Why it takes more than exposures

April 15, 2019

WRITTEN BY

Patrick Carey

Patrick joined our team to help people get better information about mental health. He drinks coffee and wishes he had a dog.

We talk a lot about exposure and response prevention around here. Commonly known as ERP, this form of cognitive-behavioral therapy has two main components. Exposures are exercises that put someone in a situation that causes their unwanted, intrusive thoughts to pop up. Not all intrusive thoughts cause us distress, but exposures are chosen specifically to trigger those that do. By putting someone in a distressing situation– often one they’ve avoided for a long time– exposures aim to gradually desensitize them to it.

The exposure part of ERP is relatively simple: you’ve been avoiding something because it causes you intense anxiety; in order to find ways to respond besides avoidance, you have to put yourself in that situation and gradually learn that you can get through it. (By situation, we mean not only events but also people, places, things, and so on.) Over time, research suggests, ERP exercises not only teach us to get through that distress but can actually help us habituate to it longer-term.

What’s missing from this explanation, though, is the fact that avoidance comes in many different forms. There’s the typical one: I don’t want to do something, so I avoid it. This is a total refusal to put ourselves in a situation and, ultimately, to experience the emotions and sensations it could involve. But even if we’re in that situation we can avoid these emotions and sensations by behaving in certain ways. We all do this, whether we’re staring at our phones in public to avoid eye contact with strangers or keeping quiet during a family party to make sure we don’t say something dumb.

When we’re talking about obsessive-compulsive disorder (OCD), though, avoidant behaviors are more of a concern. Attempts to escape “negative” feelings and sensations become compulsions, meaning we feel like we basically cannot behave otherwise. As a form of behavioral therapy, ERP’s primary goal is to influence behaviors that are harmful or unhelpful. That’s why it can be so effective for OCD, where specific actions performed in the service of avoiding unwanted thoughts and feelings actually strengthen the associated fear.

Exposures make us experience the situations we’d normally avoid altogether. But if we’re still using compulsions to avoid the resulting thoughts and feelings (or at least decrease their intensity), the exposure won’t do us much good. We have to get to the top of the roller coaster and let gravity do its thing. Refusing to get on the ride or shutting our eyes the whole time isn’t going to make the ride any less frightening the next time around.

Finally, we get to the second part of ERP: response prevention. In this context, responses are synonymous with the other terms we’ve used (avoidant behaviors and, to be more exact, compulsions). By preventing our own compulsions, we fully experience the distress caused by our obsessions with the goal of habituating to it. Over time, it becomes clear that responding with compulsions (or even responding at all) is unnecessary and probably unhelpful.

Intuitively, exposing yourself to difficult situations and getting through them without any of the behaviors you’ve developed to avoid distress can be very difficult. And even when there are clear exposures for you and your therapist to plan out based on your obsessions, coming up with strategies for response prevention isn’t easy.

By definition, compulsions feel necessary in the moment. It’s not as simple as just sitting with your anxiety or taking a moment to breathe. Strategies for response prevention need to be robust enough to counter the powerful hold our compulsions have on us.

If ERP is part of your therapy work, it’s important that you and your therapist outline specific ideas for response prevention that you’re confident you might be able to try out. We’ll be back soon with specific examples, because there really aren’t enough good ones out here on the internet.

What has helped you with response prevention in your own experience? Our community members would love any helpful tips. You’ll find them in the NOCD app!