Everything You Need to Know About Exposure Response Prevention (ERP) Therapy
Exposure response prevention (ERP) is a type of therapy necessary for virtually everyone with OCD; it is considered the gold-standard of treatment. But, before we can truly understand ERP, we must understand the umbrella under which it sits: Cognitive behavioral therapy (CBT).
CBT, used in psychotherapy (or talk therapy), is a type of treatment where patients are taught to take notice of negative and stressful thoughts and then react to them in a healthier way.
CBT involves several elements, including:
- Structured therapy
- A limited number of sessions where the tools are learned and developed
- Effectiveness for those suffering from a variety of mental illnesses or anyone experiencing life stressors (so, really, everyone)
- The ability to start and stop again (patients can always work with other specialists or restart CBT after doing it years before)
- Self-standing or supplemental treatment: CBT works on its own in some cases; in others, it’s more effective when combined with medication
The heart and soul of CBT is the exploration of how thoughts affect behaviors. But CBT doesn’t ask patients to change their thoughts (as often thoughts are something out of our control); rather, it asks patients to change how much importance is applied to those thoughts or their perception of those thoughts. Ultimately, CBT strives to empower the patient to become their own therapist.
The Power of Thoughts
Thoughts are extraordinarily powerful, whether they’re welcome ideas of creativity and invention or they’re intrusive notions that terrify us.
Take, for example, the following scenario……
You’re camping in the middle of the forest with a group of friends. In the dead of the night, you hear trees rustling outside your tent. You think:
- No big deal – it’s just the wind
- It’s a bear that will leave as soon as he realizes he can’t get to your food
- It’s an ax murder (you’re pretty sure you read something in the newspaper about a hatchet-wielding maniac on the loose)
It’s not really about the thought itself, but the power applied. Whichever thought is given the most authority is the thought that influences your emotions (relieved, cautious, or terrified) and the dictator of your behavior. It tells you to go back to sleep, keep calm but vigilant, or flee from your tent, jump into your Honda, and speed down the dirt road to safety.
The Gist of ERP
ERP takes CBT one step further, not only focusing on stripping the thoughts of power but eliminating neutralizing compulsions as well. This is a vital part of OCD treatment – the disruption of the OCD cycle, a vicious cycle of obsessions and compulsions.
The OCD Cycle
OCD is marked by intrusive thoughts that torment, terrorize, and immobilize the sufferer. In order to neutralize the anxiety caused by these intrusions, the sufferer engages in compulsions (such as counting, checking, praying, washing, or asking others for assurance).
This works temporarily, but it worsens the disease in the long-run because of the nature of this illness. OCD acts as a monster in the mind, drowning the suffer in lies that are ego-dystonic (meaning they go against the individual’s values, desires, and moral code). Each time the sufferer engages in a compulsion, they validate these intrusive thoughts, making them stronger and harder to ignore.
Eventually, the OCD sufferer enters into an unrelenting cycle that goes as follows:
Step 1: They experience an intrusive, distressing thought (or idea, image, impulse, etc.).
Step 2: They react by engaging in their neutralizing compulsion, locking the thought in and giving it credence.
Step 3: Their compulsion relieves their anxiety and they feel better for the moment.
Step 4: The temporary relief wears off.
Step 5: They experience another intrusive, distressing thought.
Step 6: They react by engaging in their neutralizing compulsion again, locking the thought in even more.
Step 7: Repeat, repeat, repeat (without help, OCD sufferers repeat this pattern throughout the course of their illness).
One of the reasons OCD is so difficult for the sufferer is because OCD demands 100% certainty, an impossibility that’s chased but never caught. For example, someone with Contamination OCD seeks 100% assurance that their hands are clean. And OCD rebuts with questions and concerns.
“What if they’re not really clean? What if you didn’t wash long enough or strong enough? What if they were clean but now they’re contaminated again? What if that soap was expired? What if you didn’t get underneath your fingernails? What if touching the faucet when turning off the water left germs on your hands?”
OCD thrives on the term What If? and is often referred to as the “doubting disease” for that reason. It is doubt that defines the disorder.
How ERP Works
ERP involves exposing the patient to triggering and stressful thoughts, images, ideas, notions, objects, or situations (their obsessions) and then instructing them to refrain from engaging in rituals (their compulsions). Typically, this rapidly increases anxiety, making it harder and harder for the sufferer to continue refraining from their neutralizing compulsion. But, nonetheless, they’re asked to sit in their anxiety and, if they can, it begins to decrease in time. This is called habituation, the reduction in anxiety that happens when the patient is able to expose themselves to their stressor without responding compulsively.
