Before I begin, I would like to link some resources about Exposure & Response Prevention (ERP). The reason for this is because, as I have said before, I am not a medical professional, or anything of the sort, Therefore I think it is best that I link to other sources, as providing guidance on what Exposure & Response Prevention Therapy is, would be beyond my remit, so to speak.
The first link provides some information about what Exposure & Response Prevention is and how it works, while the second goes into what sort of treatment plans are available for OCD (it is UK based but I think some of the information is still helpful for those elsewhere).
- https://manhattancbt.com/what-is-erp-and-what-is-exrp/
- https://www.mind.org.uk/information-support/types-of-mental-health-problems/obsessive-compulsive-disorder-ocd/treatment-for-ocd/
Therefore this article is not a guide on how to do it, and should not be seen as such, or indeed as any form of medical or professional advice. If anything you read here contradicts advice you are given by a medical professional, then you should follow their advice instead of what you see here. For more information, the site’s disclaimer can be found by clicking here.
Instead, I will try to provide a brief outline of what Exposure & Response Prevention is, and why it is important, and then I will start to talk about what I have learnt from the perspective of having done it, including the mistakes I made, which is what I actually do feel more able to talk about.
What is Exposure & Response Prevention?
Exposure & Response Prevention (ERP) is a specialised form of Cognitive Behavioural Therapy (CBT), that is designed to help people with OCD (although it can also be used for some other conditions). Too many acronyms? IDK.
It involves facing your thoughts and emotions, and learning to sit with them for a while, until they start to fade, rather than giving into the urge to perform compulsions to provide comfort, relief or reassurance.
Exposure & Response Prevention is often described as being the gold standard treatment for OCD. While it does sometimes feel (to me at least) like this wording must be part of some script somewhere, there is a very good reason why it is described as such. This is because it is an evidence-based treatment, that has been shown to work for many people with OCD, and is therefore used as a first-line treatment for it. This includes all ‘types’/’subtypes’ of OCD, as they are ultimately all the same condition.
There are varying theories for why Exposure & Response Prevention is so effective, which may lead to slight variations in how it is done. To be honest I don’t really understand the difference between these theories, so it is a good job that I didn’t need to. Whatever the exact reasoning though, what is clear is that it is a highly effective treatment for a lot of people, and I am grateful to be one of them.
It was still important to me though that I had a general understanding of why it worked, as I felt like I needed to see some logic behind it, and to know what it was I was trying to achieve. My understanding is that it is about teaching your mind that you don’t have to respond to these thoughts, and that they are not a threat that need responding to, instead, they can be left to go away on their own.
Why is it important to know about ERP?
Exposure & Response Prevention is important to know about, not only because it’s an effective treatment, but also because many other forms of therapy are not effective for OCD.
Many standard therapy methods, including standard CBT treatments on its own, are generally unhelpful or even counterproductive for OCD. This is because treatments such as standard talking therapies and such like tend to involve analysing thoughts, and reassuring yourself about them, which is the opposite of what you should be doing for OCD.
That is not to say that talking therapy is not helpful for OCD, as it absolutely can be. It is to say is that whatever the method of therapy treatment that is used, it should be a version of it that is specifically tailored for those with OCD, by a therapist who knows and understands OCD, and that brings in treatments such as Exposure & Response Prevention that can help with OCD.
This will almost certainly include Exposure & Response Prevention, although it will often be part of a wider CBT based treatment, and may also be used alongside other types of treatment, such as Acceptance and Commitment Therapy (ACT), for example.
When should you do ERP?
Exposure & Response Prevention is not a treatment that is used in a time of crisis. Instead, it should be done when you are emotionally stable, rather than when you are at your lowest. In part this is because Exposure & Response Prevention can make you feel worse to begin with, so is best done when you are in a better and more stable mental state.
As such, if you are currently at a low point, then your focus should be on stabilising things, to enable you to reach the stage where you are then able to do treatments such as ERP, which can help you start treatments designed to help you recover from your OCD.
I would also highly recommend doing it with the help of a therapist. They can guide you through it, ensure that you are doing it responsibly, and help you to deal with any low-points and set backs should they occur. This can be done on a one to one basis, or as part of a group for a lower cost.
(If you are in the UK, then you can refer yourself to NHS talking therapies, where you can let them know that you are looking for treatment for OCD. For more information you can check out this link. While the link on the site is described as talking for therapy for anxiety and depression, other treatments are available there and you can specify that you are looking for OCD treatment.)
So what does Exposure & Response Prevention actually involve?
