How Does Exposure and Response Prevention (ERP) Work? - How OCD Is Treated
Exposure and Response Prevention (ERP) is the gold standard (best results from research studies) for treating Obsessive-Compulsive Disorder. The basics of it are exposure to whatever you are afraid of and removal of safety behaviors that would make that fear lessen. The goal is to get past your fear. How it actually works is a topic of much debate, but we know it works. How you implement ERP is also a topic of much debate and strong opinions, but it works—as long as the feared thought or situation is not avoided and the typical “safety behaviors” a person uses to feel less afraid are not performed.
There is a way to implement ERP that is geared toward habituation—facing the anxiety-provoking thought or situation head-on until you feel less anxious about it. Typically, you think a distressing thought on purpose until your starting anxiety level drops by half. There can be a lot of benefit to this method, and therapy can progress quickly because many people have avoided thinking those thoughts and can disconfirm the idea that thinking that thought on purpose will send them spiraling forever. This is not my preferred approach, but it can be useful in some situations.
According to OCD expert Dr. Jonathan Abramowitz, OCD can improve without habituation. There are at least two other ways to think about why ERP works.
First, there is the inhibitory learning model. Two authors I recommend who support this model are Dr. Sally Winston and Dr. Martin Seif. In this model, someone with OCD learns safety information that basically overrides their fear. For example, someone who is afraid of not checking to see that the stove is off at least five times before leaving the house works with a therapist to check only twice, then once, then not at all. Then they reflect on the fact that no harm has occurred after consistently doing that for many days. They may even get to the point where they forget to think about the stove before leaving the house at all. Habituation may have occurred, but what definitely occurred is some new learning that inhibited the old fear. The groove in their brain that screamed at them to check the stove and caused a lot of anxiety is now less preferred than the groove that says the risk of danger from not checking the stove is simply not worth monitoring. Dr. Abramowitz uses the image of cutting a new pathway for a stream of water—one that must be deeper than the old path—so that the water, or your mind’s automatic response, more naturally flows in this new direction. I use and support this model.
Lastly, there is Dr. Michael J. Greenberg’s Rumination-Focused Exposure and Response Prevention (RF-ERP) approach. I have been trained by Dr. Greenberg, and I find this approach very useful. It is especially helpful for those with Pure O—those who don’t necessarily have behavioral compulsions like hand-washing, confessing, verbal reassurance seeking, etc. Basically, Dr. Greenberg says that rumination—any interaction with the problem in your head—is a compulsion. And what do we know about compulsions? They are the gas that keeps the engine of obsession and anxiety going. He structures his approach to first teach the person with OCD how to stop ruminating, and then do exposures second. The goal is to make treatment more gentle and palatable and to increase client compliance and retention. This approach is about agency. Clients learn that they have much more control over where they direct their mental attention than they realize—and they can often get better rapidly. I’ve also noticed, as Dr. Greenberg mentions, that many clients can go from somewhat better with traditional ERP to significantly better when this approach is mastered. As Dr. Greenberg says, OCD is made up of two parts: avoidance and compulsions. To the degree that we eliminate those two elements, we can eliminate OCD.
With a focus on one of these approaches—or a combination of all three—you can start feeling better. You might even start talking about your struggles with OCD in the past tense. Contact me today to set up an appointment. If you can’t book with me, I’ll be happy to help you find a provider who I think can help you.
