A woman making a disgusted face. « Blog

By Richard Gallagher, LMFT

DISCLAIMER: I am a licensed psychotherapist with both clinical and lived experience with this issue — and a trained OCD specialist — but this article is based on personal conclusions and opinions informed by recent literature. More research is always necessary on the subject of this article. Please discuss any treatment strategy with a mental health professional.

For the sake of simplicity, I equate exposure and response prevention (ERP) here with “directly exposing yourself to a trigger and trying to get used to it.” In reality, ERP is more nuanced than this definition and involves many distinct elements. For a more detailed description of ERP, please visit the “Exposure and Response Prevention (ERP)” page on the IOCDF site. My simplistic definition of ERP in this blog reflects the gist of my personal experience of being treated (ineffectively) in the past by trained ERP specialists.

If you suffer from OCD, the “gold standard” for treatment is exposure and response prevention (ERP). Its name is also its strategy: expose yourself to whatever it is you fear, and don’t respond to it. For example:

  • If you have an intrusive thought, don’t try to neutralize it or furiously Google for reassurance.
  • If someone or something triggers you, don’t avoid interacting with them or it.
  • If you have contamination fears, touch things that feel contaminated and don’t wash afterward.

The goal of ERP is to either get used to what you fear (habituation), or at least learn to tolerate the distress it causes and live with it (acceptance).

This approach works well for many people — but not everyone. Here, I want to focus on one type of OCD that classic ERP often isn’t particularly effective for, according to a growing body of research — and one that I suffer from myself: contamination OCD triggers based on disgust.

This research shows that ERP treatment outcomes for disgust are mixed at best, and that gains from treatment aren’t durable1,2,3. As a sufferer and a clinician, I believe I know why this is the case: ERP was designed to treat fear, not disgust, and doesn’t reflect our real-life approach to managing disgust. So I am going to discuss one possible way to tweak ERP to make this issue much more treatable.

Why disgust and fear are different: A neurobiology lesson

All contamination triggers are not the same. Some are based on fear (“I’ll get sick and die from germs!”), but others are based on disgust (“I’ll never feel clean enough and will obsess about this forever!”).

Both of these are very uncomfortable, but according to recent research, they spring from different neurological reactions. Fear is triggered by that part of your brain known as the amygdala, a brain region associated with strong emotions in response to threats; it responds to an urgent and immediate threat such as a hungry bear, so you can fight or run away from it. Exposure will often eventually extinguish unrealistic fears, or teach you to tolerate them better.

Disgust, on the other hand, is processed by a different part of the brain known as the insula. It processes sensations of disgust and stores them in our long-term memory, to keep us from being poisoned by things like eating spoiled food, breathing in bad air, or spreading noxious substances on your hands. Disgust doesn’t change easily, no matter how much exposure you do. And when change happens, it happens very s-l-o-w-l-y.

For many of us, using ERP as a blunt instrument to treat disgust exactly the same way as fear often backfires. When you expose yourself to something disgusting, the feeling of disgust often doesn’t change over the course of the exposure, nor does your tolerance of it. In fact, as you stick out these exposures, your revulsion or distress tolerance may even get worse. As much as we wish that the amygdala and the insula would behave the same way, they are separate brain regions and  stubbornly do not.

I cannot overemphasize enough the importance of how slowly disgust changes. It usually doesn’t change over hours or days — often it’s more like months, years, or never. Numerous therapists have told me privately that they’ve had clients expose themselves to triggers for months on end with no progress. This is why many sufferers find exposure therapy to be exactly like an average person smearing dog poop on everything they own, trying to get used to it, and then discovering that they can’t.

In my view, this analogy to dog poop is what may hold the key to successful treatment. Now, let’s explore this process in more detail.

How people normally adjust to fear versus disgust

People do get used to both fear and disgust in real life, but these are very different processes.

First, let’s look at fear. Remember when you first rode a bicycle? It was scary! But your parents probably encouraged you, you took small steps, and eventually, whee! It wasn’t as scary anymore. With enough practice, your brain reconceptualized this as being less scary and your fear diminished over time. This is exactly why ERP works so well for so many OCD fears and intrusive thoughts.

