When you have OCD, it’s important to understand the difference between a lapse and a relapse. A lapse occurs when OCD symptoms temporarily flare up. It’s also called a slip, and during a slip you might find yourself having obsessions that try to stick around, and you might give in to a compulsion or two. A relapse occurs when, for an extended period, your symptoms go back to around the level they were at when OCD was at its worst.
Notice how we didn’t call this chapter “lapse prevention.” That’s because everyone who has OCD is going to have a slip now and then. Everyone. And that’s okay. It’s just part of having OCD. What we are trying to do in relapse prevention is make the lapses as short, infrequent, and minimally bothersome as possible, in hopes of achieving an even bigger goal: to prevent lapses from becoming relapses. But it’s also good to understand that sometimes relapses happen. Because no one’s recovery from OCD is perfect. And that’s okay, too.
Becoming mindful of slips is really important to maintaining a strong recovery. A few slips that go unnoticed turn into more slips, and more slips, until all of a sudden you are in a full-blown relapse. Except it wasn’t all of a sudden, because it really happened slip by slip, over and over again. Alternatively, if you can catch slipping early, it’s much easier to remind OCD that this is your JOYful life, and that while you are absolutely fine with OCD making itself known from time to time, OCD is not the one in charge.
There’s a straightforward way to identify when you’re slipping: monitor the duration, intensity, and frequency of your OCD symptoms (Abramowitz, Deacon, and Whiteside 2011). To make it easy to remember, we call it the ERP DIFference (Duration, Intensity, Frequency), as this relapse prevention tool will help you know when doing an ERP game will really make a difference. Let’s explore each of the three parts of the tool in turn.
Duration refers to the length of time an obsession appears stuck in your mind. If you have a fleeting thought—such as “Did I really turn the garden hose off this morning?”—that disappears within a few seconds or minutes, that’s not a big deal. Everyone with OCD is going to have their fair share of those. In fact, people without OCD have these thoughts, too. But when an obsession pops into your mind and becomes firmly lodged there for half an hour, an hour, half the day, or the entire day (or longer)—that’s a signal that you’re slipping. For instance, if that garden hose thought is now interrupting your afternoon meeting, and you are wondering whether you should call your retired neighbor to have him check whether it’s really on, that’s a sign that the thought is going on too long and you are most likely in the midst of a slip.
Intensity refers to how much anxiety or discomfort an obsession gives you when you are in its presence. If the thought, “I might want to grab that letter opener and harm my coworker,” comes to your mind as your coworker walks by your desk, and it causes only the slightest twinge, then that’s not a big deal. That’s just life with OCD, and you can smile at it and get back to work. But if you get that instant adrenaline rush, where you feel all your worst anxiety symptoms—your stomach drops, your face flushes, you feel like you just might throw up, and so on—all at the same time, then that thought is still packing the proverbial punch. That type of intense anxiety or discomfort means that OCD’s content still has a hold on you. Unless you take quick corrective action with an ERP game, you’ll find yourself skidding and sliding on OCD’s black ice.
Frequency refers to how often you notice a particular obsession. Say you read the newspaper each morning, and every once in a while your OCD pipes up and says, “Did you really understand what you just read?” and you just keep on reading, flipping to the next section. That’s fine. That’s OCD just testing the waters. But if OCD starts asking you this question each day, ratcheting up the feared consequences each time (“What if you vote for the wrong person because you don’t really understand this issue, and that person raises taxes, and then you’ll owe extra money just because you weren’t paying attention to what you read!”), then you are heading down OCD’s not-so-fun water slide.
Or, you begin to notice that OCD is chiming in about all sorts of things in the span of an afternoon: “Was that a bump you just ran over, or the neighbor’s dog?… You’re not going to leave that picture hanging crooked, are you? Ick, it’s just wrong!… Do you think you offended Lisa when you asked about her mother today? She seemed sort of cold at the end of lunch… Did that rug already have a wrinkle in it or did I do that? What if someone trips over it and falls and I’m held liable?” A frequent stream of unrelated obsessions within a short period is another indicator that you’re slipping and it’s time for decisive action to remind OCD that you are in charge.
It’s most effective to use your mindfulness skills to keep mental notes about the duration, intensity, and frequency of your obsessions. You certainly can also write them down or track them in your phone, but be conscious of any tendency to over-monitor or compulsively track everything. More importantly, you want to mindfully observe what your OCD is doing. Notice how often it’s commenting on things, how long its running commentary runs on, and how insistent it is that you do something. In spy shows on TV, agencies often monitor online “chatter” of people who are potential threats; mindfully observing your OCD is like watching its chatter. When the duration, intensity, or frequency of intrusive thoughts begin to noticeably increase, it’s a good idea to get into ERP mode. If you experience two or three of the three signs escalating, it’s definitely game time!
By “monitoring,” we aren’t suggesting that you become hypervigilant to notice OCD’s every move, which sometimes happens to people early in recovery. They feel so much better that they just don’t want OCD to ever bother them again. But it is going to bother you sometimes. That’s what it does. We don’t want you to feel traumatized, just waiting for when it’s going to strike next—that’s the very opposite of JOYful living! Practice mindfully noticing it, making mental notes using the ERP DIFference, and tell yourself, “Hey, I’m just keeping a mindful eye on the chatter. I know OCD will try to bother me at some point, but I’ve got a strong recovery and the skills to deal with OCD when it does pop up. I don’t want to be all worked up about this, because then I’m acting the way the OCD wants me to. It’s cool, OCD. Come back when you want to. I’m just being mindful of your chatter so that I have a welcome gift/ERP game ready for you.” Then, when it comes back, you’ll be ready to take appropriate action.
