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Exposure Response Prevention (ERP) is a form of cognitive behavioral therapy (CBT) that gradually exposes clients to avoided anxiety stimuli while the client practices resisting the compulsive behaviors that maintain their fears. With repetition, commitment to reducing compulsive behaviors, and use of CBT techniques to restructure beliefs associated with fears, clients generally experience a reduction in both the intensity and frequency of their distress. ERP is considered a first-line treatment for Obsessive-Compulsive Disorder (OCD), and is also used to treat anxiety disorders (e.g., Foa et al, 2005; Simpson et al, 2008). There are a multitude of studies going back decades that highlight it as an effective strategy in therapy for OCD and anxiety, and when completed, has a 65-80% success rate for children, adolescents, and adults (Abramowitz et al, 2010).
In recent years, there has been some criticism of ERP within the therapeutic community, particularly on online message boards and via social media. It is certainly true that there must be some practitioners that misuse the terminology and basic ideas of ERP due to a lack of training or supervision. Moreover, while all therapeutic methodologies should be open to criticism and correcting based on the scientific evidence and a desire to help clients achieve their goals and live fuller lives, some of the recent criticisms of ERP seem to be based on a misunderstanding of the clinical process and assumptions based on anecdotal evidence. I will present some of the arguments I have seen in an effort to highlight the methods and ethics inherent in ERP that go against these arguments.
Criticism 1: “Having OCD is traumatic and exposures retraumatize people.”
It is true that the distress of OCD can often feel extremely debilitating and even traumatic when someone with OCD is triggered by an intrusive concern. Their concept of self and safety can be rattled to the point of panic. However, it is important to note that professional ethical codes within the counseling community highlight the need for informed consent (American Counseling Association ethical code A.2.a), avoiding causing harm to our clients (A.4.a), and not engaging in harmful practices (C.7.c). ERP has been accepted as an evidence-based practice that falls within these ethical guidelines. This is because the course of ERP treatment is guided by the consent, values, and goals of the client themselves, and, as noted above, the process of exposures is gradual and exists on a hierarchy. Using a subjective units of distress scale (SUDS) clients are asked to rank the level of distress they believe they would experience for each possible exposure, and then once a lower-level exposure is completed, and the client’s willingness to experience that exposure is increased, planning for the next level of exposure can begin.
This means there is plenty of planning, communication, and gradual increasing in difficulty that is led by the client with an emphasis on following their values and decisions. If, for example, a client has a fear of being in water, and has identified that being in a pool with deep water as a SUDS of 99/100, a well-trained ERP therapist will work with the client to identify an exposure that is a SUDS level of 10-30/100, that the client is willing and agreeable to doing, and has the possibility of leading to more difficult exposures later on. “Instead of jumping in a pool right away, and perhaps causing more fear and avoidance, maybe we can just put one of our feet in the water first and see how that goes?” To be clear, if an exposure is traumatic for the client, it means ERP guidelines have not been accurately followed.
Criticism 2: “People are forced to do exposures and it is not collaborative.”
The collaborative nature of ERP has already been discussed, but it is again worth noting some of the ethical guidelines that must be followed while doing ERP that refute this criticism. Again, informed consent (A.2.a) is an absolutely necessary function of all therapeutic interventions, and all ERP practitioners are asked to directly and fully communicate the process of exposures, and work with the client to identify exposures that they feel will be helpful and that they are willing to complete. Ethical guidelines also stipulate the need for therapists to work within, uphold, and respect the personal values of our clients (A.4.b) and to be considerate, respectful, and open to clients’ culture and diversity (B.1.a). All of these ethical codes put an emphasis on the need for collaboration, and this is seen in the therapeutic relationship.
ERP therapists are trained to be curious and ask as many questions as possible with regards to the fears, anxiety, and other distress that client’s experience and then to work with the client in identifying an exposure hierarchy that mirrors this understanding. Certainly, therapists can suggest exposures to the client, but this is done in effort to open up a conversation about this process, the feelings that are present, and its alignment with the client’s overall goals, beliefs, and values. It is very rare that different clients will have the exact same exposures as a part of their hierarchy, and this is because ERP therapists are intently aware of their client’s individualistic needs and the necessity to collaborate with their clients and follow their lead. For example, if a client is struggling with religious scrupulosity, and is a devout follower of Christianity, any planning of exposure will work to be respectful, considerate, and in-line with those beliefs while still exposing themselves to the distress their uncertainty creates.
