The main idea behind ERP is to gradually expose individuals with OCD to situations, objects, or thoughts that trigger their obsessions while preventing the accompanying compulsive responses. By repeatedly facing these triggers without engaging in their usual rituals or avoidance behaviors, individuals can learn to live with the anxiety and recognize their concerns and fears may not be as likely to occur as it feels. Over time, this leads to a decrease in obsessive thoughts and the need to perform compulsions.
For Obsessive-Compulsive Disorder (OCD), Exposure Therapy is coupled with response prevention, also known as ritual prevention, or just RP. RP is a component of treatment that is particularly important for people who have developed ritualized, repetitive behaviors such as compulsions. The compulsive behavior serves to “undo” or neutralize the anxiety that occurs when faced with an anxiety-provoking situation. Since compulsive behaviors serve to reduce or eliminate anxiety they are inherently rewarding. Therefore, they are easily repeated over and over and often become the primary method of coping with obsessions.
RP is built upon our knowledge of learning theories. According to this principle, when a behavior is no longer rewarded (reinforced) it becomes extinct. This means the behavior gradually fades away. For instance, washing hands after contact with a doorknob serves to “undo,” or negate the anxiety that occurs after touching a doorknob. Response prevention eliminates the rewarding effect of hand washing. As such, compulsive hand washing will gradually become extinct as will ritualistic reassurance-seeking, counting, checking, ordering, and arranging.
ERP works by having the client identify triggers that often initiate the cycle of OCD. The therapist works closely with the individual to identify the specific triggers that provoke their obsessions. Triggers can be external (e.g., touching doorknobs) or internal (e.g., having a forbidden thought).
From that point and together with the therapist, the individual constructs a list of situations or thoughts that cause anxiety. The list is organized from least distressing to most distressing, creating a hierarchy of exposures. This list may also focus on people, places, or things the individual currently avoids that create disruption in life. The person chooses exposure with the therapist to practice in a controlled and supportive environment to provide assistance in deliberately refraining from performing their usual compulsions or avoidance behaviors.
During exposures, individuals are encouraged to resist the urge to engage in both mental and physical compulsive behaviors. This may initially provoke intense anxiety, but with practice, the anxiety diminishes as the person learns that the feared consequences are not as likely to occur as anticipated and furthermore, the individuals learns they can live in a world of possibilities while relying on the probabilities.
As progress is made with one set of triggers, individuals are encouraged to generalize their skills to other situations and thoughts that relate to their other obsessional content. To help with the generalization of skills with OCD, it is discussed that the focus of ERP relies on the “process of OCD” and not the “content of OCD.” After completing ERP treatment, individuals are taught strategies to maintain their progress and prevent relapses. This may involve ongoing practice, coping techniques, and strategies for managing any future increases in anxiety.
ERP is highly effective because it directly challenges the core features of OCD, such as avoidance and ritualistic behaviors. By breaking the cycle of obsessions and compulsions, individuals can gradually regain control over their lives and experience a significant reduction in OCD symptoms.
It’s important to note that formal ERP should be conducted under the guidance of a qualified mental health professional. They can tailor the treatment to individual needs, ensure safety during the exposure process and provide support throughout the therapy journey.
For more information about ERP and OCD-related information, visit the IOCDF website.
Anxiety Specialists of Atlanta is now an Institutional Member of the International OCD Foundation (IOCDF). The mission of the IOCDF is important to us and aligns with our group’s goal of bringing specialized treatment to the OCD community. We hope that the Institutional Member designation will help communities in Georgia and in the over 35 states we serve to get better connected with effective treatment.