Exposure and Response Prevention (ERP) Comes to Our Home (Re-Post)

This post originally appeared on this blog in August of 2013.  It has remained one of my most viewed posts.  The photos of Blake’s hands are probably the most clicked on photos in this blog, and appear at the top of Google’s Images when you search for anything related to OCD and hand washing (and they appear to be the first “real” image of what can happen to a person’s hands when contamination OCD leads to hand washing). I thought it was worth re-posting.

* Advisory:  This post has some photos of hands damaged from over-washing.  They may be difficult for some people to look at.

This is a nearly empty bottle of liquid soap.

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It looks pretty normal sitting on the bathroom counter until you take a closer look.  That brown ring around the bottom of the bottle is dirt from our backyard.

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The bottle of soap caught my eye several days ago and I snapped a few photos of it to remind myself of where we’ve been.  This bottle, with its dirt that is settled all around the bottom has been with us this entire summer – since before I even began this blog.  It is a remnant of one of Blake’s last OCD treatment sessions before we made the  heavy-hearted decision to stop therapy.  I am sharing it with you today, as a way to share what Exposure and Response Prevention (ERP) can look like.

What is ERP?

ERP is “the most important therapy in CBT for OCD,” according to the International OCD Foundation.  In a nutshell, ERP involves a conscious choice for a person with OCD to confront the items (thoughts, situations, etc.) that create discomfort and then not do the compulsions or rituals that would normally be provoked.   The idea is for the OCD sufferer to allow his or her anxiety and discomfort to abate naturally, without using rituals to cope and thereby creating healthier ways of coping.  This is commonly done with the help of a mental health therapist who is trained to do Cognitive Behavior Therapy (CBT) with OCD (for more information, Click Here.  Janet at OCDtalk has also written a thorough post on ERP.).

In our situation, Blake was really struggling with hand-washing compulsions (in addition to many others).  It was particularly bad at the time and he ran to the sink to wash anytime he felt the slightest bit “dirty.”  No amount of salves or special creams could heal the damage he was doing to his poor hands.  Below are some photos of how his hands looked around the time.  A reminder, these are 14-year-old hands.  They are painful for me to look at.  Anyone who pokes fun at compulsive hand-washing or thinks it is a joke has never lived with a family member who is suffering because of it.  The pain is real, intense and it interferes with day-to-day activities.

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While Blake’s treatment team had done ERP work with him on the hand-washing at the office (they would touch “dirty” things and then he would not wash), we were seeing little impact of the exposures.  We all agreed at the time that Blake was “white knuckling” it through the exposure and avoiding truly immersing himself in it by reminding himself that he could wash as soon as he got home.  He never gave himself the opportunity to allow his anxiety to come down to a manageable level.  So, it was decided that one of his therapists would make the trip to our home.  The plan was for Blake and the therapist to “contaminate” our entire house so that Blake would not have a place of safety to run to in order to avoid his discomfort.

The Day Arrives…

Blake was in agreement with the plan, until the actual day arrived.  He was tired of painful hands and was hopeful that this exposure would finally put his hand-washing to rest.  He greeted his therapist, happily, at the door.  As they began to prepare for the actual exposure, he began to change his tune.

“I don’t remember actually agreeing to do this,” he told the therapist.  His anxiety was already on the rise, and he was trying to thwart the exposure from going any further.  His therapist and I reminded him of his desire to get better and advised him how important a step this was toward breaking free from the grip OCD had on his life.

Begrudgingly, he followed his therapist into the backyard where both dug into the dirt and began to put handfuls of it into a squirt bottle.  Then they returned to the house where they filled the bottle with tap water and shook it vigorously.  It looked like a muddy mess.  I silently gulped when I saw it.

Are you really going to spray that mess all over my house?

This was not going to be easy – and I really have no problems with dirt.  I can sit in it, get it under my nails, whatever…  But this – even I wasn’t relishing the idea of my house being sprayed with a bottle of dirty water.  The thing is, that was just the point.  Yes, it is uncomfortable to have dirt sprayed in your house.  It’s even kind of over the top.  BUT, it’s not going to kill anyone.  It is survivable – you can even thrive with dirt on your belongings.  The point for the OCD sufferer is to stick with the discomfort long enough to recognize that it abates and that they can have a good life without having to give in to their compulsions.

Reticent as I felt, Blake’s anxiety was rising through the roof.  He now wanted no part of this exposure.

“I changed my mind.  I don’t want to do it,” he stated.

His therapist reminded him that this exercise, as uncomfortable as it felt right now, was going to help put his OCD in its place.  She asked me to bring her all the bottles of liquid soap that were in the house.  I complied and sought them out.  Within a few minutes, I was back.  Blake was not in a good place.