Criticism 3: “Some therapists seem to get a kick out of seeing how far they can push exposures; this is offensive to those with lived experience.”
This critique is the most interesting to me as it seems to attack the therapists themselves as opposed to the evidence-base or process of ERP. It is certainly the case that in all helping professions there are some whose intentions may not be in line with moral or ethical guidelines, or those who are in it for their own personal gratification, rather than the goals and needs of their clients. However, ERP is not somehow more accepting of such individuals, and once again true ERP with proper training abides the ethical guidelines of having a strong scientific basis for treatment modalities (C.7.a), and not engaging in harmful practices (C.7.c). Additionally, ERP therapists work to uphold the broad understanding that the exploitation of others, especially those seeking services, should be avoided at all costs (C.6.d). In fact, as someone that trains students and interns to do ERP, what I usually find is a reluctance and discomfort in new therapists to tolerate the distress their clients' experience. Almost all therapeutic modalities have the possibility of being skewed towards harm if the practitioner “gets a kick out of” causing distress to their clients. It is also the case that without appropriate supervision and training some clinicians may move too quickly or not get full consent from their clients before trying to employ an exposure. If there is no consent from the client, and no detailed conversation and planning, then the exposures are unhelpful and inappropriate at best, and unethical and harmful at worst.
Criticism 4: “Evidence based treatments focus on symptoms and does not take into account the person and their culture more holistically.”
All sensitive practitioners, including those who practice ERP, should be dedicated to multicultural considerations (ACA Code of Ethics B.1.a), avoiding harm to our clients, and avoiding imposing the values of the therapist onto the clients (A.4.a). Additionally, the need for cultural humility, which includes gaining insight directly from the client, should always be followed as exposure is planned and performed. It is entirely possible that I could come up with an exposure for a client suffering from Harm OCD that does not align with their beliefs, values, culture, or identity. But I would work to be open to their feedback when offering such an exposure, and hopefully the rapport building and initial psychoeducation would allow the client to be honest about this misalignment. This would allow for the possibility of further rapport and trust as I find a new opportunity to know and understand my client on a deeper level. In truth, the idea that beneficial exposure could be performed without considering the whole person and their culture highlights a lack of understanding about exposure work in general, for a client’s commitment and willingness to do exposures often comes from their own goals and desire to live a fuller life. Both things that are integrally based on the client’s holistic self.
We also get assistance from other modalities, as most ERP clinicians utilize other cognitive behavioral therapeutic (CBT) modalities in addition to ERP. Acceptance and Commitment Therapy (ACT), which also highlights the need for compassion and client-centered application, works very well with ERP and it helps those suffering from intrusive thoughts and feelings an opportunity to change the relationship with their thoughts by accepting them, as opposed to challenging them. In general, ERP therapists are very open to third-wave CBT approaches that allow for this type of change, and do not feel beholden to stick to a single modality.
Compassion is a basic component of almost all therapeutic modalities. It is something we teach our clients to engage in for themselves through the use of self-compassion (Neff, 2004), and it is something we as treatment providers must engage in for the sake of our clients and their success. Exposure Response Prevention (ERP) is no exception. ERP has been the gold-standard for the treatment of OCD for more than 30 years, with components of ERP showing success as far back as the 60s. In that time, it has molded and changed with the times as scientific data and client feedback provided insights on how to make the treatment more effective. Additionally, all of the professional organizations, with their individual ethical boards, have observed, studied, and researched ERP over these decades and also found it in good standing with their ethical guidelines. This is because ERP practitioners are just like most therapists: we care, we know the mental health issues we treat are difficult, and we desire to treat our clients with compassion as we help them overcome their fears. Exposures are difficult, and often clients will feel resistant to doing them, or even beginning therapy, due to a strong desire to avoid their overwhelming distress. But good, well-trained, ERP therapists lead with compassion by maintaining a commitment to willingness and consent that is directly given for all exposures, curiosity and care for the holistic person and their culture, while maintaining a client-centered application of the treatment protocol.