In simple terms, Exposure & Response Prevention involves two things. Firstly it involves the deliberate triggering of the OCD thoughts, and the anxiety (and other emotions) that they provoke (Exposure), and then critically, rather than responding with compulsions to make these emotions go away, as is the natural instinct, you are to sit with these emotions until they start to fade away on their own accord (Response Prevention).
Beyond that it can vary. Due to the wide range of ways that OCD can manifest, and the fact that everyone is different, ERP can be applied flexibly, and will be different depending on the nature of the fear, the individual circumstances, and so on.
The exposure can involve a physical act, such as touching something that feels ‘risky’ to touch, but as my OCD is primarily mental, mine involved a script. That is therefore the type of Exposure & Response Prevention that I am familiar with. This script can be written down and then read, or it can be an audio script that you listen to. The script may be repeated throughout the exercise, or it may be read/listened to at the start of the script and then sat with.
I did ERP in quite a few different ways over the weeks, working with my Therapist to find what seemed to work best for me. It may also be the case that different things worked better at varying times, depending on the strength of the fear, or my emotional state at the time.
When I was starting out with an audio script, that I listened to repeatedly on a loop, I found that this was actually serving to distract me, and I wasn’t really connecting with anything. For me, it felt like reading the script, then sitting with it for a while worked better, but that was just my personal view, and like I said, everyone is different.
So that is what I did. I would have a script prepared and written down. I would read it, feel the thoughts and emotions that it may provoked (for me I always did feel at least somewhat anxious, although manageably so), and then I would sit with the thoughts until my SUDS score had roughly halved.
I tried to do this once a day, apart from the days when I really didn’t feel up to it, and I may have been through one cycle or more depending on how I felt and how long it took. And then, I would get on with the rest of my day.
Does it actually work?
The exact effectiveness varies according to different research. This source for instance suggests that between 50-60% of people who complete Exposure & Response Prevention treatment show clinically significant levels of improvement, while I have seen others suggest an even higher level of effectiveness.
For me it did work, although I think this was helped by the fact that my therapist seemed to combine it with other methods. These included elements of ACT, such as practicing acceptance and learning to tolerate uncertainty, practicing self-compassion, seeing myself as being defined by more than just certain events (and whatever may have happened/what that may have meant), and considering what my own values are.
I found these complimentary elements were particularly helpful for the more taboo topics, where acceptance of uncertainty is extremely difficult, and I felt the need to provide myself with a framework to explain to myself why it was okay not to check and not to need to know exactly what did or did not happen and what this meant, so that I wasn’t simply being immoral/selfish.
So yes, Exposure & Response Prevention is effective for many people, but it can also help to combine it with other treatments. And if it doesn’t work, it is good to know that there are other treatment options out there that may work instead.
If you are interested in finding out more on the effectiveness of Exposure & Response Prevention, then this article may be a good place to start. Or if you are interested in looking more into Acceptance and Commitment Therapy, then these links may help.
Does Exposure & Response Prevention require perfection?
Exposure & Response Prevention does not require perfection in order to work. That was certainly the case for me anyway.
The reason why I think it is important to mention this now, is because the process of Exposure & Response Prevention can itself become a target for your OCD. This was definitely my experience. I often felt like I had no idea what I was doing, I felt crippled by doubts, and I felt like I was doing it all wrong, to the point where a large part of me wanted to stop doing it all together, at least until I could work out how to improve my technique.
For me then, it was important that I kept doing it anyway, despite these worries. Instead of allowing myself to get caught up in the trap of having to do it perfectly, or not at all, I pushed through, and despite all my feelings of doubt, the actual fact of the matter was that it worked for me.
I am sure there were indeed plenty of ways in which I was not doing it perfectly. I am sure that some of my doubts were valid. I would frequently lose concentration. I was getting sidetracked by things. Even now, I don’t really feel like I know that much about how to do Exposure & Response Prevention correctly.
And yet despite this, it still worked. It turned out that I didn’t have to do it perfectly for it to work. Doing it, even imperfectly, is better than not doing it at all.
I should also note that my worries were that I was doing it wrong, so as to make it ineffective and pointless. Had I felt like it was dangerous and/or that my mental state was dangerously low/unstable, then that would have been a different matter, and is something I would have wanted to check with my therapist (or another medical professional).
Speaking of which:
Is Exposure & Response Prevention Therapy Dangerous?
