Exposure and Response Prevention

Obsessive Compulsive Disorder is known for being a very debilitating and life-altering mental illness. Yet, even thought there is no permanent cure to instantly make things better for us, there are treatment options and continuous research being done to better understand OCD. The thing is while there are many routes one can take in treating their OCD, one proven option that has the most success rate at giving people back control over their lives by managing their OCD is ERP - Exposure and Response Prevention Therapy. 

What is ERP?

If you type into google ERP you are not going to find out anything useful, besides the fact that ERP can an acronym for other information. So first we have to understand that while ERP is easier to say, type, and a bit less intimidating than the full term, we have to be able to know what the acronym means for us.

Exposure and Response Prevention!

That is what ERP stands for when we refer to it. It is a type of treatment that focuses on breaking that cycle we were talking about earlier. Here is a refresher for all of us on how OCD works and that cycle that keeps us trapped:

This is the diagram (Cognitive Model of Obsessive Thoughts) in our resource section that outlines how an OCD cycle is started. You see the trigger - usually, an intrusive thought we misinterpret - that leads to an Obsession forming and growing into a fear as we put more thought, appraisal, and overall importance to this Obsessional Fear. This, of course, will lead to anxiety, discomfort, or general unease. All bad feelings that make our bodies react so that we end up Neutralizing which just means doing our Compulsions - like avoiding, remember even though we aren't 'doing' anything, doesn't mean we have not just neutralized the fear by not facing it, doing rituals, or following a set of rules that our OCD has dictated to us. This will then create the cycle of Obsessions, Anxiety, Compulsion and Relief.


Therefore, it will only end up looping back again to the Obsession, which will trigger the cycle and add-on to the Neutralizing to relieve ourselves of the bad reaction our body goes in to - the flight or fight. Anxiety will grow and will motivate us to keep doing the cycle. It will continue to loop and loop around with the same steps yet as time goes by, more will be added to the Compulsion bit of the cycle. In the last post, we covered the reason as to the reason why we become stuck on an Obsessional Fear - it was due to the simple fact that each time we give in and do a compulsion(s), we are actually giving this Obsessional Fear validation of the intrusive thought that may have brought us harm or harm to others. It only allows this Obsessional Fear to grow until the cycle is hard to stop because it is just easier to comply with what our OCD is telling us.

Another image to help us grasps this cycle and something to keep in mind is this diagram...

Therefore, if we understand how our OCD works we will understand why Exposure and Response Prevention Therapy is the leading - pretty much the only - treatment option for OCD. We have built this reality that tells us that the only way to handle our anxiety is to do what our OCD tells us because we see instant proof of it working in the relief given from the anxiety that was building. Yet, what if we just ignored the OCD demands after that Obsession forms and faced the anxiety?

Step One to ERP is to Understand our OCD Better:

Everyone's OCD is different yet the same, in that we are all stuck in the cycle of Obsessions, Anxiety, Compulsion, and Relief. But just knowing this will not help you as an individual. Everybody has intrusive thoughts and misinterpret them in their own ways. Meaning, our basic Obsession could be similar but how we handle it can vary. Many people fall into the Contamination category, yet we all have our own struggles. Some it's all about touch, sickness, crowds, etc. Others could focus on one thing, like food and how it can become or already be contaminated. We will have to cater the ERP to our specific Obsessional Fears and therefore, even finding someone similar, we will still have to do the first few steps ourselves - or see a specialist to help you set up your initial entrance into the treatment process of ERP.

By gaining a grasp on your own OCD and where you struggle the most, you can then begin the next step of building a hierarchy. But before we move on to that step, I want to bring to light a myth that many people who suffer from anxiety tend to believe in...

One of the huge myths most people with OCD believe is that once their anxiety starts to build that it will continue and continue until we can no longer handle it. This is completely wrong, as it has been proven that anxiety cannot be prolonged forever or indefinitely. There will be a peak and it can naturally disperse over time. It can last awhile for some of our very hard Obsessional Fears that have roots buried deep in our minds and bodies. But it will still end if you don't do your Compulsions, it will just be tough but something that needs to be done with ERP Treatment. Our anxiety tends to come in waves - small or big depending on the Obsession. So, knowing this, we can better prepare for our exposures.

Step Two Building your Hierarchy:

So, after reviewing and starting to get a better understanding of our OCD, we can start to make up a treatment plan to allow us to manage our OCD on our terms, not because of anxiety or obsessions. It involves you to do the one thing that goes against our OCD cycle though, which is to become triggered by an Obsessional Fear and feel the anxiety.

That's it. No more cycle, just two components that usually has us running to do our rules, rituals, avoidance, or any other form of compulsions.

This may seem insane and overwhelming. Yet, the first rule of ERP is to make your hierarchy. You take ONE of your Obsessional fears - maybe the fear of drinking unclean water. Then you list all the rules or compulsions around this area of your OCD. After that, rate what you do to compensate for the anxiety on a scale from 0-100. The technical term for this is SUD which you might notice on some of the resources given. This really just stands for the level or percentage of anxiety you rate for each action or exposure.

Once you rate your anxiety level, start with the exposures that have the smallest anxiety attached and perform this exposure over again, consistently until the anxiety rating you started with decreases by at least half before moving up your hierarchy to the more challenging exposure. The main thing to understand is that you must plan for good and bad days because consistency is important with doing exposures. For example, you may feel very motivated and are having a good day with minor anxiety so you push up your hierarchy thinking you can maintain this pace. That's the the funny thing about this though, is that by doing the smaller exposure you have started to break the connection between the Obsessional fear and it's actual importance. So the hard exposure becomes easier to do just like the exposure you are working on will slowly become easier with less anxiety initially and with the anxiety also fading away faster.

The trick though is in the second part of the title - Response Prevention. You can do as many exposures as you like, but if you keep neutralizing and validating the threat by immediately doing your neutralization. It will take longer and be harder to overcome an Obsessional fear.

Step Three Response Prevention

So, that brings us to the third aspect of ERP, preventing yourself from doing a neutralization even after surviving your exposure and seeing that the anxiety does, in fact, go down after time and nothing bad happened will be hard to do still. This can be hard and create another wave of anxiety as your OCD tries to maintain the Obsessional Fear hold on you which is strengthened by our compulsions. Therefore, the next task will be to either try to hold off doing our compulsions after an exposure for as long as we can, making it longer each time or just not doing any. This will play a factor in the severity of the anxiety you will feel the next time around doing the exposure.

Not to reassure anyone that there is not a risk, as in life there is no total control over everything, even if our OCD tries to make it feel as if that is not the case. You have to be willing to take the risk, the full risk of being exposed and then not do anything to counter-act the bravery you took in doing your exposures.

It takes practice and time to build this skill. It also can be more challenging depending on the exposure or factors happening in your life. Stress, change or the depth of the Obsessional Fear has on your life can change how you deal with OCD.