Enhancing Exposure Therapy: Generalization For OCD Treatment

This article is a follow-up to my social anxiety generalization guide. Today let’s talk about how you can create generalization in treatment for OCD. This should help those undergoing treatment professionally or self-directed, and those who have successfully beaten OCD and want to keep it away.

What Is Generalization?

In treatment, let’s imagine you are working on being able to type on a computer, something you are not able to do as the keys feel contaminated. While making progress on typing in the therapist’s office is great, you need to learn to type on various computers at work, in public, at home, and in coffee shops. This is called generalization. Your gains in one area start being realized in various other settings.

Why Is Generalization Important?

It means that gains in one area occur in all areas of your life. As a result, if you achieve generalization then you are making treatment way more successful, in addition to reducing the risk of relapse.

What Is OCD?

OCD is a disorder that affects people in very different ways. About 1 in 40 people experience significant symptoms. The core of the issue is that someone has unwanted thoughts or images that they can’t get out of their head, which we refer to as obsessions, and so they resort to acts, rituals, or avoidance in order to prevent or stop these thoughts. These acts are called compulsions. The best treatment for OCD is exposure response prevention (ERP). Sometimes medication can be used to help enhance this treatment. For children, ERP is the best treatment option. There are more treatment options for adults, but you should start with ERP as it’s the gold standard, and move to something else if it doesn’t work.

Making generalization part of your treatment is super important when treating people with OCD because a person’s obsessions can come back or morph over time, especially for kids and adolescents across different developmental time periods. One of the main reasons I work mostly with children is for this reason. If I can work with a child to get control of their OCD and then stop it coming back by generalizing treatment gains, I will stop them experiencing distress and impairment into adulthood.

How To Treat OCD

The essence of ERP treatment is facing the fear involved in the obsession. For example, with contamination OCD, the obsession may involve avoiding germs, but the fear is about getting sick. To avoid getting sick, the person may excessively wash their hands or body. By understanding this, it hopefully makes sense how OCD works: The compulsions (e.g. washing) provide relief from distress and anxiety. It’s very reinforcing. ERP works by trying to break this association. It creates new learning in the brain in two ways: First, one learns that the anxiety-producing thing is not as anxiety-provoking anymore, and second, that anxiety comes down without the need for compulsions. By touching potentially dirty/contaminated objects, you are doing exposure. By preventing washing afterwards you are doing response prevention. The response prevention part is the real key to good treatment. To make good progress in OCD treatment, you are looking to make sure that rituals, compulsions, and avoidance of potential triggers are not occurring in everyday life. This is where the concept of generalization comes in. If you’re not doing it in your treatment, you should be!

To give yourself the best shot of beating OCD you need to turn everyday activities into exposure possibilities. How to cover this for OCD is a little tricky to discuss because it can come in so many forms. For example, people have obsessions about germ contamination, things being “not right,” moral scrupulosity, sexuality, harming themselves/others, numbers, decision making, and many other categories. I’ll focus this article on germ contamination and “not just right” experiences so it’s somewhat focused.

OCD Is About Certainty

All OCD is about is certainty – trying to make sure that the feared outcome will not occur. The compulsions are designed to make certain that the bad thing won’t happen. Let’s look at some examples:

  • When the fear is about getting sick and the compulsions try to prevent this, OCD is really working to be as certain as possible that a person will not get ill.
  • When something feels “not right,” the OCD is trying to make a person correct this to be certain that everything is “just right.”
  • When OCD is about moral scrupulosity, OCD is trying to make sure that a person doesn’t offend some moral code.
  • When there is concern about harming others, OCD makes someone avoid any situations that could involve harm to others to make certain that no harm occurs.
  • When there is decision making OCD, the rituals often involve excessive thinking through and checking to make sure that whatever decision made was the very best.

