Part 3: Habituation during ERP treatment: Always appreciated, never expected
In Part 1 of this series, we reviewed the history of ERP in OCD treatment and how that history was related to the idea that an important part of effective ERP was the experience of habituation within exposures completed during a therapy session.
In Part 2, we reviewed how the ideas described in part 1 have changed. Specifically, we reviewed that it’s no longer thought that within session habituation is a requirement of effective ERP treatment.
This brings us to part 3. If it’s the case that we’re not aiming at habituation during an exposure, what are we aiming at?
Part 1 and part 2, we emphasized the role of new learning in the process of exposures and described the ways in which habituation during an exposure is related to new learning. Although we’re not aiming at habituation, we’re still aiming at new learning experiences. What’s changed is that we’re not exclusively focused on the new learning related to feelings of anxiety decreasing over time (although feelings of anxiety often will go down over time and that’s always appreciated).
Instead, we’re primarily focused on new learning related to our ability to tolerate unwanted, distracting thoughts and related anxious, painful feelings. What’s more, we’re also focused on new learning related to our ability to meaningfully engage in our lives even when unwanted, distracting thoughts and related anxious, painful feelings are present.
This new learning is part-and-parcel of the development of the skills of distress tolerance and psychological flexibility. Like every skill, we improve at these skills the more and more we practice them. In fact, if we practice these skills enough, they become automatic and easy and that process (the process of those skills becoming automatic and easy) is what many people are looking for when they come to OCD treatment.
The difference between Knowing and Being
For example, many people who come to see me for OCD treatment will tell me that they “know” that their intrusive thoughts are related to feared events that are very unlikely to occur. However, they come to see me because their “knowledge” that the feared events are very unlikely to occur doesn’t change the fact that they feel extremely anxious. Whatever it is that they “know”, their unwanted, distracting thoughts and anxious, painful feelings make it very difficult for them to live their lives each day whether or not the feared event actually occurs.
This is where the development of the skills of distress tolerance and psychological flexibility comes in (well, technically, after we’ve reviewed the inevitability of uncertainty and the role of taking calculated risks in ERP treatment). By developing their distress tolerance and psychological flexibility skills, my client’s “knowledge” that their feared event is unlikely to occur translates into here-and-now improvement in their ability to live their lives despite the existence of unwanted, distracting thoughts and related anxious, painful feelings.
By-and-large, the more and more confident my clients become that they can handle unwanted, distracting thoughts and related anxious, painful feelings, the less and less concerned they become about those experiences arising in the future. The less and less they are concerned about those experiences arising in the future, the less thoughts they have about the possibility of those experiences arising in the future and the less anxious they feel. In other words, they move closer and closer to their treatment goals, which include having less unwanted, distracting thoughts and less anxious, painful feelings.
Crucially, the path my clients take to reduce their unwanted, distracting thoughts and anxious painful feelings is indirect. We don’t directly reduce their unwanted, distracting thoughts and related anxious, painful feelings directly (e.g., we didn’t block the thoughts and feelings, or eliminate the thoughts and feelings in one way or another – if we could directly block unwanted thoughts and feelings, OCD probably wouldn’t exist). Instead, they get really, really good at being with the unwanted, distracting thoughts and anxious, painful feelings. This getting good generates confidence that if these thoughts and feelings arise again in the future, that they can handle them.
The more confident they are that they can handle it, the less and less they’re concerned about those thoughts and feelings in the future. And now, coming full circle, we can see why it’s so important to participate in ERP instead of just “knowing” that our fears are unlikely.
Confidence comes thru practice
Confidence is generated by past success. If someone is confident they’ll be successful, this almost certainly means they have a lived history of those successes.
For example, imagine I tell you that I’m confident that I’ll beat my nephew the next time he and I play chess. You might think, “Well, William you sure are cocky, going around being so confident that you’ll beat your nephew.” And I could reply, “Well, I’m not trying to be cocky. I’m just reporting I’m confident I’ll beat him. And let me tell you why I’m confident I’ll beat him: I taught him how to play. We’ve played hundreds of times and he’s never beaten me. I consistently continue to study and improve at chess and I know my nephew has not been playing or studying chess at all because he’s too busy with college.”
Does this mean it’s 100% certain that I’ll beat my nephew if we play again? Of course not. But I probably will. I’m confident I will for the reasons listed above.
Similarly, when we participate in ERP, we want direct, lived experience which demonstrates that we can handle the unwanted, distracting thoughts and related anxious, painful feelings. And we want direct, lived experience that, even when we’re having the unwanted thoughts and feelings, we can continue to meaningfully engage in our lives. But, as you’re probably seeing clearer and clearer, it’s not enough just to “know” what the skills are in the same way that “knowing” what juggling entails is not the same thing as being able to juggle. So how do you become good at juggling? Part of it might be related to knowledge about the techniques. But a necessary component of learning how to juggle is…juggling!
So, to sum up, in ERP practice we love habituation. It feels great. But it’s not our top priority. Our top priority is getting good at a new set of skills. And to get good at skills takes practice. The more we practice, the better we get. The better we get, the more confident we become. The more confident we become, the less anxious we are about experiences that previously scared us.
In the final portion of this series, for those interested in what’s going on underneath the surface of these processes, we’ll take a deeper dive underneath the hood of what’s occurring in ERP treatment during habituation and skill development and how we think this is related to overcoming OCD.
