Free Yourself from Anxiety (11 page)

Doing exposure work for OCD is extremely effective, but it can be difficult to get started. If you feel in the grip of an eternal torment that is spiralling out of control, you may wonder how you can possibly start the process of fighting OCD.

OCD is caused by Anxiety. It is not a fundamental and unchangeable part of you. This can be difficult to accept when the thoughts seem so real and true. Like all Anxiety sufferers, your first steps in exposure work will be mainly a test, to see if it is really true that these awful feelings are caused by Anxiety and that Anxiety can go down. Gradually you will unlearn your automatic response to the trigger or triggers that set off your OCD.

Also you may feel that because of your obsessions you are odd or wicked. If you’re feeling ashamed, guilty or terrified of going mad, you may try to cover up your problems. This increases your sense of isolation and adds to your stress, which only makes the OCD worse.

You have nothing to be ashamed or guilty about, and you are not going mad. It’s as simple as that. OCD is an Anxiety disorder and it’s not your fault that you have it. It’s not a sign of weakness or moral degeneracy. It helps to talk to someone about this, and if you don’t have someone you can confide in, then use a helpline or online service (see Appendix 2 for details). This will help you realise that there are many other people out there with OCD.

A fear of having a panic attack is often the underlying fear behind the broad phobias such as agoraphobia, claustrophobia and social phobia. In other words, you tend to avoid certain situations because you are afraid of having a panic attack, not because of the situation itself. It is more unusual for someone with OCD to have a fear of having a panic attack, but it is a factor for some people.

When you start to do your exposure work your main concern will be to get through each stage without having a panic attack. This is understandable, and each time you manage it you will feel a little more confident. The trouble is, deep down, you will still be afraid of having another panic attack.

What you really need is to unlearn that fear – can you imagine how it would feel, if you could shrug and say ‘let the panic come, it doesn’t bother me?’

This leads to a two-pronged approach to exposure work for panic. You should follow the pattern of setting goals that are arranged with increasing difficulty, and you should start work on them in the hope that you won’t have a panic attack while you’re doing the easiest ones and building your confidence.

At some point though, you will start to work yourself a little harder, and then you might well have a panic attack. You will need to know how to cope – because you can cope, even though at the moment you think that you can’t.

Usually when someone has a panic attack their instinct is to leave the situation they are in (the flight part of fight-or-flight). When the panic attack subsides, the person naturally feels that leaving the situation is the
answer – when you leave, the panic stops. Except it was always going to stop whatever you did – fight-or-flight is a short term reaction remember.

So try to stay put if you possibly can. If you really must leave, try to calm yourself and return to the situation as soon as you can – within a few minutes if possible – and carry on with your goal.

Sometimes the reaction of the people around you makes the problem worse. If you are clearly in distress, and people try to help you it can add to the panic. Perhaps the first time you had a panic attack a helpful person called an ambulance, thinking you were having a heart attack. Probably you thought you were too. Even though it turned out that you weren’t having a heart attack, the memory of that awful experience is still with you.

We would suggest that you start your exposure work with a helper, someone who understands and who can deal with kindly strangers who are concerned about you. Eventually you will set new goals that don’t include a helper, but while you are building your confidence it’s fine to have someone with you.

We’ve already explained that if you learn to control your breathing you can reduce your Anxiety. If you’ve been practising the breathing exercise in Part One you should now feel confident enough to use it to reduce Anxiety levels. Before you start an exposure session, steady yourself with calm slow breathing, counting in your head to make the Out breath longer than the In breath.

If you feel the first flutterings of panic at any time, use the calm breathing technique to dampen them down.

Now you can learn a little more about breathing. Sit comfortably, or lie down. Put one hand flat on your stomach, and the other on your chest, just below your neck. Sit quietly and feel how the hands move as you breathe. Which hand is moving the most? If it is the upper hand, the one on your chest, then you are breathing in a shallow way that isn’t helpful for Anxiety.

It should be the lower hand that moves as you breathe, with the upper hand nearly still while you’re at rest (it will move more when you’re active) Here’s an exercise to help you practise good breathing.

You can count in your head as you do this exercise. Once you’ve got the hang of it, try it sitting, and then standing. When you feel confident that you’ve mastered it, you can also use this kind of breathing during exposure sessions.

The next stage is to take the easiest one of your goals and plan how you will achieve it. It may be that the lifestyle changes you have already made have created enough improvement that you feel able to tackle the goal straight away. By all means try it, but don’t push yourself too hard.

Probably you will feel that the goal is beyond you, in which case you can break it down into a series of smaller goals. Remember to make each one SMART, and remember that you need to be able to repeat it. Use your notebook to write down the goal, and the steps that you will take to achieve it.

Working through your goals is like climbing a ladder, where each rung takes you closer to your ultimate goal at the top of the ladder. When you first write out the steps you may feel that you will never reach the top of the ladder – it’s out of sight, lost in the clouds. Never mind. Write out the steps anyway, and start climbing the first few rungs. Don’t think too much about the higher rungs – eventually they will come into sight and you will be able to tackle them.