But here’s the rub…There is no way to guarantee certainty. Think about it for a moment… Can you ever be 100% sure that you won’t get sick? Or that you made the best decision? Or that you won’t harm someone? Of course not. There is no way to guarantee, with absolute certainty, that the thing you fear happening will not occur. Even if you locked yourself in a room all day, you can’t guarantee that you will not get sick as there’s always some risk. As such, instead of going the OCD route, which has you engage in rituals and avoidance to minimize the chance of something bad happening, you have to take the risk that the bad thing will happen in order to beat OCD. I think of it like a balance. On the one side, you can continue to engage in OCD rituals, but this means sacrificing a lot of freedom in life. On the other side, you can cease OCD rituals and be more free to pursue whatever you want. Which sounds best to you?

Given that OCD is about certainty, the main goal of treatment, across all forms of OCD, is tolerating uncertainty. I cannot emphasize this enough. Don’t focus too heavily on proving the OCD wrong by hypothesis testing (e.g. if I only touch the light-switch once does something bad happen?). This is a mistake for various reasons. What do you do when the fear is a long-term one (e.g. I might get cancer in 20 years), is not a simple cause and effect relationship. Or what if the negative thing being tested actually happens? Instead, focus treatment on tolerating the uncertainty that there is no way to guarantee that the bad thing won’t happen.

Generalization for OCD

As you know, to improve OCD treatment, the exposures you do need to occur in various aspects of your life (not just in the therapy office!) in order to promote generalization. Before you do any exposures, let’s identify some guidelines for doing them:

  • Know the fear. Your exposure target needs to really elicit this fear. To make the exposure good, you have to ramp up the feeling of uncertainty.
  • Know what the OCD wants you to do when feeling anxious, so you can block it. This is called response prevention.
  • Focus on what was learned as a result of the exposure. This should involve learning that a person can tolerate the uncertainty, and that compulsions are not needed to lower anxiety. Instead, completing the exposure, preventing rituals, and tolerating that feeling will result in reduced anxiety and getting your life back.

A Couple of Tips:

  1. Whenever you do an exposure, do it all the way. That means full immersion in what you do. If you only half take a risk, you’re not really taking the risk.
  2. If you do any safety behavior (e.g. you just touched a bathroom door but then you blow on your hands to get off possible residue) then the effect of the exposure is ruined. I’d highly recommend doing it all over again. The response prevention part is the most important. If you can’t do something with full response prevention, consider trying to make the exposure a little easier so that you can, and building up quickly from there.
  3. Before you do the exposure, know exactly why you are doing it and what you are testing. The most important thing to ask yourself afterwards is “what did I learn?” If the exposure isn’t designed well then you’ll not get as much out of it.

 

OCD Exposure Ideas For Generalization

To help with generalization, I have created a short list of exposure ideas in every day activities. These exposures will help you immerse yourself in the exposure lifestyle but are meant only as a supplement to your treatment. Because there are so many categories of OCD I’m going to focus on mainly two areas: “Not just right” experiences (NJREs), since about 50% of people with OCD experience these, and contamination fears since it is also very common. This won’t apply to everyone and is simply meant to give ideas that you can adapt to specifically target whatever the fear is. I could write a million different examples, this is simply meant to provide some ideas. Happy exposure hunting 🙂

Grocery Shopping:

“Not Just Right” Experience

  • Every time you find something on your list, just throw it into the cart. Leave it wherever it lands, even if it’s upside down or the “wrong” side of the cart. You will learn to tolerate it even if it feels horrible at first.
  • Look ahead and walk straight, thinking about all the cracks you may be walking over. If you practice this a lot, it will not feel as bad after several attempts! It’s important that afterwards you don’t overcorrect the feeling (e.g. by stepping on more cracks), you must sit with it and notice what happens to that feeling over time.
  • Pick up an item, put it in your cart, and put it somewhere else in the store where it doesn’t belong. This also targets scrupulosity.

Contamination

  • Watch the fruit section and wait for someone to pick up a piece of fruit that they put back. Then take that piece and buy it, before eating it. Try to tolerate the uncertainty about where their hands have been and that you may get sick.
  • Use the bathroom before leaving the store, don’t wash your hands, and then buy something for you to eat. You may worry that you have germs and could get sick, and this is true, but you have to learn to tolerate the risk.

