Self-Guided Exposure and Response Prevention Therapy (Part 1 of 2)

A Brief Overview of ERP Therapy

In this 2-part article series, I will first give a brief overview of exposure and response prevention (ERP) therapy, and then in part 2 I will explain my motivations for doing self-guided ERP therapy.

The Basics of ERP Therapy

According to scientific research, ERP therapy is the gold-standard treatment for OCD [1]. ERP therapy is a form of cognitive behavioral therapy (CBT) that involves the individual with OCD intentionally exposing themself to stimuli that trigger their distressing obsessive symptoms and compulsive urges. Then, in the midst of increased distress, the goal is that the individual chooses not to respond with compulsive behavior, which helps the brain learn three valuable things:

1. Compulsions are not necessary to reduce anxiety.

2. Compulsions are not necessary to prevent perceived negative outcomes.

3. Obsessions aren’t based on accurate perceptions and therefore don’t require much, if any, response at all.

ERP therapy is inherently quite challenging, but it’s done in a safe, controlled environment and the intensity of the treatment is gradually increased over time so the individual with OCD can learn to progressively become desensitized to their distressing obsessions (e.g. intrusive thoughts, feelings, images, urges, and body sensations).

With consistent adherence to ERP therapy, the individual with OCD will:

• experience less anxiety associated with obsessions

• experience less urgency to perform compulsive behavior

• perform fewer compulsions

• reduce avoidance of triggers

• embrace uncertainty with more confidence

Summary of ERP therapy (series of events):

1. obsessive symptoms are intentionally provoked by a known trigger (i.e. the exposure)

2. obsessional distress increases due to exposure to the trigger

3. desire to perform distress-reducing compulsions arises (i.e. the response)

4. the individual with OCD chooses not to perform compulsions (i.e. the prevention of the response)

5. distress eventually decreases without the performance of compulsions, thus retraining the brain that compulsions are not necessary to reduce obsessional distress (the therapeutic effect)

ERP is inherently stressful (but confidence-building)

ERP therapy differs from many other types of therapy because triggering discomfort during the therapeutic session is not only possible, but necessary and deliberate. Without triggering obsessional distress, there’s no way to relearn new ways to cope with the distress. Challenge is essential.

The underlying concept of ERP therapy may be familiar to you because it is also used to treat common fears and phobias that don’t necessarily relate to OCD (e.g. fear of heights, fear of public speaking, fear of swimming). Everyone has an example of a fear they’ve worked through via exposure and response prevention, even if they’ve never heard the phrase “exposure and response prevention” in their life.

ERP therapy creates positives changes in the brain

When irrational compulsions are repeated as a coping strategy to reduce anxiety and prevent perceived negative outcomes, the brain creates causal associations between the performance of the compulsions, the reduction of obsessional distress, and the prevention of perceived negative outcomes. For example, if someone experiences an OCD theme about their home being broken into overnight, and they perform a nightly 20-minute door-locking ritual before bed to prevent the outcome of a home invasion, the brain is gathering evidence that:

1. compulsions were performed

2. obsessional distress decreased because a sense of certainty was achieved through compulsions

3. no one entered the house overnight

Through such connections, the brain learned compulsions were necessary to feel a sense of certainty and prevent the house from being broken into (neither of which are true). Simply locking the door once and walking away would not change the feared outcome compared to a 20-minute door-locking ritual, but the brain is a pattern-collecting and meaning-making organ that can be a bit dumb at times, especially when significant anxiety dysregulation from OCD is added to the mix.

The longer compulsions are performed over time, the stronger the brain associates the compulsions with being effective and meaningful actions. ERP therapy intends to weaken those irrational associations between obsessions and compulsions gradually over time by giving the brain opportunities to learn new, more accurate associations. Referring back to the nightly 20-minute door-locking ritual, part of a gradual ERP intervention could look like spending 15 minutes a night doing the ritual for a week, then 10 minutes a night the following week, and so on. In such a way, the maladaptive compulsive response is gradually prevented. Also, the obsession loses its power because it’s shown to be based on distorted thinking and amplified emotional responses (both of which are involuntary in those with OCD).

With each incremental reduction in the compulsive behavior, the brain progressively learns that a reduction in compulsions does not change the likelihood of the perceived negative outcome, which in this case is a miscreant simply opening the door and entering the home during the night. Of course, someone could potentially break and enter the home, but that is always a risk that compulsive locking will not change. Developing a healthier relationship with uncertainty is also something individuals with OCD will learn through ERP therapy. Everyone walks through life being exposed to literally thousands of risks at any given moment, most of which are extremely unlikely to happen. For those with OCD, unlikely risks are magnified and involuntarily perceived by the mind/body in powerfully vivid ways, provoking intense anxiety that can become disabling.

A realistic example of how ERP therapy is practiced

Below is a more detailed (but still relatively simplistic) description of ERP therapy being used to treat someone with OCD:

• Beth has OCD. Her predominant OCD theme is “harm to others”. She loves her partner very much and would never intentionally hurt them, but she has vivid, intrusive, egodystonic thoughts, images, and urges about stabbing them.

• In an attempt to reduce anxiety from the intrusive thoughts, images, and urges, Beth performs various compulsive behaviors that worsen over time:

  • At first, she insists her partner does the cooking because handling sharp objects triggers her OCD symptoms.

  • She quickly realizes not handling the sharp objects is not enough to quell her OCD symptoms, so she removes all sharp objects from the house.

  • Now, she can’t stand seeing images of sharp objects while looking through cooking magazines, so she throws the magazines away.

  • Eventually, she avoids even saying words like “scissors”, “knife”, and “stab”.

• Beth’s life has become very limited due to a descent into compulsive behavior, primarily in the form of avoidance (i.e. avoiding stimuli that trigger her OCD symptoms).

• Beth goes to see a therapist specifically trained to treat OCD with ERP therapy.

• By collaborating together, Beth and her therapist begin the ERP process:

  • They work backwards through her compulsive descent, starting with simply looking at the word “scissors” printed on a piece of paper. Upon viewing the word, Beth’s anxiety, uncertainty, and obsessive thoughts are triggered. It takes about 30 minutes for her to feel calmer.

  • After a few weeks of consistent therapy done in the clinic, she can view words for sharp objects with only mildly distressing thoughts and feelings.

  • Over many months of ERP practice done in the clinic and at home, Beth and her therapist gradually bump up the exposure challenge to saying words for sharp objects out loud, then looking at pictures of sharp objects, then handling sharp objects alone, then handling sharp objects around her partner, then returning sharp objects into her home, and then finally cooking for her partner.

As mentioned in the introduction of this article, my next post will be about my motivation for doing self-guided ERP therapy. If you’ve read this far, thank you for your most valuable resources – your time and attention. Please subscribe to this blog if you find my content helpful. If you believe my content may be beneficial for others, please share it. This blog is free and requires a lot of time and effort, so knowing people are interested in it will motivate me to continue writing. Also, feel free to add your insights or questions in the comments section below this article. May all who have OCD find their best path to recovery.

References

1. Ferrando, C., & Selai, C. (2021). A systematic review and meta-analysis on the effectiveness of exposure and response prevention therapy in the treatment of obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 31, 100684.