Exposure and Response Prevention (ERP) Explained

Exposure therapy is the crucial ingredient for overcoming any form of OCD. The idea behind it is this – if we repeatedly expose ourselves to feared “triggers,” our mind will eventually learn that the anxiety response is no longer warranted because the feared consequence never occurs. Putting ourselves in uncomfortable situations is not enough. We need to refrain from performing compulsions. This is the “response prevention” component of exposure therapy. Think of a child that sleeps with a stuffed animal at night because they are afraid of the dark. Instead of clinging to stuffed animals, OCD sufferers look to things like reassurance seeking, avoidance behavior, and rumination to bring about comfort in times of intense anxiety over obsessive thoughts. When we remove the compulsions, we disrupt the OCD circuit allowing the mind to see that compulsions don’t actually prevent any consequence from happening – because it doesn’t actually exist.

Exposures are Only Half the Battle

Sounds simple enough, doesn’t it? However, a big part of the battle is actually getting OCD sufferers to perform exposures. They have hangups. What if during the exposure they somehow “lose control” and end up acting out their obsession? Worse yet, what if they become so comfortable with the situation that they lose their inhibitions and do something terrible on their own accord? Then you have treatment-centered apprehensions. What if I’m doing the exposures wrong? What if the exposures completely change my personality and I become a monster? These apprehensions are all skillfully crafted by the disorder to keep you on the OCD hamster wheel.

How to Design Effective Exposure Exercises

The first challenge in crafting exposure exercises is finding a good starting point. We need to find a median so that the anxiety is not too overwhelming nor easily tolerable. Someone with Harm OCD of the hit-and-run variety won’t be too receptive to driving in areas with heavy pedestrian traffic. A more manageable exposure might be to have them drive in a grocery store parking lot, where small bursts of pedestrian traffic is common. This scenario also allows them to take a break between exposures. This exercise could easily evolve into something more anxiety-provoking, like driving near malls or near bicycle lanes. Once the anxiety response has been brought down to an acceptable level, the sufferer can challenge themselves with new exposures.

Eliminating Compulsions

It is naive to think that someone with OCD can stop doing compulsions cold turkey. Sometimes, the person learns on their own that compulsions serve no redeeming purpose. If you perform a compulsion long enough, you eventually reach the point of diminishing returns. It is no longer enough to check that you locked the car door just once. Now you need to do it three of four times for only half the relief. From here, it quickly spirals out of control.

An incremental effort needs to be made to eliminate compulsions. When doing exposures, it helps to use cognitive restructuring to lessen the desire to perform compulsions. Someone who suffers from sexual obsessions may automatically think they are a sexual predator after having accidentally bumped into another person or looked at someone “inappropriately.” These thoughts often elicit reassurance seeking behavior and other compulsions to counter the feelings of anxiety, guilt and shame. A closer look at the thought reveals that it is riddled with cognitive distortions like magnification and personalization. A more grounded version of the thought might be “People bump into others all the time, that doesn’t make them sexual predators.” Weeding out these distortions takes practice but can make the exposures much more tolerable. In the same token, they can become a compulsive behavior.

The ultimate goal is to build up to accepting your OCD thoughts. This philosophy is often preached by those who have successfully recovered from OCD, but is largely misunderstood. Acceptance doesn’t mean that you embrace the content of the OCD thoughts, but that you accept the air of uncertainty that they create. If the OCD tells you that you are gay, you don’t try to refute it. You accept the possibility, however infinitesimal. Once you reach this stage, your anxiety will spike for a second and by the next you will entirely forget about the thought. At this point, your brain has learned that the thought is not important.

Exposure Therapy is A Marathon, not a Sprint

Exposure exercises aren’t something you do for a few days to a week. They need to become a daily habit as OCD can be unpredictable and opportunistic. There are plenty of ways to do exposure exercises during your daily routine. If you have contamination OCD, touch the parking meter and light post on the way to your car from work. Harm OCD? Keep a sharp scissor at your desk. Sexual obsessions? Read news articles about sex offenders without trying to draw comparisons between yourself and them. Do whatever it takes to keep yourself a little on edge. It may take days, weeks or months worth of exposures to overcome an obsession. Continued exposures are essential for keeping the OCD at bay.

A Word on Testing and Reassurance Seeking

It’s not uncommon for someone with OCD to turn exposures into testing/reassurance seeking activities. Someone with sexual orientation OCD may look at pictures of the same sex and check for arousal. The checking is a form of reassurance seeking that renders the exposure pointless. Someone with Harm OCD may get thoughts about jumping off a building. They will touch the railing trying to “prove” that this is just OCD. This backfires because the OCD immediately makes them feel guilty to the point that they begin questioning their motives. Watch closely for these compulsions while performing exposures.

A Call to Action

It’s very tempting to slate exposure exercises for another time. Yes, it’s uncomfortable but so is OCD. The longer you let it roam your mind, the harder it will be to supplant. Identify your triggers, plan and execute your exposures and you will be well on your way to successful treatment.