Unfortunately, this model doesn’t work the same way with disgust, because disgust is much more stubborn and hard to change. Let’s look at an example of how many veterinarians — a profession someone once described as “a flash flood of poop” — actually get used to dog poop. At first, contact with poop feels terrible. New vets may use lots of safety behaviors, such as wearing gloves, washing their hands every five minutes, and avoiding whatever they can. However, their response to this is to continue to practice veterinary care versus actively trying to confront the poop. And, in time, they learn to reduce the accommodations they need to do this because they put themselves back into the situation every day and these triggers eventually soften, over a l-o-n-g period of time. During the first month, vets may wash their hands constantly. Six months in, it’s uncomfortable, but they’re more used to it. After a year, they still don’t like poop (and probably never will) but when the inevitable happens, they shrug, clean up, and move on. The exposure — and the habituation — isn’t to poop: poop is as disgusting as ever. The exposure is to being a veterinarian, and doing what veterinarians do every day, in the presence of poop.

This is precisely how most people learn to manage disgust in normal life. Paramedics don’t spend all day hanging around dead bodies to get used to them — they keep working as paramedics. New mothers don’t stick their hands in a pail of dirty diapers — they keep changing their babies. Sanitation workers don’t roll around in garbage — they keep going to work. In other words, they live their lives, do whatever they need to do, and over a long enough period of time, it gets easier and they need fewer accommodations.

By comparison, classic ERP would be like having these veterinarians carry a lump of dog poop around in their hands and not wash their hands, until they get used to it. (Or more realistically, perhaps carry around a tissue contaminated with dog poop — an actual exposure some clinicians have proposed for contamination fears.)

Some of these vets might get used to the poop, but this won’t happen quickly — and many of them will never get used to it. (I suspect that even seasoned vets would still avoid sitting in a chair with visible poop on it.) Some of them may find that they actually get worse, particularly if they cross-contaminate more things, and feel even more closed in. Quite a few of them will “flunk” this exercise, and perhaps even decide that they aren’t cut out for the field. (P.S. I “vetted” this section with an experienced veterinarian who agrees with everything here.)

This is often what happens in general when you use ERP for disgust-based triggers. It works for some people, but head-on exposure to triggers will still fail others or even make them worse. These people may even be dismissed as “treatment failures” when, in fact, the problem may actually be the treatment approach itself. It isn’t the same as, say, dealing with a fear by facing it head on, because disgust stimuli change much too slowly.

Now, let’s look at a strategy for treating disgust-based OCD that has worked, for myself and others:

Do whatever you need to comfortably get into disgust-inducing situations for a l-o-n-g enough period of time for your response to your triggers to soften. Then, gradually reduce your accommodations.

Let’s call this a “mastery” approach versus an exposure approach. Your goal is to master situations you avoid, even when your triggers may still remain disgusting for a very long time. Most importantly, you aren’t trying to expose yourself to discomfort — you are trying to be comfortable enough to do lots of practice for a long time. In other words, the focus is on the RP (response prevention), not E (exposure).

Let’s compare common wisdom from ERP about contamination fears with a mastery approach:

 

ERP Mastery
Face your feared triggers head-on. Spend more time in situations you want to master, despite the trigger.
Contaminate everything so there is no escape. Do whatever you need to do to be comfortable, and focus on reducing your accommodations over time.
Learn to tolerate distress. Stay comfortable enough to get more “reps” with the situation (e.g.,  doing your job or being in your house) versus the trigger (e.g., poop).
Treatment is focused on exposure and response prevention to triggers. Treatment is focused around gradually improving your functioning, and doing what you want to do.

Of course, what differentiates disgust-based OCD from normal disgust is its degree and intensity: sufferers feel disgusted by things that wouldn’t bother most people, feel it more acutely, and often obsess about avoiding these triggers. But in my opinion, our normal disgust reactions are what make this issue different from other forms of OCD — and why classic ERP, however well-intentioned, often fails.

Now, let’s look at some real-life examples to show how this works.

