Exposure and Response Prevention (ERP)
Exposure and response prevention (ERP) is just like a fitness program for your brain. However, instead of shaking up your fitness level, it’s designed to shake up stubborn OCD symptoms. Let’s expand on this analogy.
Reasons for Doing Exposure and Response Prevention (ERP)
People don’t adopt fitness routines for no reason at all; physical exercise is not a random activity. We don’t accidentally buy gym memberships or wake up on treadmills. Exercise is always purpose-driven and typically is intended to improve one’s quality of life in some quantifiable way. Common goals for exercising are related to health, aesthetics, or the feelings it evokes.
Treatments like exposure and response prevention (ERP) are also intended to enhance your life in a meaningful way. Just like with exercise, your ERP efforts will be driven by your own personal motivators. Maybe you want to spend less time on your rituals so that you can be living more deliberately and less reactively. Perhaps OCD has caused your world to shrink, and you want to take it back. Maybe you’re motivated to fight OCD so that you can be a better parent or spouse. Maybe you simply want your days to be filled with more fun and less panic.
These reasons form the basis of your recovery plan.
If these reasons don’t exist for you…if you’re doing treatment for someone else rather than for yourself, the road will be difficult. In order to be able to sustain effort through challenges, you will have to identify personal motivators that are meaningful to you.
Just like with physical exercise, your ERP has to be purpose-driven or you will lose your momentum.
This analogy can be taken even further.
Exposure therapy is not a singular activity.
Physical exercise is often based around targeting a particular muscle group or certain aspect of health. People who want big biceps do different exercises than people who want to lose weight.
This is similar to exposure and response prevention therapy. People who want to be less bothered by unwanted thoughts (e.g., thoughts of hitting someone with your car) do different exposures than someone who is afraid of contracting a deadly disease. The form of the “exercise” reflects a specific therapeutic goal.
You can target your OCD symptoms in multiple ways.
People who want to work on their abs might consider crunches, leg lifts, push-ups, etc. In ERP, there is no one exposure that will help you get better. Instead, there is an array of options that might work for you. Develop your treatment plan deliberately and thoughtfully on the basis of your OCD symptoms.
Exposure therapy is based on a hierarchy that builds skills over time.
Physical exercise is hierarchical. If you want to get stronger, it’s smart to start with light weights and build up to heavier ones. It would be downright dangerous to attempt a 500lb bench press without proper training. In ERP, going for that “10″ on your hierarchy is ill-advised at the beginning of treatment. Before going there, you need to lay the proper groundwork first. A gradual approach might take more time, but it will get you to the destination without subjecting you to unnecessary injuries.
Like any exercise, ERP will make you “sore” at first.
If you’ve ever started a personal fitness program, you know that the first few days or weeks of a new routine can be downright painful. It’s common to feel aches and soreness in muscles that you didn’t even know you had. If you’re unaccustomed to exposure and non-avoidance, early exposures might feel especially challenging. However, like any exercise program, the soreness associated with exposure and response prevention will decrease with practice and give way to increased mental and behavioral flexibility.
Therapists, like trainers, have different styles.
Not everyone is a drill sergeant. The best trainers will listen to you, work with you, and try to understand where you’re coming from. They’ll then use their expertise to design an individualized plan for you that is based on your goals, preferences, and unique perspective. The best therapists I know follow this same approach to treatment. If you’re completing an exposure under duress, you’re unlikely to benefit from it. It’s the process of choosing to face your fear (and willingly embracing the uncertainty that comes with it) that leads to lasting recovery.
ERP is a personal journey.
Even the best trainer in the world can’t do the work for you. The success you will have in your therapy depends on the amount of time and effort you invest in the process. The right support system can be critical to your success, but ultimately there is no substitute for hard work. Own the process of treatment.
Progress in treatment requires consistent day-to-day effort in addition to your scheduled therapy sessions.
If you go to the gym only once a week, you will never look like a champion bodybuilder. Large investments of your time will result in significant gains, whereas small investments may yield little (if any) benefit. For you to reach your treatment goals, you must prioritize your recovery and keep exposure time from getting swallowed by life’s hectic pace. This means putting forth effort even when you don’t feel like it.
SSRIs can be helpful, but they are not a substitute for therapy.
Protein may fuel muscle growth, but it’s unlikely to yield any significant benefit if it doesn’t accompany behavioral changes like exercise. Similarly, “supplements” like SSRIs can be helpful, but you shouldn’t consider them a “magic bullet” that will eliminate your OCD with no effort on your part.
Treatment effects can generalize.
The squat is considered the “king” of lower body exercises, because it results in a flood of human growth hormone that can stimulate muscle development in other body areas. Exercises like squats have the potential to pay whole-body dividends. Similarly, solid exposure and non-avoidance skills transcend the specific symptom area you’re targeting. Once you understand the process of exposure and response prevention, you develop core skills that go beyond your immediate treatment goal and result in generalized improvement.
Exposure and response prevention (ERP) is based on human physiology.
If you visit your doctor and ask what you can do to build muscle and strength, he or she will recommend exercise. If you ask your doctor for alternative strategies for muscle development, he or she would be pretty hardpressed to come up with a list of effective alternatives. Exercise works because it’s based on human physiology. There’s no real substitute for exercise when it comes to muscle growth and development.
So, too, for exposure. Exposure is one of the only evidence-based treatments for OCD. Exposure and response prevention works because it capitalizes on human physiological processes like habituation. What causes ERP to fail sometimes? It’s often not ERP itself that fails but rather that the treatment wasn’t delivered in an effective way. For example, important factors might go overlooked when developing your treatment plan. This might cause you to select exposures that target the wrong “muscle” groups. Of course, other likely causes for treatment non-response are issues related to the consistency or form that exposures take. This is one of the reasons why it’s helpful to have a therapist oversee treatment and provide feedback.