In essence, OCD puts the sufferer on high alert when no threat really exists. It hijacks the body, warning them of danger that is purely imagined. ERP aims to reset the body’s alarm system.
Why ERP Works
ERP works because it forces the sufferer to face their fears, desensitizing them to that fear in the process. The more the sufferer faces their fears (i.e., the more they expose themselves to their OCD trigger), the more detached they become from their intrusive thoughts. And the more manageable those thoughts feel.
In neuroscientific terms, ERP achieves the following inside the brain:
- Breaking the conditioned response between obsessions and compulsions
- Extinguishing the fear response and minimizing symptoms
- Forming new memory structures based in reality rather than fear
- Learning new responses that compete with former responses (the compulsion)
- Inhibiting the original excitatory response (however, it doesn’t prevent this response from returning, which is why ERP is not a one-time fix but a life-long practice for OCD sufferers)
Importantly, OCD breaks habitual compulsions and this breakage decreases the obsessions. OCD is very much a disease that wants the sufferer’s attention and it gets this attention through compulsions. Once the compulsions go away – once the sufferer refuses to give OCD the attention it covets – the obsessions follow, weakening before disappearing too.
OCD can be thought of as a used car salesman, determined to sell automobiles by telling customers whatever it wants. The more customers buy cars, the better a salesman OCD becomes. But, if the customers see through the lies OCD tells and refuse to purchase, OCD finds itself in trouble with the boss. Eventually, it’s fired from the lot and exiled to the unemployment line where it no longer has the chance to swarm customers with falsities.
ERP and Avoidance
People with OCD know their triggers well and go to great lengths to avoid these triggers. Someone with Pedophilia OCD, for example, may avoid going to schools, playgrounds, parks or anywhere else where children frequent. Someone with Harm OCD may avoid sharp objects. Someone with Relationship OCD may avoid alcohol or anything that lowers inhibitions.
Because of this, part of ERP addresses avoidance. Sufferers are not only encouraged to stop avoiding their triggers, but they’re encouraged to expose themselves further. Someone with Contamination OCD who avoids sitting on public toilets may be encouraged to touch the toilet seat with their hands repeatedly, something that isn’t normally a part of regular bathroom use.
The History of ERP
OCD treatment has changed over time, evolving with our understanding of the disease. It’s evolved so much, in fact, that we now look back on previous treatment and cringe.
In 1965, for instance, a psychologist named Arnold Lazarus treated his OCD patient through shock therapy. The sufferer, a compulsive handwasher, was instructed to shock herself whenever she engaged in handwashing. While the patient believed it successful, this type of aversion doesn’t get to the root of the problem. It also sets the stage for the Whack-a-Mole game OCD constantly plays; the shock treatment might have moved the patient away from handwashing, but OCD will undoubtedly latch onto another area. Because that’s what OCD does.
ERP itself came about during this same time: The 1960s. But it was foreshadowed before that. Even Ivan Pavlov, the Nobel Prize-winning Russian physiologist whose late 1800s/early 1900s work revolved around the conditioned response, played a role in its development.
In the 1920s, Mary Cover Jones, an American psychologist known as “the mother of behavior therapy,” used conditioning to successfully treat the fear of rabbits in one of her patients. This was significant not only to future treatment but also for womanhood as Jones became a trailblazer in a field dominated by men.
In 1958, Joseph Wolpe, a South African Psychiatrist, developed systematic desensitization using elements of classical conditioning, cognitive behavioral therapy, and applied behavior analysis. His work was so influential that the Review of General Psychology ranked him as the 53rd most cited psychologist of the 20th century. Impressive and ironic, since Wolpe was a psychiatrist and not a psychologist.
During this decade, behavioral therapy grew in use, before evolving into cognitive behavioral therapy and, eventually, ERP.
The Birth of ERP
One of the most central figures in OCD treatment is Stanley “Jack” Rachman, a psychologist and professor who specializes in OCD. Rachman credits ERP’s foundation to Vic Meyer, a British psychologist and the “father of behavioral case formulation.”
In the mid-1960s, he performed what is believed to be the first successful ERP treatment on an OCD sufferer. Previously, ERP had proved beneficial in animals but Meyer showed that it worked in humans, too. He used ERP in two patients, one whose fear of contamination (and subsequent rituals) ruled her life and another whose intrusive sexual thoughts made the simplest of acts, such as dressing, take up to six hours a day. Neither patient was cured by ERP, but both experienced newfound manageable levels of anxiety, proving the treatment successful.
Rachman credits Meyer with “breaking the ice” and introducing a novel, impactful form of OCD therapy into the mainstream.
