Exposure and Response Prevention for OCD

June 24, 2019
Exposure and Response Prevention (ERP) is currently one of the OCD treatments supported by the most empirical evidence. In this article, we'll discuss the therapeutic advantages of this method, as well as its downsides.

Obsessive-compulsive disorder (OCD) is a psychological disorder that involves obsessions (thoughts, images, or impulses) and compulsions. Compulsions are the mental or physical actions that OCD patients carry out in order to neutralize the anxiety that their obsessions provoke and prevent an imagined threat. Exposure and Response Prevention is an effective method for the treatment of OCD.

When Thoughts Are Unhealthy

Everyone experiences obsession at some point or another. As conscious beings, sometimes our minds create absurd, unrealistic, or exaggerated scenarios and ideas. When that happens, most people don’t place any kind of value or importance on those thoughts. They let them pass, and continue on with their day. Most people know that they’re thoughts and nothing more. They know they have nothing or very little to do with reality.

People with OCD aren’t able to reason that way. On the contrary, OCD patients worry a lot about their thoughts and place too much value on them.

These thoughts cause a lot of anxiety. Even if people with OCD are bothered by these thoughts, or don’t identify with them, they still believe them. Consequently, they feel the need to do something that would neutralize their anxiety and prevent the supposed threat that’s on the horizon.

When an OCD patient carries out their compulsion, they feel relief. Their anxiety goes away, and their obsession with it. Consequently, they feel like they “avoided” what could have been a devastating catastrophy. As you can see, in spite of the fact that most OCD patients are quite intelligent, their reasoning process is completely biased.

A woman with OCD biting her nails.

You know that thoughts in and of themselves can’t generate an actual threat. But that’s the thought pattern that exists in OCD patients’ minds and the one they follow to the letter. Consequently, OCD patients become exhausted and hopeless because they’re never truly free of their obsessions.

In light of that, Exposure and Response Prevention (ERP) is perhaps the most successful intervention that experts have come up with for the treatment of OCD.

The Importance of Exposure to Obsessions

In general, exposure tends to be the treatment of choice for disorders that involve high levels of anxious behavior. Anxiety is a normal emotional response that arises when you interpret a fact, situation, or stimulus as threatening and you think that something could compromise your life or the lives of other people. In that sense, anxiety is an ally that helps you face the inherent problems of life.

However, the same anxiety that can be helpful in certain situations ceases to be functional when you’re in a situation that doesn’t present any particular danger. That’s when this kind of anxiety becomes a problem. That’s because it isn’t a response to real things; it’s actually the response to an unrealistic expectation.

When a person has obsessions, they wrongly think that something is going to happen that could either cause harm, is immoral, or reflects a lack of responsibility. These obsessions aren’t real, there’s no evidence to back them up. However, OCD patients can’t get them out of their heads without turning to compulsions.

That’s why it becomes necessary to expose the patient to the stimulus that they believe could cause them harm. That way, they’ll be able to see for themselves that, even without practicing their compulsion, the thing they fear will happen never actually does.

Habituation

The idea of Exposure and Response Prevention is that patients will be able to tolerate, manage, and control their obsessions without their compulsions. They do that through a process called habituation.

ERP means showing patients that nothing will happen if they touch elevator buttons, for example. Through ERP, reality cuts through the expectations again and again, until they eventually stop.

So, if a person with OCD always performs their compulsions, there’s no way to disprove their unrealistic thoughts. That’s because they believe that their compulsion is what keeps bad things from happening. The reality, however, is that their fears don’t come true because they’re irrational.

Exposure and Response Prevention for OCD

Studies demonstrate that ERP is the treatment that has the best results for people with OCD. It works best with patients who carry out obsessive rituals. 

The challenging thing about implementing ERP is that OCD patients are averse to the high levels of anxiety that ERP involves at the beginning. The anxiety is actually a sign that the treatment is working, however, because it means that the patient is exposing themselves and not covering up their anxiety.

It’s absolutely critical to explain to the patient how ERP works so they know how important it is to expose themselves to their fears. They also need to know that their rituals are the reason why their problems don’t go away.

A psychologist writing notes about Exposure and Response Prevention.

To begin, the patient has to run through a hierarchy of anxiety-producing stimuli. The therapist has to be in charge of making the hierarchy because if the patient does it, they might be too easy on themselves. The list has to include things that actually induce anxiety. The patient has to rate the triggers based on the Subjective Units of Distress Scale (SUDS) which ranges from 1 to 100. 

Ideally, the patient will start with things that have an intermediate SUDS score (40-50). The patient’s anxiety has to be reduced by at least 50% in the therapist’s office. If it doesn’t, they move on to the next item. Otherwise, you risk further sensitizing the patient to the stimulus instead of habituating them to it.

The sessions should last as long as possible. Sometimes, the exposure therapy can last 24 hours by modifying certain stimuli in the patient’s home, for example. This is really helpful for the habituation process.

Challenges of Exposure and Response Prevention

ERP is very effective, but it can be difficult for people with OCD to follow through with the treatment. They’re extremely averse to tolerating the anxiety that their obsessions trigger without doing their rituals.

The key is to offer quality psycho-education and to establish a good therapeutic relationship with the patient so that they trust in the treatment. As much as possible, the patient has to commit to the process and do all of the exercises correctly, during and after the session.

It’s also very helpful to work with the patient’s family, significant other, or friends to make sure that they aren’t reinforcing any obsessive-compulsive behaviors. Having a co-therapist that’s close to the patient can help them recover by motivating them to avoid their rituals and do their ERP correctly.

Vallejo, P, M.A. (2016). Manual de Terapia de Conducta. Editorial Dykinson-Psicología. Tomo I y II.