This is a guest post by Alegra Kastens, M.A., LMFT, founder of The Center for OCD, Anxiety, and Eating Disorders.
Exposure and Response Prevention (ERP), a behavioral therapy that falls under the Cognitive Behavioral Therapy (CBT) umbrella, is the frontline treatment for Obsessive Compulsive Disorder (OCD). The modality entails facing one’s fears head-on through exposure to feared stimuli while simultaneously preventing compulsive rituals (mental and physical). Through such exposure, one may habituate to the stimulus—the more they are exposed to a triggering stimulus, the less anxiety-provoking it becomes—and/or learn safety: that the feared outcome is far less likely than their brain makes it out to be. They also learn how to tolerate anxiety and discomfort in the face of a trigger while moving toward their values.
There’s a misconception about exposure therapy, and the nature of exposures in particular, which can lead to avoidance of the therapeutic modality itself. People may think that all exposures are as extreme as licking the inside of a toilet bowl. This is typically not the case, and I as a therapist would never do such a thing. Exposures frequently involve facing fears in everyday situations that a person with OCD avoids: changing their baby’s diaper, riding an elevator, using kitchen knives to chop vegetables, driving on the highway, etc. They can also involve writing down triggering words, looking at triggering images, watching TV shows that are triggering, and more.
Exposures can be anxiety-provoking, even when they’re things that most other people do on a daily basis. People with OCD have a hyperactive fear center in the brain, alerting them of danger when imminent danger is not actually present. While someone without OCD might not think twice about using knives to cook, a person with OCD using knives might experience comparable anxiety to being stuck on train tracks with a train speeding at you.
So why would someone willingly engage in treatment that involves facing fears head-on that might be uncomfortable, anxiety-provoking, and even scary? Among the various possible benefits, here are five that might motivate you:
Your World Expands As You Change Behaviors
Those with OCD often compulsively avoid what they fear as it relates to their specific obsession. This could look like an avoidance of sexual intimacy for someone with unwanted sexual obsessions, an avoidance of driving for someone with “hit-and-run” obsessions, or an avoidance of bathing a newborn for someone with postpartum harm obsessions. Avoidance is a compulsion utilized in an attempt to escape anxiety and discomfort associated with obsessions, prevent something bad from happening, or reduce the likelihood of being triggered.
On paper, avoidance seems like the answer. If you just avoid what your brain is telling you is dangerous, you won’t feel anxiety and nothing bad will happen, right? Unfortunately, it doesn’t work that way. In reality, when we avoid something, we are directly signaling to our brain that the thing that we are avoiding is dangerous. Our brain wants to keep us safe, after all, and avoidance fuels the ever-present nature of obsessions. It keeps the fear alive, validates obsessions, and leads us to believe that the false alarms are actually real alarms.
While the reasons a person avoids may vary, the outcome remains similar: their life becomes smaller as activities of daily living are restricted. This is where ERP can help a person get their life back. As a person starts to face fears head-on, without compulsively avoiding, their world expands. In the case of someone with postpartum OCD, they can change their baby’s diaper, bathe them, play with them, and do other activities that were once avoided because of OCD. In the case of someone with hit-and-run OCD who stopped driving altogether, they can get their autonomy and independence back as they begin driving again.
It’s not just an acquisition of activities once avoided, but of time in your life, as you are not spending so much of it on compulsive rituals. With a successful response prevention practice, the minutes to hours spent on compulsions per day are freed up and make space for things more meaningful.
You’ll Increase Your Tolerance for Discomfort
We are not certain of much but there is one thing I know for sure: discomfort is a part of life for everyone at some point. Whether it’s dealing with death and loss or merely the struggles of everyday living, we must become more comfortable with discomfort to survive. This change in our relationship to discomfort is part of a successful ERP practice. We learn how to relate to anxiety and other uncomfortable emotions in a new way as we face our fears. We learn to accept the presence of such discomfort, without fighting with it or attempting to escape it, and co-exist with it.
ERP work, by nature, increases one’s tolerance for discomfort. This is a universal skill that can help us in all areas of life, not just mental health struggles. I tend to believe that if you can survive OCD, you can survive anything.
