How Should I Set about Starting Treatment for Myself?

The first thing to do if you want to start working on your OCD is to fully assess the problem yourself. Imagine you had a magic wand and could make all your OCD symptoms go away. What would your life look like? Where would you be living? What job would you be doing? What would your social life look like?

Next, assess what you would need to do to achieve your goals. Would you need to go back to college to gain some qualifications? What would be necessary for you to learn to be more independent, etc. This list may appear daunting, but bear in mind that there is no rush, and every step in the right direction is a step nearer your goal.

It may be helpful to keep a list of your goals nearby to remind yourself of your dreams when treatment is tough. Some people place a reminder of where they are aiming next to their bed or keep it written on a card to look at when they become disheartened.

What Next?

Think about the problems and write them down. These may be similar to the following:

• ‘Fear of dirt and germs for fear I may become ill and spread the infection to other people’

• ‘Fear I may contract HIV’

• ‘Fear I may be a paedophile and may act on this’

• ‘Fear that unless I perform everything perfectly I will be rejected’

• ‘Fear that unless I check doors, windows, gas, and electrical appliances, a disaster will occur’

• ‘Fear that unless I perform tasks in a set way I won't feel “just right” and will be anxious and uncomfortable’

These are just a few of the possibilities. It can be difficult to identify exactly what the fear is, but it is worth spending the time to try to identify it. Many people may have more than one major fear or ‘theme’ of their obsessions. Identifying the fear in this way not only makes it easier to perform the next step in the ERP but also makes the OCD seem more manageable. People with OCD are often overwhelmed by their problems and feel they ‘cannot see the wood for the trees’. By isolating a few ‘themes’ in this way, it can make you realise that the problem is, indeed, containable.

How Do I Develop My Goals of Treatment?

After you have identified the fear(s), consider what task you would be able to do to demonstrate to yourself and others that you have overcome it. For example, for a fear of contamination, the task might be ‘Visit a public toilet, sit on the toilet seat without using disinfectant, use the toilet and leave with a 30-second hand wash’. For fear of paedophilia, it might be ‘Sit in a place full of children without checking’. For fear of disaster occurring in the house, it might be ‘Leave the house without checking’. For perfectionistic fears, it might be ‘Deliberately leave the house without checking my hair and clothes’.

Although this stage is not essential, it can help with devising the hierarchy.

Set out a ‘Ladder’ or ‘Hierarchy’ of Fears

In this step, the stages on the way to facing the fear are identified without performing any anxiety-reducing compulsive rituals or reassurance-seeking. It is important to remember that these tasks need to be performed without the compulsions, and the anxiety needs to be scored in this way. For some compulsions, such as ‘hand washing’, there will still be a ban on the compulsions and a whole ‘new’ way of hand washing will be introduced. Once you have identified the stages in this way, score the anxiety/discomfort you think you will feel whilst engaging in them. A useful scoring system is to score as follows:

• 0 = no anxiety

• 2 = mild anxiety

• 4 = moderate anxiety

• 6 = severe anxiety

• 8 = extreme anxiety/cannot be higher/panic

As an example, Table 10.1 presents a hierarchy of someone who has fear of dirt and germs for fear of contracting and spreading an illness.

The hierarchy may contain many more items than listed in Table 10.1. It is also important to remember that the exposure tasks should be performed without performing compulsive rituals. With regard to hand washing, clearly everyone needs to wash their hands during the day, but the key here is the extent and way in which this is done. Most people with ‘decontamination rituals’ perform them in set ways. For example, they may always wash in running water and may wash beyond their wrists. The hand wash may take several minutes. In the exposure programme, all hand washing except that before meals or food preparation should be banned. Hand washing should involve putting some water in the basin and then washing to the wrist only for approximately 30 seconds (or the time it takes to sing ‘Happy Birthday to You’ in your head). Programmes should not be performed immediately before preparing meals but, rather, are best performed after eating, and after the hand washing has been performed, to prolong exposure time.

How Should I Perform My Exposure Tasks?

