Exposure and Response Prevention (ERP)
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What is Exposure and Response Prevention?
Exposure and response prevention, or ERP, is the gold standard treatment for obsessive-compulsive disorder (OCD). In other words, numerous studies have demonstrated that ERP is an extremely effective treatment for OCD and is superior to all other available psychological and behavioral interventions. ERP is a form of Cognitive Behavioral Therapy (CBT). Therefore, ERP also addresses behaviors and cognitions that are maintaining obsessions and compulsions in a structured and skills-based format. What does this evidence-based treatment entail? In exposure and response prevention, the goal is to learn that thoughts are just thoughts and that they do not contribute to behavioral or situational outcomes without intention. OCD is considered by some to be a thought phobia in which a phenomenon called thought-action fusion occurs. Thought-action fusion is the belief that whatever thoughts come to mind will result in behavior or action in the world (Grayson, 2014). In other words, OCD is often considered a thought phobia because individuals with OCD are afraid of their thoughts and the power of thoughts. How will you learn that thoughts are not as powerful as they feel? By sitting with anxiety and intrusive thoughts without neutralizing them or trying to eliminate them in any way (Foa et al., 2012). You will learn to "sit with" anxiety and intrusive thoughts using a variety of techniques that allow you to confront the stimuli that trigger anxiety and distress, both mentally and physically. With enough exposures to the feared thought or related stimuli, you will eventually learn that you can tolerate the trigger, that nothing bad or dangerous will happen, and that the anxiety will subside eventually if you do not engage in a compulsion. |
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What exactly does this treatment consist of?
An exposure exercise entails repeatedly and systematically encountering the feared situation or thought using a variety of exposure techniques until the fear diminishes. In treatment, we will help you create what is called a hierarchy of feared triggers so that you can gradually overcome your fears. For example, if you are afraid of driving due to fear of harming someone while driving (a very common obsession in individuals with OCD), your hierarchy may look like sitting in the car in a parking lot, driving in the empty parking lot, driving in the parking lot when it is busy, driving around the block, driving on a main road, etc. Your clinician will assist with developing a plan for you to get used to or habituated to each step. Habituation takes place when you get used to or desensitized to unhelpful or unrealistic anxiety (Abramowitz et al., 2019). For instance, you would repeatedly drive in the parking lot until your anxiety reduces by at least 50% before moving onto the next step. Anxiety/distress levels will be recorded and monitored during the exposure exercises for this reason. Scientific measurement of and tracking of symptoms will also assist in ensuring you are gradually habituating to fears and reducing related functional impairment.
In this way, ERP is systematic and gradual, as you will not typically move onto the next item of your hierarchy until the anxiety, distress, and/ or perceived level of danger regarding the thought or situation have significantly reduced during the previous step. Eventually, you will start to see that your intrusion is just a thought and that you do not need to be afraid of your thoughts, as you will also start to see that your fears are highly unrealistic. We all have intrusive thoughts. One other component of treatment is accepting uncertainty. We cannot eliminate all uncertainty and we will discuss how, even though anything is possible, we can’t live our lives trying to prevent every single possible risk we could encounter because we would not be able to live our lives at all. In this treatment, you will not be asked to take risks that most people would not take or that could cause serious harm to yourself or others. However, you will be asked to accept tiny amounts of uncertainty that we all must accept. The techniques learned and implemented in this treatment will help you do so.
In sum, the goal of ERP is to help you take control of your thinking and behaving in order to feel better. The highly effective will help you to do so both in and out of treatment. The end goal is to ensure that you can be your own exposure therapist to during and after treatment; because everyone continues having intrusive thought, the end goal is to learn how to react to them in the same way your did before developing OCD: A thought is just a thought.
References
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response Prevention for Obsessive-Compulsive Disorder: Therapist Guide (2nd ed.). Oxford University Press.
Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.
An exposure exercise entails repeatedly and systematically encountering the feared situation or thought using a variety of exposure techniques until the fear diminishes. In treatment, we will help you create what is called a hierarchy of feared triggers so that you can gradually overcome your fears. For example, if you are afraid of driving due to fear of harming someone while driving (a very common obsession in individuals with OCD), your hierarchy may look like sitting in the car in a parking lot, driving in the empty parking lot, driving in the parking lot when it is busy, driving around the block, driving on a main road, etc. Your clinician will assist with developing a plan for you to get used to or habituated to each step. Habituation takes place when you get used to or desensitized to unhelpful or unrealistic anxiety (Abramowitz et al., 2019). For instance, you would repeatedly drive in the parking lot until your anxiety reduces by at least 50% before moving onto the next step. Anxiety/distress levels will be recorded and monitored during the exposure exercises for this reason. Scientific measurement of and tracking of symptoms will also assist in ensuring you are gradually habituating to fears and reducing related functional impairment.
In this way, ERP is systematic and gradual, as you will not typically move onto the next item of your hierarchy until the anxiety, distress, and/ or perceived level of danger regarding the thought or situation have significantly reduced during the previous step. Eventually, you will start to see that your intrusion is just a thought and that you do not need to be afraid of your thoughts, as you will also start to see that your fears are highly unrealistic. We all have intrusive thoughts. One other component of treatment is accepting uncertainty. We cannot eliminate all uncertainty and we will discuss how, even though anything is possible, we can’t live our lives trying to prevent every single possible risk we could encounter because we would not be able to live our lives at all. In this treatment, you will not be asked to take risks that most people would not take or that could cause serious harm to yourself or others. However, you will be asked to accept tiny amounts of uncertainty that we all must accept. The techniques learned and implemented in this treatment will help you do so.
In sum, the goal of ERP is to help you take control of your thinking and behaving in order to feel better. The highly effective will help you to do so both in and out of treatment. The end goal is to ensure that you can be your own exposure therapist to during and after treatment; because everyone continues having intrusive thought, the end goal is to learn how to react to them in the same way your did before developing OCD: A thought is just a thought.
References
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd Ed.). The Guilford Press.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response Prevention for Obsessive-Compulsive Disorder: Therapist Guide (2nd ed.). Oxford University Press.
Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.
