Kyle: Dr. Yip, in terms of exposure exercises, I understand there’s three of them. I’d love for you to explain what they are and how they’re applied. The first one I understand is in vivo exposure, right?
Dr. Yip: So in vivo exposure basically means that you are actively in this situation. And that is of course, the best type of exposures that we can have a patient engage in. Because remember, when we’re doing exposures, we want all five of your senses to be completely immersed in the experience. We don’t want you to be, licking the bottom of your shoes, but then thinking about Disneyland.
We want you to really experience the exposures completely and fully immersing yourself in the exposures.
Kyle: So if my fear is a thought, how do I fully immerse myself in my thought?
Dr. Yip: There is a term that’s called pure o. And pure O means pure obsessional.
However, I think the myth is that people who have pure O don’t have compulsions. When in fact, their thoughts are also their compulsions. These are called mental compulsions. So a person with pure O might be mentally counting, might be mentally reviewing past events, might be mentally checking their thoughts to see what happened or what was correct or incorrect.
They might also be purposely having good thoughts to counteract bad thoughts. Or they might even be mentally editing or rationalizing with their thoughts because the trigger words, one of the most common trigger words for an obsession is what if? What if that doorknob really is contaminated?
What if I don’t use soap and my hands will get contaminated or I won’t be cleaning them enough? So the what if is a big problem. And what a lot of people do who are intellectualizing or rationalizing, they will basically what I call ping pong back and forth.
It’s almost like you have your devil and your angel on your shoulders, and they’re talking to each other and what if this? Oh no, that can’t happen because the statistics show…
And then what happens is that you get lost in your content.
And the person suffering from mental compulsions can be lost in the content of doing this ping pong back and forth for hours and hours. And of course, because it is so uncomfortable that they basically become frozen in their thoughts. So when we’re doing exposures to people with mental compulsions, what we do have to do is teach them a lot of mindfulness techniques – teaching them how to stay with the uncomfortable scenario. And we might actually do some mental exposures as well. Imaginal exposures. So that’s the second part of ERP.
Kyle: The imaginal ones, right?
Dr. Yip: Yes. So in vivo is always the best. However, the reality is that not every exposure is possible or ethical or even legal.
So if you have a fear of molesting children.
Kyle: I have a fear of it happening?
Dr. Yip: You have a fear that you might be a pedophile.
Kyle: Or that I will go molest a child?
Dr. Yip: And therefore just looking at a child will trigger the thoughts that you might molest a child.
Now, I just want to remind everyone that people with OCD don’t want to have these thoughts. It’s not like they gain pleasure from the thoughts, or it’s not like the fears, the obsessions fit with their values, right? They actually do not want to have these thoughts. However, again, when you are trying not to think of the yellow duck, what happens?
Kyle: Of course you think of the yellow duck.
Dr. Yip: So if you are fearing that you might be a pedophile and you’re trying not to think of these sexual thoughts of children, what are you going to do?
Kyle: You’re gonna think about sexual thoughts.
Dr. Yip: Exactly. Right now, for most of us, if we have a sexual thought, we’ll just go, eh, okay.
And keep it moving.
People with OCD give credence to the thoughts, and therefore they will appraise it with value that really doesn’t justify the reality.
Dr. Yip: So they will think, oh my goodness, I just had that thought. Why did I have that thought? I must be a sick person.
What kind of person am I? I must really be a pedophile to have such a thought. And therefore, they will continually try not to have the thought. And again, you get stuck in that vicious cycle. So for people with mental compulsions, we will purposely expose them to the thought. One of the things that we do to facilitate that process is we will have patients write a script.
We’ll have them write a narrative of visually seeing themselves actually going through the process of molesting a child. Now I see your eyes bug out there…
Kyle: I’m shocked by that.
Dr. Yip: Well, of course.
You have to realize it’s not like the person gains any pleasure from having the visual images, right?
Kyle: But part of my shock is thinking if you ask me to do that I don’t know if I would.
Dr. Yip: Well, if you don’t have OCD, you probably wouldn’t have to. And if you do have OCD, and if you want to get better, if you want to gain long-term relief, then this is the way, this is the way.
Kyle: This is what you do. Okay.
Dr. Yip: Remember, if you are only to think of the yellow duck. Does the yellow duck last?
Kyle: If I only think of the yellow duck? Well, eventually it’ll go away.