Do bear in mind that you need to feel some Anxiety while you are doing your exposure. If you don’t feel any, you won’t have learnt anything, and if you feel too much you’ll feel disheartened. In practice, most people will need to do many repetitions of the first few steps while they are regaining their confidence, and they may have to do fewer repetitions as they get further up the ladder.

If you can’t see a way on to the ladder, then start with visualisation. Lie or sit comfortably, close your eyes, and imagine yourself doing the goal. Try to create a complete picture, including not only a visual picture of the event, but also the noises and other sensations associated with it. Put yourself in the picture behaving calmly and succeeding at the goal.

The examples that follow give you an idea of how to create your ladder.

Here’s an exposure ladder for someone who had a panic attack in a busy supermarket and now dreads going back there in case it happens again. Their ultimate goal is to return to the supermarket and they devise the following steps:

Visit corner shop when quiet.
Visit corner shop when busy.
Visit shopping precinct and walk past supermarket late in the day, when deserted.
Visit supermarket at quiet time, with a helper, and buy one item.
Visit supermarket at quiet time, without helper, and buy one item.
Visit supermarket at quiet time, with a helper and buy several items.
Visit supermarket at quiet time, without helper, and buy several items.
Visit supermarket at busier time, with a helper, and buy one item, and so on.

Let’s look at someone who’s housebound and who feels there’s no point in trying any more. In fact the tiniest goals can lead to bigger things – it’s always worth trying, however silly or ridiculous it might seem to do these things.

Visualise leaving house.
Put on coat and outdoor shoes (to get used to the feel of them again).
Put on coat and outdoor shoes, stand by front door till Anxiety subsides.
Put on coat and shoes, take rubbish to dustbin.
Walk to first lamppost, return home.
Walk to second lamppost, return home.
Walk to postbox, post letter.

Eventually someone with agoraphobia needs to practise staying in situations, so they could move on to the shopping ladder in the panic example, or they could devise a new ladder that focuses on being with other people.

If you have a specific phobia, exposure is designed to increase your tolerance of the thing you fear. Each ladder has to be individually tailored. Here is an example for someone with spider phobia.

Look at a cartoon of a spider.
Look at a photo of a spider.
Touch the photo of a spider.
Watch a video about a spider.
Look at a spider in a sealed jar.
Hold a jarwith a spider in it.
Hold a spider.

Sometimes it can be difficult to repeat the exposure – thunderstorms for instance only occur occasionally. Consider buying a CD or DVD of the thing you fear and using that in your ladder.

If you have GAD, exposure work can be used to increase your activity level and build up your stamina. Goals might include meeting friends,
going to public places, doing voluntary work or doing a sport or social activity. Construct a separate exposure ladder for each one.

There is another aspect to GAD which is the act of worrying itself. If your attempts to do more are constantly interrupted by worry, you can create an exposure ladder to help you reduce the time you spend worrying. Start by writing down your worries in your notebook – this will help you see them more objectively. You can set goals that aim to cut down the number of thoughts, or reduce how many times you allow yourself to go round the thinking loop. Another approach is to set aside times for worrying:

Worrying allowed on the hour, every hour, for ten minutes.
Reduce each session to five minutes.
Omit every other session, and so on.

Fear of travelling often forms part of a wider group of phobias which make up the agoraphobia cluster, or may apply to a specific situation such as driving on motorways. Here are two examples.

Take the bus for one stop, at a quiet time, sitting near the door with helper beside you.
Repeat, but for two stops.
Take the bus for five stops, sitting apart from helper.
Take the bus for one stop with helper following by car.
Take the bus for two to five stops with helper following by car.
Take the bus one stop without helper following.
Take the bus two to five stops without helper following.
Repeat the journey at a busier time.
Practise taking the bus to visit friends, go shopping etc.

Be a passenger with helper driving:

Sit in the stationary car for a short time in passenger seat with helper in driving seat.
Go for a five-minute drive on quiet street with helper driving.
Go for a longer drive in quiet area with helper driving.
Go for a longer drive in traffic with helper driving.
Go for a longer drive including dual carriage way with helper driving.
Go for a longer drive including motorway with helper driving.

If you need to re-establish yourself as a car driver, then consider repeating the steps above with a helper in the passenger seat, then following you in another car. However if you feel you won’t be safe on the road, for whatever reason, then consider taking refresher driving lessons.

This example is for someone whose social phobia is around eating and drinking in front of other people.

Invite someone into your home for a short visit.
Have a slightly longer visit, make a drink but don’t drink yours.
Have a visit where they are able to watch you make the drink.
Have a visit where you also drink something.
Walk past a fast food outlet, observe people eating and drinking.
Accompany someone to a fast food outlet but don’t eat or drink yourself.
Accompany someone to a fast food outlet, eat or drink something yourself.
Continue the process to include pub meals, and then restaurant meals.

An exposure ladder can be constructed for any Anxiety disorder. If you still feel stumped about how to construct your own ladder, then there are many leaflets available from No Panic or First Steps to Freedom.