Identifying Core Fears in ERP Treatment for OCD
A quick review of the basics of ERP treatment:
Exposures are when you deliberately confront situations that scare you and response prevention is abstaining from the safety behaviors you typically use to reduce your anxiety (e.g., checking, analyzing/ruminating, washing, avoiding, etc).
To effectively identify and target exposures, ERP treatment involves the construction of a graded hierarchy. A graded hierarchy is a ranked list of feared events and activities on a one-to-ten scale. For example, if I’m working with someone whose primary obsessions are related to contamination with germs that might cause them to get sick and die, they might rank touching the wall in my office as a “two”, touching the door knob of my office as a “five”, touching my office garbage can as a “seven” and touching the toilet flusher in my office bathroom as a “nine”.
All of these exposures listed above are classified as “in-vivo” exposures, meaning something like “real life” exposures that take place in the world. In-vivo exposures are very important in many instances of ERP treatment. However, frequently ERP treatment is missing crucial exposure targets by focusing only on in-vivo exposures.
Effective ERP treatment often includes “imaginal” exposures. Unlike in-vivo exposures, which take place out in the world (e.g., going into a public bathroom), imaginal exposures take place within the mind.
Imaginal exposures are so often a central component of ERP treatment because imaginal exposures can effectively target core fears. What are core fears and what does the identification of core fears have to do with ERP treatment?
Most of us with OCD have a very good idea what “triggers” or “activates” us. We have our “theme areas” and we confidently expect that we’ll have obsessions, anxiety, and be motivated to complete our compulsions if certain events related to our theme areas occur. Underlying our triggering situations, though, usually lurks more fundamental core fears.
Core fear identification and OCD:
To illustrate the relationship between surface level fears and core fears, consider Laura. Laura came to see me because she was having a hard time driving. During our first session, she reported to me that she’d all but given up driving due to the obsession that she might have hit a pedestrian without realizing it. In Laura’s case, the surface level fear was that she might have hurt or killed someone while driving.
Looking further into Laura’s fear, however, is what allows us to more precisely tailor Laura’s ERP treatment. In order to look further into Laura’s fear, I asked her, “Laura, could you tell me what might happen if you did, in fact, hit someone with your car without realizing it?”
“Well” Laura said to me, “it’s actually a couple of things. First, I imagine someone in agony in the road. They need help but I don’t know if they’ll get help. And I really don’t like that image. When I get that image it’s hard for me to do anything else and I feel very anxious. It makes it hard for me to function.” (Laura is identifying a “metacognitive fear” which I describe here).
Laura continues, “So that’s one thing I don’t like. But, and I have mixed feelings about this, something I like even less is the idea of the police coming to my house and telling me I’ve hit someone and left the scene. Then being charged with hit-and-run. Going through the court process and the prosecutor putting me on the stand and ripping into me. Seeing the face of the jury as they look at me like I’m some sort of irresponsible monster. All of this is so scary to me. But even that’s not the worst.”
“What’s the worst?” I ask.
“The worst” Laura went on, “is when I think about being sentenced to jail. I think about being in jail. Wearing one of those orange suits. Being locked up with criminals. I get so anxious thinking about how I’d get on in that environment. But the absolute worst is thinking about my kids. If I were in jail, I’d be apart from my kids, probably for years. I’d no longer be a part of their lives. They’d be able to come see me from time to time, but I’d only be able to see them through the glass, like you see in movies. Would I even get a chance to physically be around my kids? I don’t even know if I could touch them. My kids would think of me as ‘Their mom who’s in jail’. I’d miss their childhood. I would feel so guilty. I’d be so heartbroken. I don’t think I could bear it.”
In Laura’s case, we can notice the increased precision in the identification of her core fear. The surface level fear plaguing Laura, each time she drove, was “What if I hit a pedestrian?” This thought appeared at the forefront of Laura’s mind each time she was driving. But, when we take the time to look further, what we can see is that the root of Laura’s fear is that she’ll make a mistake that results in her being taken from her kids, leaving her kids hurting and Laura feeling guilty, heartbroken, and perhaps not able to bear it. So, while hitting someone with her car is, in itself, scary, it’s the idea of being ripped apart from her children that, for Laura, is even scarier and continues to fuel Laura’s OCD. This deeper identification of Laura’s fears sets the stage for identification of imaginal exposure targets, which we’ll review in further detail later in this post.
But before we discuss imaginal exposure targets, let’s examine another example of core fear identification, this time reviewing my own experience with OCD.
How do imaginal exposures target core fears?
When my OCD began in 2007, it was focused on the possibility that I might contract HIV. So, my surface level fear was HIV and it was related to the obsessions I had all the time every day. Obsessions like: “What if there was blood on that door knob?” and “What if that liquid on the counter was Semen?” followed by the thoughts, “If that was blood / semen, then maybe I’m at risk of contracting HIV.”
Like Laura’s example, at first glance, it might seem like my fear is simply contracting HIV. But, just like Laura, my fear went deeper. Of course, I didn’t want to contract a chronic disease such as HIV. However, my deeper fears were 1) if I contracted HIV I would be negatively evaluated by others as negligent or irresponsible and 2) that I would never be able to be in a romantic relationship because no one would get into a relationship with me if I had HIV and, thus, I’d be romantically alone forever.
Of course, I couldn’t know for sure that others would negatively evaluate me or that someone wouldn’t get into a relationship with me if I had HIV. However, in my mind, these unfortunate events might occur, and that possibility was enough to terrify me. Just like Laura, my day to day was filled with thoughts about the possibility of contracting HIV. But within these thoughts were my core fears and it’s these core fears fueled my OCD processes.
As alluded to earlier, the identification of core fears is an important part of ERP because it makes the way for participation in imaginal exposures which target the core fears.
How do imaginal exposures target core fears?
Scripts in ERP treatment:
One of the most common types of imaginal exposures is the use of scripts. Scripts are, in essence, scary stories where the core fear becomes true. In Laura’s case, for example, these scripts included a detailed narrative account of what it would be like for her to be arrested, sentenced in court, incarcerated in jail, including how she felt, what she thought, and the behaviors she participated in during this process. And, as you can imagine as a result of Laura’s core fears, what it was like for Laura to see her children when they came to visit and miss them when they were gone.
The same was true for my ERP. When my core fears were integrated with my exposure hierarchy, my hierarchy didn’t just include in-vivo exposures like touching doors, toilets, and surfaces. It also included imaging situations during which my core fears came true. For instance, a script in which I did have HIV and went on a first date with a new possible romantic partner. During the date, I feel obligated to let this person know about my HIV status. After I tell her about my HIV status, she gives me a disgusted look and cold demeanor. She tells me she couldn’t possibly date someone with HIV. I drive home feeling so alone and so, so sad. I imagine getting to the end of my life, decades later, still alone.
The process of identifying core fears is often challenging. The imaginal exposures suggested by the identification of the core fears are frequently very hard. And going through the process of core fear identification puts us in a place to more comprehensively assess our willingness to participate in ERP treatment, which includes deliberately taking calculated risks for the sake of our values (which I describe in this post).