April 21, 2021

What Is Exposure and Response Prevention (ERP) Therapy?

Exposure and response prevention (ERP) refers to a specific type of cognitive-behavioral treatment. ERP includes exposing oneself to certain stimuli and, subsequently, avoiding compulsive behaviors when triggered. This therapy is one of the gold standards for treating obsessive-compulsive disorder (OCD). It can also treat specific phobias, generalized anxiety disorder, and PTSD.

Understanding OCD

OCD is a specific disorder characterized by the combination of intrusive, involuntary thoughts (obsessions) and repetitive behaviors (compulsions). These obsessions and compulsions are often time-consuming, and they can impede someone’s quality of life

Common OCD obsessions include:

  • Fear of contamination and germs.
  • Fear of harm or danger.
  • Fear of losing control and hurting yourself or others.
  • Fear that things are not orderly or safe. 
  • Fear related to superstition and something terrible happening.
  • Fear of punishment. 

To ease these fears, people with OCD engage in compulsive behaviors. Some common compulsive behaviors include:

  • Repeatedly ensuring that loved ones are safe (calling or texting multiple times, even after receiving reassurance).
  • Excessively checking certain switches, locks, or appliances to make sure they are turned off or turned on appropriately.
  • Tapping, counting, or repeating certain phrases.
  • Washing hands or showering several times in a row.
  • Praying continuously or participating in religious rituals due to anxiety.

Many people with OCD have insight into their condition. They understand the obsessions or compulsions may seem irrational, but they still struggle to stop engaging in them. 

Unfortunately, this dynamic can trigger an ongoing cycle of guilt, shame, and low self-esteem. Likewise, they also tend to feel uncomfortable disclosing their struggles to others- they don’t want to be judged or ridiculed. 

The Challenges With Past Treatment Models

Before ERP, many practitioners struggled to treat clients struggling with OCD. They found that typical talk therapies weren’t sufficient enough for change. In some cases, clients regressed!

That’s because OCD is undoubtedly a complex condition. In the thick of the cycle, someone tends to desire absolute control or certainty. 

For instance, a person might want 100% proof that their loved one won’t die in a car accident that night. Of course, we this kind of guarantee is impossible (and the person struggling tends to know that). However, the person still partially believes that engaging in compulsions may help avoid their fears from coming true. 

Is ERP Another Version of CBT?

CBT is an overarching evidence-based treatment that can help with numerous mental health conditions. CBT focuses on the relationship between thoughts, feelings, and behaviors. CBT typically entails:

  • Structured, collaborative sessions.
  • A specific treatment plan with outlined goals and objectives. 
  • Challenging cognitive distortions (negative automatic thoughts).
  • Developing healthier coping skills.
  • Becoming more aware of the cycle between thoughts, feelings, and behaviors.

CBT helps clients feel more empowered in their lives. By learning that thoughts are subjective (and can be challenged), clients can improve their self-confidence, relationships, and mental health symptoms.

ERP is a branch of CBT becuase it is both cognitive and behavioral. Individuals learn how to challenge their thoughts, and they also learn how to challenge their compulsions. Focusing on the thoughts alone isn’t sufficient enough. In ERP, people must target both.

What Should You Expect With ERP Treatment?

ERP is a structured, evidence-based treatment offered by qualified mental health professionals. Like with any therapy, there are no guarantees. However, many people report significant improvements after completing treatment. 

When beginning this process, you will start with an initial intake. This intake entails a thorough assessment of your medical and psychiatric history. Your therapist will ask you many questions about your condition, including your past and current symptoms, how it impacts your life, and any other concerns you have. 

Additionally, your therapist will obtain your informed consent to begin treatment. When you provide consent, you essentially agree to the terms of therapy. You indicate that you understand the session fees, length, and treatment outcomes.

In ERP, you may learn several new clinical terms. Let’s review some of the common ones. 

Psychoeducation

Psychoeducation simply refers to your therapist explaining particular concepts to you. Their explanations may include: 

  • Relevant statistics and research.
  • Common symptoms associated with your condition.
  • Expected treatment outcomes.
  • Alternative treatment methods.

If you have a specific question, ask! Your therapist wants you to feel empowered and knowledgeable. You just need to let them know when you need clarification.

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Exposure Hierarchy

Your therapist may ask you to indicate various anxiety-producing situations and rank them from least to most distressing. For instance, if you struggle with germs, you may rate ‘shaking someone’s hand’ as a 6, but you may rate, ‘not washing your hands after using the bathroom’ as a 10. 

This hierarchy allows your therapist to structure your treatment. Eventually, you will start ‘exposing’ yourself to these fears. This exposure is gradual and controlled. Your therapist will break it down into safe, manageable steps.

Habituation 

Exposure therapy operates under the assumption of habituation. Habituation happens when we become desensitized to certain stimuli over time. 

For example, think about swimming in the ocean. When you first step in, the water may feel like it’s freezing. After a few minutes, your body adjusts. Or, let’s say you’re outside and there’s a lawnmower running. You may not even notice it was running until the noise stops!

Exposure therapy utilizes habituation by exposing clients to repeated stimuli time and time again. In the past, some clinicians used flooding, which meant jumping to the worst fear early on. If you had a fear of swimming, for instance, they’d want you to jump off the pier into the ocean. 

Today, therapists do not practice this way. Instead, they focus on more gradual exposure. You might start by simply looking at pictures of people swimming in bodies of water. After that, you might stand next to a pool. From there, you would work into dipping a toe into the pool. As you can see, there may be many, many steps you take to work through this fear!

