If you’ve looked into help for obsessive-compulsive disorder (OCD), you’ve probably seen references to exposure and response prevention (ERP) therapy, which is considered the gold standard for OCD treatment.
ERP therapy teaches you how to manage your OCD thoughts, images, and urges so they eventually stop bothering you as much. This lets you overcome your fear responses and regain the control that OCD tries to take away.
The International OCD Foundation compares the process to rewiring a home alarm system. Alarms exist to alert you to danger, but what if a home’s alarm was so sensitive that it went off every time something touched the house — a raindrop, a tree branch, or even a stiff wind? There would be no way of telling whether a real danger was present, and the residents wouldn’t be able to get a moment’s peace.
OCD hijacks the body’s alert system in a similar way. It registers intense danger even when the threat is very small. Your mind fixates on the perceived threat, and your anxiety levels rise. To get rid of anxiety, you feel like you have to perform a particular action to feel better. Sometimes, the distress and resulting compulsions get so bad that you start avoiding situations that set off your body’s alarms.
ERP lets you break the cycle and rewire your body’s alarm system. You learn to challenge your OCD mind when it tells you that something is a catastrophe. You move through the fear, learn to rely on healthier responses, and become more capable of managing your anxiety.
What can you expect from ERP therapy?
ERP therapy can be challenging and scary. Just getting started requires a lot of motivation and courage — after all, for ERP therapy to work, you have to willingly enter situations that scare you and deliberately avoid responding in the usual compulsive ways.
It sounds difficult, but you don’t have to go through it alone. It’s best to do ERP with a licensed therapist who specializes in OCD and ERP. That person will have the knowledge and experience to help you understand your experiences, fears, and goals and teach you how to empower yourself.
Your therapist will design exposure and response-prevention exercises that are customized to your needs and goals. Each exercise targets a particular OCD-related fear. Your goal is to experience that fear without running away from it or doing the rituals that you normally do to reduce your distress.
Over the course of your ERP therapy, you’ll probably face several fears, starting with one that’s neither the least nor the most distressing. As you get used to the experience, you’ll feel less anxious and more capable of making healthier choices.
What happens in the first couple of sessions?
ERP follows a particular sequence:
1. Understanding your fears and compulsive behaviors
The first step is talking about your fears and compulsive behaviors with a therapist. You’ll cover four topics:
- Your obsessions, intrusive thoughts, and urges
- Your mental and physical rituals, including what you do to reduce your anxiety or keep an unwanted consequence from happening
- What you fear will happen if you don’t finish your rituals
- What you avoid so you won’t feel nervous or have intrusive thoughts or compulsions
2. Setting expectations
Next, you and your therapist will talk about OCD in general and the experience of ERP, including why it works and what your therapist expects you to do.
3. Starting treatment
Once you’ve covered the details of ERP, you’ll get started with your treatment plan. That usually means making what therapists call an OCD hierarchy or, less formally, an “anxiety ladder.”
To create your personal anxiety ladder, you’ll start with a list of places, situations, and things you avoid. Your therapist may ask you to rank each in terms of distress on a scale of 0 to 100. Therapists call this the Subjective Units of Distress Scale, or SUDS. You create your ladder by ranking your avoided situations from lowest to highest. While you may rank them from lowest to highest it’s more than likely you and your therapist will start with something that falls more toward the middle of that scale rather than at the bottom.
You’ll then set a goal related to each avoided situation. Your goal should be as realistic and specific as possible.
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For example, if you have harm OCD and a deep fear of throwing yourself off a train platform, your eventual goal might be to take the subway to work every day for a week. Don’t worry — you won’t have to do this right off the bat. You’ll set a few smaller goals to hit first, like having a friend accompany you to the train station and watching people board.
Once your anxiety ladder and goals are set, your therapist will lead you through your first exposure and response-prevention session. Most of the time, therapists start with a situation that’s low on your SUDS scale. You’ll learn to get through the situation without resorting to rituals or compulsive behaviors.
In early ERP therapy, you’ll typically face the same situation multiple times. The scenario may be the same each time, or you may work yourself up to a goal. For example, if you avoid cleaning the cat’s litter box because of a fear of contamination, you may start by sitting nearby while a friend cleans the box, then work your way up to putting the scoop back, and finally begin scooping the box yourself.
