ERP Part 4: Psychological Flexibility
The second skill developed during ERP practice is psychological flexibility. (If you haven’t already, it’ll likely be informative and helpful to review parts 1, 2, and 3 of my ERP series).
A typical vision of OCD recovery is not one in which every time you have an intrusive thought, and related anxious feelings, you have to go sit in a corner for an hour until you habituate.
Instead, our vision is that you’re able to meaningfully engage with your life even when you’re experiencing unwanted, distracting intrusive thoughts and related painful, anxious feelings. The ability to do that, and do that well, is psychological flexibility.
Like all skills, psychological flexibility improves with practice and that’s one of the reasons it’s important to include it within ERP.
What does practicing psychological flexibility look like?
Alexander’s Example:
Alexander was a middle-aged, married man who entered treatment because of constant intrusive thoughts of harming others. Alexander reported frequent intrusive thoughts about murdering his wife, sexually abusing his children, and killing the family dog.
Like practically all OCD treatment, Alexander and I first reviewed critical information about his experiences and OCD, including:
How Alexander is experiencing both object-level and metacognitive concerns
The importance of identifying values and committing to take calculated risks
It was then time to begin ERP. Alexander and I reviewed what ERP is and how ERP works, emphasizing the importance of new skills like distress tolerance and new learning experiences associated with expectancy violations and habituation.
And we also practiced cognitive flexibility.
In Alexander’s case, cognitive flexibility included giving Alexander frequent practice in deliberately participating in meaningful activities while intentionally holding his intrusive thoughts in mind (and allowing the related anxious, painful feelings to be present).
Practicing Psychological Flexibility:
For example, part of Alexander’s at-home practice was to, everyday, watch a TV series he and his wife enjoyed. During these practices, he would sit next to his wife, and, the entire time he was watching the series, he simultaneously held the thought “I might inexplicably strangle my wife.”
To support this practice, Alexander and I planned for him to have a timer that went off every two minutes. This timer was a reminder for him to refocus on the thought in case it slipped away (as intrusive thoughts often do when we deliberately try to hold on to them). As in all exposures, Alexander was also tasked with not completing his safety behaviors (e.g., sitting on his hands, distancing himself from his wife, mentally repeating his safety phrases).
At first, Alexander found this process difficult. It was difficult because the thought was distracting, the thought contributed to anxiety, and, when he wasn’t distracted with the thought, he frequently realized the thought had drifted away on its own. However, with time, Alexander became much better at this process. It became easier to watch the TV series even while the distracting thought and painful, anxious feelings were present, the thought caused less anxiety, and the thought drifted off less.
As Alexander practiced more and more psychological flexibility exercises, he found it easier and easier to apply the skills he was practicing in these exercises when he had intrusive thoughts throughout the day.
For example, he described an instance when he was bowling with several of his friends and noticed a handful of kids in the bowling lane next to him.
“I had the intrusive thought of pushing one of the kids down and throwing a bowling ball into his face” Alexander told me. “And then, almost automatically, I was telling myself ‘OK, well, I guess I’m going to hold onto that thought for the rest of tonight’s bowling’. And you know what? It worked just like when I was at home watching a TV series! I was able to bowl the rest of the night. I didn’t like the thought being there, and it didn’t feel great. I was still anxious. But I did it and even noticed having to deliberately bring the thought back because it kept slipping off.”
That’s psychological flexibility in action.
It’s useful to notice the difference between psychological flexibility practice and an exposure which is solely focused on aversive content. An exposure which is solely focused on aversive content might be, for instance, having Alexander repeatedly and single-mindedly listen to an imaginal script related to his core fears. In this type of exposure, Alexander’s task is to immerse himself as fully as possible in thoughts, images, and feelings associated with the script while not doing anything else.
Alternatively, during an exposure in which Alexander is practicing psychological flexibility, he is tasked with doing his best to deliberately hold on to intrusive content (e.g., the thought “I might inexplicably kill my wife”) while also watching an episode of a TV show (or any other meaningful behavior).
