← Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression
Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression
474 ERP at Home: How to Build an Exposure Plan Without a Therapist
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Did you know that it takes between 7 and 14 years for someone to be correctly diagnosed with OCD? What? How is this even possible? But the truth is it's similar for a lot of other anxiety conditions. Hello, my name is Kimberly Quinlan. I am on a mission to equip 1 million people with a evidence based anxiety skills. And so today in this episode, we are going to talk about how to build an exposure plan without a therapist and help you trouble the common, you know, issues and concerns people have as they try to do this alone. Now, in no way am I saying that you should do it alone. If you need a therapist and you have access to a therapist, by all means having an ERP trained therapist is going to be so, so helpful. But for those of you I know a lot of you either don't have the resources financially or access to someone who is skilled in this area. So my mission again is to teach you as much as I can. All right, so let's get going. First, so what is an exposure plan? I want to be really clear about something first. When we say the word exposure plan or exposure therapy, that's technically not the right terminology. We, when we are building an exposure plan, we're actually talking about something called exposure and response prevention. So let's talk about what that looks like. The first step is exposures. This is where we face our fears or we face our discomfort. That is the first step or concept. That's not all it is. It also must involve what we call response prevention. And this is where we reduce the safety behaviors that you engage in that circle you back and cycle you back into having anxiety. In the moment they might feel like they're helpful, but they're actually making your anxiety worse. And then the last component is where we have to manage self criticism. Now this one doesn't technically have to be involved with an exposure plan, but research does suggest that those who manage self criticism and all of the mean things they say tend to do better mental health wise and tend to have reduction in relapse. And so I thought I would throw it in there. I try to throw it into every single component that I teach because I think it's a key component to giving you long term recovery. Now in your OCD toolkit, which is an online course, we have, I teach my students a start to finish treatment for ocd. And that's actually the steps I take with my one on one clients to help them move through exposure and response prevention treatment. Now it involves six specific steps. The first one is assessment and education. The Second is treatment planning. The third is mindfulness training. The fourth is self compassion. The fifth is exposure and response prevention. And the last is relapse prevention and maintenance. But for today, what we want to do is we want to really hone in and get close to stage two, which is treatment planning. That's what we're here doing today. We're coming up with an ERP plan or an exposure plan. Now, what does that involve? Now? Now, the treatment planning stage involves first identifying your obsession and compulsions. And we may also look at what are your family accommodations. I'll explain what that means here later. Then we can discuss how cultural and religious and personal values impacts the symptoms. And then again, we are going to identify self criticism and punishment and come up with measurable goals. Now here, when we talk about step number two in terms of discussing culture and religious, when we come up with these things, I want you to really think about am I doing this behavior because of fear and anxiety or am I doing it because a true religious or cultural ritual or routine or belief that I have? If it is the latter, then we would not label that as a compulsion. But if you are doing it because of that uncertainty and that, that anxiety and discomfort, well, then we definitely want to hone in on that today. So, so what I'm going to have you do is I want you to get a piece of paper. We are going to brainstorm down all of the ways in which anxiety impacts you. So the first thing you're going to ask yourself the question, what do I avoid? What are the things that we avoid in the day to day because of fear or uncertainty or discomfort? Once you've written all of those down and it's okay, I say in all, with all my clients and with all my students, it doesn't matter if it's one page or 17, please be gentle. We just want to get a thorough list. The next question will be what scares you? What thoughts scare you? What feelings? What sensations scare you? Are there any places or people or things that you are particularly afraid of? Please write all of those down. We want a thorough list. Again, please be gentle with yourself as you do this. Question number three is what physical behaviors do you do or do we do to relieve our fears or discomfort or uncertainty? What physical things do you deal and I'll go through some examples of that. Common ones are washing your hands, checking your body, checking for reassurance. What physical things are you doing? Step number four is what mental behaviors do you do to, to relieve your fears, discomfort or uncertainty? So what are you doing from your neck up? What mental hula hoops and ropes and hoops are you jumping through? How much rumination are you engaging in? What are you doing in your mind to try and reduce or remove that uncertainty and anxiety? Number five is what do others do to help you reduce or remove your discomfort? Now this is what we call a family accommodation. This is where you're anxious in an effort to reduce your anxiety, somebody else changes their behavior so that they can relieve you of your anxiety. A very common one for this is someone saying to their family members, you're not allowed to touch A, B and C because that makes me uncomfortable. Or you're not allowed to say A, B and C because it makes me uncomfortable. You're not allowed to watch this TV show because it makes me