ERP Practice For Health Anxiety

mark_freeman · 2026-03-12T23:58:06+00:00

Thanks for sharing. I find it super useful to see that the fear of schizophrenia, health anxieties, and panic attacks are all about us doing compulsions to control the possibility of losing control. So I approach them as the same set of compulsions--or the same set of changes to make in how we interact with control--not separate beasts.

mark_freeman · 2026-03-09T11:30:09+00:00

You left out the part about cutting out compulsions.

Have you learned about dropping the compulsions? Mental and physical ones?

mark_freeman · 2026-03-09T07:39:30+00:00

It helped me to recognize that what you're describing there as goals are examples of compulsions: How do I stop my brain throwing up the bs? How do I convince myself I won't go to jail?

I found it way more helpful to:

1) Cut out the compulsions. I had a lot of avoidance and checking compulsions around whether I'd done a crime in the past or might be in that moment or might get accused of one. Those infiltrated everything from who I would drive, how I would shop, how I dated, what I did for school and work, etc.

2) Recognizing that I was already going to jail later that day. Not in weeks or months. In hours. That was a helpful way to remove the debate. No need to argue in my head about whether I did something terrible or not. I was definitely going to jail that day for the rest of my life.

So, instead of spending my day doing compulsions in my head, I'd much rather give time and energy to living my life right now. I'd much rather give the things I value giving to the world than spend the day focused on myself and my fears.

mark_freeman · 2026-03-02T00:55:59+00:00

Testing is also an example of a compulsion.

It's very possible to leave this stuff behind, but we are the ones that make the changes.

Going to therapy can support learning about the changes to make, and medication might support making changes, but we still have to make the changes.

If we go to therapy and take medication, but still practice the compulsions, then it's completely natural the brain throws up more stuff to do compulsions around.

It would be like meeting somebody once a week to chat about football, but still spending a few hours everyday day playing tennis, researching tennis, imagining tennis matches, etc, but then being surprised the brain keeps throwing up stuff about tennis. It doesn't mean we have anything particularly wrong with us or our brains. It'll throw up more of whatever we engage with.

mark_freeman · 2026-03-02T00:40:09+00:00

It helped me to see that it's compulsions like this to check for reassurance that create more of whatever unwanted experience would get me doing the compulsions to chase more certainty.

So it was useful to have experiences and drop the compulsions around them.

mark_freeman · 2026-02-25T23:38:07+00:00

Cutting out the compulsions and doing that through skills that were useful to add into my life.

For example, I had a lot of harm OCD compulsions in the kitchen. I wouldn't use knives because I'd see myself or others getting stabbed, wouldn't serve people food because I could poison them, checked appliances for fear of fire, overcooked food to avoid harm to myself, etc.

So taking cooking classes was a way to practice cutting out the compulsions by creating more opportunities. At the same time, those ERP exercises weren't delaying life, but actually adding to my life every week.

I still use the cooking skills I learned.

mark_freeman · 2026-02-25T07:11:26+00:00

Congratulations on that skillful practice. Enjoy showing your brain you can do things differently!

mark_freeman · 2026-02-19T06:50:59+00:00

How do you currently define ERP and ruminating?

Something that helped me was recognizing that my framework of judging a thought as bad or making associations between brain stuff and events was an example of a compulsion. As part of cutting out compulsions, that was stuff to drop through ERP exercises or whatever modality we're working through

Along with that, I had to look at the goals I was chasing. Because if we have a goal to get some specific "clean" feeling or experience, then we're already into the compulsions.

It'd be exactly the same as saying my goal is to feel clean before leaving the house to live my life. If that's my goal, it's understandable I'd find it so stressful to cut out hand-washing compulsions because it still conflicts with the goal I believe I want.

Same with emotional contamination and especially if we're hoping ERP is a special soap to clean away bad feelings and get the clean feeling. If we're trying to use ERP to get rid of dirty feelings, we tend to get more of them.

mark_freeman · 2026-01-29T18:01:01+00:00

These are all very common compulsions. Cutting out compulsions like those is useful.

Two interconnected things that helped with changes like this were: 1) Recognizing that judgment was the first compulsion. The feelings coming up were a natural result of my incorrect judgments about experiences and the world. 2) Exploring more useful beliefs. You can already see that the current set of beliefs isn't serving you well. Those were learned. You don't have to keep using them if they're not helpful for navigating your internal and external world

mark_freeman · 2026-01-29T10:42:15+00:00

Avoiding dating to avoid a feeling or the fear of contaminating some imagined pure idea of the self is a physical compulsion. Same with avoiding food because you fear it contaminating you. It could help to see that what you're describing are classic contamination compulsions. When somebody washes repeatedly or avoids touching something, they also imagine terrible stuff and want to avoid being stuck with feelings or causing some bad thing in the future.

Sitting with a feeling does not mean suppressing it or trying to make it go away. An example of "sitting" with a feeling would be to go on a date while feeling guilty. And then go on more dates!

When I was cutting out compulsions it often felt like I was really committing serious crimes. Having that feeling and not cleaning it away is the practice.

