Exposure and response prevention (ERP) is an evidence-based treatment for OCD, but it’s not just a science. Implementing ERP is an art that requires nuance, individualization, and a thorough understanding of the modality. Sometimes, these nuances get missed in popular discussions of the treatment. So, let’s dig into some common misconceptions about ERP—so we can understand what it is, and what it isn’t.
Myth 1: The goal of ERP is to purposely make someone as distressed as possible.
Reality: This is a reductionist conceptualization of ERP. Exposure to obsessions and what triggers them will likely be anxiety-provoking. However, the goal is not always to create additional distress but to help a person utilize skills (such as response prevention or mindfulness of a current emotion) if and/or when that distress arises. For example, changing a baby’s diaper might be distressing for someone with pedophilia OCD (POCD). They can learn to tolerate the feeling that naturally arises during the diaper change while practicing response prevention—without needing to manufacture a situation that would cause a greater level of anxiety.
Some therapists practicing ERP might work up to purposely inducing as much distress as possible, but that should always be a gradual, consensual process, and it’s not the whole picture of what ERP is, nor what all clinicians practicing ERP do.
ERP cannot be reduced to making someone as distressed as possible. There is more to the modality and more goals that ERP can move toward, including:
- Learning: understanding that your brain is lying to you, that you are safe, that your thoughts/sensations/images are not rooted in reality, that you can cope with the discomfort that arises from not performing a ritual (that urge can be very strong, especially after habitually engaging in compulsions for years), that you don’t need to perform compulsions or engage with obsessions, and more.
- Desensitization: repeated exposure to triggering stimuli (even our own thoughts) can help lessen the emotional intensity of them.
- Getting one’s life back: Oftentimes, people with OCD compulsively avoid what might trigger OCD. They may do this because they are attempting to prevent a dreaded outcome, don’t want to experience an intrusive thought or image, don’t want to get stuck in OCD’s grip, etc. This compulsive avoidance can make someone’s world so small. Through exposure to feared stimuli, while practicing response prevention, you can gradually get your life back.
Myth 2: There are universal exposures that will help everyone with OCD.
Reality: “What exposures are helpful for POCD?” is the wrong question to be asking. Exposures must be tailored specifically to each person’s symptoms: obsessional doubts, core fears, and triggers. For example, some people with POCD are triggered by diaper changes because they irrationally worry they will snap and touch their child, whereas others with POCD might not struggle with obsessions related to snapping. Instead, they might avoid all media because they worry that it will trigger irrational doubt that they are a pedophile. Some people with contamination obsessions are triggered by blood and feces, whereas others are triggered by the idea of germs on surfaces or in the air. OCD is idiosyncratic. While the disorder is characterized by obsessions and compulsions, the content of obsessions and specific compulsions can vary from person to person. It’s important that treatment plans are individualized, not generalized.
Myth 3: All exposure is active (planned).
Reality: Passive exposure exists. What I mean by that is: living life can mean facing a trigger head-on that wasn’t planned.
For example, someone who irrationally worries that HIV is spread through doorknobs will naturally have to open doors when out in the world. Someone with harm OCD who irrationally worries that they’re capable of shoving someone in front of the subway may feel that they have to take the subway to the office. Someone with hit-and-run OCD might encounter a speed bump while driving to work and irrationally doubt that they’ve hit a person.
In the context of OCD, exposure means confronting something that triggers your OCD. This can happen naturally in everyday life and, when it does, it’s an opportunity to use your ERP tools in real time.
Myth 4: You cannot do ERP if you’re navigating OCD alongside another mental health condition.
It is not uncommon for someone with OCD to struggle with another mental health condition. Eating disorders, generalized anxiety disorder, major depressive disorder (MDD), and OCD-related disorders like body dysmorphic disorder (BDD) and trichotillomania/dermatillomania often co-occur with OCD. While treatment plans vary from person to person, these conditions are commonly treated concurrently.
Many OCD therapists who utilize exposure and response prevention (ERP) therapy as a primary treatment modality also specialize in OCD-related disorders and anxiety disorders. When their client is dealing with different symptom presentations, the therapist might simultaneously incorporate varying treatment modalities. For example, they might use ERP for OCD, habit reversal training (HRT) for dermatillomania, and metacognitive therapy (MCT) for generalized anxiety disorder. It’s also important to note that ERP is a frontline treatment for specific phobias and is often incorporated into eating disorder treatment. If an OCD therapist doesn’t specialize in a client’s co-occurring condition, they recommend that the client add another therapist to the treatment team for adjunctive therapy.
What does all of this mean? You can partake in ERP therapy while seeking help for symptoms of other conditions.
Myth 5: ERP = Fear Factor
Reality: ERP often involves tasks of everyday living: driving, cooking, changing a diaper, hugging a family member, sex, etc. The goal is not to do the scariest thing possible just because (like licking a toilet bowl, for example). While this kind of extreme exposure can help some in a specific context—if the client consents and wants to take it that far, for example—it can be counterproductive and harmful when done just to do the most extreme exposure. Oftentimes, exposures are values-based, meaning that they move a person toward their values. This might look like bathing your baby because you desire that connection, using a knife to cook dinner because you value creativity in the kitchen, or driving a car because you value travel with your family.
ERP therapists should consider the why of exposures and tailor treatment plans accordingly. Of course, there will be some exposures that do not seem as ordinary as cooking. However, ERP should always be something we are all willing to do!
Exposure and response prevention (ERP) is the frontline treatment for OCD. By facing what triggers your OCD while resisting the urge to perform compulsions, ERP can create re-wired neural pathways in the brain and help you get your life back. As your OCD gets smaller, your world gets bigger.
At NOCD, our licensed therapists deeply understand OCD and are specialty-trained in treating OCD with ERP. They’ll work with you to create a personalized treatment plan based on your unique needs—so you can get back to doing the things you value and care about. You can book a free 15-minute call with our team to learn more about getting started with OCD treatment.