Your therapist may witness you doing the ERP activity, or you may do it by yourself and report back. Either way, therapy sessions end with a recap where you talk about what happened, how you felt, and how you made it through the exercise.
How will you feel?
When you first start exposing yourself to situations you usually avoid, you’ll probably feel anxious and afraid. You’ll want to escape the feeling and the situation that causes it, which means you’ll probably feel the need to do your compulsive behaviors.
That’s normal. In fact, that’s what therapy is all about.
OCD rituals exist because they make you feel less afraid. Your body knows that when you do them, you feel better, and that’s the source of your compulsion.
In order to break that cycle, you need to fully experience the anxiety associated with a particular situation. You need to feel your way through it and choose a different behavior because otherwise, your body won’t believe that you can.
This is ERP’s make-or-break moment — when you choose to feel the anxiety and stay in the situation without doing a ritual behavior or letting compulsion overwhelm you. If you can hang in and tolerate the distressing feelings you experience, your mind and body will start to learn that you don’t have to perform your rituals.
What happens as treatment progresses?
Once you’ve gone through the exposure and response-prevention process with a moderate-level fear, you’ll start to work your way up the anxiety ladder. You and your therapist will decide together when it’s time to move from one avoided situation to the next.
Usually, you’ll move up the ladder when your discomfort with a situation is significantly lower than it was, and you can move through any related anxiety without worrying whether you can manage it. When you get there, you can start working on something scarier.
In therapy, you’ll practice ERP in specific contexts. But as you become more comfortable and skilled at response prevention, you’ll start finding yourself applying it to manage “sudden triggers.”
OCD triggers can arise unexpectedly — at work, at school, and elsewhere. As treatment progresses, it becomes easier to apply response-prevention skills when OCD takes you off guard.
When you can apply response prevention in these kinds of situations, that’s when life really starts to change.
How will you feel?
As you get more experience with ERP therapy, you’ll get more familiar with the anxiety and discomfort that come from facing your fears. That doesn’t mean you’ll feel less anxious right away or that you won’t initially want to do your rituals to reduce distress.
In your ERP therapy, each new goal will still be somewhat anxiety-inducing. That’s the point. If a particular activity doesn’t cause you to feel distress, or if it’s easy to push through that distress, it’s a sign that you’re ready to move on to the next goal.
But in time, as you learn to manage your intrusive thoughts, those thoughts will start to happen less frequently. People who use ERP therapy learn to accept uncertainty and therefore don’t find their thoughts to be as intrusive. Then, you’ll spend less time in the OCD cycle and more time living your life. You’ll still have periods of anxiety and moments when your OCD comes back, but you’ll be prepared to manage it. There will be much less ebbing and much more flowing.
Then, you’ll be free.
How will you change?
The more ERP exercises you do, the more in control you’ll start to feel. It’ll be easier to break the cycle of feeling distressed and automatically doing a ritual.
Your therapist might call this “habituation” — a formal term for getting used to the situation. Your body and mind become familiar with the feeling of being anxious and choosing not to do a ritual behavior. You convince yourself that you don’t need those behaviors to get through your fear.
ERP therapy is all about this transformation.
ERP doesn’t get rid of anxious thoughts and compulsions — instead, it teaches you to assess situations more rationally to determine whether there’s a real threat and to respond healthily. Once you realize you can do something besides engaging in compulsive rituals, a whole new world opens for you.
What happens as you near the maintenance phase of recovery?
You’ll know you’re getting close to the maintenance stage of your recovery journey when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.
For most people, the change is distinct and transformative. You’ll find yourself participating in an activity that OCD would once have dominated. It will be a situation you wouldn’t have been able to handle at the beginning or even in the middle of your ERP journey, but by this point, you’ve worked your way up to it and you’re ready. You’ll even end the activity feeling good — something that would have been out of your reach before ERP.
How can you expect to feel?
As you near the point of ERP therapy where you and your therapist consider decreasing or discontinuing sessions, you’ll probably still feel some anxiety when facing situations you used to avoid. The difference is that the anxiety may fade much faster than it used to, and you’ll feel much less of an urge to make the anxiety and thoughts go away. Eventually, the fear will be so manageable that you can enter the maintenance stage of your journey therapy.
And that’s a beautiful moment.
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If you are dealing with OCD and need effective and affordable ERP therapy consider giving us at NOCD a call. A free 15-minute call with our Care Team can help get you on your way to therapy and overcoming OCD.