What is Exposure and Response Prevention?
You may have heard of cognitive behavior therapy (CBT) before. CBT refers to a group of similar types of therapies used by mental health therapists for treating psychological disorders. The most important type of CBT for OCD is exposure and response prevention (ERP).
The exposure component of ERP refers to practicing confronting the thoughts, images, objects, and situations that make you anxious and/or provoke your obsessions. The response prevention part of ERP refers to making a choice not to do a compulsive behavior once the anxiety or obsessions have been “triggered.” All of this is done under the guidance of a therapist at the beginning — though you will eventually learn to do your own ERP exercises to help manage your symptoms. Over time, the treatment will “retrain your brain” to no longer see the object of the obsession as a threat.
This strategy of purposefully exposing yourself to things that make you anxious may not sound quite right to you. Maybe it sounds difficult. If you have OCD, you have probably tried to confront your obsessions and anxiety only to see that you become very anxious and fearful. With ERP, the difference is that a trained clinician is working with you to develop a plan for exposure. Then, that therapist coaches you through confronting the situation, leaning into the feelings it provokes, sticking with it, and resisting the urge to engage in compulsive behavior.
Doing ERP is challenging, for sure! But when you do it correctly, the following things happen:
- You will feel an initial increase in anxiety, uncertainty, and obsessional thoughts.
- You will find that these feelings and thoughts are distressing, but also that they can’t hurt you — they are safe and manageable.
- When you stop fighting the obsessions and anxiety, these feelings will eventually begin to subside.
- This natural drop in anxiety that happens when you stay “exposed” and “prevent” the compulsive “response” is called habituation.
- You will find that your fears are less likely to come true than you thought.
- You will get better at managing “everyday” levels of risk and uncertainty.
A Good Way to Think About OCD and ERP:
Think of anxiety as your body’s alarm system. If your fire alarm goes off, what does it mean? The alarm is there to get your attention and prompt you to take action to protect yourself and your family. But, imagine what would happen if your fire alarm went off every time you burnt a piece of toast or blew out birthday candles? That’s what happens in OCD.
OCD takes over your body’s alarm system so that instead of only warning you of real danger, that alarm system begins to respond to any trigger (no matter how small) as an absolute, terrifying, catastrophic threat.
When your anxiety “goes off” like an alarm system, it communicates information that you are in danger, rather than “pay attention, you might be in danger.”
Unfortunately, with OCD, your brain tells you that you are in danger a lot, even in situations where you “know” that there is a very small likelihood that something bad might happen. This is one of the cruelest parts of this disorder.
Now consider that your compulsive behaviors are your attempts to keep yourself safe when that alarm goes off. What does that mean you are telling your brain when you engage in these behaviors? You are reinforcing the brain’s idea that you must be in danger. Birthday candles are the same as a blazing fire.
In other words, your compulsive behavior fuels that part of your brain that gives out these many unwarranted alarm signals. In order to reduce your anxiety and your obsessions, you have to make a decision to stop the compulsive behaviors.
However, starting ERP can be a difficult decision to make. It may feel like you are choosing to put yourself in danger. And in the short term, that feels uncomfortable. In the long run, however, you begin to challenge and bring your alarm system (your anxiety) more in line with what is actually happening to you.
How is ERP different from traditional talk therapy (psychotherapy)?
Traditional talk therapy (or psychotherapy) tries to improve a psychological condition by helping you gain “insight” into your problems. Talk therapy can be a very valuable treatment for some disorders, but there is no research evidence that it is effective in treating OCD . While talk therapy may be of benefit at some point in your recovery, it is important to try ERP or medication first, as these are the types of treatment that have been shown through extensive research to be the most effective for treating OCD .
-  National Collaborating Centre for Mental Health (UK). Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society; 2006. (NICE Clinical Guidelines, No. 31.) 5, PSYCHOLOGICAL INTERVENTIONS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56465/
-  American Psychiatric Association, Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., & Simpson, H. B. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007. Available online at https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-1410197738287.pdf ↩