In the previous part, I talked about the fact that Exposure & Response Prevention (ERP) is a proven treatment for OCD, with a high success rate, especially when done with the help of a therapist who knows about, and is qualified to treat, OCD. It may be used as a standalone treatment, or as part of a wider treatment plan.
I talked about the importance of doing it responsibly, and finished up by talking about how the goal of ERP is not to make yourself feel as anxious as possible, and that it should not be viewed as simply being the case that more anxiety equals higher effectiveness.
As always, what you read here should not be seen as medical or professional advice, and so you should always follow what you are told by a medical professional instead of what you read here. What you read here is simply my personal opinion, based on my own experiences with OCD and with having done ERP. I do not have medical training, and do feel out of my depth with some of this, so I linked some sources in the previous article, as well as another source in this one. The site’s disclaimer can be found here.
So what is the goal of ERP?
As the name might suggest, the goal of Exposure & Response Prevention (ERP) is first to expose yourself to situations and/or thoughts that provoke anxiety and an urge to respond, and then to not give in to them, but to instead choose not to respond. By doing this, you are retraining your brain, to teach it that these thoughts, and the anxiety they provoke, don’t control you, and that you do not have to respond to them.
Older theories of ERP tend to promote the aspect of reducing your anxiety levels, and therefore ask you to wait until your SUDS score has halved before stopping. This theory therefore emphasises the goal of reducing your anxiety, which teaches your brain that the anxiety will go away on its own. Success can therefore be measured by anxiety reduction.
A newer theory (Inhibitory Learning Theory), meanwhile, says that the main benefit comes from showing your brain that you do not need to respond to anxiety, and that you can live with it instead. You therefore do not need to wait for the anxiety levels to reduce, because rather than anxiety reduction, the goal is to learn that you can tolerate anxiety.
You are thereby showing your brain that the anxiety is not a threat to begin with (even if it is clearly unpleasant to experience), so you do not have to get rid of it (although obviously you would like to), in order to be able to live your life. You are also showing your brain that despite how it may feel, the anxiety is ultimately toothless, and that you can cope with the uncertainty, without needing to do the compulsion.
This link provides more information on the differences between these theories, and on Inhibitory Learning Theory more specifically, which I think is well worth listening to.
These theories are different, but share common ground, and both deliver results, so therapists may often use aspects from both theories, as mine seems to have done. The main differences are in what dictates when the ERP session should end, with older practices often wanting to wait for the SUDS to halve, while ILT may not require the use of SUDS at all (or if it does, it might use it as a tracker rather than as a target), and in what the measure of success is (anxiety reduction or tolerance).
Both involve provoking, and then sitting with your anxiety, and both theories state that the goal of ERP is not simply to make yourself feel anxious (although unfortunately that is a necessary element of it), but instead, to show your brain that this anxiety does not control you, that you can sit with it, and that you do not need to perform compulsions in order to rid yourself of it. While anxiety is therefore necessary for ERP to work then, it should be at a level that you are confident that you are able to manage, without the need for compulsions.
According to the older theories of ERP, this is to show your brain that the anxiety will start to fade away on its own, while according to the Inhibitory Learning Theory it is to show that this anxiety is not a threat. Instead, you can sit with the anxiety, and see that you will be able to cope with it (and I also think it is important to realise that despite what your mind may say, you will not be stuck with the anxiety forever if you don’t do the compulsion).
How do you do ERP?
Across the two articles I have done so far, I have mentioned a few different variations on how it can be done. Whether that is about what decides when to end the session, about whether the exposure is an action or a thought, or about whether to listen to the script or read it. These can depend on the ‘type’/nature of the OCD, and the nature of the individual doing the ERP.
This means that what works for me may well be different from what would work for others, so ultimately it is about finding what works best for you as an individual. All I would say, therefore, is that you should be aware that there are different options, and that you should do whatever you find best allows you to focus on the ERP itself. You should also talk it through with a therapist and follow their advice on what to do. I would also recommend that you bring up any issues you have with them, as they can help you with them.
Regardless of these details, though, some things are the same. The aim is to engage with these thoughts and with your emotions, and to learn to sit with your anxiety and the urge to do compulsions, without then giving in and responding to them. Therefore, you should aim to have as little in the way of this as you can.
This means that you should create the best circumstances and environment for you to do it in as possible. This includes doing it at a time of day that is right for you, such as doing it at a time when you are not in too much of a hurry, and shouldn’t be disturbed, and also that fits in well with your daily routine, such as avoiding times of day when you often are (or soon will be) in a low mood. I also found that doing it too late in the day seemed to impact my sleeping, so I made an effort to do it earlier.
