Part 1: Introduction and Critiques of Habituation
The three of us (Mimi, Allyson, and Kris) are healthcare providers with our own lived experience of OCD. We are passionate about neurodiversity affirming care, and through the lens of our identities are curiously reflecting on ways in which the “gold standard treatment” of ERP isn’t built for us. This series of blog posts is informed by our intersectional identities and specifically speaks to critical aspects around neurodivergence and systems of oppression. We believe this lens is strongly needed in mainstream OCD treatment, which tends to lack a critical justice oriented lens in its treatment; and thus, has quite a low “success” rate, long term, and leaves many further traumatized.
What is ERP?
Exposure response prevention (ERP) is considered the “gold standard treatment” for obsessive compulsive disorder (OCD). It is one of many therapy modalities such as DBT, ACT, and IFS. Various modalities have different ways of conceptualizing the root of mental health symptoms and therefore, offering unique solutions. A very watered down example is that cognitive behavioral therapy (CBT) conceptualizes anxiety and depression as stemming from negative core beliefs and irrational thought patterns that in turn, impact our feelings and behavior. The treatment, then (again boiled down) is to examine and reframe our thoughts and beliefs in order to improve the way we feel and behave.
ERP conceptualizes the disordered symptoms of obsessions and compulsive cycles as difficulty or inability to accept uncertainty and hyperfixation on topics of concern. A guiding goal of ERP is to practice relying on internal regulation, re-instilling trust in our body’s natural calming response systems to respond to fears. The idea is that compulsions provide a false sense of protection from contamination, from hurting others, etc., and it’s important to accept that we don’t have control. ERP states that if we continue using compulsions, the brain will continue to believe that these are actually protecting and keeping us safe.
Exposures are experiences meant to mimic real life fears to help an individual habituate or get used to the fear without using compulsions. The idea is a) that we will learn to trust our body’s natural anxiety calming response instead of having to use external compulsive behaviors or b) that inhibitory learning will take place (aka: a fear response still happens, but we learn we can cope with the intense feelings).
The ERP model includes the creation of what is called a hierarchy. This is specific to the different themes of OCD that an individual experiences (think what category of fears and responses such as contamination, moral/religious fears, driving, etc.) and what exposures would address each of these. An individual with OCD will then rank how much anxiety they believe an exposure will bring them. Gradually, they will be exposed to the feared stimuli until (in theory) their nervous system habituates and calms down on its own. This is called habituation.
What’s Wrong with Habituation?
Parallels of Habituation and Colonization:
Cultural assimilation typically refers to the ways in which immigrants to the United States are supposed to conform to European Anglo Saxon norms. The idea is that any language differences, accents, cultural food practices, etc. should be forgone and are less than.
Cultural assimilation is based on a long tradition of colonization where difference and diversity were viewed as threat. In order to reduce the threat due to fear of power being taken away, colonizers identified differences and began to associate them with savagery. Assimilation prioritizes sameness by making difference out to be a problem. Colonization speaks to this historical and ongoing process in America around assimilating into European, white, cisgender, heteronormative “norms.”
In many ways, ERP’s goal of habituation parallels colonization as it is itself a type of cultural assimilation, or pressure to conform to created “norms” around how brains “should” function. There are various neurotypes (themes of how different people’s brains may similarly operate). Neurotypical is one neurotype that refers to what has been prioritized and centered when thinking about systems, including mental health treatment. Similar to how race has been systematically taught to have moral differences, brain functioning has been taught to be abnormal if it doesn’t fit one way of operating. Neurodivergent brains, including those with OCD, are expected to assimilate to neurotypical norms.
Another way we can see this parallel of habituation and colonization show up is in the expectation for marginalized groups to go beyond what is considered “norm.”
