What is exposure and response prevention (ERP) therapy?
The best way to describe exposure and response prevention (ERP) therapy, aka “exposure therapy,” which is the evidence-based treatment for OCD and the most effective treatment for anxiety is with an example. Let’s say that you are deathly afraid of bridges. Big bridges, little bridges, bridges in between….you want nothing to do with them. You see them and you just freeze up. You say to yourself, “I didn’t want to go to what’s on the other side of the bridge anyway. I’ll just stay here.” And so you stay there. And unfortunately, you end up staying afraid.
Because when we avoid what we’re afraid of, it stays this big, scary thing. Our brains are already tuned to what’s scary, because that’s how they keep us alive. Unfortunately, our brains then mistakenly draw this well-intentioned but wrong conclusion: that the only reason we survived the [almost] encounter with our feared situation is because we avoided it in the first place. So we keep avoiding. As a result, our brains never have a chance to learn that we actually can handle this feared situation. Avoidance seems like it keeps us safe, but it actually creates more fear.
Bridging the gap
Fortunately, there is a way to help the brain come to a different conclusion about what we’re afraid of, and this is where exposure comes in. Let’s say you decide you do want to go to whatever’s on the other side of that bridge. So you decide to try going over a little bridge, where you can’t really fall off:
The exposure part of this exercise is going onto the bridge. The response prevention component is not doing any of the safety behaviors that you would have previously used to make yourself “feel” safe on the bridge. For instance, safety behaviors could include closing your eyes as you’re going over or retreating as soon as you get a little ways onto the bridge. We want to prevent those responses, because if we use them, the brain mistakenly concludes that the only reason we survived the experience is because we used the safety behaviors. And that’s not true: we survived because we can handle the experience, but our brains don’t know that until we have the experience without the safety behaviors.
You decide to do ERP by going back and forth over this bridge slowly a bunch of times with your eyes open. It turns out not to be so bad. You think that maybe you could try something a little bigger:
After crossing the bridge numerous times, again without using your safety behaviors, you are feeling a little better about bridges. You decide you want to try an even longer one:
You go over this bridge repeatedly, really looking at the bridge and being mindful of being on it. You do this so many times that it just doesn’t bother you anymore. So you try an even larger one:
After traipsing across this one so many times that you feel like you have the bridge memorized, you feel like you are ready to start going over normal roadway and interstates bridges each day on your way to work. After awhile, you don’t even realize you are going over them!
But you are still a little scared of really big bridges. So you decide to go for it, to face this fear. You dig out some frequent flier miles and fly to San Francisco, where you hire a taxi to take you over the Golden Gate Bridge:
You are really scared the first time, but you focus on the beauty of the bridge and the feel of the tires bumping along as they go across. It isn’t so bad. You decide the views from the bridge are pretty good, so you ask the taxi driver to take you over it again. And then you do it again, and each time you are a little less scared. After awhile, it turns out this is actually getting kind of boring (and expensive)! So you tell the taxi driver to take you to one of the best restaurants in the city, where you celebrate that you can now go over bridges. You have just successfully done exposure therapy!
Exposure for OCD and anxiety
For OCD and anxiety, that’s how we do exposure (although we might not need to fly to San Francisco!). You and I make a list of the situations, thoughts, images, etc… that your OCD or anxiety disorder is afraid of. After doing some preparation work, we will then decide where to start with our exposures. Normally we’ll start out approaching items that are moderately scary and that you and I think you can handle.
When we approach those items, we agree that you won’t do your rituals, either mental or physical. Rituals serve as safety behaviors in OCD, meaning that we feel that the only reason we survived being exposed to our feared situations, objects, thoughts, etc. is that we did our rituals. Instead, with my support and guidance, you will expose yourself to these fearful stimuli without doing your rituals, so that your brain can learn you can handle it. Because you can! I know this sounds hard and scary, but trust me, you can do it. You’ll probably feel anxious during the process, but that’s OK, as that helps you get better.
Over a period of weeks or months, we work our way around your list of fears at your own pace, and you cross your own bridges, so to speak, over and over again. Believe it or not, exposures offer the opportunity for a lot of creativity, and I even try to make it fun. For instance, we’ll talk about what rewards you’re going to give yourself if you do your exposures. (Hey, so maybe a fun trip to San Francisco will be in your future!)
The whole time, you are in control of doing the exposures. We measure your progress as we go to see how you are doing. And we make sure to celebrate success along the way.
I look forward to the opportunity to help you close the gap between what you’re afraid of and what you can do, so you can take your life back, and live the kind of life you want to live!