Well, you did everything right. You took your medication as prescribed, you saw your therapist and brushed up on your CBT tools, used the ERP DIFference, upped your meditation game, exercised more, ate healthier, connected with your support group, reread this book you’re holding in your hands right now—and still, you crashed. You’re on the floor in a fetal position being repeatedly kicked by your OCD, and now even the OCD is bored with it. So now what? How do you pick yourself up off the floor when you feel so stuck?
The first time you had your life chopped up and handed to you on a platter by the OCD, you didn’t know what you’d done to deserve it. You might not have even known you had OCD. You just thought you were losing your mind. But as you stand there in the relapse hole, it’s important to recognize that starting from scratch must include also having amnesia. Wait—this is impossible, because you can’t not know you have OCD. True! So that means you’re never starting back at square one. Don’t let your OCD negate all the work you’ve done and all the knowledge you’ve gained just because you’re in a difficult spot. You do great work in difficult times, and you will get back on top. Experiencing a relapse can feel like being at the bottom of a deep, dark well. Fortunately, however, this well is equipped with a ladder that has five firm steps you can use to find your way back to level ground.
Self-criticism can be a major barrier to getting back out of the hole from an OCD relapse. All of the questions—such as “How did I find myself back here again? Where did I go wrong? Why does this keep happening?”—can be distilled to “What is wrong with me?” This is a nonstarter. Nothing is “wrong” with you. You have OCD, and OCD is mean and crafty, and it is going to bring you down from time to time. Before you can get a better grip on the tools that keep you in command, you have to brush off the self-criticism with self-compassion. Digging yourself out of the hole your OCD put you in isn’t all about exposures. The first thing to address is how you are treating yourself. If you are focused on self-hatred and self-abuse, then you are not focused on the climb ahead.
In part 1 of this book we discussed how the first step to self-compassionate coping is mindfulness. So once you’ve brushed the dirt off your shoulders, it’s time to take a look around and mindfully accept the position you are in. People often confuse acceptance with simply allowing things that are bad to persist. But acceptance is actually the initiator of change. If you see that you’ve gotten out of shape, it isn’t motivating to try to squeeze into pants that don’t fit. What you get from that is just more self-criticism and the desire to escape—into ice cream. If, on the other hand, you buy pants that actually fit, nice pants that look really good on you as you are now, you’ll start treating yourself better. This leads to making healthier choices overall. The same is true in OCD. If you deny that things have gotten hard, you’ll just keep punishing yourself. But if you accept that things are the way they are, your attention is freed to focus on getting back on track.
Now that you’ve switched to self-compassion mode and acknowledged that things have gotten rough with your OCD, it’s time to call in the troops and up your support game. You’re not alone, so don’t be alone. If you’re not yet up for one-on-one discussion, you might start by making contact with an online support group. Or maybe you have a support buddy who knows you well enough to have seen you here before. That means they also know you well enough to remind you that you’ve gotten out of this before. And of course, reach out to your therapist if you have one. It’s not about your therapist telling you what you already know and making you feel bad about it. It’s about getting back to the work with confidence.
Hard times in OCD don’t always mean doing the hardest exposures. It’s fine if you can meet the OCD head on, but if you’re climbing out of the relapse hole, it’s also fine to just work on what you know you’re ready to work on. If you’re struggling with contamination obsessions, for example, and you feel overwhelmed by all of the urges to wash, you might not be ready to touch the dirtiest thing you can find and then resist washing. But maybe you can commit today to using just one pump of soap instead of the five OCD wants you to use. At this stage, what you need is a little taste of success. Setting the goals too high means you’re likely to get kicked back down into the hole and start self-criticizing again, calling yourself a failure. Do exposure at a level that is challenging, but likely to empower you, not the OCD.
The character Don Draper on the show Mad Men had a great response to someone asking him to rehash the past: “I move in one direction. Forward.” Once you get the mindfulness and ERP tools back in action, keep yourself focused on reclaiming whatever OCD stole from you in this latest battle. If you let the shame of having a relapse pull you backward, focusing on “I can’t believe I let myself get that bad again,” the outcome is predictable. What happened is what happened, and you have the power to get back on top of this thing. It’s up to you if you want to keep score and count your lapses as failures—but we don’t recommend it. We recommend congratulating yourself for learning from each stumble along the path.
Lapses are going to happen, and, left unchecked, they unfortunately can turn into relapses. But using the ERP DIFference to monitor OCD’s chatter can help you identify when OCD is throwing spaghetti against the wall, testing what content might “stick” and get your attention, and when it’s using more strategic moves to slowly but surely get you doing compulsions again so that it can stage a comeback. By becoming mindfully aware of what your OCD is doing, you’ll become more attuned to whether letting it be or taking a more assertive stance (such as playing an ERP game) would be to your advantage. However, you know what they say about the best-laid plans! Sometimes, regardless of how hard you’ve worked on your recovery, OCD can prevail. During these times, focusing on self-compassion, acceptance, support, and doing manageable exposures is the best way to get back on track.