The Battle Begins

While I’d been on my mission, Blake’s therapist had opened my bottle of dish soap (which Blake uses all the time to wash his hands) and poured a good amount of that muddy water right into it.  Blake was going to have none of that and before anybody could convince him otherwise, he’d dumped the entire contents of the bottle down the drain and placed the empty container in the recycle bin.

“Blake,” she reminded him, “we need to contaminate all the things you use to relieve your anxiety.  You remember; we talked about this.”

“No,” he said firmly.  “I don’t want to do it.”

She continued with her task and began to pour muddy water into the liquid soap bottles I had brought to her.  Blake’s face grew red.

“I said, ‘No’,” he stated.  “LEAVE.”

The therapist continued.  She was finished contaminating his sources of washing.  She took a rag and sprayed it with the dirty water.

“Come on, Blake.  Help me.  Let’s contaminate the house together. It’s better if you’re a part of this.”

NO! LEAVE!”  His voice was powerful.  Anxiety was making way for fury.

“Remember?  You wanted to get better.  I’m not going to stop because I care about you.  I care about your hands and I don’t want you to have to keep living with OCD bossing you around and controlling your life,” she told him.

THERE’S NOTHING WRONG WITH ME!!!!  I’M TIRED OF THIS!!! I’M TIRED OF BEING TOLD THAT I’M SICK!!!  SICK! SICK! SICK! LEAVE!!! GET OUT OF MY HOUSE!!!!”

Blake was absolutely getting out of control at this point.  He’d never said an angry word to his therapist before.  Now, he was screaming at the top of his voice and looking like a maniac. My heart was breaking for him.  I didn’t know whether to cry or burst out into giggles at the sheer anxiety the whole thing was creating in me.

His therapist continued with her quest.  She carefully wiped the dirty cloth over all the furniture, the walls and our personal belongings.  Our entire family was going to be in on this exposure.  But was Blake going to buy into it?

Blake Hits His Breaking Point

“I TOLD YOU TO LEAVE!!!  I CAN’T TAKE THIS ANYMORE!!  I’M JUST GONNA…”

Blake lunged for the pencil cup on top of the cabinet near him.  In one swift move, he pulled out the sharpest pair of fabric shears in the house and raised it up over his head, as if he were about to plunge it into someone.  But it wasn’t clear to me if he was going for his therapist or himself.

“Put it down, Blake!” I commanded, but my words weren’t necessary.  Blake’s hand hesitated in the air and his expression turned to horror and he began to tremble.

“What am I doing?  What am I doing?”

He ran down the hallway to the living room where he started sobbing.

“I’m sorry.  I’m sorry.  I’m sorry,” he repeated.

The therapist stepped outside to call her supervisor.  Blake looked at me through his tear-filled eyes.

“I wouldn’t have hurt myself,” he said.  “I just wanted her to stop.  I can’t believe how far I went to protect my OCD.”  He cried quietly for a few minutes until his therapist stepped back into the room.

“Do you want to talk?” she asked him.

“I’m so sorry,” he said.  “I wouldn’t have done anything.  I know what I need to do now.”

He walked down the hallway with a half-smile on his face and picked up the abandoned squirt bottle.

“May I?” he asked.

“Of course,” she answered.

He began to make his way through the house, squirting that dirty water on the walls and the countertops.  He covered his game consoles in it and his favorite sitting areas.  Tears streamed down his face, but now they were tears of relief.  He knew this was what he needed to be doing.  Then, he directed the therapist to his room.

“We need to do my room,” he told her and he contaminated his entire room with that water, making sure he didn’t miss a thing.

The Aftermath

Blake adjusted relatively quickly to his contaminated surroundings (although I did put away all sharp objects, just in case).  He didn’t care that there were pieces of dirt in the soap bottles.  He relished it when I reminded him that our entire home was contaminated.  He’d won another battle in the war on his OCD.  His hands healed.

But the other areas his OCD affected were untouchable.  He wouldn’t budge on them; held onto them like a badge of courage and battled us to keep them.  Of course, this lead to us ultimately discontinuing treatment and to being in the limbo that we are in.

Today I still find remnants of that exposure, though it is about 3 months in the past.  There are still places that are too high for me to reach where he aimed that squirt bottle – and I kind of like the bits of dirt that remain anyway because they remind me that we still live with contamination to some extent.  They also remind me how far Blake was willing to up the ante to protect his OCD, how powerful the disorder can be in asserting itself.  And I wonder when Blake will grow in his own power and desire to take it on.  We can only wait and see.

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7 thoughts on “Exposure and Response Prevention (ERP) Comes to Our Home (Re-Post)

  1. Wow, Angie, this had even more of an impact on me than the first time I read it. Just shows how powerful OCD can be. But Blake is still stronger than his OCD……..he just has to realize it once again. Hope things are going okay for all of you and wishing you all good things for 2016.

