Written by Dr Celin Gelgec
Clinical Psychologist and Director at Melbourne Wellbeing Group
While we are learning to live with COVID-19 and adjust to our new normal, people with OCD are on high alert and need longer to rebuild their stamina and re-adjust to life. This applies to all sorts of sub-types of OCD, not just for people with OCD who have contamination as a trigger. This is because whether someone experiences contamination triggers, or pedophilic triggers, or triggers about offending people, etc. the last two years of isolation has meant that people with OCD have been unable to fully immerse themselves in exposure therapy treatment the way they normally would.
Exposure and Response Prevention (ERP), which is the gold standard form of treatment for people with OCD, helps people to learn ways to sit with anxiety and uncertainty instead of relying on compulsions to manage. Through repeated exposures, people with OCD can create new neural pathways that are neutral and, if performed often enough, will override, or inhibit their pre-existing OCD behaviour pathways. For example, someone who fears that they may have accidentally hit a pedestrian while driving their car without knowing, might first practice thinking about driving through quiet streets to trigger doubts about hitting someone. While thinking of this scenario, they will practice ways to learn to sit with doubt and uncertainty, as well as guilt and anxiety, so that they can learn that they can cope with this distress without relying on a compulsion.
The next steps of exposure might involve practicing driving through quiet back streets close to home, and then building up to driving through busy streets. The response prevention for these exposure tasks would involve them resisting the urge to engage in their usual compulsive behaviours, such as checking their rear-view mirror while driving, driving back around to see if they’ve hit anyone, watching the news to check if there had been any motor vehicle accidents, or calling local police for reassurance.
These exposures with response prevention are repeated on numerous occasions and in various settings and situations to ensure that new neural pathways are created for change to occur. This second aim of ERP, which is repeating exposures in various settings and contexts, is problematic when people are not able to experience different situations and settings during lockdowns and isolation. For this reason, many people with OCD have sadly plateaued in treatment over the last two years or have even regressed.
The impact of this regression or plateau in treatment for people with OCD has meant that OCD triggers occurred more frequently and were more intense, making it harder to partake in exposures due to increased anxiety and uncertainty. Consequently, treatment involved becoming creative with how to ensure that clients kept up with exposures over the last two years so that they can maintain their gains and not regress further. This meant that clients had to rely on using imaginal exposure and trigger scripts during exposures to help get them through the conditions of the pandemic. This ensured that when we were all able to experience our usual freedoms of going out and about to see family and friends, travel, and eat out, etc. people with OCD could re-expose themselves to triggers they had previously mastered.
Where driving down a busy highway may have been easy to do, restrictions meant that they had to re-learn to do this again after not being able to do it for some time. Re-learning how to do things that were previously mastered has been challenging, and for some clients has created a sense of hopelessness and helplessness.
As we continue to learn to live with COVID-19 in our world, our role as clinicians is to continue to hold hope for our clients so that they can keep confronting their triggers. If the last two years has taught us anything it has shown us that without repetition to exposures, OCD is loud.
