May 28, 2024

You Want Me to Do What? An Overview of Exposure and Response Prevention Therapy

Exposure and response prevention (ERP) gets a bad rap. In fairness, the fault doesn’t lie solely on the treatment itself. How ERP is utilized can make all the difference in the effectiveness of the treatment. ERP is not a one-size-fits-all approach. In my experience, ERP is most successful when it is a gradual, collaborative, and consensual process.

There are ample examples of stories of ERP gone wrong. There are also, endless numbers of success stories from individuals that have regained the lives they desire and deserve after receiving effective ERP treatment. 

In conceptualizing ERP, there are two main parts. The first one is exposure, and second is response prevention. Exposures are intentional confrontations of feared stimuli, situations, thoughts, images, items, etc. that produce obsessions and anxiety. Response prevention is resisting rituals and compulsions that are an attempt to lessen the anxiety felt as a result of exposures. Intentional exposures are effective at letting OCD know that we are going on the offensive and attacking it.

Sometimes when utilizing ERP we have client focus on the response prevention portion of ERP. We do this by asking clients to practice resisting compulsions and rituals in their daily lives as they naturally get exposed to things that “trigger” their anxiety. This can be especially helpful for a client who is newer to treatment when building insight, awareness, and motivation to engage in exposure.

Exposure and response prevention has been one of the frontline, gold-standard treatment modalities for obsessive-compulsive disorder for decades. ERP should be gradual, collaborative and consensual. This is a modality that is designed for therapeutic benefit and needs to be utilized in an ethical manner that helps individuals live the lives they want and deserve.

ERP is one tool to improve quality of life.

Some things that can go awry in ERP include introduction to exposure too quickly and at a level that is too distressing for the client, otherwise known as “flooding.” Another is asking clients to engage in exposures that have no application/benefit to their daily life. For example, we would never ask a client to eat something off of a dumpster or lick bird feces, because neither of these examples is something someone would do in their daily life. Poor psychoeducation and limited understanding of how and why ERP is utilized can also lead to low awareness, insight, and motivation.

How we use and apply exposure and response prevention has somewhat changed over the years. This is a good thing. Historically the habituation model was utilized when conceptualizing the application of ERP. In a clinical setting for the treatment of OCD, habituation refers to an individual's ability to experience distress and anxiety and allow themselves to realize that naturally on its own the anxiety will subside over time. This approach posits that strict repetitions of exposures should be used to experience fear reduction. 

One analogy I often use to depict habituation is, Let’s say you jump into a pool or lake and the water is cold, what happens if you can remain in the water for 5 or 10 minutes? The answer: your body gets used to the cold water after a while and you habituate to it. ERP using the habituation model posits the same thing. If you have anxiety/distress and you resist engaging in the compulsions and rituals, you will habituate to the anxiety.  Eventually, it will come down on its own without engaging in compulsions or rituals.

More recently the inhibitory learning model has been applied to exposure and response prevention. This approach does not rely on habituation to feared stimuli and has some key additions. An inhibitory learning approach to exposure and response prevention includes several key elements to enhance the efficacy of exposures. These include: variety in exposures, using multiple fear cues, integrating an element of surprise, building anxiety tolerance, and disconfirming expectations.

Therapists who work with OCD should be familiar with ERP.

Historically, OCD is a misunderstood, misdiagnosed and under-treated disorder. Even when a proper diagnosis is given, many do not receive effective treatment. Sometimes individuals will seek treatment for OCD and receive “talk therapy” or general psychotherapy. To date, there is no evidence that talk therapy is beneficial in treating OCD. There can be many reasons for avoiding ERP. Therapists might not be trained in ERP, and it can be distressing to ask a client to intentionally do something that is going to make them feel distress and anxiety. It can be easier to avoid doing exposures and just talk about things instead.

ERP is not the only treatment modality commonly utilized today to treat OCD and anxiety-related disorders, and it is not effective for everyone. CBT (cognitive behavioral therapy) and ACT (acceptance and commitment therapy) are often utilized in addition to ERP when treating OCD. Both ERP and ACT are types of cognitive behavioral therapy. Additionally, more recently, Inference-based Cognitive-behavioral therapy (I-CBT) has gained popularity in the treatment ofOCD.

Finding a clinician that is trained and skilled in utilizing these treatment modalities can set you up for success. There is hope and recovery that can be achieved from these symptoms. We are hopeful and optimistic about the growing body of research, literature and training being offered to address OCD and anxiety related disorders.