Driving

“Not Just Right” Experience

  • On your drive, try messing up whatever that symmetrical feeling is. Say to yourself that maybe that horrible feeling will never go away, but that doesn’t mean you can’t tolerate it or even have fun. For example, if you have to use the right and left turning signals equally, towards the end of your drive, go around a block in only one direction in order to use only one turning signal.

Contamination

  • Take an Uber/Lyft and put your hands on the back seat and the handle of the door. Take a guess at the last time that seat was cleaned, if ever. When you get out, rub your hands over your clothes and face to contaminate everything. Then try to go about your day.
  • Buy some candy. Take it out of the bag and put some on the passenger seat or in the cup holder. Then just enjoy your snack.

Taking the Bus

“Not Just Right” Experience

  • If the “not right” experience is having both feet on the floor feeling the same, you would sit down, and then maybe cross your legs such that only one foot is touching the floor.

Contamination

  • Hold onto the handrails. Think about how many people must have touched them. Imagine all the germs on your hands.
  • Eat something while on the bus. Yes, you may get sick with all the germs that are on the bus, but the goal is to learn that it’s fairly unlikely you’ll get sick, that if you get sick it’s not as bad as your worst case scenario, and that your anxiety about getting sick decreases with time without the need for any of your rituals like hand washing.
  • Put your bag on the floor and let it sit there the whole ride. Afterwards, make sure to fully touch all the surfaces of the bag. The goal is to get as contaminated as possible, not do anything to clean or reduce the contamination, and continue with your day without avoidance to allow that anxious feeling to go down.

Walking

“Not Just Right” Experiences

  • A common one is walking over the cracks. Try walking to a shop, or for several blocks, without looking down. Tell yourself that maybe you are walking over the cracks, it could do harm or it could just feel horrible. You’ll learn that the horrible feeling associated with this will decrease over time, and though you know that harm could occur, it’s just a risk that you have to take to beat OCD.

Contamination

  • Do your shoelaces outside, on the grass. You know that might get dirt, dog pee, or any number of contaminants on you. You’ll learn that you don’t get sick as often as you think, that you can tolerate being sick, and that life is much better even though you’re taking the risk.
  • Drop some food on the ground and then eat it. The 5 second rule is great, but if you want to challenge yourself then you can leave the food longer. Tell yourself “maybe I’ll get sick” just to ramp up the challenge by blocking any self-reassurance.

Hanging out with Friends

“Not Just Right” Experiences

  • You might be tempted to arrange things in the room, or on your plate if you’re eating. Instead, how about you try to mess things up a little bit more?
  • Perhaps the clothes you are wearing have to match in some way, like colors or symmetry. To break this, it’s very easy to choose something that doesn’t quite match, or to break your dress symmetry (e.g. wear two different pairs of socks)

Contamination

  • Shake your friends’ hands. Remind yourself that you have no idea what they have touched, when they last washed their hands, or when they went to the toilet last. Again, this increases your anxiety and blocks reassurance, which is exactly what we are looking for in exposure treatment. Make sure you eat something too, just to increase that sense of contamination.
  • If your friends have any animals, make sure to pet them. Sit on the floor with them, with your hands touching the floor. Think about how contaminated they must be and that you might get really sick. Get a sense of how high your anxiety is and ride it out. You’ll notice that your anxiety decreases. In addition, try to have fun. Just because you’re contaminated doesn’t mean you can’t have fun.

Watching TV

“Not Just Right” Experiences

  • Sit in a different place to the usual one. Try pressing the remote buttons with a different finger to the one you usually do. This will feel uneven, but you can handle it!
  • When you walk into the room, make sure only one foot touches the crack dividing the 2 rooms

Contamination

  • Never wash your remote and have as many people use it as possible so that it always feels dirty.
  • Touch something a little sticky (e.g. honey) and let it just dry on your hand (this is also an NJRE exposure). Then clean your hand by licking it clean.
  • Do something that feels really messy first, such as picking things off the floor with your hands, touching various door knobs, putting your bare hands into your dirty laundry, then sit and watch TV without doing anything to decontaminate. I bet you’ll have fun watching TV and you’ll see that your thoughts move from feeling distressed to enjoying the TV program.