ERP has been honed since, of course, adopted to include more modern treatment like mindfulness. Rachman has played a big part in this, publishing books and articles on OCD (as well as other anxiety disorders), introducing new treatments and cognitive models, and proposing new ideas around the conceptualization of fear.
ERP doesn’t always involve exposing the OCD sufferer to the actual thing (for instance, a real doorknob); it can be performed in a variety of ways.
The three main methods include:
In Vivo Exposure: In vivo exposure is the type of exposure most often addressed in this article. During this method, the sufferer exposes themselves to their fear. If someone with Harm OCD fears matches (fearing that they’ll intentionally light someone on fire), they’ll be asked to hold a pack of matches in their hand without engaging in any of their neutralizing compulsions.
Virtual Reality Exposure: Virtual reality exposure is a type of exposure that uses virtual reality to expose the sufferer to an imaginary stressor. If someone with Contamination OCD fears dirty shoes, they’ll be put through VR where they virtually hold shoes full of gunk and funk.
Imaginal Exposure: Imaginal exposure is a type of exposure that uses the sufferer’s imagination to expose them to a fictional thought. If someone with Relationship OCD fears that looking at other women will cause him to cheat on his wife, he’ll be asked to imagine standing in a room full of females.
Graded Exposure vs Systematic Desensitization vs Flooding
ERP is often done from a graded exposure standpoint. With this, sufferers expose themselves to manageable fears before progressing into more challenging ones. During the more tolerable steps, the sufferer enhances their skills and better learns to handle their anxiety. This ultimately prepares them for the harder exposures that lie ahead.
Graded exposure leads to systematic desensitization, or the process in which the sufferer detaches from their thoughts. Systematic desensitization may be coupled with relaxation techniques that enhance a patient’s ability to withstand their discomfort. These relaxation methods may include deep breathing, progressive muscle relaxation (tensing and then relaxing the muscles in the body), guided imagery (or relaxation visualization), and meditation.
Flooding is another technique, though it’s a bit like ERP on steroids. This fast and furious method involves exposing a patient to all their fears at once. It can feel extraordinarily intense (or downright traumatic), which is why it’s not typically used; its propensity to overwhelm the patient leads to a high dropout rate. However, flooding is effective, and often at a faster rate than systematic desensitization.
ERP and Pure-O
ERP is sometimes believed to be ineffective for Pure-O, a type of OCD that doesn’t involve visible compulsions. But this assumption invokes a misunderstanding of what Pure-O truly entails. Sufferers experience intrusive thoughts, ideas, or images and then fail to engage in physical rituals, but they certainly engage in mental ones. ERP works for Pure-O by eliminating these mental compulsions.
It might be more difficult for a therapist to use ERP in someone with Pure-O as the therapist is unable to tell with certainty that the patient isn’t engaging in their rituals. This is different than other types of OCD where the therapist visibly sees the compulsion. If someone with Contamination OCD is asked during a session to touch the floor without wiping their hands on their jeans, the therapist can watch them to make sure they are not reverting back to their neutralizing behaviors.
Even so, the therapist has no way of knowing if the patient is engaging in rituals outside of the office (they must take the patient at their word). They also have no way of knowing whether the sufferer who touched the floor will leave their office and spend the next hour in their car dousing their hands with sanitizer.
The point is this: Regardless of the OCD type and whether the compulsions involved are mental ones or physical ones, the therapist must trust the patient to do the ERP’s largely on their own.
The Effectiveness of ERP
While there is no doubt that ERP works, how well it works depends on the source you cite. Some sources claim it works between 75-85% of the time while others cite 50%. The deviation likely has to do with why ERP fails: Up to 30% of patients drop out of treatment because of the anxiety it involves.
Medication is usually combined with ERP because of the above: SSRIs and other meds make it easier to do the exposure exercises. Without medication, the anxiety is more overwhelming and the patients are less able to sustain their resolve. Other modalities may be combined with ERP as well, such as mindfulness and Acceptance and Commitment Therapy (ACT), in an attempt to ease the sufferer’s burden.
Those who complete ERP treatment – they’re able to sit with their anxiety instead of reverting back to their compulsions – often enjoy a high rate of success. Yet this triumph isn’t immediate; it’s not forever, either.
On average, ERP treatment requires 8-12 weeks before symptoms noticeably decrease (though they may start to decrease to some degree well before that). ERP has a habit of getting easier the more the patient does it. After all, gradual desensitization is the entire point.
Still, doctors often compare ERPs to a daily medication taken for a physical health problem (such as the baby aspirin taken every day to lower the risk of heart attack). In short, the run-of-the-mill OCD sufferer isn’t cured after their ERP treatment is over; instead, ERP is something that must be practiced each day. Abandoning it, and going back to compulsions, reverses its efficiency and sets the patient back at square one.
