In the summer before fourth grade, one of my friends got a drum set. I’d go over and see it sitting there, shiny and red, imagining myself learning to play and becoming a drummer. So I brought it up with my parents one night. I presented my case– wouldn’t it be enriching if I switched from cello to drums, because I’d actually want to practice?– and showed them a few printed-out options ranging from inexpensive to absurd.
They probably didn’t believe that I’d practice for long, but they gave in and I did. I got a serious teacher who came over once a week until I graduated from high school nine years later. I performed with jazz bands, orchestras, and bands with friends that lasted a few days. I loved playing drums, and by tenth or eleventh grade I was thinking about music school.
A few years in, though, something weird started happening. I’d be working through a big book of exercises when a weird thought appeared: If I don’t get this right in the next three tries my family will die. I thought it was strange, and on some level I knew this wouldn’t actually happen, so I tried to push the thought away. As I kept going, though, it stuck. And then it exploded into all these other thoughts. I felt warm, like I’d get sick; I failed on the first try, and the second, and I had to stop before the third. I knew it wouldn’t happen, but I felt like it could. That was the only thing that ended up mattering.
Sometimes I was able to keep going, but other times I put the drumsticks aside and went upstairs to do homework or stare at a computer. I didn’t tell anyone, and I never would have. The idea that other people might have something similar was inconceivable. This was too strange, and whatever variations the thoughts came in I buried them away.
I never talked to anyone about my mind until the spring of twelfth grade, and that was about my mood. Six months later a doctor said I seemed to have some obsessive-compulsive tendencies. I looked back and realized these patterns had infected every aspect of my life. Rumination occupied so much of my time; I was being bullied by my own thoughts into doing certain things in specific ways, all day long.
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I didn’t get any treatment yet, but I’d begun to know that although my thoughts were idiosyncratic there were plenty of people facing deeply disturbing, seemingly random thoughts all the time. It seems trite, but I’ve never had a more helpful realization about my mental health. Thoughts about suicide or hurting someone had always seemed like omens: so this was who I really was, and the future had been decided, because I would eventually give in.
Now I learned I didn’t have to deal with thoughts at all. I bought books, read articles, tried to learn.Of course, this realization is helpful but not sufficient. If you’ve ever told someone to just take their most disturbing thoughts less seriously, you probably know how poorly it works.
Eighteen months later I was referred to a specialist in exposure and response prevention (ERP) and acceptance and commitment therapy (ACT). Nothing surprised her. She recognized what I was dealing with, and we got to work.
Because I’ve already talked about drumming, let’s go back to that earlier part of my life and pretend I’m already starting ERP. It’s such a clear example, in retrospect, of obsessive-compulsive thinking.
My parents help me find a psychologist, and I have my first appointment after school. Although I feel nervous, I really do want to tell the psychologist about these thoughts so I can get back to drumming (and living) normally.
When I tell her everything, she nods and takes notes. She tells me about ERP and why it’s important: so I can learn how to encounter these thoughts without responding to them in any special way. She says response prevention basically means these ERP exercises will only work if I’m facing my thoughts head-on, without using compulsions. And she tells me we’ll focus on drumming first, because going after all of my obsessions at once will probably get overwhelming.
Let’s go through this in a structured way, as most OCD specialists would when introducing you to ERP. To flatter myself and self-plagiarize, here’s what I wrote in a recent post:
ERP is a type of behavioral therapy that exposes people to situations that provoke their obsessions and the resulting distress while helping them prevent their compulsive responses.
What good are all these words in a tough moment? In this case the situation is practicing drums. (From my experience and what I’ve heard from other people, distressing thoughts often revolve around things we really care about or enjoy. This is a convenient and fun fact about OCD.)
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As I’ve mentioned, practicing drums often provoked my obsessions. Technically the trigger was more specific: whenever I was really struggling with a certain exercise, instead of cruising through it, I would start getting those irrational ultimatums in my head.
The thoughts about my family dying if I messed up were intrusive, meaning they were unwanted and involuntary. Sometimes they were just thoughts (If I don’t get this right in the next three tries my family will die) but they could also be images of bad things happening to my family. Because I’d never wanted my family to get hurt and I felt like my thoughts signaled a catastrophe that I needed to prevent, they caused me extreme distress.
The catastrophic assessment I made turned the intrusive thought into an obsession. Assessment is a term psychologists use, and in a way it sounds too deliberate. You’re not standing there for an hour, clipboard in hand, evaluating your thoughts. Usually it doesn’t feel like you have much of a choice about catastrophizing. But the concept helps us realize that intrusive thoughts only become obsessions if we feel like they’re urgently important and we need to respond to them.
In fact, I first made this assessment a while earlier, and since then the obsession had built on itself as I tried to argue with it. As the obsession intensified and I felt increasingly distressed about my family being harmed, I developed compulsions:
In short, messing up while practicing drums provoked intrusive thoughts of harm coming to my family. Because I felt these thoughts were catastrophic they stuck around and turned into obsessions. In response to my distress I developed compulsions including self-reassurance and avoidance.
It’s our second appointment now. My first ERP exercise is to write down the worst case scenario. What would happen if I didn’t protect my family and my thoughts came true? My psychologist asks me to write down every detail that pops into my head, but I’m hesitant. She asks how anxious I am right now and I tell her maybe 8 out of 10. Then she asks me to read it out loud, and I don’t want to let her down so I mumble my way through it. She tells me to read it out loud twice each day for a week, and make a note in my notebook whenever I end up using a compulsion.
By the time I see her a week later, reading the script no longer makes me anxious. But I noted how many times I tried to convince myself nothing bad could happen– earlier in the week this process could repeat for hours. So she says before we go on to any actual drumming we’ll need to talk about response prevention.
You learn pretty quickly that hardly anyone has clear answers on how to do response prevention in general. Working with an experienced clinician is important in part because every response prevention plan will inherently be different. In this case, she tells me we’re going to confront each of my compulsions. I’ll do any exercises my teacher assigns me (confronting avoidance), remind myself that my family could die and I could be responsible (confronting reassurance), and practice for a set time rather than a certain number of tries (confronting “giving in”).
For a week I practice only 45 minutes at a time, and my exposure is simply to play drums while doing responsive prevention. The next week gets tougher: whenever I start obsessing about getting things right within three tries I’m supposed to deliberately mess up all three attempts. This turns out to be too difficult, so I call her and we decide I’ll start with something easier until I see her again. My goal is to try exercises only once before moving on, no matter what my thoughts suggest, and then I can come back to them the next day if I mess up.
Gradually we build up in intensity until I’m no longer being bossed around by my thoughts. They still appear, and a lot of the time they still bother me. But music matters a lot to me, and I’m motivated to do ERP until I don’t even feel like I need it in this particular situation.
Once we decide that I’m doing well enough with drumming, we move on to other areas I’ve been struggling with. Each time I do ERP for one type of obsession I gain insights I can use with the others. I’m able to think: Hm, I’ve dealt with thoughts like this before. And it wasn’t really worth paying attention.
Telling people how to do ERP is not only ill-advised (you should see a professional for guidance). It’s like telling someone how to deal with any other issue in their life: it can be helpful to offer a framework, maybe even some ideas, but everyone is different and these individual differences end up shaping the whole thing.
The important part, first, is to know that you can enjoy the things you care about more often and feel terrified of your own mind less often. Whether you accomplish this through ERP or any other kind of treatment, your life can get a whole lot better.
If you or someone you know is struggling with OCD, schedule a free call today with the NOCD clinical team to learn more about how a licensed therapist can help. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP. At NOCD, all therapists specialize in OCD and receive ERP-specific training.