Case examples

Case 1. An exterminator sprays insecticide all over a client’s kitchen. Now she is afraid to use it.

ERP: Expose herself to gradually increasing levels of insecticide, eventually applying it herself.

Mastery: Explore how the client might get back into the kitchen again. If the only way she can do this is to wear ratty old clothes or gloves at first — fine. Above all, try to find ways she can comfortably start spending lots of time back in this kitchen, preparing food and living life. Then, work on gradually cutting down on her safety behaviors.

Case 2: A client washes his hands constantly for fear of contamination.

ERP: Restrict handwashing and expose himself to the feeling of contamination.

Mastery: Have him track how often he washes and seek ways to reduce it every week, while he keeps doing whatever it is he wants to do.

Case 3: Your client’s son, Herman, LOVES peanut butter and jelly sandwiches. But your client feels “grossed out” by having sticky substances like jelly on her hands, and obsesses about it long afterwards — so she makes Herman bologna sandwiches for his daily school lunch instead, which he hates.

ERP: Do exposures to having jelly on her hands.

Mastery: Make peanut butter and jelly sandwiches for Herman every day, doing whatever she needs to do to be as comfortable as possible. Strategize how she might handle the occasional errant bit of jelly when it happens. Then track her comfort and level of accommodation each week.

In conclusion

Some clinicians will recognize the theoretical underpinnings of this approach: it borrows heavily from Acceptance and Commitment Therapy, or ACT4 — particularly, its core principles of moving towards your values, and focusing on willingness rather than exposure. (I am not talking about the kind of gently-talk-you-into-more-exposure approach to ACT that is sometimes combined with ERP — our goal here is functioning better, not habituating to disgust.) ACT is an evidence-based therapy for OCD with good research support behind it, and in my view it is tailor-made for working with disgust-based contamination fears.

Here are some of the advantages of this approach:

It is humane and well-tolerated. The focus is on being comfortable enough to do lots of practice, not getting used to discomfort.

It avoids the all-too-common unintended consequences of cross-contamination, and further sensitizing clients to things we want them to desensitize to.

Clients see rapid benefits in terms of functioning better, do not feel shamed for “not doing enough exposure” with a trigger that remains disgusting for a long time, and do not lose hope when exposure doesn’t work for them.

It leverages how humans normally adapt to disgust, instead of treating it incorrectly like fear.

How well does this approach work? In my experience — admittedly with a small sample size — it works well. In 2018, I published an IOCDF research poster on using a very early mastery-based approach with my own cases, focused on approaching ERP by expanding one’s comfort zone instead of tolerating distress, with a 90% treatment response rate. Fine-tuning this approach substantially around disgust issues eventually helped me experience a nearly 40% decline in my own Y-BOCS scores, after multiple failed trials of ERP.

In closing, this approach is based on one person’s clinical and lived experience with disgust-based OCD. More research is needed to see if my hypothesis is correct. Either way, I hope we keep learning and refining more effective treatment strategies for this frustrating and difficult disorder.

Q&A

Q: ERP is about getting used to something you fear. Your “mastery” approach involves doing more of what you avoid. Isn’t that kind of saying the same thing in a different way?

Of course, overcoming any fear ultimately involves doing what you previously avoided. But working from a mastery framework has some important differences:

The focus is on being comfortable and doing more practice, versus being uncomfortable and getting used to it.

I am OK with judicious use of safety behaviors, as long as they are (a) specific, (b) targeted towards the goal of more practice, and (c) gradually removed as triggers soften.

It models people’s normal lived experiences. If a non-OCD sufferer feels a doorknob is dirty, they would probably clean it off AND start using it again — not get used to the yuck, or worse, avoid it until they feel ready to face the yuck.

It explicitly rejects exposing yourself to extreme triggers (“bending the pole”) as a treatment goal. For disgust-based triggers where habituation may be difficult or impossible in the short term, I feel this approach is both ineffective and needlessly cruel.

Q: You are OK with (gasp) introducing some safety behaviors. Isn’t that like giving booze to an alcoholic — or more to the point for OCD, enabling another compulsion?