uncomfortable. Or I'm going to need you to do that one task or that one activity because it creates anxiety for me. Okay? So that's what we call a family accommodation. We want to write all of that down as well. If you are really in a trusting relationship with your family members, you may go to them and ask them, what behaviors do you do to reduce or remove my anxiety? How is it impacting your life? And use that as a part of your brainstorming. Now, as you know I have a private practice. I have six amazing therapists in Calabasas, California. However, we do not take insurance. Now if you are looking for insurance covered OCD or BFRB treatment, I want to let you know about nocd. NOCD provides face to face live video sessions with specialized licensed OCD therapists. Now their therapists use exposure and response prevention. We know this is the gold standard standard for ocd. So you can be absolutely confirmed that you're in the right place there. And they have a clinically proven app that helps you stay connected to your therapist and others who have OCD between sessions so you'll always feel supported. Now the cool thing is NOCD is available in all 50 US states and even internationally and they accept most insurance plans making it a affordable and accessible. We love that. Now if you think you might have OCD or you're struggling to manage your symptoms, you can book a free call. Just click the link in the show notes@nocd.com I am honored to partner with NOCD. I want to remind you that recovery is possible. Please do not forget that. Now big hugs and let's get back to the show. Now once you have all of the answers down. So now we are going to write what we call an exposure list. So after looking at those questions, we're going to think about what have we come up with? Number one might be we're going to. These are just examples, by the way. Maybe you said, I avoid eye contact. Maybe you wrote down I avoid thoughts about sickness or thoughts about, you know, certain things or people or places. Maybe you wrote, I hold my breath when I pass the hospital or a cemetery or a certain place. Maybe you wrote, I think about positive things to neutralize negative things like intrusive thoughts. Or let's say it's a thought about death or a thought about someone dying or a thought about something bad happening. So maybe you're doing neutralizing compulsions. Maybe you wash your hands when you touch anything in public. That's a very common one for contamination ocd. Maybe you avoid movies that have illness in it. Maybe that's more a health anxiety. Or maybe you have, again, contamination ocd. Maybe you don't allow your family to spend time with the Smiths, the people who live down the road. And again, that could be a religious obsession. It might be a contamination obsession. It might be a. Again, it could be anything. A harm obsession. It doesn't matter. Again, we're trying to identify specifically for you what specific behaviors you do. Another example might be I pray repetitively so I don't get sick. Another example might be I asked my husband if I could get sick. A form of reassurance. Maybe I ask my husband if I have a temperature. Okay, maybe there's a lot of these are health anxiety. Maybe I Google illnesses or I google, you know, certain bad things that you're afraid of happening to see if you have that illness. Now, that is an example of an exposure list. But now what we want to do is you've done most of the hard work. Now what we want to do is plan out how we are going to face these fears. So what I want you to do here is I want you to ask yourself, out of 10, 10 being the highest, how hard would it be for me to do the opposite of this behavior? Okay, so let's go through our list again, our exposure list that we came up with. That. That example one. And I'll show you how we do this. So let's say we talk about avoiding eye contact. How hard would it be for me to not avoid eye contact? Maybe I give it an 8 out of 10. It would be pretty hard. The next one would be, I wrote down avoid thoughts about sickness. How hard would it be for me to not avoid thoughts? Maybe a 7 out of 10. Next one. How hard would it be for me to not hold my breath when I passed a hospital? Oh, that's a 10 out of 10. Really hard. Really most hardest thing I could ever do. How hard would it be for me to not think. Think a positive thing to neutralize a negative or scary thought? Oh, that would be more of like a 5 out of 10. These are just examples, right? There's no right way to do this. Just write down as honestly as you can, how hard would it be to not wash my hands in public if I was out touching things? Although, again, 10 out of 10, that would be really, really hard. Okay, how hard would it be to not avoid movies about illness? Oh, that's only just a 3 out of 10. So you can see here we're going to be giving a number value to those. Now, if the numbers are too hard, you could actually just write moderate, easy, and hard. That's fine, Teal. But when we do that, now we have a plan of how we can gradually move up this hierarchy. So if we're looking at our list, we're going to first start with the easier things. On my pretend example list, it would be not avoiding movies. So I would start there. That's where I would practice my first exposure by maybe watching a movie. Now, let's say you say, well, to watch a movie is really only 3 out of 10. But if I had to watch the entire movie, that actually would make it really difficult. And so then you can break each exposure down into small baby steps. So you could even say, I'm going to watch five minutes of the movie. I'm going to watch 10 minutes of the movie. Let's say you're getting higher into your hierarchy and you're up to, like, the eight, like, not avoiding eye contact. That first one we talked about, that was an 8 out of 10. You might say, okay, that's a pretty high one. What is a manageable realistic goal that you could try to achieve? Oh, I could do it once. Great. Once is great. Then practice it once a day. And then you can move up to twice a day or twice in every time you go to the supermarket. And what you're doing there is you're gradually increasing the exposure as you go and