Rituals are like junk food.
If you’re doing exposure in one moment and ritualizing the next, it’s a bit like going to McDonald’s after your workout. You might think you’re getting thinner, but you might actually be gaining weight. Rituals will sabotage your efforts. It’s important to adopt a philosophy of living that incorporates consistent response prevention.
Recovery is not an endpoint; it’s a lifestyle.
Although you might accomplish your specific goals related to fitness, in order to maintain the gains you’ve made, you need to figure out how to incorporate exercise in your daily life. The same principle is true for exposure.
Exposure therapy is not a strategy to be set aside after reaching your therapeutic goals. Instead, it’s a technique that you want to integrate into your day-to-day lifestyle. Moreover, just like exercise, there will likely be times when you’ll need to increase the frequency or intensity of your exposures. Just as many people up their exercise after the holidays, so too will you have to dial up your exposures during periods of stress or change.
Questions? Comments? What strategies do you use to maintain your fit brain?
How would you go about the ERP on ppocd? Especially if its the fear of you or your baby being possessed? Thats my main issue right now. Ive gotten through the other OCD parts(Ive had it since 16) and this one I cant kick. My baby is only 4 months, but this terrifies me, so I think I need to stop my “what if” thoughts? Thats all I can think to get through this. I live in WA state, so I’d love any resources you may know of near me. Thanks 🙂
Hi Tiff, thanks for your question. When I’ve treated individuals with a fear of demon possession, I’ve found that response prevention is absolutely critical. It would be important to resist rituals like blessing your child, checking your child for signs, ritualistic prayer, ritualistic baptisms, etc. ERP is typically ineffective if these behaviors continue.
The exposure portion of treatment typically involves writing imaginal exposure scripts about your baby, watching demon possession movies, and making statements about your baby being possessed. Because this can all be quite intense, it’s important that you proceed according to a well-developed hierarchy. It might also be helpful to work with a therapist who has experience in treating scrupulosity.
Wishing you the best with this!
FYI, you might also read my articles on scrupulosity.
I’m in my late 30s, and discovered I have mild OCD symptoms few years back, which are counting and having to have things in the exact order.
How can I practice the exposure and response prevention method on my own?
Appreciate your advice, thanks in advance.
Hi Jenny, there are a lot of good self-help books on OCD out there. I would recommend using one of them as a guide. In general, you would build a hierarchy of situations involving disorganization that would cause your anxiety to spike. RE: counting, you could practice resisting the urge to count or purposefully miscount items.
So I just started getting aggressive obsessive thoughts that I hate. I want it to go away and it is affecting me every day. It started out with anxiety and then panic attacks and now this. I keep thinking I’m going to go crazy or lose control and I started to think I was being possessed I think about all these things constantly and don’t know what to do to get over it
Also I’m only 19 and get scared that I’m going to live with this for the rest of my life
i am not a doctor, but i suffered from the same/similar thoughts and panic attacks, it is all manageable and solvable, i just wanted to assure you because you were not replied:) i have been through the same, but i worked really hard and i am better and better, sometimes i have my lows back, but with all the knowledge that i gained they no longer last. what i did was went to therapy extensively, and read read read and watch videos about similar issues, videos about spirituality, etc. i dont know which road you gonna take, but trust me there is always a way, always, even if you at your lowest. dont be affraid of your thoughts, most of them arent true, but a product of a mind that s like a puppy who got frantic. in the meantime, i wouldnt expect it to go away by itself, you have to make steps in order to change things, just do it. what that IT is, depends on your personality, what works for you. hope that helps, wish u all the best, you not alone in this, remember that and dont be affraid.
I am not diagnosed with OCD but I have been in therapy for about two years to work on excessive procrastination and perfectionism in academic work (I am a professor and researcher). I personally think we are all on a continuum so maybe I have OCD tendencies; whatever I have, it affects me so I want to work on it. Thanks so much for this and your other articles, I am going to use these techniques with my psychiatrist to work on obsessive behaviors that I carry out to evade anxiety-producing activities which I procrastinate on when I feel the anxiety. I am going to try to think of how to not carry out the obsessive behavior when more than a ritual (although it probably is a ritual but I just don’t see it) it feels like a behavior that is an evasion. Such as not sitting down to write (or finish) an article, prepare a class or correct a thesis (instead of doing that work, I read novels for example). So, just having written that i think it is probably the same thing. I just need to think what my rituals or obsessive behavior is and then work on that with these techniques. The idea that this is not going to be a one time thing is especially helpful.
i have sexual ocd problems.(homosexuality)
im studing medicine
i want to try erp on myself.
please lead me
Hi, good afternoon I have been diagnosed with anxiety and obsessive thoughts. I can not shake my thoughts off. I am in a relationship which is quite fresh. I know deep down inside I have strong feelings for my girlfriend and do not want to lose her however my thoughts can not stop telling me to break up with her. Drop her. Telling me that I don’t have feelings for her etc. it’s overwhelming and very hard as I do not want to lose her but I am scared of giving in to these thoughts as they are so realistic and constant to the point I do not know what to believe. I am worried for our relationship and for my life please help. I recently was started on remeron last week and take clonazep as well to help me sleep Please respond ASAP. Thank you
This analogy was really eye opening and interesting to think about. It kind of made me think about how, while it is supposed to help you, it will still take hard work to overcome the pain along the way. When I thought of ERP I always thought of it as getting rid of weakness, but this made me realize that it is actually building the strength to get through it.