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Obsessive Compulsive Disorder is a relatively common psychological disorders that can range from mild, causing little impairment to a person’s life, all the way through to extreme, where the impacts on a person’s quality of life can be profound. Characteristic of most forms of OCD is DOUBT. Doubting yourself, doubting if you would harm someone (physical, sexually, or otherwise), doubting your own capacity, doubting what you have or haven’t done, doubting your partner, etc.. It has been called the ‘Doubting Disease’.
Just as the severity of OCD symptoms can vary considerably, so too can the content of people’s intrusive and obsessive symptoms.
Below we will talk about what Exposure and Response Prevention looks like. But first, a look at some of the intrusive thoughts that people can struggle with.
Anxiety loves avoidance. If we feel anxious, we quite naturally want to escape from the situation or trigger, which can lead to a temporary reduction in anxiety. The problem, however, is that if I had to escape today to get some relief from my anxiety or to feel safe, then I’ll have to keep escaping if this is the way I’ve chosen to cope with my anxiety. In the long run, avoidance doesn’t work, we’re left constantly running, which is exhausting. The compulsions involved in OCD are often used as strategies to avoid or escape the true fear that has been provoked by intrusive thoughts. These compulsions are aimed at either reducing anxiety or avoiding some sort of feared outcome that I believe might occur.
But there is another way. One of the most widely researched treatments for OCD, and most effective, is Exposure and Response Prevention.
Exposure and Response Prevention (ERP) involves coming to understand how your intrusive thoughts are specifically affecting you, your behaviours and actions, and how you have been responding to them. From here, you begin to unpluck your responses, which may have been occurring for weeks, months, or for many years, and find new ways of responding that begin to break down your OCD, rather than strengthen it. ERP treatment for OCD involves the development of an individualised treatment plan, because just as every person can be different, so too can the presentation of OCD symptoms and a person’s unique intrusive thoughts.
As the name implies, this therapy aims to expose, or have the client confront (in a gradual way) the triggers that have been provoking their anxiety. You may be asking, what, you want me to move towards the very thing that I’m fearful of? Well, if avoiding these triggers was effective and was helping you, then your OCD symptoms would be gone already. But are they? Avoiding difficult experiences tends to make these triggers seem bigger and scarier, it doesn’t make them easier to handle in the long run, and it can result in them lasting for longer.
When ERP therapy commences, a list (or hierarchy) is created with a range of possible targets. These targets may be the things you have been trying to avoid, difficult thoughts, places, actions, people, reminders, etc. Then, the right starting point needs to be chosen. Jumping in too quickly, or too slowly, can lead to poor results, or can even lead to someone abandoning ERP therapy altogether.
The hierarchy that you develop may include objects, people, places, thoughts, memories, doubts, etc. ERP therapy can include both situational (in vivo) and imaginal exposure. Situational exposure involves gradually approaching physical places, objects, people, actions, saying statements aloud, etc., things that can be physical accessed. Imaginal exposure is used to gradually approach things that cannot be accessed in a physical sense, or at least not easily, for example thoughts, ideas, mental images, and memories. Imaginal exposure can also be utilised as a step towards a later situational exposure task.
Some people question how simply imagining something could be helpful. They may think “how could just imagining something help me”. However, it’s also the case that many of our anxieties originate purely in our thoughts, beliefs, and expectations, not in actual events or situations. Think of all the things that you’ve worried about throughout your life, and how many of these events have actually come to fruition. Chances are, the vast majority of these worries never occurred, but that doesn’t stop us from losing sleep, seeking reassurance, getting prepared, and creating solutions to problems that don’t yet even exist. It doesn’t take too long to recognised how key our thoughts are in the creation, and maintenance, of our anxieties.
