must trigger anxiety, otherwise they are a waste of time. To fully identify effective exposures, you have to first understand what kinds of things make a person anxious and why. 

Let’s look at a two common obsessions in harm OCD:

  1. Many individuals with harm OCD fear that they ran someone over when driving without realizing it. They may drive for 30 minutes and for 5 of those minutes they were distracted by their own thoughts. When they realize that they’ve been distracted, they worry “what if I killed someone?” 
  2. Another common obsession is that they may have stolen something. A person might go to a store and buy something. When they get home they don’t remember if they paid for the item or not and worry “what if I stole this?”

Notice the role of uncertainty here; it is a critical component of both of these worries. A person cannot remember something (they are uncertain), and thus, they worry that they might have done something harmful. It is not the case that they actually remember harming someone, rather they aren’t certain about what happened and worry about the possibility of having harmed someone. 

This distinction is essential to understanding treatment and it is the true fear in harm OCD. Individuals with harm OCD may appear to have a fear of harming others, but that is inaccurate. The core fear in harm OCD is of uncertainty surrounding harming others. This is highly important when designing exposures. It tells us that a good exposure isn’t one in which the person actually harms someone, but rather a good exposure is one that triggers uncertainty about the possibility of having harmed someone. 

This is great news as we don’t actually have to drive and run someone over to get better; instead, we have to drive long enough that we can’t remember every moment of the drive and thus experience uncertainty about what happened during the times we can’t remember. Similarly, we don’t actually have to steal anything, we just have to shop frequently enough that we can’t remember every single purchase and feel uncertain about what happened during the times we can’t remember. Without this uncertainty, there is no exposure. 

As already discussed, we also have to engage in Response Prevention (resisting the urge to engage in compulsions).This means that after driving and experiencing uncertainty about possibly having harmed someone, then we don’t drive back to look for signs of a dead body and we don’t ask others who were in the car “did I hit someone?” We resist our urge to examine the car to look for evidence of a crash. 

Likewise, after leaving the store and having the thought, “what if I stole this?” then we don’t ask others if they think we stole it and we don’t go online to look at our credit card receipt and we don’t try to piece together every moment of my time in the store to convince ourselves that we didn’t steal it. 

The response prevention component is critical here: compulsive efforts to eliminate uncertainty have to be resisted in order to get better.  This is very difficult work and individuals with OCD (and their families) often fall into the trap of trying to reduce or eliminate uncertainty. Individuals think, “Okay, I’ll practice the driving but only if I can figure out a way to be sure that I didn’t harm someone” or “I’ll go shopping and then write down what I paid for immediately so that I’ll always be certain about what I did at the end of the day.” Parents or partners think, “If I tell him over and over again that he didn’t harm anyone, he’ll start to believe it.” While these compulsive efforts to reduce uncertainty often reduce anxiety in the short-term, they ultimately will make OCD worse in the long-term because the core fear (uncertainty surrounding possibly harming someone) is being avoided. 

Successful treatment for OCD isn’t about getting rid of uncertainty; it’s about getting used to uncertainty. The only way to get used to uncertainty is with repeated prolonged exposure to it. When individuals repeatedly expose themselves to uncertainty and resist urges to reduce this uncertainty (ERP), they experience a significant reduction in symptoms.