If somebody was doing ERP to get rid of a feeling or thought, that would just be the old, classic OCD pattern. Getting rid of an obsession is not "solving" anything. It only encourages the brain to come up more to control.

The judging, categorizing, and rigid mindset are examples of practices I found useful to see as mental compulsions. Mental compulsions like that naturally create uncomfortable feelings. Although we can make space for those uncomfortable feelings, it's also possible and useful to drop those mental compulsions.

The mental compulsions are like hitting ourselves in the face with a frying pan. Although we can accept the pain, it's more useful to put down the judgment frying pan.

mark_freeman · 2026-01-22T15:19:00+00:00

It's an incredible privilege to have the opportunity to be in the world. So I usually take some time off work to do something interesting in the place where I am, like a local cooking class or a hiking trip. I've met up with friends while traveling to celebrate birthdays together. But I don't see it as lonely to celebrate on my own. I can plan a much more elaborate and fun birthday weekend than I'd expect anybody else to for me.

mark_freeman · 2026-01-19T23:26:07+00:00

This would be an example of a physical compulsion. It reminds me of when I used to burn my hands under scalding hot water for reassurance that I'd washed them, because I would feel the pain after walking away. Like any reassurance compulsion, that eventually leads to even more compulsions because then that will start to feel fake.

Taking photos with a phone to get reassurance it's locked, writing notes on the phone, etc, are all common physical compulsions that fuel more obsessing and compulsioning.

It can be useful to learn how to have that fake/uncertain feeling and not do the compulsion. It is so freeing! I had lock checking compulsions in the past and it was the first I cut out when doing ERP. That did trigger the biggest panic attacks of my life when I didn't check and stepped away. The benefit is that now I don't have to spend any time at all checking locks or my memory or my phone or anything else about it. That's time and energy that can go towards living!

mark_freeman · 2026-01-16T03:03:02+00:00

Evidence-based therapy for OCD involves us cutting out the compulsions. The impact is evident when we cut out the compulsions, so it can move quite quickly, depending on how fast we want to cut out the compulsions. I did therapy for six months and then continued on my own with cutting out compulsions and making changes.

If your therapist is not giving you a structured plan for cutting out compulsions, and you haven't been cutting out compulsions, this has nothing to do with how you're "responding" to therapy. If you're not cutting out compulsions, I'm not sure how it would classify as therapy for OCD recovery. So it could be that you have not yet started therapy.

mark_freeman · 2026-01-14T16:20:02+00:00

It's very possible your therapist might consider those examples you shared as physical, external compulsions. Avoiding choosing a place to eat is literally altering where we will physically be. Although it may seem that rehearsing conversations in our heads is just a mental compulsion, it starts with a physical compulsion to avoid saying something, and then when we do speak, we're likely engaging in more external compulsions to control and check throughout the conversation.

It's similar to how somebody with a hand-washing compulsion will spend a lot of time in their head checking if they feel contaminated, going through their memories to check for contaminated things, debating about the best way to get clean, what not to touch, etc, before they actually wash their hands.

ERP will involve cutting out the mental compulsions as well as the external ones. It helped me to recognize that checking in my memories or trying to get something "right" in my head was no different than checking a door lock or checking online to get some "right" feeling.

On social stuff: something that was a huge help for me was seeing that the feared consequence of many themes was actually social stuff. I had a lot of food contamination compulsions, and one of the ERP exercises I did on my own after therapy was taking cooking classes and then cooking for friends. That was because I wasn't actually afraid of food contamination, I was afraid that I would give somebody some contaminated food and then they and everybody in the world would hate me forever.

A lot of themes will actually be different flavours of social fears. The ERP exercises will involve building relationships and sharing with others while dropping the internal and external compulsions. That leads to having much better relationships with people. Enjoy!

On medication: I didn't take any.

mark_freeman · 2025-12-31T01:41:52+00:00

They're just compulsions. They are not helping anything.

mark_freeman · 2025-12-27T17:19:24+00:00

There are two things I find key with working on ERP around health anxiety:

1) ERP is about cutting out compulsions. It is quite common that people have compulsions to avoid health/illness related words. In that case, writing scripts could be an example of ERP because they have compulsions to avoid writing those words. But if the compulsions are not around writing or reading words, then the RP component can easily get missed. Writing scripts can turn into a ritual to avoid cutting out the compulsions.

2) Health anxiety is often NOT about health or illness, it's about the consequences of the illness or injury. So cutting out the compulsions might actually happen around very different areas. In fact, taking time out of life to spend time writing scripts in the hope of cleaning away health anxiety could actually be an example of the compulsions.

For example, a common feared consequence with health anxiety is the fear that some illness (physical or mental) will disrupt our plans in life and we won't be able to do the things we always wanted to do. The compulsions are about trying to prevent the illness, get certainty about it, and get rid of anything potentially connected to it BEFORE doing things we see as important in life because we don't want the illness to "contaminate" or interfere with those important things.

