After I teach patients how to stop ruminating, I use a series of additional exercises to help them practice that skill, and apply it even when faced with a trigger. This helps to build confidence in using that skill, and also sets the stage for doing exposures in the context of not ruminating.
As in RF-ERP in general, the goal of these exercises isn’t to make the patient anxious. We’re only triggering their anxiety in order to practice turning it off by not ruminating.
Please note that I developed these exercises for patients with ‘Pure O,’ so some elements (such as some of the homework assignments) are less applicable to other OCD presentations.
Exercise 1: Response Prevention
First we have to teach someone How to Stop Ruminating. This exercise is described in detail here. Please note that just telling someone they are ruminating is not the same thing as teaching them how to stop, and is not helpful.
Homework:
-
Stop ruminating all the time.
-
Monitor any times when you feel like you can’t stop.
-
In session, address any of the problems discussed here and here, as well as any justifications, that are getting in the way.
Exercise 2: Practicing Response Prevention
Note: If the person doesn’t ruminate without a trigger, proceed to the next exercise.
Now that you know how to stop ruminating, let’s practice turning it on and off.
Let’s ruminate for 30 seconds, and then when I ask you to stop, I want you to stop immediately. Go ahead.
(Pause for thirty seconds.)
Okay, now stop. (Pause for a moment.) What is your anxiety level?
0? Great. Let’s stay there for about a minute. (Pause for a minute.) Still 0? Great. Let’s move onto the next exercise.
Greater than 0? Seems like you were still ruminating. Let’s look back at the issues we addressed in Exercise 1 and see where you might have been getting stuck. (Address issues.) Okay, let’s try again.
Repeat this until any problems have been addressed and it is easy to turn rumination off and keep it off.
Note:
The exact times don’t matter. Just keep in mind the goal of the exercise, which is to practice turning rumination off and keeping it off.
Homework:
Same as before:
-
Stop ruminating all the time.
-
Monitor any times when you feel like you can’t stop.
-
In session, address any of the problems discussed here and here, as well as any justifications, that are getting in the way.
Exercise 3: Exposure and Response Prevention
Now that you know you can turn rumination off even when you’re anxious, let’s practice doing it even when you encounter a trigger.
Let’s do/read/watch/look at something triggering for a moment and then refrain from ruminating.
Okay let’s confront the trigger. Do you feel anxious? Okay, let’s immediately stop ruminating. (Pause for a moment.)
0? Great. Let’s move onto the next exercise.
Greater than 0? What do you think was going on? (Address issues.) Okay, let’s try again.
Notes:
Use the lowest level trigger possible, and confront it for only enough time to feel somewhat anxious.
In ‘Pure O’ cases, another way to do this exercise is for the therapist to periodically say triggering things, while the patient refrains from ruminating.
Again, the exact timing and number of repetitions doesn’t matter, as long as the person gains confidence in their ability to refrain from ruminating even when triggered.
Homework:
-
At a scheduled time (whether once or multiple times a day), do/read/look at something triggering for a moment — as little time as it takes to do/read/look at it — and then move on without ruminating.
-
In ‘Pure O’ cases, another way to do this is to set reminders throughout the day to bring the obsession to mind.
-
As always, address any of the problems discussed here and here, as well as any justifications, that are getting in the way.
Exercise 4: Exposure and Response Prevention with an Ongoing Trigger
Now that you know that you can refrain from rumination even when you encounter a trigger, let’s practice refraining from rumination even when you encounter an ongoing trigger, since that’s a common situation in real life.
Let’s do/read/watch/look at something triggering, and refrain from ruminating while we are doing so.
What’s your anxiety level?
0? Great.
Greater than 0? Sounds like you’re ruminating. What do you think is going on? (Address issues.) Okay, let’s try again.
Notably, many exposure exercises should not be assigned until a person can successfully engage with an ongoing trigger without ruminating. Otherwise they’ll just be ruminating while doing the exposure, which might show them that they can do something despite feeling very anxious, but doesn’t show them that they can do it without feeling very anxious.
Homework:
Engage with ongoing triggers (e.g., watching or reading something, going somewhere, being around someone) while refraining from ruminating, both during and after.
Notes for therapists:
-
Be sure not to move on to the next exercise until the patient can do the previous one easily — and I do mean easily.
-
Although I have suggested potential homework to accompany each exercise, this does not mean you can do only one exercise in a session. You can do several or all of them within a session if the patient progresses quickly.
Notes for patients:
-
These exercises are not intended to be done repeatedly. They are intended to help you master and build confidence in not ruminating. Once you have done so, the goal is to apply these skills in your everyday life, not to revisit the exercises.
-
If you do decide to revisit the exercises, be careful not to turn them into an excuse to ruminate or check. In order to avoid this, I recommend (1) scheduling the exercises in advance, and (2) planning the number of times you will do each exercise in advance.
-
Remember that the goal of these exercises is just to show you that you can stop ruminating. Doing these exercises will not make your symptoms better or make you ruminate less. That’s your job. These exercises just show you that you have the ability to do your job.