I realize that ERP purists recoil at the idea of introducing a safety behavior — in their view, this feeds an ever-widening spiral of accommodations and fuels a worsening of OCD. At a macro level, I agree with them. But at a micro level, I feel this is, in fact, one of the more important interventions for treating disgust — and for me personally, it was game-changing.

To me, the distinction is whether you are moving towards better functioning or away from it. Crutches, for example, allow people to walk while a broken leg heals, after which you stop using the crutches or perhaps switch to a cane — while never ever using a crutch may mean walking with unbearable pain or injuring yourself. In my view, this is an exact analogy to why many disgust sufferers fail ERP, and what we need to do differently for a trigger that habituates as slowly as disgust.

I do not endorse safety behaviors as a mechanism for simply increasing avoidance. In my view, acceptable safety behaviors are limited, surgically-chosen strategies designed to get you back IN to a previously avoided situation to enable lots of practice — not just an accommodation for avoidance. There is even some recent research support for this: for example, check out these papers on judiciously using safety behaviors in treatment5,6, as well as recent literature on the “rubber hand” technique for disgust exposure.

Q: What do you mean by “NOT the kind of gently-talk-you-into-more-exposure approach to ACT that is sometimes combined with ERP”? Are you knocking how people currently use ACT for OCD?

No, I actually feel that can be very effective for OCD in general — just not for disgust. Here’s how I see the difference:

ERP: I’m going to do something uncomfortable and try to get used to it.

ACT/ERP: I’m going to do things I value, which will involve doing uncomfortable things and tolerating the distress.

ACT/Mastery: I’m going to do things I value, find ways to do them as comfortably as possible at first, and do them often enough that I need less and less accommodation over time — often a long period of time.

Put another way, strategy 2 makes sense if whatever you are doing will get better soon with practice — like many fears. With disgust, it’s more like trying to get used to sitting in a hot car or wearing an itchy sweater — you could do it all week and not feel any better about it, or even feel worse. Strategy 3, on the other hand, allows you to practice the situations you want to master long enough to see real change.

Rich Gallagher, LMFT is a therapist based in Ithaca, NY. He is the author of numerous self-help books including The Anxiety Journal (Rockridge Press, 2022), Stress-Free Small Talk (Rockridge Press, 2019), How to Tell Anyone Anything (AMACOM/HarperCollins, 2009), and many others.

References:

1Ludvik, D., Boschen, M.J., & Neumann, D.L. (2015). Effective behavioural strategies for reducing disgust in contamination-related OCD: A review. Clinical Psychology Review, 42, 116-129. doi:10.1016/j.cpr.2015.07.001

2Bhikram, T., Abi-Jaoude, E., & Sandor, P. (2017). OCD: obsessive-compulsive…disgust? The role of disgust in obsessive-compulsive disorder. Journal of Psychiatry & Neuroscience, 42(5), 300-306. doi:10.1503/jpn.160079

3Novara, C., Lebrun, C., Macgregor, A., Vivet, B., Thérouanne, P., Capdevielle, D., & Raffard, S. (2021). Acquisition and maintenance of disgust reactions in an OCD analogue sample: Efficiency of extinction strategies through a counter-conditioning procedure. PLoS One, 16(7): e0254592. doi:10.1371/journal.pone.0254592

4Twohig, M.P., Hayes, S.C., Plumb, J.C., Pruitt, L.D., Collins, A.B., Hazlett-Stevens, H., & Woidneck, M.R. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705-716. doi:10.1037/a0020508

5Rachman, S., Shafran, R., Radomsky, A.S., & Zysk, E. (2011). Reducing contamination by exposure plus safety behaviour. Journal of Behavior Therapy and Experimental Psychiatry, 42(3), 397-404. doi:10.1016/j.jbtep.2011.02.010

6Blakey, S.M., Abramowitz, J.S., Buchholz, J.L., Jessup, S.C., Jacoby, R.J., Reuman, L., & Pentel, K.Z. (2019). A randomized controlled trial of the judicious use of safety behaviors during exposure therapy. Behaviour Research and Therapy, 112, 28-35. doi:10.1016/j.brat.2018.11.010

 

4 Comments

  • Sakina

    My therapist recommended this article. It was very helpful and I plan to incorporate some of these concepts in my OCD treatment.