ERPs are individualized; using a one-size-fits-all scenario isn’t effective because OCD manifests as different types of fears and obsessions for each person. For instance, someone with Contamination OCD may be asked to touch a trash can and then refrain from washing their hands. Asking someone with Harm OCD to perform the same ERP is pointless as they’re unconcerned about contamination (or at least not concerned in the OCD-sense). Instead, their ERP should focus on harm.
Yet, even within the same flavor of OCD, wide variations exist. One person with harm obsessions may be afraid of running over a jogger while driving their car. Another may fear grabbing a knife and stabbing their sister. Another may fear pushing shoppers down an escalator in a crowded mall. Each of these people would have ERPs that look different.
The person afraid of running over a jogger would be asked to drive their car without avoiding areas with pedestrians, without stopping and checking to make sure they haven’t hit anyone, and without searching their car for signs of impact (such as dents on the hood or blood on the headlights).
The person afraid of stabbing their sister would be asked to sit on the couch next to their sister while holding a knife, without asking their sister for reassurance, without checking the knife for signs of blood, and without searching their sister’s arms, legs, or face for stab wounds.
The person afraid of pushing shoppers down a mall escalator would be asked to ride escalators, without putting their hands in their pockets (or doing any neutralizing behaviors), without checking to make sure no one’s laying on the ground below, and without avoiding escalators filled with particularly vulnerable people (such as kids or the elderly).
Not all ERPs involve stopping a physical act (such as physically avoiding or physical checking); some ERPs are designed to help the patient avoid mental compulsions. Many OCD sufferers engage in mental compulsions, too (sometimes in addition to their physical compulsions or on their own). These may be words or prayers they think of in their minds, reassurances they tell themselves, numbers they silently count to, or images they think of to counteract their anxiety. In these cases, the ERP involves the patient exposing themselves to the stressful thought and then refraining from praying, counting, imagining, etc.
The whole point of ERP is to prevent ritualizing; thus, it’s custom-designed around whatever rituals the patient possesses.
Other Mental Conditions that ERP Treats
However, the above conditions differ from OCD because the exposure is enough to prove effective. For instance, if someone is afraid of heights, they desensitize themselves from this fear by climbing ladders, walking on roofs, looking down from mountains tops, riding in glass elevators, etc. Once they do it enough, they learn they can handle the anxiety and the phobia begins to wane.
In OCD, the exposure is never enough because of the compulsions those exposures elicit. If someone with Contamination OCD exposes themselves to their fear by touching a soiled rag and then engages in their ritual (compulsive handwashing), the exposure will fail to fight the illness; rather, it’ll reinforce it. The response (the refusal to engage in the ritual) is as important as the exposure itself.
What to Know About ERP Before Starting
When discussed in text, ERP feels a bit misleading. That’s because the idea of facing your fears – on paper – sounds simple, easy, and straight-forward. In reality, ERP is extraordinarily difficult for the sufferer and can involve many starts, stops, and moments of frustration and sheer terror.
That’s, perhaps, the most important thing to know: ERP is difficult and causes surges in anxiety that the sufferer is asked to withstand. It feels overwhelming and frightening, which is why getting through the exercises are so effective.
Three other things worth knowing before starting include:
It’s important to choose a proper therapist: Not all therapists are experienced in ERP (not all therapists are experienced in OCD, for that matter). Some treat OCD with Freudian inspired therapy, which risks making the OCD worse. When choosing a therapist, it’s important that they’re trained in CBT, with ERP specifically.
ERP doesn’t have to involve a sink or swim mentality: Some people dive into ERP headfirst (or are instructed to dive in headfirst by their practitioner). A sink or swim mentality works in some patients, but it proves too overwhelming in others. In other words, patients don’t need to begin ERP by facing their most potent fear or obsession; they can start by facing more tolerable discomfort (this is previously discussed above under graded exposures). Once they learn to manage the easier thoughts, they then move onto the more difficult experiences.
ERP is not a straight line but peaks and valleys: For most patients, engaging in ERP doesn’t mean the exercises will be 100% successful. Some patients may find themselves avoiding their compulsions only part of the time or they may have days when the exercises are easier and days when they’re prone to fail. It’s crucial for the patient to keep this in mind so they don’t throw in the towel prematurely. ERP might involve one step forward and two steps back at times but sticking to it assures forward movement eventually.
ERP is not an easy road to travel – it’s filled with anxiety, setback, and probably a fair share of tears. But if the sufferer sustains, they’re rewarded with a much more manageable illness. To sum it up, ERP is hard but living a life dominated by OCD is even harder.