Alternatives to ERP?

[Mister_Ecks]

I am so frustrated that there appears to be no treatment for my condition. I suffer from Mental Contamination OCD. Essentially people I deem as "intrusive" become the mental equivalent of the proverbial "dirty doorknob." Things they say get stuck in my head, so I avoid, where possible, and wear ear plugs where avoidance is not possible. People often comment that I make a strange "growling" sound, which is really me trying to do a low frequency "hum" to act as white noise to further block the contaminating voices. This has become so automatic that I catch myself doing it subconsciously.

My problem is that, in the case of physical contamination OCD, the patient has a clear, physical compulsion - washing hands. ERP works because hand washing can be "prevented." I have no such compulsions to "wash my brain." I basically live with the misery until is subsides. The ear plugs and "humming" aren't compulsions - they are part of the avoidance mechanism, like someone not touching a doorknob, or wearing gloves. They are not the same as washing - I have no such compulsion.

There is no "doubt" or "uncertainty" that characterizes typical OCD - I fully accept and embrace that the worst will happen as the result of exposure. I've discovered, over many many years, that avoidance is the only effective course of action, even though it just reinforces and amplifies the power of the "trigger."

Is there some alternative to ERP for people, like me, that have no "compulsions" to "prevent?"

Thanks,

Mr X

[Kerry100314]

It sounds like you are trying to cleanse your brain or keep your brain safe from the contamination by avoiding hearing the sounds so I’d think that is the compulsion. What happens when you feel someone’s voice is contaminating? Your FFF response gets activated so I think the exposure would be to be around someone you find contaminating and let the feelings of panic be there without trying to muffle their voice. The key is to go into the situation knowing and accepting your going to feel terrible and not do anything about it. I wish their was an alternative but I haven’t heard of anything that’s as clinically shown effective as ERP

[Mister_Ecks in reply to Kerry100314]

Audio contamination leads to words or letters getting "stuck," which is a horrible, painful experience. Imagine trying to enjoy a movie when every time a certain word or letter is spoken, the person in front of you turns around and yells it in your face. I see the intrusive people as the equivalent of a dirty doorknob. When someone avoids a doorknob, that's not a "compulsion," in terms of ERP. The "response" to be "prevented" is the physical act of handwashing. I am avoid my equivalent of doorknobs (intrusive people) but once contaminated I have no equivalent "compulsion" that provides relief. So I have no "response" to "prevent" and that has been my frustration with ERP.

[StuckForYears in reply to Mister_Ecks]

It can be a bit of a mind-bender, but ERP actually does classify avoidance as a compulsion. You can see avoidance's effects in people like me--where I used to go mad trying to keep the objects around me clean, now I avoid interacting with everything I think is dirty...which is now essentially my whole house. It's as much of a trap as the cleaning compulsion.

I'm sorry to hear your difficulties with your OCD. I might suggest trying a few specialists to see if any of them have an approach that you feel makes sense to you. I am in a slump with my OCD right now, but what helped me when I was first starting my ERP was finding a specialist I felt I could trust to take me through it without completely taking me beyond my ability to cope. Then it was trusting them when they said that when I did an exposure, that the anxiety would come down. This was vitally important to me because I was afraid of feeling levels of anxiety that would drive me over the edge. So it was important to know that I would be ok once on the other side of an exposure.

[Mister_Ecks]

I ran across Meta-Cognitive Therapy while looking for alternatives, but that has the same fundamental problem as ERP. It is based on the idea that the obsessive thoughts are decoupled from any actual consequence - for example, it's extremely unlikely that someone will get sick or die from touching a doorknob. Where this all falls apart, in my case, is that exposure leads to the very real and quality-of-life-destroying effect of the words and letters that get "stuck" as the result of exposure. I realize this all sounds like exactly like OCD talking. Where I have a problem with specialists is that every book, website, forum, etc., describes the same handful of OCD manifestations, with clearly defined E., R. and P. With mine I always hear "never saw that before," followed by therapeutic gymnastics to try to shoehorn this manifestation into a familiar pattern. It just starts to feel like there is a co-morbidity at play.