This kind of exposure is designed to give Alexander practice being with intrusive thoughts and anxious feelings while still participating in his life and that’s related to, but not the same as, giving Alexander practice being with intrusive thoughts and anxious feelings while doing nothing else (e.g., Alexander solely focusing on the exposure and response prevention task).
Of course, this type of practice can involve any number of activities, from watching a TV episode, cooking a meal, going for a walk, playing a game, etc. The basic structure of the process is the same: Deliberately holding onto the aversive cognitive content and related painful anxious feelings while simultaneously engaging in meaningful behaviors.
Julie’s Example:
Let’s review another example. Consider Julie, who came to see me because of frequent and debilitating thoughts and feelings about the possibility of having unknowingly hit someone with her car. One of the most challenging aspects of Julie completing ERP treatment was driving to work without circling back on her route to ensure she didn’t hit someone. One reason this was challenging for Julie to not circle back and check to ensure she hadn’t unknowingly hit a pedestrian was because it was very anxiety producing for her in the moment. Another reason it was challenging for Julie to not circle back and check to ensure she hadn’t unknowingly hit a pedestrian was because Julie expected that if she didn’t circle back to check (her compulsion), even if she hadn’t struck a pedestrian, she’d still be stuck with the distracting and painful thoughts and feelings the entire day at work (an example of a metacognitive fear).
Thus, for Julie, part of her ERP practice was focused on exposure and response prevention, during which she would drive, sometimes for hours, without completing her compulsions (e.g., checking her rearview mirror, driving in circles, etc) and allowing the intrusive thoughts and related anxious, painful feelings to be there (practicing the skill of distress tolerance).
Another form of Julie’s ERP practice was focused on psychological flexibility, including having her drive to work without checking and then deliberately hold on to the thought “I might have hit someone on the way to work this morning” while, at the same time, engaging in work on her spreadsheets for her employer.
Notice, when Julie was practicing psychological flexibility, Julie wasn’t just driving without checking. When practicing psychological flexibility, Julie was meaningfully engaging in her life while simultaneously deliberately staying connected to the intrusive thoughts and and related anxious, painful feelings.
Is Psychological Flexibility A Distraction Technique?
Sometimes my clients, and even other therapists, will challenge me by asking something like, “But isn’t psychological flexibility a distraction technique?” This is a common objection that Reid Wilson (a famous anxiety and OCD therapist) and I reviewed at his recent workshop on OCD treatment at the 2024 ADAA conference.
During the workshop, Reid asked me to review with the attendees a prototypical example of an ERP exercise that was emphasizing cognitive flexibility.
“When focusing on psychological flexibility” I began to explain, “I didn’t just have my client grasp a contaminated object and then contaminate himself and his environment. Instead, I had my client:
Grasp an object he identified as contaminated
Cross contaminate himself and his environment
Deliberately hold onto the thought ‘I’m contaminated and my environment is contaminated’
Remind his body that his body can feel however it needs to feel, however intensely it needs to feel it, for however long it needs to feel it.
And, and this is the key portion of practicing psychological flexibility, then, while he continued to hold the object and stay connected to the thoughts and feelings, we played a game of chess.”
Playing chess isn’t a distraction technique,” I explained, and Reid later elaborated on, “because we’re not playing chess in order to suppress, neutralize, or avoid the intrusive thought ‘I might be contaminated’ and the anxious, painful feelings associated with that thought.”
“Instead, we’re playing chess while my client deliberately stays connected to the intrusive thought and related anxious, painful feelings. My client is given the opportunity to see and practice that, even though it’s challenging, and not a lot of fun, to play chess while holding onto these thoughts and feelings, it can be done. And psychological flexibility is a skill that gets better with practice.”
How much practice does it take to become skilled at psychological flexibility? Everyone is different. Within my practice, it’s common that clients report improved psychological flexibility within twenty to thirty hours of deliberate practice. Of course, psychological flexibility isn’t the only skill we practice in ERP and integrating it with practicing distress tolerance and the new learning experiences also part of ERP is important.