  2. Paul

    Very tough for me to read this…but in a good way as it makes me feel less alone. I have been battling OCD for 30 years and been in treatment for 25. Medications have helped me improve by perhaps 50%. I used to think it was 70%, but this post makes me feel like I am kidding myself. I have attempted ERP therapy off and on during my 25 years with very little success. It is painful for me to say that as I know how important ERP is. In my case it takes nearly superhuman strength to tolerate an exposure exercise, and even when I succeed at tolerating the fear which is rare, my compulsions do not seem to improve. I find the exercise just as hard the next time around.

    I just wanted to say thank you for sharing this post. People need to understand how hard it is to overcome OCD. Many people think they “get it”, but it is hard for them to understand the intensity of the anxiety involved. A difficult ERP session feels (to me anyway) something like jumping out of an airplane and (because of OCD) being absolutely convinced that you have no parachute no matter how many times the doctors tell you that you do. Under conditions like that, it is nearly impossible for me to make myself “jump out of the plane.” To me, that is what a difficult ERP feels like.

    I pray that everyone with OCD makes progress towards overcoming it in 2016.

    Peace,
    – Paul

      1. Hi Lauren,

        I’m glad you reached out and wrote a post!
        We need to support and help each other as much as we can!

        I ended up writing a lot below. Consider it a “random list” of things that have helped ME fight OCD. (Your results may (and probably will) vary.) 🙂

        I know fighting OCD is hard, VERY hard…so hard that words can’t describe it. It is also frustrating beyond words.

        But I want to share some positive with you:

        Even though ERP hasn’t helped me all that much, I still attempt it EVERY DAY. I have a terrible time shutting off faucets. I can’t walk away from a faucet after I shut it off because I’m afraid it is still on…I’m afraid I will flood the house by accident. But every day I make myself turn a faucet on and off. I’m usually not doing proper ERP because I can’t overcome the anxiety and if things don’t “feel right” I go back and turn the faucet on and off again. Sometimes I’m done in 30 seconds. Occasionally (usually when I’m over tired) it takes me 15-30 MINUTES before I can stop performing this “faucet on/off” compulsion. Thankfully, that only happens once or twice a month. But I get angry and frustrated with myself every day because I “fail” at proper ERP.

        I TRY IT ANYWAY. And every time I do it I attempt to use “self talk” to try to weaken the grip of OCD. Before I turn the faucet on/off I tell myself: “Try to tolerate the fear because it ALWAYS goes away.” Or I tell myself: “Once the faucet handle can’t go further the faucet is OFF, so STOP! THE FEAR ALWAYS GOES AWAY!!” Or: “TOLERATING THE FEAR IS THE WAY OUT. IT IS THE WAY TO GET BETTER/HEALTHY”. I have very limited success with this, but ONCE IN A WHILE I BREAK THROUGH AND SUCCEED AT THE ERP. THOSE MOMENTS GIVE ME HOPE.

        My idea is this: I believe that if I avoid faucets completely, OCD will get an even stronger grip on my life and my inability to use faucets will get even WORSE. I WON’T allow that. I won’t allow it because I am going to fight OCD until I take my last breath on this good Earth. I WANT TO MAKE THE MOST OF THE HEALTH THAT I DO HAVE!!

        PEOPLE WITH OCD HAVE AS MUCH OF A RIGHT TO BE HAPPY AS ANYONE ELSE.

        A few more thoughts. I’ve had 3 psychologists work with me over the years, and I forget how many psychiatrists…perhaps about 6. My first psychologist was my favorite. I worked with him for 9 years before he moved out of town. He taught me about the importance of:

        – DON’T compare your success (or failure) to treat OCD with anyone else. EVERY CASE IS DIFFERENT.
        – ERP, creating an ERP hierarchy to work from, and keeping a journal of how your ERP work is going. This is a big one!!
        – Thought Stopping (I struggle with this but I like the concept)…it is part of “preventing the response”.
        – Get regular exercise (I am terrible at this). But in the past I have gotten into good shape and it helped a LOT.
        – Relaxation exercises
        – Good nutrition
        – Getting enough rest
        – Doing things you love to do whenever you can to get your mind off OCD. In other words: PLAY!!
        – Manage your stress as best you can. In my case, I do MUCH better on days with low stress.
        – He introduced me to Mindfulness and Meditation a bit too.

        I’ve tried them all. Some more than others.
        Here’s what I’ve learned:

        EVERY LITTLE BIT HELPS!!
        WHEN YOU COMBINE ALL OR EVEN A FEW OF THESE “TOOLS” YOU CAN IMPROVE YOUR HEALTH AND HAPPINESS.

