What is Exposure and response prevention?
Exposure and response prevention (ERP) is a recovery strategy for anxiety disorders where the individual is gradually exposed to the feared stimulus, without engaging in the neutralising compulsion. This has been shown to help desensitise them to the fear which gradually lowers their anxiety levels after multiple exposures.
The problem with neutralising compulsions
People with obsessive compulsive disorder (OCD) experience repetitive intrusive thoughts and negative emotions that cause them distress and drive them to engage in coping compulsions in an attempt to keep their anxiety levels down. These coping compulsions, include neutralising rituals or avoidance behaviours.
The problem with neutralising compulsions is that they drain a significant amount of time from a person’s life – in severe cases, this can take up more than 2 hours of someone’s time per day.
Many sufferers of OCD go for long periods of time without leaving their house – this is an example of avoidance behaviour.
The problem with avoidance is that it keeps you trapped in a box of limitations and it stops you from living life to the fullest and doing the things that you care about.
In contrast, ERP teaches individuals to gradually get out of their comfort zone until they can finally break free from these limitations.
How to do ERP in 7 steps:
Step 1: Create a hierarchy of a list of triggers that cause you to experience discomfort and negative emotions (from least triggering to most triggering)
Step 2: Select and start with the least anxiety-provoking trigger
Step 3: Expose yourself to the stimulus
Step 4: Refrain from engaging in the neutralising compulsion
Step 5: Practice accepting and making room for the emotions and discomfort
Step 6: Keep repeating over time until your anxiety has gradually reduced
Step 7: Move on to the second least difficult trigger, repeat the process and slowly move down the hierarchy list
Using a therapist for accountability
I have personally found from first-hand experience that tracking my progress every three weeks with an ERP therapist has been the most accountability strategy. I do this by filling out the questionnaire which tracks my stress and anxiety levels as well as the amount of time I spend engaging in neutralising compulsion. The app NOCD helps measure my progress over time. Gradually my anxiety and stress levels have decreased over time. However, it’s important to point out that a significant part of my journey in recovering from scrupulosity OCD involved changing my beliefs and adopting unconditional acceptance.
Examples of ERP in action
An example of ERP for someone who has contamination OCD would be to purposely not wash their hands and then eat food. Or to set a limit to how long they can wash their hands. For magical thinking OCD, it could be placing an object in an undesired position without engaging in the neutralising compulsion. For moral scrupulosity OCD you could listen to a tape recording of yourself saying “I am bad person” a certain number of times until it no longer causes distress, or deliberately thinking of an intrusive thought.
Why do I need to start with the least anxiety-provoking trigger?
Like any skill, mental health requires you to practice and slowly get better at confronting your fears. It’s easiest to start with the least frightening trigger so that you can practice being able to accept the discomfort and refrain from the neutralising compulsion.
What is the main goal of ERP?
The main goal is to gradually reduce the individual’s anxiety and discomfort when exposed to anxiety-provoking stimuli and to reduce the time that the person spends engaging in compulsions.
Are there any other treatments or therapies that can be used in conjunction with exposure therapy to enhance its effectiveness?
Yes. Other recovery strategies for OCD include CBT, acceptance and commitment therapy, medication and TMS.
Can virtual reality be used in exposure therapy for OCD?
Yes, virtual reality (VR) can be used in exposure therapy for OCD. Virtual reality exposure therapy (VRET) uses virtual environments to simulate real-life situations and scenarios that may trigger obsessive thoughts and compulsive behaviors.
The patient is then exposed to these virtual scenarios in a controlled setting while receiving therapeutic guidance and support. Recent studies have shown that VRET can be effective in treating OCD symptoms. VRET can be done in conjunction with traditional in-vivo exposure therapy as well.