Understanding Exposure Therapy

What is ERP?

ERP, or Exposure and Response Prevention therapy, is the gold-standard for OCD treatment. In ERP, you voluntarily expose yourself to the source of your fear over and over and over again, without acting out any compulsions to neutralize or stop the fear. By repeatedly facing something you’re afraid of, you force your brain to recognize how irrational it is.

For example, a person with Harm OCD who is afraid of being around kitchen knives might be asked to start cooking dinner with one nearby. From there, they may be asked to carry a pocket knife around with them. Over time, their massive fear diminishes and their brain realizes that they are not a threat to themselves or others. While their harm thoughts may not go away entirely, they are no longer debilitating.

ERP practices should be used inside and outside of therapy for the greatest impact. The more and more you rope its techniques into your everyday life, the stronger your coping mechanisms become. Certain apps, like nOCD, make ERP more convenient and accessible.

Professional Perspective

OCD3, Ep6: Choosing Exposure Response Prevention (ERP) Therapy

Is ERP the same as CBT?

All recommended therapies for OCD fall under a model of treatment known as Cognitive-Behavioral Therapy, or CBT. CBT focuses on creating strategies for managing negative thinking, behavior and emotions. It is rooted in the idea that symptoms of mental disorders can be minimized by learning new ways to process information and develop healthy coping habits. CBT Therapists help patients evaluate themselves, recognize harmful thoughts, behavior and emotions, and learn to react to them in less-distressing ways. Make sense?

The two most trusted therapies for OCD — ERP and ACT — are both types of CBT therapy. There are other types of CBT available. You can learn about them here.

How does ERP work?

That’s a loaded question. Let’s start by explaining ERP a little bit further.

ERP is all about exposing yourself to the source of your anxiety. For someone with Contamination OCD, it might be a kitchen sink. For someone with Pedophilia OCD, it might be a playground of children. But it’s often a lot less obvious than that. For instance, if a person has Relationship OCD, their fear might be “obsessing over my partner’s physical characteristics” or “being unable to focus during sex because I’m worrying about our compatibility.” For people with Harm OCD, it might not be as straightforward as fearing knives (not to say that isn’t very upsetting). It could be fears about picking up pieces of glass on the street and using them to harm passerbys, or worrying about randomly attacking loved ones.

OCD is an extremely complex disorder, which means therapy needs to be personalized to our unique fears and how they impact our everyday life. In ERP therapy, a professional will work with you to understand your symptoms, your triggers, your avoidance techniques and how OCD is interfering with daily tasks. They’ll then work with you to develop something frequently referred to as a fear ladder — a hierarchy of activities that will help you slowly overcome your anxiety.

To create a fear ladder, you identify a specific OCD-based issue that you’re having. Based on the issue you’ve identified, you then set a “goal” you’d like to reach. The goal should be conquerable and specific. If it’s too broad, you won’t be able to come up with a plan for beating it. For example, “never being anxious again” is not a good choice. It’s unattainable and doesn’t focus on a particular problem. A good goal would be “go to the swimming pool without feeling too anxious.” It targets a specific problem you’re having and is something you can work towards.

Once it’s identified, your doctor will create a “fear ladder” that consists of incremental tasks that slowly expose you to your trigger (i.e. swimming pools). You’ll then perform these tasks one by one until your anxiety starts to subside. After each task, you’ll rank your anxiety so you have an idea of its intensity and if you’re ready to move onto the next one. Let’s take a look at an example fear ladder:

Fear

Being contaminated by harmful and potentially life threatening diseases at public pools

Goal

Enjoy time at the pool without experiencing intense anxiety

Fear Ladder:

  • Task 1: Drive by the local pool each day for one week and pay attention to all the people swimming.
  • Task 2: Watch YouTube videos of people swimming in crowded, public pools.
  • Task 3: Bring your sibling to the local pool and watch them swim.
  • Task 4: Bring your sibling to the local pool and walk around without shoes on.
  • Task 5: Go with your family to the pool and get your feet wet.
  • Task 6: Go with your family to the pool and wade in up to your chest.
  • Task 7: Go with your family to the pool and dunk your head under water.
  • Task 8: Go with your family to the pool and spend 5 minutes in the water.
  • Task 9: Sign up for a 50 minute one-on-one swim session at the pool.
  • Task 10: Attend a pool party and swim with friends.

