When OCD Exposures Go Off Course: A Therapist Guide
It can be one of a new OCD therapist's biggest fears: you're conducting an exposure with a client and it suddenly starts to veer off course. Although you collaboratively mapped out the initial content, something shifted during the exposure. The client's mind jumped to a bigger or different fear, one they weren't prepared to face, and since this is one of your first exposures together, they feel overwhelmed and unready for what their mind is throwing at them.
The Dilemma: Pushing Forward vs. Abandoning the Exposure
As the clinician, you feel stuck between a rock and a hard place. To press on might mean pushing the client to sit with something they're clearly communicating they're not ready for. While there are times to challenge that resistance, this might not be one of them. On the other hand, abandoning the exposure could be equally problematic. After all, the goal of exposure is to teach the client that they can tolerate distress. If they start the exposure, encounter unexpected intensity, and then flee, it can reinforce the belief that distress is intolerable or unsafe.
Fret not, o burgeoning OCD expert! There is a way to gently land this plane.
Managing Exposure Intensity: The Solution
In moments like this, your job is to moderate the intensity of the experience while still creating a meaningful learning experience. One effective approach is to shift the focus away from specific intrusive thoughts and toward the physical sensations of distress. This technique, borrowed from Acceptance and Commitment Therapy (ACT), is called an expansion exercise.
How to Use the Expansion Exercise Technique
Here's how it works:
Guide the client to focus on the physical experience of distress. Ask them to describe in detail where they feel it in their body.
Prompt them to observe its different qualities. What shape does it take? What is its texture, color, or temperature?
Then, help them explore the boundaries of the discomfort. Often, acute distress occupies only a small portion of the body, frequently the chest or stomach.
Once they can identify its location and size, invite them to breathe around the discomfort—not to get rid of it, but to make room for it. Encourage them to soften any muscles they've been tensing around the discomfort, allowing space for the feeling to simply exist.
Benefits of the ACT technique in OCD Therapy
By gently turning toward the physical discomfort without amplifying or resisting it, the client still learns the main two lessons of an exposure:
how to skillfully sit with distress and
that in doing so, distress is easier to manage than they might have predicted.
This can have a calming or even relieving effect, similar to what we often see with well-structured exposures. Once you've successfully landed the plane, you can step out of the exposure and have a conversation about what new fears arose and how to gradually build toward addressing them in future sessions.