    Reply
  • Dana Ryder

    Rich, please help us relate the ACT/Mastery approach for our 16 year old daughter who on average sits on the toilet for hours wiping a thousand times over until they get the “just right” feeling. But even if/ when that feeling occurs, Meredith still feels contaminated and often will not shower due to ocd telling them that the contamination will be spread all over her body. So they retreat to their bed to avoid life until the next day when they go to the bathroom for hours again to void out all the contamination to get the feeling that they can try to shower. Two weeks can go by easily without a shower.
    What is the thing of “Value” in this scenario? What are we supposed to accommodate them with regarding safety tools… more and more toilet paper and baby wipes??
    Our daughter has been at an ocd/anxiety residential center twice in the past year and a half. (Four months, then six months). Their contamination ocd does not get treated successfully when they are there. Other minor facets of their ocd responded to the ERP but not the wiping/toilet condition. They describe it as feeling their skin crawl and they feel contaminated internally as well. The toilet episodes are almost every day at well over 8 hours each time with sometimes lasting overnight. They are hopeless right now and we have very little resources for this type of ocd in our area to help us. They even looked into the idea of smoking pot or at least taking cbd gummies or vaping weed. They take Olanzapine and Cymbalta so those might be compromised or a bad reaction could result if they vaped. And I’m not condoning it but it is curious if cbd would lessen the obsessive thoughts.
    I’m scared for their future and actually for them right now.
    We are desperate for help!! Meredith has suicidal ideations and doesn’t hesitate to tell us that they are just a burden to us and everybody would be better off without them. One of us is always home with them and they haven’t acted on this. Taking them to the psych unit of a local hospital will not help either. We’ve done that already a couple of years ago.
    Do you know of any programs anywhere that our daughter could get the help specifically for their type of ocd?
    OR, can you help us relate your ACT treatment protocol to Meredith’s needs?
    Thank you!!!
    Dana Ryder

    Reply
    • Sarah Young

      Hi Dana,

      Did you get a reply on this, as my 16 y/o Yuri is suffering from similar OCD for the past 2 years. We are in the uk and under CAMHs and waiting for treatment with national service, but it is so hard managing this daily. However, they do shower, but excessively after which is exhausting for them. I just wonder if anything improved or if your daughter got the right treatment in the end.

      Many thanks

      sarah

      Reply
  • Delyan Savov

    Hi Rich,
    Thank you for sharing this mastery approach. Being trained in ACT, in my work with clients I strive for getting them to be able to do the things hey want to do. Just like you, I do not mind (that much) if they do some strange behaviors/compulsions if that is what is needed to get where they would like to be. However, reading this article and listening to you on a couple of podcasts, I found myself asking how exactly do you differentiate between fear-based and disgust-based obsessions. Where do you draw the line? If you do. If we take the distinction that in fear-based obsessions we have a story of something bad pending in the future and in disgust-based – no story, just a yucky feeling, then some of the examples here and on the Fearcast with Kevin Foss, do not fit these categories for me. Namely the insecticide example here and the more poisonous than cyanide liquid from the Covid testing kit from the Fearcast. Do you think there is a story of something bad possibly happening in the future after being in contact with these substances? Or you think it’s just a yucky feeling and nothing bad might come to mind after being in contact with these potentially deadly substances? Now having said that, I think that the experience of disgust is just a shortcut for the same thing as being afraid of something bad possibly happening in the future without having to come up with an elaborate story. Mother nature had it built in for us so that we can save some mental energy. So essentially disgust a proxy for fear. And especially with your example of the liquid from the Covid testing kit – did you experience the disgust when you came in contact with this (I assume clear) liquid or after you read what that liquid is? Was your experience a response that mother nature has built into you or was it a result of a story you came up with after you have read the information? Thank you, Delyan

    Reply

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