You’ll Experience Enhanced Confidence
Exposure therapists often build a hierarchy of exposures with their clients, ranked from 1-10 on an anxiety scale, that acts as a blueprint to follow throughout treatment. While therapists may jump around on the hierarchy at times and have clients do exposures at varying levels of anxiety, most therapists start out with lower-level exposures: a 3 or 4 out of 10 rather than a 10 out of 10 on the anxiety scale. One of the reasons for gradually moving up the hierarchy is to help the client build confidence in their ability to carry out the ERP work. By starting at a level 3 or 4, the client learns that they can face a fear head-on and tolerate lower levels of anxiety without performing rituals. This success and confidence that comes from lower levels of exposures can help a client buy into the more difficult exposures.
This confidence does not just exist within a vacuum of the therapy office. ERP can build a client’s confidence to do hard things at any point in life. It is universal, as is tolerating discomfort. The more you face your fears head-on, the more assured you may be of your ability to tackle hard, scary, difficult things. Life is full of them. This doesn’t mean that you have no fear, as the word fearless implies, but that you are growing confident in your ability to feel the fear and do the hard thing anyway.
ERP Rewires the Brain
Research not only shows that the brain with OCD is wired differently than the brain without OCD, but that ERP therapy actually changes the brain. You heard that right! In a study of the effectiveness of ERP therapy, brain scans—of people with OCD—taken prior to and after ERP treatment differed vastly. The scans exhibited substantial increases in connectivity between eight different brain networks, such as the cerebellum and caudate/putamen and the cerebellum and dorsolateral/ventrolateral prefrontal cortices.
The cerebellum, which previous research has exhibited to have abnormal activity in the brains of those living with OCD, involves information processing and the coordination of voluntary movements. The ventrolateral prefrontal cortex is involved in response inhibition and threat detection, among other cognitive functions. The dorsolateral prefrontal cortex is involved in the control of cognitive processes and executive functioning (such as selective attention and working memory), and studies have shown this particular brain region to function abnormally in the OCD brain.
What does increased brain activity offer? One of the findings of this particular study found a correlation between increased brain activity and a reduction of compulsions. In other words, the reduction of compulsions may change brain activity. Moreover, increases in the activity of particular brain regions may reveal a person’s learning and inhabiting new behaviors (non-compulsive, goal-directed behaviors) and thought patterns after a course of ERP.
ERP Helps Us Disconnect from Unhelpful Stories and Call OCD’s Bluff
OCD lies to us…a LOT! It tells us that imminent danger is present and that the only way to escape it or prevent something bad from happening is to perform a compulsion. It tells us that our intrusive thoughts, images, and urges, are factual, threatening, and dangerous. It tells us that we won’t be able to survive and cope if we don’t engage in rituals. And here’s the thing: it’s CONVINCING! Even when we logically and rationally know that something is off, that our obsessions are ridiculous, and that the compulsion isn’t going to be helpful, we often have a hard time connecting to that logic when the brain is in fight-flight-or-freeze survival mode. It feels…so…real!
People with OCD often try to out-think the obsession, aka perform mental compulsions, and find themselves stuck in a game that is difficult to win. This is where, quoting Steven Hayes, getting out of your mind and into your life with ERP can be helpful. Instead of attempting to learn safety by convincing ourselves that the obsession is false, and staying immersed in the mind, we can learn safety by changing our behavior and showing our brain that the story is unhelpful. We can call OCD’s bluff and disconnect from the story by facing our fears head-on without performing compulsive rituals. When we do this, we often learn that the bad thing (that scary story) is not as likely to occur as our brain makes it out to be.
We are not always in control of our thoughts (think those intrusive thoughts that happen to you) and feelings, but we are in control of our behavior. Changing our behavior through both exposure and response prevention can help us disconnect from those thoughts and feelings, and potentially change them. An example I often provide clients relates to feelings of self-worth and deservingness. It is difficult to think ourselves into feeling more worthy and deserving, but we can change our behavior and act as if we are. Treating ourselves as if we are worthy and deserving can change how we feel about ourselves.