What if my anxiety is not decreasing during ERP?

If you are going through OCD treatment right now using exposure and response prevention (ERP) therapy, then you are likely familiar with the term habituation. Habituation refers to a natural process that often occurs where repeated and prolonged exposure to a feared situation leads to reduced fear responding. Put simply, the more we face our fears, the easier it gets.

You might not realize it, but you have almost certainly experienced habituation at some point in your life. Most of us have had natural childhood fears of things that initially seemed scary, like pedaling a bicycle without training wheels, watching a horror film, or swimming in the deep end of a swimming pool without a floatation device. As most kids do, we overcame those fears by facing them (i.e., putting ourselves in the situation repeatedly), which likely led to a progressive reduction and eventual elimination of any anxiety we experienced. 

For decades, ERP experts have emphasized the importance of habituation in overcoming OCD and other related anxiety conditions. People receiving ERP are frequently instructed to (1) remain in the feared situation until their anxiety level has reduced significantly, often by 50%, and (2) continue to repeatedly practice the same ERP exercises until their anxiety level has diminished to a minimal amount or has gone away completely. These time-honored instructions have helped countless individuals make gains and overcome OCD for decades.

However, if we only focus on habituation during ERP, we might encounter problems. First, while most people experience habituation during and between ERP exercises, some do not—and that’s ok. Additionally, focusing exclusively on habituation may unintentionally send the wrong message that anxiety is an unacceptable feeling that we must get rid of, which is not necessarily true. The reality is that we need to feel anxious in certain situations that are objectively dangerous in order to keep ourselves safe. If you began to cross a busy street without checking for traffic, it would of course be a good thing to be anxious, as your anxiety would cue you to engage in reasonably safe behavior (e.g., checking for traffic). Finally, if our focus during ERP is strictly on habituation, we may lose out on other factors that have been shown to be important in facilitating a positive treatment outcome.

What are other important things to pay attention to during your ERP work beyond habituation? 

1. We learn that our feared outcomes were less likely than we expected. For most individuals with OCD, their anxiety is fueled by an underlying expectation that something bad will happen (e.g., harm, illness, or serious misfortune) unless they engage in a compulsion. This expectation is referred to as a fear expectancy by experts in the field of OCD and anxiety disorders, and it is suggested that fear expectancies should be targeted in ERP with the aim to disconfirm them. In other words, ERP is believed to be effective to the extent that a person “tests out” their expectations about feared consequences that might occur. In most cases, people learn that the likelihood of their feared consequences “coming true” was significantly less than they had previously believed.

2. We learn that we can tolerate our distress and don’t need to “get rid of it.” Research on predictors of positive outcomes in ERP has shown that toleration of distress is a stronger predictor of symptom reduction when compared with the extinction of distress. What does this mean for you? If you are concerned about a lack of habituation you’re experiencing in your ERP, you don’t need to worry about this too much. Even if you continue to experience notable anxiety during your ERP exercises, if you are doing ERP for a prolonged period of time, you are likely developing an improved ability to tolerate the anxiety you’re experiencing. That is, you’re showing yourself that even though you’re not fond of feeling anxious, you can handle it, get through it, and live your life without feeling compelled to always get rid of anxiety.

3. We learn that we can handle negative outcomes and unpleasant circumstances. As scary as this might sound, one of the most therapeutic things that could happen during your treatment is if one of your feared outcomes actually “comes true.” This of course does not apply to you if your feared outcomes are undeniably catastrophic in nature (e.g., premature death of a family member, being responsible for serious harm to someone). However, many folks with OCD fear and try to prevent consequences that are relatively common for many individuals (e.g., losing a personal item, embarrassing oneself in front of others) and can be handled well despite the inconvenience. In these cases, ERP can help you learn that even though these outcomes are unpleasant and create anxiety, we can nonetheless handle them and move on with our lives. 

4. We grow in our confidence and willingness to do hard things. In relation to #3 above, when we learn from ERP that we can handle feared consequences better than we ever imagined, it leads to increased confidence in our ability to do hard things generally in life and manage whatever distress we experience. So many of the members we’ve treated have described how ERP helped them to develop a general “can do” attitude when it comes to many of life’s challenges. This has helped them live their lives more fully with confidence in their capability to manage these situations, and the same can certainly happen for you.

5. We connect with our values and do what is important to us in spite of anxiety. OCD often robs us of the freedom to do the things that are most important to us. Being able to connect to valued activities, people, and situations is a great way to show ourselves that while OCD may cause anxiety, it does not rule our lives. In addition to paying attention to how anxious you are during ERP, it might help you a lot to also pay attention to how connected you feel to the things in life that are most important to you.

Although reducing fear and anxiety—habituation—is an important area of focus in ERP, it should not be the only focus. There are other factors that come into play in ERP that are associated with a positive therapeutic outcome. If you feel you are too narrowly focused on habituation in your ERP work, consider speaking with your therapist and mentioning some of the other variables in this article that can be helpful to pay attention to when you’re doing ERP.

If you’re struggling with OCD and haven’t started ERP yet, you can schedule a free call with the NOCD care team to find out how this type of treatment can help you. NOCD offers live face-to-face video therapy sessions with OCD specialists, in addition to ongoing support between sessions, so that you’re fully supported during the course of your treatment. All NOCD therapists specialize in OCD and receive ERP-specific training and ongoing guidance from our clinical leadership team. Many of them have dealt with OCD themselves and understand how crucial ERP therapy is.