Beyond that, it is quite simple, at least in theory anyway. I would read/listen to the script, let the meaning of it sink in, feel the emotions that it provoked, and sit with it. I would try to stay calm (without distractions or reassurance), and if necessary, I would remind myself that these were just thoughts, and that I was learning to accept them, and that I did not need to respond to them.
I would wait for my anxiety to reduce before stopping (although, as I mentioned, according to the ILT theory of ERP this is not necessary, and also using SUDS did provide something that my OCD was able to latch onto, as I shall talk about later), either stopping then, or doing more than one cycle, depending on how long I felt like I should do it for.
Once I had finished, I would make a note of how it went (how long it lasted for, how anxious I felt, any improvements I thought I should make), and then I would get on with my day. This last part is important, because you should not spend time analysing your thoughts or reassuring yourself afterwards, and should instead show that having worries does not mean that you can’t live your life. This shows your brain that you do not need to take these thoughts seriously, or let them dictate how you live your life.
What counts as a response during ERP?
I have talked before about what counts as a response when it comes to OCD thoughts in general. However, with Exposure & Response Prevention specifically, I think there is perhaps slightly more leeway, or at least a difference.
I was told by my therapist that it is okay to remind myself that these are just words/just thoughts, as that is what I am trying to teach my brain. Now while this could technically become a compulsion, I feel like this isn’t all that likely. I would say a warning sign could be if you always feel the need to say it to yourself, and doing so is accompanied by a sudden feeling of relief. Otherwise I would say it is useful to remind yourself of this when needed. Ultimately they are just thoughts, that is what I am trying to show myself.
Therefore statements such as ‘That’s just a thought. I can handle the uncertainty.’ or ‘I’m learning not to respond to my OCD.’ are allowed during ERP, and can actually be helpful to do, as they are helping to reinforce the lesson that you are teaching your brain, that thoughts are just that: thoughts. And that the same is true of emotions. They need not control you, or be seen as indicators of truth, but as simply being what they are. Anything more is making an assumption that may not be reliable, and when you have OCD, very likely isn’t reliable.
What mistakes did I make?
The first mistake I made was something I have spoken about previously: that I was trying to make myself as anxious as possible during the session. I felt like in order to make progress my chest should be tight, my heart pounding, and so on. So I tried to add onto the script other things to make me feel more anxious, as I felt like I wasn’t feeling anxious enough. Instead, I should have stuck to the script, and trusted it to provide the exposure, and the emotional response, whilst I focused purely on how to respond to it (by not responding).
If the script still didn’t work, then I could have changed it later, but I should not have gone off script. Additionally though, just because I wasn’t feeling super anxious, that didn’t mean that the ERP wasn’t working. I compared it previously to weight lifting. You don’t always have to lift the heaviest weights you can possibly manage for the exercise to work. It can help with ERP to prove to yourself that you can cope with the worst your mind can throw at you, in order to show that you can live with your anxiety, but this should be done responsibly, and certainly doesn’t need to be done all the time.
The other major issue I had, was that the methods I used to decide how long the ERP session would last (being either a timer, or a SUDS score), become distractions.
In the case of the timer, I would feel an urge to keep checking how long had gone/was left, which I felt became a compulsion. Sometimes I would do this in order to reassure myself that I was getting through the session and that there wasn’t that much left. I.e. I am 30% of the way through now. Now 50%, I am getting through it. And so on.
At other times though, the doubts were more insidious ones, such as, ‘what if I forgot to set the timer?’, and I would then worry that I could end up keeping going for hours and messing up the timings of the rest of my day and inconveniencing other people for example. This was something that my OCD latched onto in order to distract from the ERP itself, when I should have been focused on the session itself, rather than on the timer.
I did actually do a few sessions where I forced myself not to check, treating this as the anxiety and urge to do compulsions that I was to not respond to. While I feel this did work, and did me some good, I still feel like it was best that afterwards I switched to a different method of dictating the session length, to allow me to focus more on the ERP itself, rather than being on a tangent.
However, as it turned out this was easier said than done. When I switched to just waiting for my SUDS score to halve before ending the session, my mind took advantage of this as well. When I was getting close to the point where I thought that I could finish, my mind would either repeat the script to raise my anxiety and stop the suds from declining enough to end, or cause me to feel a claustrophobic sort of fear, about what would happen if my SUDS score never declined enough, trapping me in the session for hours.
Ultimately when the things that were supposed to help me became distractions and issues, that was a sign that they were no longer fit for purpose. If I were to do an ERP session now then, I would probably just choose to do it for however long I felt like, without these distractions.