        I’m not great at doing all of the above at the same time. It’s a lot of work!! But when I combine several of the “therapies” above and work on all of them at the same time, my symptoms DO IMPROVE to some degree. That’s a wonderful feeling! It gives me HOPE that I can improve if I work harder and/or smarter to fight OCD.

        I also try to remember to be grateful for all the blessings in my life and there are MANY!!
        – I have a roof over my head.
        – I have enough to eat and clothes on my back.
        – I have a loving family that tries to help me when they can. (Yes they get frustrated with my need for support, but they never give up on me. That blessing is HUGE!)
        – I have a great psychiatrist right now. He has a photographic memory and is amazingingly intelligent.
        – I have a few hobbies like using a computer that I can do fairly easily and when I “escape” into that “virtual world” for a time I don’t worry about OCD at all. I’m doing that right now!! It gives me a chance to take a much needed BREAK from worrying about OCD. I happen to be VERY hard on myself (beat myself up) when I fail to get better.

        Consider trying a new approach to your treatment from time to time. You don’t know what will help until you try. Right now, I am thinking that my current psychologist knows the concepts of ERP, but may not be giving me enough “hands on” support and coaching. When I see him I feel like I’m just revisiting old ideas for treatment. We talk a lot. He does not help me try ERP practice in his office. Actually none of my three psychologists have done that. So it may be time for me to visit a new psychologist to get a fresh perspective and some new ideas on how to help myself. (I just have to get up the courage and make the time to do that! It’s not easy as we all know.)

        I believe it helps to review the basics of ERP on a regular basis. One key basic rule of ERP is that THE FEAR ALWAYS GOES AWAY. ALWAYS ALWAYS ALWAYS!! I have never had fear or anxiety that has not gone away eventually. Rarely it takes days or weeks. USUALLY it takes just seconds or minutes once I break out of the ritual that I’m caught up in because of OCD !!! Once my mind focuses on something new, I’m good to go (until the next obsession pops up LOL).

        I have days when OCD “owns me”, but I also have low stress days when I’m well rested. On those GOOD days I can “manage” OCD fairly well (fight it off…do OK with faucets, etc.)
        DON’T FORGET TO CELEBRATE WHEN YOU HAVE SUCCESS IN YOUR BATTLE WITH OCD!! 🙂 REMEMBER THOSE TIMES OF SUCCESS. When you have a bad day remember that bad days pass.

        I’ve said a lot here. Sorry if it’s overwhelming. My main point is that EVERY LITTLE THING YOU DO TO MANAGE YOUR OCD HELPS (at least in my case), and if I can COMBINE several of these “healthy” ways of living they add up to at least SOME improvement in the quality of my life.

        If I STOP these healthy habits my OCD gets more control over me and the quality of my life gets worse.

        SO my personal opinion is: NEVER QUIT TRYING, and don’t be afraid to TRY NEW THINGS (I’m not so great at that).

        TRY TO LIVE AS HEALTHY A LIFESTYLE AS YOU CAN. AT LEAST IN MY CASE, THAT MAXIMIZES THE QUALITY OF MY LIFE…

        …AND QUALITY OF LIFE IS WHAT IT’S ALL ABOUT. THAT’S THE GOAL.

        ALSO WHEN YOU DO BETTER, YOU MAKE LIFE BETTER FOR THOSE AROUND YOU WHO YOU LOVE AND CARE ABOUT. When you feel well you put less stress on your “support team” (family, friends, even doctors!!)

        So my advice is DON’T GIVE UP. But don’t push too hard all at once either because then you may burn out from trying too hard (I do).

        ALSO REMEMBER LIFE IS SHORT!
        Most people are fighting some sort of battle that we don’t know about. They might be in debt and fear losing their home. They might have a relative who is very ill…and on and on. Life is a challenge for most of us in one way or another.

        OK. Summary:

        – DON’T GIVE UP JUST BECAUSE ERP IS NOT HELPING.
        – KEEP TRYING NEW THINGS TO IMPROVE YOUR HEALTH!
        – COMBINING MULTIPLE GOOD HEALTH HABITS MAY LEAD TO IMPROVEMENT IN YOUR OCD SYMPTOMS!

        THERE’S ALWAYS SOMEONE OUT THERE WITH TOUGHER PROBLEMS THAN YOU, SO BE GRATEFUL FOR WHAT IS GOOD IN YOUR LIFE. Remember there are innocent civilians who are trapped by the war in Syria right now. They face death from stray bullets/bombs every day, and they are literally starving to death and have no place to turn for help in many cases.

        LIFE IS SHORT AND PRECIOUS!
        DON’T WASTE IT!
        DO THE BEST YOU CAN WITH THE “HAND YOU HAVE BEEN DEALT”.
        FOCUS ON THE POSITIVE THINGS IN YOUR LIFE AS MUCH AS POSSIBLE!!

        I wish you the best of luck on your journey!

        – Paul K

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