You might’ve noticed that exposure and response prevention, or ERP, is the most commonly recommended form of therapy for obsessive-compulsive disorder (OCD). And along with serotonin reuptake inhibitors (SRIs), it has consistently been shown to be the most effective treatment.
OCD is a common psychiatric condition characterized by intrusive, distressing thoughts and repetitive behaviors aimed at reducing that distress.
This means people with OCD do certain things over and over because they’re trying to get rid of really unpleasant feelings– not because they want to behave compulsively, or because they necessarily think their behavior is rational.
What is ERP?
ERP is a type of behavioral therapy that exposes people to situations that provoke their obsessions and the resulting distress while helping them prevent their compulsive responses. The ultimate goal of ERP is to free people from the cycle of obsessions and compulsions so they can live better.
Response prevention is key, because anything that gets rid of distress makes it impossible for us to get used to it. When people don’t turn to compulsions, they learn how to accept their obsessions instead of acting desperately to neutralize them. The thoughts are still difficult sometimes, but they no longer seem like a huge problem.
This process of getting used to something is what psychologists call habituation. As patients habituate to the feelings their obsessions bring up and reduce their reliance on compulsions, they spend less time and energy avoiding pain.
ERP is fundamentally about shifting one’s orientation to unpleasant thoughts and feelings- not about getting rid of them.
When we feel able to handle discomfort, obsessions (which used to create a sense of profound uncertainty) are no longer reinforced by avoidant behaviors that teach them the content of their every thought is both important and reflective of their true nature. And when we don’t feel an overwhelming need to be certain about ourselves, the future, and our standing in the world, we can live with less unnecessary suffering.
Developed in the 1970s, ERP is recommended by the American Psychological Association and many other organizations for its wealth of scientific backing.
Why is ERP the recommended treatment for OCD?
Studies show that everyone experiences some of the intrusive thoughts involved in OCD. Maybe you’ve thought I could drive off the road right now or What if I don't actually love my significant other? People without OCD are usually able to write off distressing thoughts as strange and random occurrences, but those with this condition feel compelled to neutralize them. Obsessions and compulsions reinforce one another because it seems like a thought that had to be avoided with a compulsion must have been pretty important (and worthy of more fear). In most cases OCD symptoms do not resolve on their own.
A cognitive approach– traditional CBT, for example– asks patients to challenge their obsessions. This can actually reinforce the belief that thoughts are significant and that we’re morally responsible for the content of our thoughts. Although cognitive interventions can be useful in many ways, recent studies comparing ERP and CBT suggest that ERP is more effective specifically for OCD.
Any behavior that engages with the obsession– e.g. asking for reassurance, avoidance, rumination– reinforces it. By preventing these behaviors, ERP teaches people that they can tolerate their distress without turning to compulsions. It thereby drains obsessions of their power. Especially when paired with medication and other types of therapy, ERP is consistently demonstrated to be the most effective form of treatment for OCD.
How does someone actually do ERP?
There’s a good chance we’ll be writing more about this soon, but the best way to see how ERP works is to check out the NOCD app. We built it from the ground up to provide ERP tools, and worked with top experts to make sure it’s closely aligned with the version you’d get in a therapist’s office.
Isn’t ERP kind of messed up?
You’re not alone if you think therapy that asks people to do things that really bother them is kind of unfair or strange. And this suspicious comes from a place of empathy– why make people go through pain? Isn’t it okay to be anxious about things, and why wouldn’t you be bothered by something as disturbing as a thought about harming your own baby?
Is it strange to think that you could treat a psychiatric condition by doing things like telling yourself over and over that you might lose control and become a pedophile? Yes, and it’s not the kind of thing most of us would like to spend our time doing. But let’s say you’re so bothered by one fleeting thought like “I might be attracted to my 3-year-old nephew” that it makes you physically sick. You think all day about it, write mental lists of reasons you’re a good person, arrange your drive to work so you don’t pass any elementary schools or day care centers. But then the thought pops up when you see a toddler on a billboard, or when a coworker brings their kid in one day. You stop going to visit your sister and nephew, coming up with different excuses every time they ask. The thoughts torture you, and it seems like your whole life revolves around avoiding any thought about how you might have been attracted to a kid.
This is the kind of stuff that gets people into ERP. It’s not really about someone who has one quick thought about pedophilia– we all have thoughts we’d rather not have. Rather, this is a form of treatment for people whose lives are stuck because of their thoughts. That’s why patients are willing to push through the pain and strangeness, and why clinicians are willing to temporarily make the pain worse so things can get better.
In ERP a fair amount of distress in inescapable, and that’s an unfortunate fact. But clinicians and advocates of ERP, like the NOCD team, suggest it because the pain of treatment usually ends up insignificant compared to the drawn-out suffering of untreated people who go through their lives in anguish over thoughts that aren’t actually worth a ton of attention.
ERP is about shorter-term pain for long-term gain. But it has to be done carefully, with an experienced clinician you respect and trust. It’s good to weigh the pros and cons beforehand: What do you value, and how can ERP help you get there? What are your goals? And what are your limits for the amount of distress you’re prepared to go through? How long do you want to be in treatment? How’s your support system outside of therapy? These questions can help guide you as you decide whether or not ERP is the right fit for now.
An important note here: pedophiles are viewed in our society as some of the worst people imaginable, and this shame undoubtedly weighs on people anguishing over their thoughts. But the key separator between a pedophile and someone whose OCD centers around pedophilia is that someone with what therapists call “pedophilia OCD” doesn’t enjoy those thoughts. In fact, they can become the bane of their existence. A pedophile may feel shame too, and may not be without remorse, but probably won’t experience these thoughts as contrary to their values or who they really are. For both people with OCD and the rest of us, it’s important to understand the differences between thinking about something and wanting to do it.
Another important note: although pedophilia obsessions seem like an extreme case, they’re not. OCD takes all kinds of disturbing and difficult forms. Further, there’s no evidence that someone with more typically “disturbing” obsessions (e.g. pedophilia, harming other people) suffers more than another person with something that would seem more trivial to others. In OCD there’s no such thing as an obsession that feels trivial, or distress that isn’t valid.