Treatment Highlight: Exposure and Response Prevention Therapy

Exposure and Response Prevention therapy (also known as ERP), is a type of cognitive behavioral therapy known for treating obsessive-compulsive disorder (OCD), anxiety disorders, and other mental health issues. It’s the gold standard for treating OCD, but there are surprisingly few therapists out there who are trained in ERP (I’m one of them!). So let’s break it down: what is ERP, how can it help, and what are exposure and response prevention examples?

What is Exposure Response Prevention Therapy and How Does It Work?

ERP was designed to treat OCD, post-traumatic stress disorder, and certain anxiety disorders, including phobias. Also known as exposure therapy, ERP works by exposing a client to their fear in a safe, controlled environment while removing the compulsive or avoidant behavior to avoid that fear. 

Disorders like OCD, phobias, anxiety, and PTSD get worse when we engage in certain avoidance or compulsive behaviors in order to avoid anxiety. However, we start to associate feelings of safety with those avoidance behaviors, and it becomes nearly impossible to feel safe without them.

This association is due to classical conditioning, in which a response to a stimulus strengthens with each pairing of the stimulus and response. The problem with this is that avoidance behaviors nearly always shrink your life down to the size of a pea – and they increase anxiety in the long term. 

What are avoidance or compulsive behaviors? Here are a few examples:

• Turning down an invitation to a party because you’re worried about other party-goers thinking you’re weird.
• Avoiding eating in public because you have emetophobia, or fear of vomiting.
• Refusing to go out in public because you’re afraid of contamination by germs, and you don’t want to touch door knobs or risk getting sick.
• The thought of being in crowded rooms or environments makes you anxious, so you stay home instead.

When done correctly, ERP is incredibly effective at breaking the anxiety-avoidance cycle. 

OCD Thoughts Are Not Real… Are They?

OCD thoughts aren’t real. Right? Well… yes, they are real. But that doesn’t mean they’re true.

OCD thoughts are absolutely authentic in that they cause a lot of distress and anxiety in the person who experiences them. OCD thoughts and any strong anxiety thoughts hold so much power over you because they are exceptionally convincing. They spike your fight-or-flight response, which is a human’s most primal survival state. You can’t “out-logic” survival mode: it hijacks your ability to reason and think clearly. 

At the same time, these compelling anxieties are usually not true. A strong anxiety thought might be, “if I go out while I’m sad or anxious, everyone will see what a mess I am and never want to talk to me again. So I’ll just stay home until I feel better.” While this thought is very real, the anxiety is lying to you. People love you. The worthwhile ones don’t care if you’re sad, stressed, or anxious. The idea that you’ll be rejected because you’re less than perfect is simply not true 99.9% of the time. However, the more you keep yourself homebound, the more you’ll reinforce the anxiety that accompanies socializing.

To treat OCD or phobias, you have to retrain your brain to stop associating anxiety relief with avoidance behaviors or compulsions. That’s where ERP comes in. 

OCD: ERP Treatment Plan

ERP therapy involves two critical components: exposure and response prevention. During the exposure phase, you’ll face your fears in a controlled and systematic way. This might mean touching a light switch for someone with contamination fears or driving for someone with a fear of accidents. The response prevention phase is about resisting the urge to perform anxiety-reducing rituals or avoidant behaviors. The two phases performed in tandem helps teach you that your anxiety will ease over time without the need for avoidance or compulsions.

Exposure 

The goal of the exposure phase is to help you face thoughts, fears, scenarios, images, and objects that cause anxiety or distress, without engaging in your usual avoidance or compulsive behaviors. In other words, you’ll be gradually exposed to anxiety-provoking situations until you learn they’re safe.

I know this sounds terrifying and intense, but you won’t be alone. A trained therapist will guide and support you throughout your whole fear-facing journey. 

Here’s what the process of exposure looks like:

1. Fear hierarchy: We’ll work together to create a list of your anxieties. We’ll rank them in order of least anxiety-provoking to most anxiety-provoking to provide an order for exposure therapy. 
2. Gradual exposure: Then we’ll start with exposure to the least anxiety-inducing fear first. Once you feel more comfortable with this fear, we’ll move on to more challenging ones. 
3. Real-life and imagined exposures: You’ll most likely have direct exposure to your fear in real life. However, in scenarios that are abstract or difficult to recreate, it also works to vividly imagine the fear playing out. Either way, your therapist will walk you through the scenario, and we’ll work up to facing the fear.

The keys to effective ERP are prolonged exposure and repetition. Prolonged exposure is staying in the situation long enough for your anxiety to naturally decrease, rather than leaving as soon as you start to feel anxious. However, your anxiety is strong, and so are the urges to perform compulsive or avoidant behaviors. By repeating exposure exercises again and again, your anxiety will decrease and your distress tolerance will increase over time. 

Response Prevention 

In the response prevention phase, you’ll actively resist the urge to engage in compulsive behaviors or avoidance tactics that you usually turn to when you’re anxious.

Here’s what that looks like:

1. Identifying compulsions: Just like we made a list of your fears, we’ll also list out specific compulsive or avoidance behaviors you typically engage in. 
2. Distress tolerance: During exposure exercises, we’ll practice refraining from engaging in these behaviors and build your distress tolerance for anxiety.
3. Support and encouragement: Throughout the process, your therapist will be encouraging and supportive. We’re here to cheer you on and help you tolerate the anxiety that we know is really tough to manage.

Response prevention helps you break the cycle of compulsive and avoidance behaviors. You’ll learn alternative strategies to cope with your anxiety, such as mindfulness or relaxation techniques. Response prevention helps you feel empowered and capable, because you learn that you can tolerate anxiety without relying on the compulsions that currently feel so compelling.

Empowerment and freedom from the cycle of anxiety and avoidance? You can get there. And if you ask me, that’s pretty badass. 

Support For Anxiety and Avoidance Behaviors

If you want to try ERP therapy but aren’t sure where to start, I’m here to help. Together, we can break the cycle of your anxieties and avoidance behaviors for good. As a trained ERP therapist who specializes in anxiety, I’ll help you:

• Understand your fears and compulsions
• Find safe ways to expose yourself to your fears
• Learn distress tolerance and anxiety management
• Feel empowered and grateful for showing up for yourself in this process

Learn more about my therapy services (including EMDR and talk therapy) if you’re located in Idaho or Iowa. For all other locations, check out my coaching services. My coaching program offers all the same expertise, tools, and guidance as therapy in a more direct and goal-oriented approach that you can benefit from anywhere. 

‍Reach out today to schedule a complimentary consultation and see if we’re a good fit. Let’s start building a better future together.