I don't mean to sound totally negative. I have been treated by psychiatrists, although they have gone with a medication-first approach. I am fortunate enough to have access to Trintellix, which is wonderful, but triggers are still there, which is turning me into the Disciple of Avoidance, which can't be a good thing.

[aparente001]

May I ask, how many ERP-trained therapists have you tried to work with so far, and for how long? My son made significant progress with ERP, but it took several years. It was not a quick fix for him.

Have you considered taking a two-prong approach, combining therapy with a high dose of SSRI? (It's important to ramp up slowly.)

Best wishes.

[sedulous]

Let's assume the worst and that what you say is true: the only effective course of action is avoidance which just reinforces and amplifies the trigger. What would you do then? Your goal is to minimize your suffering but you suffer in both directions: you suffer when you avoid (if you didn't, you wouldn't be on this forum searching for alternatives) and you suffer when you don't (the words and letters get stuck and many of us with similarly intrusive thoughts know how excruciatingly painful that can be). So I suspect you would be forced to engage in a painful project of trial-and-error where you experiment with varying levels of avoidance (from zero to as much is possible within the constraints of your most basic responsibilities) until you find a level of avoidance that is close to the bottom of that U-shaped curve. I don't want to condescend. Perhaps everything I said is already obvious to you. But I firmly believe that part of finding peace with one's obsessive mind is acknowledging one's limited amount of control over these thoughts. I hope you have more control than the worst-case scenario but, if not, I cannot see a more logical course of action.

Now I think it's likely that the worst-case scenario is not true and, of course, you too our holding out hope for that possibility. So, to answer your question directly, there are, in addition to ERP, a wide range of SSRIs, one tricyclic (clomipramine), and several antipsychotics commonly used to treat OCD (and yes, I think this is definitely OCD even if it cannot be finessed to fit the official definition given in the DSM-5) . If ERP is out of the question, and the medication regimen you're on is only providing limited relief, I think it would make sense to first experiment with raising the dosage of the current medication and then, if that fails, to start experimenting with others (under the supervision of a psychiatrist, of course). If you're unwilling to do that or if your OCD remains unresponsive to a wide range of pharmaceutical interventions, then I think at that point you embark on a long and serpentine journey through the jungle of alternative medicine: yoga, meditation, dramatic changes in diet, exercise, Chinese medicine, supplements, psychedelics...literally whatever you come across by talking to other people, reading books, and scouring the internet for treatments that have helped others suffering from mental illness. Here is a link to the IOCDF's survey of potentially effective over-the-counter supplements: iocdf.org/expert-opinions/o...

Having said all that, ERP does seem to be one of the most, if not the most, powerful tool psychiatrists and psychologists have in tackling this condition...which is why you are having such trouble escaping it. But I sympathize with your experience and I do think attempts to manualize it are often deeply misguided. In my opinion, ERP needs to be adapted to every person individually and eventually that person needs to understand their brain and the nature of their obsessions well enough to develop an intuition for how, when, and to what extent to apply their personal "ERP" for any given flare of symptoms. And, for that reason, I agree with the previous posts in that I don't think you should completely count out ERP until you've met an extremely talented therapist who understands what you're going through, has treated others like you, and does not leave you with the impression of shoehorning anything. I am not that person, of course, but just for argument's sake...have you tried intentionally contaminating yourself with triggering voices every possible moment of the day? If so, for how many days, and what happens? I assume when a word or letter becomes stuck you do your best to ignore it and get on with your life until the pain subsides. Have you tried instead taking time out of the day to focus on the presence of that word or letter and all painful sensations it induces for 30 minutes or so? That would be my first very uninformed ERP-like suggestion for what you're describing.

[Mister_Ecks]

Thank you for all of the thoughtful replies. I have never gone to an ERP therapist. My two psychiatrists were big believers in the power of medication. The problem I have is that avoidance "works," in most cases. Since my triggers tend to be people I have zero desire to be around, there's really no loss. It's just those occasions where there is no escape that cause problems - as you have all said, the avoidance makes the eventual contamination worse. My fear with going down the EPR path is that no one gives a reasonable time frame for it to be effective - I have seen "years" mentioned. That, to me, doesn't sound like a cure or a treatment - years of self-inflicted discomfort seems more like a punishment.