The ultimate goal is to reach the end of your fear ladder having tackled the issue at hand. Not only will you be able to accomplish that specific task, but you’ll have developed healthy coping mechanisms along the way (even if you don’t realize it). ERP teaches us how to identify the things that are bothering us, handle anxiety in real time and overcome our biggest fears.

This process can be repeated as many times as necessary.

From the Community

OCD Treatment: Introduction to Exposure and Response Prevention
ERP Support for OCD: The Uncertainty Curve
The Risks and Dangers of Self-Directed ERP Therapy

How Do I Perform Exposures Outside of a Session?

We know it can sound scary to practice anxiety-inducing tasks on your own. It might also sound embarrassing. But it doesn’t need to be.

ERP takes some getting used to, so don’t beat yourself up if the transition is a little rough. That said, if you’re routinely finding excuses to skip your homework and exposures, it might be time for some self-reflection. Are you actually too busy to do them? Or are you avoiding them?

It often helps to create a plan for yourself. A lot of people will use apps to schedule their exposures so that they can stay on track. When they receive a reminder, they’ll step away from what they’re doing to practice their exposure. Some people can do them at work, others might need to do them at home. Whatever works best for you is the right call. If you’re doing them at work or in other public spaces, find time to go to the bathroom or take a walk around the block so you can complete them in private.

It might also help to alert your family, friends, partners, or if you’re comfortable with it, bosses, to what’s going on. Having allies in recovery is really important. They’ll help you stay accountable, on track, and supported while you’re dealing with something really tough.

Lastly, your therapist is there to help. They’ll give you advice for completing worksheets and exposures. They’ll help you figure out what approaches work for you. Don’t be afraid to open up to them and ask for help. That’s their job.

What should I expect from ERP?

Most effective OCD treatments require hard work and dedication. ERP is no exception. For it to work, you have to put time and energy into the process. That said, practitioners are normally understanding of how difficult therapy can be, and will start out slow and pick up speed over time.

ERP is different from traditional therapy because it focuses less on talking through issues and more on addressing them through action. That’s not to say you won’t discuss your exposures — there’s plenty of analyzing that gets done through conversation. Just prepare yourself for the uniqueness of ERP therapy and how it differs from talk therapy.

If you’re starting ERP therapy, here are a few things you can expect:

Homework: You’ll be asked to fill out worksheets or practice techniques outside of therapy. Make sure to commit to these assignments. They are crucial to progress.

Doubts: Many people spend their first few weeks, or even months, wondering how much of an impact their treatment is having. ERP takes time. You must be willing to be patient in order to see results.

Discomfort: ERP is supposed to make you uncomfortable. Don’t let this scare you off. If you’re anxious, it’s likely working.

Self-awareness: In order to be successful at ERP, you have to be willing to analyze and critique yourself. Prepare to discuss your emotions and the tasks at hand. Hold yourself accountable when necessary.

Discipline: ERP takes real work. And for its effects to last, you have to practice outside of your weekly therapy session. Don’t let yourself falter.

Is ERP hard?

Depends on who you are! Treatment is different for every single person. No two journeys are the same, which means every sufferer has their own opinion on the methods that work and don’t work for them. What we will say, is that you should never expect therapy to be easy. All options take time, energy and dedication. They require a real desire to get better. If you’re searching for a quick fix, you’re going to come up short.

If you’re feeling overwhelmed by your treatment journey, and as if success feels too far away, focus on the here and now. Therapy only needs to be as intimidating as your next session. Don’t think in terms of weeks, months and years. Think “I have X number of days until my next session, and X number of assignments to get done. That’s not so bad!”

Are there more resources I can check out?

Of course! What we’ve provided is really only an intro to ERP. There is so much more to be explored if you are considering it as an option. Below you’ll find other sites, worksheets, videos and books that can help you better understand and practice ERP. Additionally, you’ll be able to browse our library of fear hierarchies to gain a better understanding of what they look like and how you can create your own.

Webpages

Worksheets / Toolkits

Organizations

Videos

Books

Explore Hierarchies