Exposure therapy needs to be done in a specific way. Approaching feared objects, heightening your anxiety, and then simply leaving the situation would not be considered exposure therapy. This is more like just creating or triggering your anxiety. This can potentially leave you more fearful of the source of your anxiety. Two very important changes occur during ERP treatment: 1) over time your anxiety naturally subsides (this is just the way our bodies react when we stay with the source of our anxiety, psychologists call this habituation), and 2) ERP treatment allows us to test out our beliefs about some sort of feared outcome occurring, which often results in different and more helpful ideas about the source of our fear.
Duration and repetition are key in effective exposure therapy. Exposure and Response Prevention is a form of Cognitive Behavioural Therapy. It has been specifically developed to assist those struggling with OCD symptoms. ERP treatment is also a form of exposure therapy. These sorts of therapies are among the most effective forms of psychotherapy. Often simply gaining a psychological understanding of how your OCD symptoms are affecting you, can provide significant relief. Learning how to think about OCD and its symptoms (becoming your own psychologist) can provide you with a framework and blueprint to better understand and cope with your OCD symptoms.
The Response Prevention part of ERP therapy is equally as important as the exposure component. Response prevention refers to ceasing or resisting the things you might try or do to manage anxiety or prevent a feared outcome. In the most basis sense, response prevention refers to the compulsions that people engage in. If compulsions are used during exposure, then true exposure therapy is not achieved, and truly learning that you are safe and ok without these compulsions, is missed. The compulsions that OCD suffers engage in only serve to increase anxiety and doubt in the long run. So, they must go. The case study below of Julian will help you to understand what ERP therapy looks like in session.
Julian, a 24-year-old man, had intrusive thoughts of harming his parents and pet dog with the knives in his kitchen and other sharp objects in his home. These intrusive thoughts caused him high levels of distress and anxiety. On some days, his anxiety was debilitating, and he was consumed by his intrusive thoughts and compulsive behaviours. Hours each day were being spent on his OCD. He would see a scene play out in his mind of these feared events taking place. In his mind, these scenes were graphic, bloody, and confronting. As a result, he avoided his kitchen, and vowed that he would never set foot in there again. When he had these thoughts, he would go and check on his parent and pet dog, to make sure that they were ok. If television shows came on which included gore or violence, he would turn the television off immediately and leave the room. He demanded that no one else in the home watched these shows either. He sought repeated reassurance from his parents that he was a good person, that he would never harm them, and that he hadn’t ever harmed them, or anyone else, in the past. He left his job due to the interference of his OCD symptoms.
Julian’s psychological treatment for OCD was Exposure and Response Prevention. Julian and his Clinical Psychologist created a list of his intrusive thoughts, avoided events and places, and safety behaviours, and an exposure hierarchy was created. These anxiety provoking triggers were all ranked for the intensity of anxiety that he thought they would cause. Gradually, and as he felt capable and confident, Julian was encouraged to return to the kitchen, cease seeking reassurance from his parents, and to even voluntarily provoke an image of his loved one getting harmed, without engaging in any reassurance or safety seeking behaviours. After all, harmful thoughts are not the same as harmful actions, no matter how confronting they may seem, this is something he learnt from his ERP therapy. Eventually, Julian was back in the kitchen, even when his family and pet dog were nearby or right next to him. He learnt that his thoughts don’t need to be feared, that they don’t lead to behaviours or actions, and that strange and sometimes confronting thoughts happen for everyone. He could again watch movies that included violence, and he returned to work.
Other components of Julian’s psychological treatment for OCD included training in relaxation skills to reduce the physiological tension caused by his intrusive thoughts and associated anxiety. He was provided with psychoeducation about OCD, how it works, how his responses to OCD were prolonging his troubles, and about the mechanisms of psychological treatments and why they are thought to be effective. He was engaged in cognitive therapy to learn to evaluate his perceptions of his intrusive thoughts, and he leant that intrusive thoughts are in fact normal and common, even amongst those who do not have OCD (around 90% of people experience intrusive thoughts, so, practically everyone).
We hope this gives you an insight into what Exposure and Response Prevention for OCD includes and looks like. If you have any other questions about ERP therapy, please be sure to reach out, we’d be happy to be of help.
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