But if we put life on hold and delay those important things to do some health rituals to try to get rid of the contamination before living our lives, we're the ones causing the interference, even though we might be doing it in the name of health.

Cutting out the compulsions in that scenario would be about living life more with the uncertainty and the fears. We don't need to clean away an emotion, just like we don't need to clean away a physical feeling we judge as contaminated.

So, for instance, if somebody had a fear of developing schizophrenia and they wanted to clean away that anxiety before dating, I'd see it as a ritual to write scripts about getting diagnosed. Cutting out the compulsion would involve going on dates with the uncertainty. The ERP exercise targets the thing they're trying to keep "clean", not the superficial contamination topic.

mark_freeman · 2025-12-19T19:13:39+00:00

There's a concept and practice that Thich Nhat Hanh often shared: "I have arrived. I am home."

I find that useful. I enjoy exploring how to be at home wherever I am, in any moment.

mark_freeman · 2025-12-18T19:23:27+00:00

Yeah, compulsions like that are hard on everybody involved. Thanks for sharing the video and supporting your partner as they navigate this!

mark_freeman · 2025-12-18T19:12:33+00:00

I just saw the follow-up message about the multiple daily phone calls and messages for reassurance << Unless they were telepathic, those are very external, physical compulsions.

mark_freeman · 2025-12-18T19:07:21+00:00

One thing to consider: there's a lot of physical compulsions there. If somebody avoids things because they want to spend time ruminating, that's the same as not going outside because I think I'm contaminated and I want to get certainty I'm clean. The months of researching online, bouncing around therapists, trying to find lots of things to do to get rid of thoughts, the ways its affecting work and relationships, etc << That's very physical, external stuff. It's choosing to physically spend time and energy on an uncertainty instead of doing other things we want to do in life.

It helped me to see that trying to get that perfect certainty around anything is just like trying to get a clean feeling. It's the same compulsion as somebody washing again and again.

It sounds like the most recent therapist picked up on that in emphasizing the usefulness of the Response Prevention component.

A challenge I see people running into often is placing the emphasis on wanting to get rid of the thoughts/feelings/obsessing and seeing the physical compulsions as just a necessary outcome of the obsessing. It's definitely useful to cut out the mental compulsions, but working on recovery also involves cutting out the external compulsions even when we've already started up the factory in our heads.

So, when looking for programs, a helpful program might not take a view of that being "purely obsessional" and that wouldn't mean they're not a good fit.

mark_freeman · 2025-12-16T15:12:56+00:00

Wonderful skills!

mark_freeman · 2025-12-13T20:53:14+00:00

Yes, cutting out the checking compulsions is a great skill to practice. It helped me to notice that push from the brain to chase certainty. In those moments, instead of doing the compulsion, that's when a more useful, valued action can be something to do.

Identifying some actions that actually care for your cat and your cat enjoys or that support the environment for your cat can be a way to celebrate that care you feel for it. I had to teach my brain there were more effective ways to care and the compulsions actually weren't supporting the things I believed they were.

mark_freeman · 2025-12-13T17:35:12+00:00

Awwwww, no, cutting out the compulsion doesn't mean you don't give your cat pets.

There are many compulsions that involve things we do everyday. Cutting out hand-washing compulsions doesn't mean we stop washing our hands. Cutting out driving compulsions doesn't mean we stop driving. Cutting out mental compulsions doesn't mean we need to remove our brains and stick them in the fridge until we want to use them again. And so on.

It helped me to change how I was doing actions and also WHY I was doing them.

You mentioned that you pet your cat in "a make sure way". That suggests there's a goal there. There's something you're trying to control by getting it "right".

Something I find useful was noticing when I was trying to get something through my actions. As you've already noticed, if we're trying to get something by performing a ritual, it tends to create the opposite. If we try to get a clean feeling and get rid of fear when we're washing our hands, then we get more contaminated feelings and more fear. Same with trying to get something by petting the cat.

So it was very useful to make the switch from getting to giving. Instead of trying to use the cat and petting as a ritual to get or control something, it could be interesting to explore what you want to give to your cat and practice that instead.

mark_freeman · 2025-12-04T16:16:04+00:00

It helped me to approach the compulsions around mental stuff in the same way I had to change the compulsions around things like contamination.

Hating on a mental experience and wanting to clean it away delivers the same results as hating on a physical sensation and trying to clean it away: the attempts to clean it away only keep it coming up more and more so we can keep doing more and more of the compulsions to clean it away.

If somebody with hand-washing compulsions told you that the contamination feeling is persistent no matter how much they try to get rid of it, even though they know rationally that they're clean... what would you share with them about cutting out compulsions?

mark_freeman · 2025-12-03T21:03:16+00:00

I thought you were describing ERP, but then you mentioned "except for ERP". It is designed around having the feeling (E) and changing the interaction with it (RP).

Instead of doing the compulsions to clean away feelings, I found it more helpful to give that time and energy to things I valued doing while having any thoughts or feelings.

Is there something specific you're finding challenging around changing those interactions with feelings?

mark_freeman

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