Exposure and Response Prevention (ERP)
Exposure and response prevention (ERP) is a form of cognitive behavioral therapy (CBT), which is a type of treatment that involves changing one’s thought patterns to then change one’s behaviors. ERP is especially useful when used for anxiety related disorders like OCD and phobias. In fact, ERP is the most effective treatment for OCD and phobias, helping patients to overcome their fears, and obsessions and compulsions through guided exposure to their triggers.
In OCD, a patient has obsessions, which are recurring thoughts, images or urges that come with intense feelings of anxiety or discomfort. In OCD, to alleviate these feelings, the patient engages in certain compulsive behaviors. This becomes a cycle that the patient can’t get out of, affecting his/her quality of life and daily functioning. In phobias the individual may go to extremes to avoid the things they are phobic of, for example being afraid of flying, so choosing to never fly.
What is ERP?
The goal of ERP when utilized with a patient who has OCD is to decrease the anxiety that drives the obsessions and compulsions, eventually breaking the cycle and providing the patient with healthier coping skills. It accomplishes this by repeatedly exposing patients to the things that cause anxiety, and then helping them to keep their compulsive behaviors at bay. Over time, a process called habituation occurs, which is when patients become less physiologically activated to the triggers.
The goal of ERP when utilized with a patient with a specific phobia is similar to that of OCD. However, when an individual has a specific phobia, they often avoid the anxiety causing stimuli, as such they do not develop maladaptive coping mechanism (i.e., compulsions).
When a patient begins ERP, the therapist will start by determining the patient’s triggers, which can be internal thoughts or external stimuli. Along with learning about the patient’s triggers, the therapist will learn about his/her obsessions and compulsions (if there are any), including what the patient fears will happen if he/she doesn’t follow the compulsions.
The Steps of ERP
Once the content of the patient’s fears or obsessions and compulsions has been determined, ERP can begin. There are two main steps in ERP:
● Exposure: the patient is slowly and methodologically exposed to the triggers, which are the thoughts, images, circumstances, or objects that lead to anxiety.
● Response prevention: the patient confronts his/her fears using therapeutic techniques to resist the compulsive behaviors that the anxiety prompts him/her to do.
Since this exposure can cause a great deal of distress, the therapist starts the process gradually, beginning with the situations, images or other stimuli that will cause the least amount of anxiety. Once the patient has habituated to a triggering stimulus, the therapist will introduce a slightly more difficult one, ensuring that the patient is ready for each new step.
For instance, when working with a patient who has a fear of germs, the therapist may begin ERP with having the patient imagine touching a doorknob without washing his or her hands afterward. When doing this becomes bearable, the patient may then touch an actual doorknob, using coping skills to resist the urge to wash his/her hands.
Once the patient is successfully able to do this, the therapist might ask him/her to touch the doorknob and then touch his/her face. By being exposed to gradually more distressing situations, the patient conquers his/her fears and learns to cope without resorting to compulsive behaviors.
What to Expect in ERP
During ERP, the patient will initially feel anxiety and distress. Resisting the urge to act out compulsions will be difficult. However, after sitting in the discomfort and distress without acting out a compulsion, the patient will eventually feel a decrease in anxiety, showing the patient that his or her fears are less of a threat than he or she realized. This means that habituation has happened, and the patient’s nervous system has become less activated by the trigger.
Throughout the process, the therapist guides the patient, helping him/her to feel the anxiety while curbing the impulse to act out a compulsive behavior or leave the objectively safe situation. Using a plan for exposure, the patient can experience a trigger while resisting the compulsion that he or her would typically use to relieve the anxiety. Over time, the therapist will transition to more and more distressing stimuli, until the patient has conquered his/her obsessions.
Sessions will typically be done in the therapist’s office, but they will sometimes involve a specific location that triggers anxiety for the patient. For instance, if the patient has a fear of tight spaces, the session might happen in a building with an elevator. Eventually, patients will learn to do ERP exercises on their own, allowing them to manage symptoms in their daily lives. At the end of ERP, the therapist and patient create a plan for what to do if the patient relapses.
How ERP Works
Exposure and response prevention is a method to rewire your brain, training it not to see anxiety triggers as threats. The habituation that occurs during ERP means that the neural pathways telling the patient to be afraid have weakened, allowing for different pathways to form.
Along with changing how your brain reacts to stimuli, ERP teaches patients that the obsessions, thoughts or feelings that lead to phobias or compulsions are less threatening than they previously thought. Throughout the process, patients discover that being exposed to the object of their fears doesn’t cause the consequences they are afraid of, and that they can cope with obsessions and anxiety without resorting to compulsive behaviors.
Although ERP can be difficult and scary, it is the leading treatment for those with OCD and phobias. Some therapists will recommend ERP on its own, while others may use a combination of ERP and medications. Despite its initial difficulty, ERP can break the cycle of obsessions and compulsions, and irrational fears allowing those with OCD to enjoy a higher quality of life and function more successfully.