Ongoing habituation is the key component for managing obsessions. The more you surround yourself with the fear (and survive!), the less frightening it feels.

In Vivo Exposure 

Habituation can happen in several ways. In one method, therapists use ‘in vivo exposure.’ This exposure refers to real-life, real-time exposure. You’re in the present situation facing the obsession and avoiding the associated compulsion.

For this reason (with appropriate consent), some therapists will conduct sessions in places like parks, restaurants, or other triggering locations. Doing so will increase the risk of the client exposing themself to their obsessions.

Guided Imagery

Guided imagery refers to a meditation practice where your therapist has you imagine certain situations. This approach is practical when they cannot accompany you for certain types of habituation. They may use specific prompts or scripts to help you imagine that you’re in a particular setting.

Response Prevention

Response prevention (sometimes known as ‘ritual prevention’) helps neutralize the anxiety associated with an obsession. In ERP, response prevention refers to abstaining from engaging in compulsions, even after having obsessions.

At first, this abstinence tends to feel agonizing. You are learning to change deeply-rooted habits, and it’s normal to feel a heightened sense of anxiety.

But over time, the more you abstain, the less intense the obsessions become. You are essentially retraining yourself to how you respond. 

Making the Most of ERP

It’s not enough to just show up for treatment. You need to be willing to dive in and invest in your growth. Like with most treatments, the more you put into the work, the more you will receive in return. Here are some tips to consider before you begin. 

Know That Treatment Can Be Uncomfortable

ERP can feel challenging. You’re trying new things, and you’re confronting some of your greatest fears. Be patient and kind to yourself during this process!

Your therapist may warn you that things will feel worse before they feel better. This phenomenon is relatively common in mental health treatment. Having to sit with discomfort is difficult, and you may find yourself feeling quite triggered to engage in compulsions.

Remember that this discomfort is temporary. The more you learn to tolerate such anxiety, the easier it becomes.

It’s Important To Complete Your Homework

Your therapist may assign you specific exercises to practice between sessions. At times, you may resist doing these tasks. After all, they can feel uncomfortable!

However, the majority of your growth doesn’t actually happen in therapy. It happens as you integrate the information you learn in therapy. Implementation is everything- if you want to change, you must be willing to implement new skills into your daily routine.

Speak up if Something Feels Too Distressing

Everyone progresses at their own pace. While it’s normal to feel challenged and uncomfortable, you shouldn’t feel obliterated by your emotions. This could be a sign that you need to slow things down or take a different direction.

Try to e honest and forthcoming with your therapist. Remember they are there to support and help you. Furthermore, they want to ensure that you feel safe with them guiding your treatment. 

Remember That Progress Requires Ongoing Practice 

If you’ve been struggling for a while, you may feel desperate for relief. Furthermore, it makes sense to want quick results!

But progress requires continuous practice. These skills take time to cultivate and integrate. It’s essential to stay consistent even if the results aren’t there yet.

Keep in mind that a lapse doesn’t mean you have failed. Like any medical condition, mental health issues have their ups and downs. It’s normal to have some ‘hard times.’ Instead of beating yourself up, try to reassess the situation and reflect on what you can do differently moving forward.

Can You Do ERP on Your Own?

Self-help therapy is possible, and there are several ERP workbooks and courses people can complete. These tools can come in handy when working through your condition. 

With that in mind, most professionals warn against people solely taking this approach without proper intervention. As mentioned, ERP can be stressful, and many people feel worse before they feel better. It’s easy to give up quickly if nobody is helping to hold you accountable.

Trying to tackle your condition on your own can result in excessive anxiety and discomfort, which can actually exacerbate your condition. You need a clear plan for treatment, and therapy is one of the best ways to provide that.

Finally, everyone has blind spots. If you try to engage in ERP on your own, you might overlook certain obsessions and compulsions. If this happens, you may subconsciously overcompensate some behaviors for others.

How Long Does ERP Treatment Take?

Like with most treatments, there isn’t a universal answer. The length of your therapy depends on your mental health history, specific condition, and your overall treatment engagement.

With that in mind, improvements take time. Don’t expect a miracle in just one or two sessions! Most people need about 3-6 months of work. 

Moreover, it’s not uncommon to engage in ERP along with other treatments. Many clients simultaneously participate in ERP while also participating in group therapy, psychiatric medication such as SSRIs, or couples or family therapy. 

Most therapists avoid using the word ‘cure’ when it comes to mental illness. Instead, you can expect overall management and recovery. 

How To Find an ERP Specialist

Not all therapists treat OCD. Similarly, not all therapists have adequate training in ERP. You will benefit from working with someone who has this experience.

You can start your search by looking into the International OCD Foundation. They provide a national directory with qualified specialists. Enter your location to determine therapists in your local area.

You can also ask your primary care physician if they have any recommendations. Most doctors are affiliated with mental health professionals- if they have insight into your condition, they may be able to point you in the right direction.

Final Thoughts

If you or a loved one is struggling with anxiety, ERP can be a wonderful solution. It’s safe, effective, and offers long-lasting benefits. Reach out for support today!

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Disclaimer: This information is not specific medical advice and does not replace information you receive from your healthcare provider. This is only a brief summary of general information. It does NOT include all information about conditions, illnesses, injuries, tests, procedures, treatments, therapies, discharge instructions or lifestyle choices that may apply to you. You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

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