Dr. Yip: It’ll eventually go away. Same thing here, right? What we’re trying to teach patients is that rather than avoiding the thoughts, rather than not thinking of the thoughts, which is actually going to trigger them to be even more powerful, we want you to immerse yourself in the thoughts.
Dr. Yip: Full throttle.
Kyle: I get that. I get that.
Dr. Yip: So that the thoughts lose their power and lose the credence, right?
So we would write up a narrative, write up a script from beginning to end. And what I tell patients is that you have to use active verbs. So like I am running versus I ran.
It has to be in the present moment. It has to be present tense. It cannot be in the past. You’re not seeing yourself as if you’ve already done it. You’re actively engaging in it right now. And then what we’ll do is we’ll have them record it on an audio tape, and they would replay that again and again.
And we call that loop tape exposures. So we would have them put on the earbuds, keep playing it again and again. And for some people who are able to compartmentalize very well, they might be hearing it, and yet they’re mentally escaping, right? Which is no good, which is not what we want, right?
We want you to completely immerse yourself. So for those people, what we do is we will put you in situations that would actually reinforce the imaginal exposure. So for example, even though I can’t have you go and molest a child, right? We can put on the headset and we can go into a Carter store or a toy store, or we can go to the playground and put on the headset.
Kyle: Now people are gonna hear this and go, you are taking somebody who is having thoughts of molesting children, having them make an actionable game plan of them doing that and then taking them to where kids are. People are gonna go, why are you doing that?
Dr. Yip: Because the person doesn’t really want to have the thoughts.
A lot of patients with OCD will say, “Dr. Yip, how do I know that I’m not really a pedophile? How do I know that I’m not really a bad person? How do I know that I’m not a sexual predator?” And the reality is that a pedophile would not be asking that question.
A pedophile would not wonder. Am I really a pedophile or not?
Dr. Yip: A pedophile would not question why am I having these thoughts? A pedophile would not find the thoughts disgusting.
Whereas a person with OCD finds the thoughts and images disgusting.
Kyle: Okay, I get that. I get that. So the self-guided exposures, is that using the headphones and the tapes?
Dr. Yip: Yes.
Kyle: Now could you ever use an imaginal exposure or the self-guided exposures as a step before the in vivo? Meaning if I have severe contamination, can I start with headphones?
Dr. Yip: We can. And I think it really depends on the situation. Depends on the person, it depends on the situation. If a person is unwilling to actually play with children then we might start with that. We might start slow and move our way up. So that is a possibility.
Kyle: If you have more than one compulsion. How do you know which compulsion to tackle first?
Dr. Yip: You always have more than one compulsion.
Kyle: Oh, okay. Great. So how do I determine which one is the most important?
Dr. Yip: Depending on what that rule is. So again, when we developed the Fear Hierarchy. We determined what are the rules that we’re going to break, and here’s the thing, it is easy to say just don’t wash your hands.
Just don’t check again. Just don’t seek reassurance. That’s always easier said than done.
So my three rules for breaking compulsions is if you can not listen to the OCD monsters at all, do that. Because that is completely owning your decision to not engage and entertain the OCD monster.
Kyle: So I wake up every morning for 10 years. I wash my hands three times. If tomorrow I can wake up and I feel that urge to go wash my hands, and I go, no, that’s my OCD monster, I don’t do what he says anymore, Joe. So I’m not gonna do it. You like that option?
Dr. Yip: Yes.
That would be of course, preferable.
However, as I’ve said, not everyone can do that. And that is very challenging. So if you cannot completely resist, not engage with the compulsion, then the second option is to do the opposite of what the rule tells you to do.
So if the rule says you need to take five steps forward, maybe you take five steps backward, right? So you do the opposite. And if that also is challenging, then we have to break the rule by doing something differently. So again, rather than washing your hands three times, maybe you just wash it two times. Maybe you wash it one time.
Maybe rather than using hot scalding water, you use cold water. Rather than using three pumps of soap, you use half a pump.
Or maybe you don’t use soap.
So you’re changing up the rule. As long as you can change the rule, then that will allow you the feedback that, oh, okay. I didn’t do exactly the same thing and I’m still okay.
I’m still here. So let me try to break it even further. Break the rule even further. And your job is to completely break the rules over time.