Exposure & Response Prevention should not be dangerous. It will almost certainly feel unpleasant, but it should not feel dangerous. If it does, then I would suggest that you might possibly be doing it wrong. This is because the goal is to be able to manage your reaction to the thought/emotions that are provoked, so that you can manage not to respond to your thoughts, even when they are causing you to feel anxiety and uncertainty.
It should therefore be done in such a way so as to be controllable/manageable. It is much better to start off too small and then change things up, than to start off too big and not to be able to manage things. So if things do feel dangerous/out of control, then this suggests that you might be biting off more than you can safely chew. You could compare it to lifting weights. Just as you wouldn’t start off with a massive amount of weight, but would instead do only what you feel confident you can safely manage, the same is true with ERP.
Exposure & Response Prevention is about creating a controlled environment. Another comparison would be to a sparring match in boxing. You can choose when and where you do it, and which thought that you are dealing with. You should make sure you are in a good mental state, and that you have support in place if at all possible, and that you are choosing to trigger a thought that you are confident you can manage.
Compared to the unpredictable thoughts that OCD normally comes up with then in regular life then, it should actually be safer. It always felt safer for me because I knew that the reason why I was having these thoughts was because of the Exposure & Response Prevention exercise I was doing, unlike with regular thoughts, where I feared that having them suggested that there must be some truth to them (which is not the case either as I have previously spoken about).
And again, Exposure & Response Prevention Therapy is a recovery treatment that should be done when you are emotionally stable, rather than when you are at your lowest. Treatment in a crisis is different, and is designed to stabilise you, and get you to a point where you are able to do treatments such as ERP, so if you are currently in a crisis, you should seek other help first, before embarking on ERP.
What risks are there?
There are still risks of course. One thing I found is that my more open mental state, combined with my anxious mood, could open the door to intrusive thoughts that were not in the script, or supposed to be involved at all. These intrusive thoughts should not be engaged with, although obviously this is easier said than done. At least I knew that there was a clear reason for why I was having them, that did not trigger the incorrect fear that having these thoughts suggests that there must be some truth to them.
Additionally, like I said, things will likely feel worse to begin with, which can lead to lower days, and the consequences thereof.
This is why you should do your best to do it responsibly, have support networks in place (such as friends, family, a therapist, plus anything else that you can think of to help) and look after yourself, especially at the beginning, even if that just means being nicer to yourself, or eating something nice. And crucially, again, Exposure & Response Prevention is not a treatment for a time of crisis, but is a recovery treatment that you should only embark on when you are in a more stable place of mind, so that you are better able to whether any setbacks that may occur.
It is also important to understand that it is not a challenge to deal with the most anxiety you can feel, and suffer through it. While it may well be unpleasant, that is not the goal, or the marker of whether or not you are doing it right. It doesn’t have to be an awful experience in order to work. It can also be fine, and still work. This was a mistake that I made when I first started doing it.
Anxiety is not the goal:
When I first started doing Exposure & Response Prevention, with a weak/vague script that I was listening to on repeat, it didn’t really make me feel all that anxious. As a result, I was worried that this meant that I wasn’t doing it properly. I was even went as far as to ‘add’ thoughts on top of the existing audio loop, in order to try and make myself feel as anxious as possible.
This was incorrect. Not only should I not have added to the script, but also the goal isn’t to make yourself feel as anxious as possible. Nor is it a competition, or a race. Anxiety may well be inevitable, but the goal is not to feel as anxious as possible. The goal is to not respond.
Depending on how you understand Exposure & Response Prevention, anxiety could be seen as being a necessary evil for the ERP to work, or as being unnecessary, and nothing more than an unfortunate potential side effect of the thought/action. Either way though, the aim is not to feel as bad as possible, with more anxiety equalling more effectiveness.
The goal is to teach your brain that you do not have to respond to thoughts and/or emotions with compulsions, and that instead you can accept that the thoughts and emotions are there, and then move on with your day. This can be done with low, or even no anxiety or discomfort (with the low/no difference depending on what theory of ERP you believe). Either way though, you certainly don’t have to feel highly anxious at all for it to work.
As such, your focus should not be on making yourself anxious, but on responding to that anxiety. Or rather, teaching yourself how to not respond to it. Any discomfort or anxiety should come purely from the script/action that you have selected, and your focus should be solely on how you react to it, not on trying to feel anxious in the first place.
So when I first did it and was trying to cause myself to feel physically anxious and panicky, this was not what I should have been doing. If Exposure & Response Prevention is like a boxing sparring match, what I was doing was the equivalent of hitting myself because I was worried that my opponent wasn’t providing enough of a challenge. That is to say, neither helpful nor fun.