Eating breakfast

“Not Just Right” Experiences

  • Eat with your utensils switched, so that if you eat with your left hand you would eat with your right hand or vice versa. You’re learning that you can tolerate the feeling and get through the day. That weird sense will go away and you’ll solidify your learning that you don’t need those compulsions.
  • If you can’t have your food touching, mix it up even if it doesn’t taste as good that way. The sacrifice will be worth it as you’re just giving OCD a little kick up the backside!

Contamination

  • Guess what? You should do something around making your food contaminated. You can do this by putting food in places that are contaminated. However, you can also contaminate your eating utensils in the same way. The goal again is to tolerate feeling contaminated without having to reduce it through compulsions, and to risk getting sick because a life where you get sick more often is so much more preferable to a life with OCD.

Getting Dressed

“Not Just Right” Experiences

  • Wear your watch on the opposite wrist for a day.
  • Put on your clothes on the “wrong” way – however that looks for you.
  • Mess up any symmetry you might have or let your clothes not match. Tighten your tie only to the point where it feels wrong. The goal with all of these is to tolerate that things just don’t feel right, and over the course of the day that feeling will disappear, along with the hold that OCD has in various areas of your life

Contamination

  • Put a little something dirty on your clothes so you know they are ruined for the day. Even though nobody else may be able to see it, you will know they are contaminated and you’ll carry that around with you for the whole day which will be excellent exposure provided you don’t engage in any compulsions to lessen this feeling.
  • When you put on one sock, hold the other one using your teeth. It’s a good direct exposure to getting something you may associate with contamination.
  • This one will sound gross, but wear a pair of socks or your underwear for a second day running. This is a harder exposure for many. You’re learning to allow yourself to get contaminated without having to engage in safety behaviors, which will free you from OCD.

Working/School

“Not Just Right” Experiences

  • Put something in your bag upside down, or mess your desk up for the day.
  • Write with a pencil instead of a pen, as that feeling can be challenging. Or write over the lines on any paper so your writing feels “messed up.”
  • Sit in a different place in the room, or with a different body position (e.g. crossed legs if you don’t usually).

Contamination

  • When you use the bathroom, don’t wash your hands. This may be difficult and you may argue it’s gross and even unsanitary. I’d argue that point with you. First, we know that up to half of people don’t wash their hands anyway, so it’s not uncommon. Second, even if you do wash your hands, all those germs you think you are avoiding you’re getting on you anyway: Such as when you open the door that has been touched by many who didn’t wash their hands, shake someone’s hand who may not have washed their hands, or even simply touch your shoes which have been all over the bathroom floor. Yes, you’re risking getting sick doing this exposure, but the point I’m arguing is that you take this risk anyway without knowing it, so own the exposure and see what happens. To beat OCD, you have to learn to live with the uncertainty that there is no way to guarantee that you won’t get sick. Doing what OCD says will guarantee that your life gets severely disrupted though.
  • If you can do the above exposure, take it a step further. Have a snack in the bathroom. Use your phone. Don’t use a toilet seat cover. All while not washing your hands. This will help you learn to live with the uncertainty that you may get sick, without resorting to compulsions.
  • When you have lunch, make sure your food touches a table at work that has been used by others.
  • Use a communal pen for the day. You can find them at the front desk of an office, or your teacher will likely have one.

 

I hope this gives some ideas for exposures in various areas of life that will facilitate generalization in treatment and stop OCD from coming back if you’ve already beaten it. This really gets to the heart of the “exposure as a lifestyle” idea. Thanks for reading, please feel free to leave comments below, and if you want to be notified about future articles please click the like button to follow my page!

One comment

  1. This is your best article yet! I really enjoyed reading it. You provide very helpful suggestions for treating OCD through ERP. Well done!

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