doing what feels manageable. Now, something to remember is the exposure is when you practice facing your fear and your discomfort. But the response prevention is reducing those safety behaviors you do to eliminate that discomfort. So remember we were talking about eye contact. Say you said, a realistic goal is for me to do one look at one person in the eye and that's it. That's all I can do. That's fantastic. But what we want to practice is also once you've done those exposures, you can't run out and avoid that place and never come back in fear of that person. You have to keep going back. That's the response prevention. It's practicing not engaging in any additional behavior that undoes that success of that exposure. Okay? So be careful with that as we go back. Let's say you. Let's say you went out in public and you didn't wash your hands. That's great. But then when you got home, if you did an extra long hand wash, that means you did the exposure, but the response prevention was the area you needed to work on. So I know this is a little complex, but the. I hope you get the picture in that you have to have that exposure and you have to have that response prevention for it to be super successful. But again, please go gentle. This is not easy. Okay. From there, we also want to reduce self punishment. This is going to be key. So as you're doing this, practice while you're writing it down, while you're giving it a number value, while you're going out to practice it. We want to get extra bonus points for reducing any self punishment that we can. Number one, try your hardest not to engage in any self judgment. Number two, try to catch any self criticism mean words that you're using about yourself. We also don't want to punish ourselves. So self punishment might be saying like, you're bad. So I'm going to induce pain on you now that you deserve to be punished for doing that exposure or for having these intrusive thoughts. We don't want to be doing that. We also don't want to be doing any pleasure withholding, which is, oh, because you have these thoughts that you don't like or you did these compulsions. I'm not going to let you have the nice toilet paper. I'm not going to let you order the salad you love. You have to eat something boring and horrible. We want to make sure we're catching those little subtle compulsions. The next one is a concept I call gathering. This is a term I made up. It's not science based, but gathering is where we sit and we gather all the data of how bad we are and how wrong everything is and how bad things will be in the future. When we're doing this mental gathering, we're only inducing more pain. And the last one is isolating. We don't want to isolate when you're doing exposures, ask for help, reach out to people, get support. Your success will be so much more if you do ask for help and reach out when you're struggling. Now, common issues that people have with this process, people often get caught up in what if my thoughts mean something? Well, remember, thoughts aren't facts. And a big part of this is as you do the exposure, you don't you want to actually practice not giving meaning to whatever thoughts and feelings you're having. The next one is, can I handle this anxiety? I'm going to tell you here 100% you can handle anxiety. You will not explode. Anxiety is not going to harm you in any way. It is uncomfortable. But if you're kind, it actually feels much more tolerable. The other person might say, what's the point now this is a common hopelessness thought. The point is with this work, you actually get your life back. You can start to reverse the cycle of OCD and these OCD related conditions. The next question might be I don't want to feel uncomfortable. This work exposure work involves and response prevention involves the willingness to be uncomfortable. So really explore, maybe journal about what it is about the discomfort that you don't want to feel and practice your mindfulness skills as much as you can. We have all kinds of resources to help you practice this skill. In fact, I'm going to give you one here in a few minutes. The next one is it's not fair. You are right, it is not fair. It's not fair that you're going through this, but we have to do it anyway. We have to radically accept that everyone has something and this is the thing that you are going to be working on. But I promise you that with practice and with compassion, it will get a little easier each time. And the last one is I need more help. Well, if that's the one for you, of course I'm going to say, if you need more help, by all means seek professional help from an ERP therapist. Now, I also understand, as I mentioned before, we don't all have access to that. I understand, I've been there myself. Therapy costs a freaking fortune. And so for those folks who don't have resources and don't have access, we have created your OCD toolkit. This is a step by step goal of taking you through exactly what I teach my clients with OCD. It is there for you. Head on over to cbtschool.com or you can click any links below. And another one is if you're a therapist, listening and you want to learn how I do this? We have a course called the Clinicians OCD Toolkit which will teach you how I use exposure and response prevention with my clients. Now, as always, I want to remind you you can recover. These are conditions that are treatable. But please be kind with yourself, be gentle, it does take time and let it be messy. Number two here is, as I always say, it is a beautiful day to do the freaking hard things and I'm so excited and proud you for being here and doing it with me. I cannot wait for you to listen and learn more as we do this together in the mission again to help a million people manage anxiety. I'm so grateful you're here. I know how valuable your time is. So thank you for giving some time to me. Have a wonderful day and I will see you in the next episode. Please note that this podcast or any other resources from CBTSchool.com should not replace professional mental health care. If you feel you would benefit, please reach out to a provider in your area. Have a wonderful day and thank you for supporting CBTSchool.com.