Kyle: Yes. Okay. How long does an ERP therapy program typically last?
Dr. Yip: Again, that depends on the individual person, on the severity. If a person has your very straightforward OCD then an ERP program can be six months or less. On a once weekly basis. However, that’s rarely the case. And if we are to go back to the statistic that it takes a person 14 to 17 years from the beginning of symptoms, from the symptom onset to actually getting appropriate treatment exposure, response prevention therapy…that is a lot of time for behaviors to be formed.
And for compulsions to evolve and morph and just gain strength. So by the time a person actually finds treatment, you are rarely seeing just your straightforward contamination checking or ordering. You’re usually seeing many different types of compulsions that become very complex and become very severe.
Some patients might be completely debilitated – they’re not able to attend to their work, to their school, they’re not enjoying any social activities and therefore that is when a more intensive approach is needed. So at my treatment center, at the Renewed Freedom Center, we have our three to six week intensive outpatient program.
As well as the next level up would be your partial hospitalization program. So intensive treatment is more of, you’re seeing your therapist for more than 45 minutes. Once a week. You’re seeing them for maybe three hours a day for five days a week. Or you might be seeing them for six hours a day for five to seven days a week.
And the purpose of these intensive treatments is to repeat the exposures.
Kyle: That does not sound fun.
Dr. Yip: It doesn’t. However, if you’re training for a marathon, what are you doing? You’re just gonna go and run for 60 minutes and that’s it? Get ready for your marathon?
Kyle: And maybe it’s not fun, but what is also not fun is living a life slave to the OCD monster.
Dr. Yip: Exactly.
Kyle: And so I rather really fight hard for six months or a year or two years and then have my life back. What are the chances, what’s the probability of me finding meaningful recovery? And I want you to define what meaningful recovery is when I participate in ERP?
Dr. Yip: Meaningful recovery to me means that you are able to gain your quality of life back.
Meaning that you’re able to engage in your world in ways that are valuable to you, that is meaningful to you, that you find fulfillment in, you’re able to be at work and not be stuck in your ruminations. You’re able to be at a dinner table with your family. If people still do that these days…
Be at the dinner table with your family and actually engage in a conversation without constantly having to distract yourself because you’re stuck in a mental compulsion. That you’re able to just be outside and live the life that you want to live.
So that’s what a meaningful life means to me. And in order to gain that meaningful life, you do have to go through the rigorous training.
And I’m going to call this training because it is what it is, right? You’re training your brain to do something different than be an OCD slave. So if you want to live a quality life, you have to go through the mental exercises, the mental training in order to get stronger.
In order to build that tolerance, in order to gain the resiliency and confidence to fight back your OCD monster.
Kyle: So what percentage of people who go in and fight come out with a meaningful recovery?
Dr. Yip: Research shows that at least 70 people who go through ERP or medication actually gain relief.
They gain, they find benefit.
Kyle: 70% of people?
Dr. Yip: 70% of people.
Kyle: Okay. That’s great.
Dr. Yip: Yes. That is great.
Kyle: That’s amazing.
Dr. Yip: So you know there is a large proportion of people – 30% – it’s still a big part to me who do not find the relief that they want. There’s a term called refractory OCD, which means that you’re just resistant to ERP.
And I think a lot of it is…is the patient really resistant or have they not been properly educated about what is the process that you’re signing up for? Are they not prepared? So they don’t really believe in treatment or they’re not really motivated to engage in treatment.
So obviously if a person really understands the purpose of ERP and how it works, then it only makes sense to go through this rigorous training in order to gain that relief because whether you go through the training or not, to be realistic, you’re going to be mentally engaged in your obsessions anyway.
And the question is, do you want to let the OCD monster control those obsessions telling you what to do, when to do it, how to do it, or do you want to gain that control back? And if you want to gain that control back, then you do have to go through that rigorous training.
Kyle: So well said.
Dr. Yip. I highly encourage you to check out Dr. Yip’s other MedCircle series – Freedom from OCD. And because ERP is so closely related to cognitive behavioral therapy, I’d also suggest you check out that series at MedCircle as well. Dr. Yip. Final words on ERP?
Dr. Yip: ERP is exercise for your brain. The more you flex those muscles, the stronger you’ll become.
Kyle: Thank you for watching. I’m Kyle Kittleson. Remember, whatever you’re going through, you got this.