In ERP, this is sometimes referred to as overshooting. The idea is that if an individual is extremely “overreactive,” they must learn to tolerate more discomfort through exposures in a treatment setting than what might be considered “typical” in order to cement the orientation toward life that discomfort isn’t to be feared. Frequently, these “overshooting” exposures require the person with OCD to do things even someone without OCD would never do, such as telling a person with relationship fears to tell a loved one they hate them, someone with contamination fears to lick the bathroom floor, or someone with religious fears to hold a Satanic ritual.
This mirrors how systems of oppression operate in society- often forcing those who do not hold ‘dominant’ identities to work harder to prove they can do the same job as the cishetero white man, for example. Instead of recreating oppressive systems in the microcosm of OCD treatment, we propose values based and client driven exposure to be more autonomous and agentic. Agentic care is crucial in OCD treatment, as it helps foster self trust which is often a core wound among many folks with OCD.
Habituation & Neurodivergent Nervous Systems:
Now that we’ve covered some important groundwork, let’s dive into why ERP’s goal of habituation may not be effective (and actually harmful) for neurodivergent nervous systems.
The ERP model recognizes difficulty habituating to feared stimuli as a significant challenge faced by individuals with OCD. What it misses is that different nervous systems are differently sensitive or activated by the same external stimuli. It views compulsions or external attempts to regulate as “irrational,” even though it’s important to understand that internal regulation may not function in the same way for neurodivergent nervous systems, making the whole model flawed for the vast majority of OCD sufferers.
For many with OCD, relying on external regulation measures makes perfect sense. It’s a valid coping mechanism when internal regulation doesn’t offer the same relief.
Additionally, the ERP model does not hold space for the fact that habituation can override important signals. Sometimes initial responses / sustained heightened responses offer important warning signs. While this may be touted as “irrational” or “overdrive,” the world for marginalized folks is filled with high threat and not acknowledging this is harmful.
We know systemic issues are a contributing factor to OCD obsessions and compulsions. Habituation as the blanket goal can miss honoring the ways in which neurodivergent bodies are rightfully responding to systemic issues. Pushing clients to do exposure therapy and discouraging talk therapy or exploring content of themes is problematic. Exploring content of themes can provide more information, which is especially helpful for autistic individuals to process, and is also important for connection, relational healing, and advocacy.
The ERP model also misses that habituation is different, harder, or even impossible for neurodivergent (especially autistic) nervous systems. Due to this truth, habituation cannot be the goal of OCD treatment for every individual. The inhibitory learning model offers an alternative, but still requires exposure and has its limitations.
As understanding around neurodiversity grows, there is more conversation around what approaches and experiences have been touted as ideal while pathologizing neurodivergent people’s different brains and nervous systems. Pathologizing refers to the process of viewing something different as problematic or abnormal, and in need of fixing. When we are told the way we are coping (compulsions) is pathological, it adds immense shame to a disorder that already comes with a hefty side of shame. What if we could see compulsions as attempts to cope with overstimulation instead? Compulsions, under ERP, are then treated with exposures, which end up activating some nervous systems even more. More shame and more activation? It’s no wonder people often drop out of ERP “prematurely.”
We often pathologize the ways our bodies are trying to protect us and keep us safe and are alerting us to signals in the environment that something isn’t right. You may have heard the idea that activation or hypervigilance from trauma is actually the body doing its job responding to overwhelming experiences. Through this lens, we understand that activation and compulsions and feeling highly alert is in many ways, albeit not a fun experience, a protective alerting that everything is not okay. When we add in layers of understanding around intergenerational trauma, we can see that OCD is, in some ways, a right response to things that feel deeply uncertain and scary, that deserve certainty.
Stay tuned for parts 2 & 3 of this series!
Want to learn more about integrating a neurodivergent affirming lens into clinical work?
Mimi Cole, MS, ACMHC (she/her)
www.mimi-cole.com IG: @the.lovelybecoming
Allyson Inez Ford, MA, LPCC (she/her)
www.eatingdisorderocdtherapy.com IG: @bodyjustice.therapist
Kris Scover, RDN, LD (they/them)
www.nourishedED.com IG: @nourishedED