Exposure tasks need to be performed consistently and regularly. You need to start at the bottom of the hierarchy and not jump to higher levels. Stick with one or two items and conquer those before moving on.

The exposure must also be performed regularly, ideally three times a day but at least daily if you are to experience benefit. Record your anxiety during each exposure task (using the same 0–8 scale discussed previously). You will find that initially your anxiety will last for two or three hours, but the more you practice, the shorter the anxiety will last, and the level of anxiety will also decline.

You may find yourself performing compulsive rituals before you realise it. This is normal and natural. If you do perform the compulsions, then go back and re-expose yourself to the fear. With decontamination compulsions, after touching the item it can be useful to touch your body, clothes, and hair and, if possible, lick your hands because this is much more difficult to ‘undo’.

Compulsive thoughts are much more difficult to control. For this reason, it is often best to make a recording of the obsessive fear-provoking thought and listen to this on repeat mode on your mobile phone or similar portable device whilst performing exposure. It is difficult to always ‘undo’ the exposure if the exposure is repeated.

Some people try to ‘jump around’ the hierarchy and suddenly perform a much more difficult item. This is not a good idea. People who do this end up disappointed and disillusioned. Remember that you need to learn to walk before you can run. It takes time, but the gradual approach is best.

Once the items at the bottom of your hierarchy are causing little or no anxiety, it is time to step up to the items causing moderate anxiety. You will probably find that having done the groundwork with easier items, these more difficult items are now easier than you expected and may only cause mild anxiety. Once you have conquered the items causing moderate anxiety, move on to the more difficult items.

At the end when you have performed all the items on the programme, take stock of where you are with respect to the initially stated therapy goals. Think about your life goals and whether now is the time to move forward by taking on a training course or other challenge. Remember that obsessions can expand to fill a vacuum in your life and so keeping busy can be useful in the battle to overcome OCD.

Troubleshooting

Therapy does not always work out as it does in books. There are certain things you need to be aware of.

First, the obsessions will still persist for a long time even after you have faced up to them. The important thing is not to give in to the compulsions. Eventually, over time, the obsessions will fade.

In addition, sometimes as you start to tackle one obsession, another even worse obsession develops. Do not get distracted by this. Remind yourself that, however unpleasant, it is just an obsession, and once you have dealt with the one obsession, you can move on to dealing with the next one. Do not get disheartened – this is all normal and will just take time. Remember, you will overcome the problems in the end.

What If the Anxiety Is Not Coming Down?

Have you exposed yourself for long enough without performing compulsions? Remember it will often take two or three hours before the anxiety comes down. The other issue is whether you have performed the exposure three times a day. Although it does not have to always be three times a day, it must be at least once or twice a day if you are to achieve good results. Three times a day usually leads to the quickest results. Have you been honest about your compulsions? Are you still getting some reassurance or performing other compulsions which will serve to maintain your anxiety? However tempting it can be to engage in compulsions, they really do help maintain anxiety.

If you are sure you have dealt with all the previously mentioned issues, then it may be worthwhile to consider either trying a course of SSRIs or trying some professional help.

Reward and Praise Yourself

Finally, remember that ERP is far from easy. You need to be very brave to face your fears. Once you have truly faced your fears, you need to reward yourself. Take stock and pride in what you have achieved. Remember that true heroes experience anxiety but face it. That is what you have been doing, so you deserve to be kind to yourself. OCD is not a weakness nor a character flaw but, rather, a very real illness, just as any physical illness is not a character flaw or weakness. Praise yourself for what you are doing for yourself, and remind yourself of where you are heading. Do not get disheartened if progress seems slow; it is much better to have a slow but effective programme than a ‘miracle cure’ which collapses within a short time.

Set yourself small rewards after completing your programmes – whatever you enjoy that does not completely break the bank. Maybe a relaxing soak in a bath (assuming you do not have washing compulsions!). Perhaps a walk in the park or a favourite meal? Pamper yourself a little!

Good luck and remember that even people who do not succeed the first time often succeed when they try again. Be kind to yourself, and keep your sense of humour!