In general, I would say that most of the mistakes I made were about getting too caught up in either the processes of ERP, or in worries about whether I was doing it perfectly, when really I would have been better focusing my attention on the ERP itself, and just getting on with it. It is one thing to worry about whether I was being dangerous/irresponsible (which is another reason why I think it is much better to do it with a therapist to guide you), but my worries about whether or not I was doing it effectively seem counter-productive to me.
That is not to say that none of my worries were valid about whether I was doing it right were valid. Some of them probably were. It is just to say that they were often more of a distraction, and any valid worries would be far better considered in-between ERP sessions, rather than during it.
More than that though, I would say that my worries and feelings that I was doing it wrong and it was all hopeless had much more to do with my OCD than about any actual failings in how I was doing the ERP, and I am very glad that I pushed through them and carried on doing the ERP session, in spite of my worries that it was pointless to do it the way I was doing (because it very much wasn’t pointless).
Other problems that may arise:
One dilemma I had was this: when I was feeling low, should I take a day off from doing ERP? Some days I would feel like I just wasn’t in the right state to do it, plus I was concerned about worsening an already low mood, so I did skip it at times. As things went on though, and I began to improve, I started to push myself more, as while I felt feeling dangerously low was a good reason to skip a day, not feeling like it was not a good reason, and ultimately I am not by nature a disciplined person.
I don’t know whether or not this was the right thing to do, and this is very much the sort of thing you should talk to a therapist about, however at the very least the ERP worked for me anyway, even though I didn’t do it every day, at least to begin with.
Another thing I found is that during ERP, some combination of anxiety and my mind being ‘open’ would lead to non-script intrusions, which could both hijack the session (not that big of an issue really, even though it is not ideal), and also cause some real panicky times for me as I was blindsided by some bad thoughts, whilst being in a vulnerable state (this was more of an issue).
These is something to be aware of, and is a big reason why you should try to create as strong a support system as you can during ERP, even if it is just how you support yourself. You should also be aware that if you do feel low when doing ERP, the vulnerable state that you are in is almost certainly the reason why, rather than that the thoughts are more true all of a sudden, or that you are suddenly doing more things wrong.
Finally, for me tiredness was also a big problem, which really affected my ability to focus on the Exposure & Response Prevention itself. I tried things such as using a fan to try to keep me more alert, but I also resorted to pacing during the sessions, which at least kept me more focused. I would say that this is okay, as long as it doesn’t become either a distraction, or a compulsion.
Now that I have covered some of the problems, and issues, I would like to end this article on a more positive note, because after all, doing ERP was hugely beneficial for me, so I certainly wouldn’t want to present it as being all doom and gloom.
So what was my ERP progress timeline like?
Before I begin, I would just like to say that this was my personal timeline. And by this point I had already done multiple therapy sessions to identify things that might prove to be barriers to progress, and to generally lay the groundwork for the ERP itself to begin in earnest. It is also only my personal experience, so if you find that progress isn’t so quick, then that shouldn’t be seen as a sign that progress won’t come with time.
To begin with, doing Exposure & Response Prevention definitely did make me feel worse. By just over a week in, I was having some real low points, not so much due to anxiety, but more down to a general low mood and feelings of despair and hopelessness. This is ironic now, seeing as I now know that I was finally on the right track, but at the time I didn’t have this knowledge, and it was tough.
By about 2 weeks into ERP I was starting to have some moments of giddy optimism. Feelings that things may finally be getting better, and a feeling of possibilities, like the first day of the summer holidays when I was younger. This was intertwined with feelings of loss and painful nostalgia, like I was emerging from a mental deep freeze, becoming aware of what I had missed out on. Overall a largely positive, but still a strange and tricky experience.
However, while in some ways this sudden optimism was a sign of what was to come, it was not a straight line towards progress. A couple of days later for instance, I was back to feeling hopeless. These moments continued, even when it was becoming obvious that I had made substantial progress since starting ERP. I worried that perhaps this progress was just a coincidence.
By about 3 weeks in though, I think the progress was becoming undeniably clear. I was able to think more clearly. To do more things, and generally start to live a life not constantly overshadowed by my thoughts and my anxiety. That is not to say that everything is okay now, as I still have issues I need to work through. But I have made a lot of progress.
I do still have intrusive thoughts, and they do still cause anxiety, albeit usually less so in both respects (especially in their regularity). That is okay though, and I do not see this as being a sign of failure, although I am glad that they are less regular.
What really matters to me though, is that I am now better able to cope with them. I am more able to accept these emotions, and then quickly move on with my life, enabling me to actually be able to live my life, rather than being stuck with these thoughts, going over and over them in my head. I do still respond to these thoughts more often than I should, and perhaps I should do more ERP to reinforce this, but I am in a much better place than I was, and have a much healthier self-image.
