Pure-O OCD: How Can ERP be Effective if I Don't Have Any Compulsions?
Pure-O is a term that was developed to describe a type of OCD in which there are seemingly no compulsions - only obsessions. One may classify themselves as having Pure-O when there are no overt, ritualistic behaviors, including, but not limited to, washing, checking, or tapping. However, the term Pure-O is a bit of a misnomer, as it does not take into account the plethora of mental compulsions, as well as the subtle physical compulsions, that individuals find themselves engaging in, often without realizing (OCD is sneaky!). By definition, a compulsion is any act done to relieve the discomfort elicited by an unwanted, intrusive thought, image, or feeling.
Some less-obvious compulsions that may be overlooked include:
Mentally replaying events or conversations
Neutralizing a bad thought or image with a good one
Providing self-reassurance that "all will be okay," "I'm a good person," etc...
Seeking reassurance from friends, family, or the internet (ex. "I'm not a dangerous person, am I?" "Did you hear me say anything offensive in that conversation?" or frequently using Google to research specific symptoms, or to seek answers in moments of uncertainty).
Repeating a silent prayer
Avoidance: This can be physical avoidance of a person, place, or object, or mental avoidance (such as trying to distract yourself by thinking other thoughts, or by repeatedly telling yourself to "stop thinking about this!").
Since Exposure and Response Prevention (ERP) is the act of confronting your obsessional thoughts while refraining from rituals, it makes sense that ERP can absolutely be applied to "Pure-O" cases. I will put "Pure-O" in quotes, since we've now learned that having obsessions without compulsions is not quite accurate. Compulsions are the fuel keeping OCD alive. Without compulsions, OCD cannot thrive (and is therefore the very reason treatment focuses on reducing/eliminating them).
What are some ERP exercises I can do with "Pure-O?"
Keep in mind that everyone's OCD symptoms are unique, and that ERP exercises need to be carefully tailored to an individual's specific thoughts and behaviors. The following are general examples of exposure exercises to help get you started. However, it is best to work with a trained professional to ensure you are practicing them in the most helpful manner.
Instead of avoiding specific thoughts via distraction, or telling yourself "don't think about ______," practice intentionally thinking these thoughts, either by agreeing with them, repeating them to yourself, or writing them out on index cards and leaving them around your house.
Instead of replaying events or conversations looking for reassurance, tell yourself that what you fear is true. Perhaps you said something offensive, or acted in a manner that you would feel makes you a bad person. Assume this is all true.
Instead of neutralizing a bad thought with a good thought, allow yourself to intentionally be in the presence of "bad thoughts," just like in example #1. You can also make a voice recording of yourself saying triggering thoughts and phrases, that you can listen to on repeat throughout the day.
Write out a detailed, imaginal exposure story in which your worst OCD fears/obsessions come true. Then read this story 15x each day while visualizing the consequences.
Instead of avoiding people, places, or objects, confront them (you can do this gradually). Say yes to events you would otherwise say no to, be close to people your OCD would otherwise have you shy away from, and instead of having someone else do a task that would trigger your OCD symptoms,, impress yourself by taking on the challenge of doing it yourself!
While the list of ERP exercises to engage in can be endless, the key to designing a good exposure is to make sure you are approaching what you fear, without seeking relief. Allow your discomfort level to rise without controlling it, recognizing that any means of control is a compulsion, and will only serve to maintain, and even exacerbate, your OCD symptoms long-term.
Summary: ERP can absolutely work for "Pure-O" cases, and in fact, is still the gold-standard choice of treatment. OCD is sneaky - while you may not be engaging in any overt, physical compulsions, it is important to be on the lookout for more subtle rituals, especially mental compulsions that cannot be seen. Always remember that no matter the content of your OCD thoughts, and regardless of the type of compulsions you find yourself engaging in, ERP treatment is highly effective, and with proper guidance and hard work, you can certainly find relief!
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