How Does Exposure Response Prevention (ERP/ExRP) for OCD Work?
One of the really frustrating things about living with OCD is that the ways we try to cope with having OCD tend to become the compulsions that make OCD worse. In order words, we struggle to deal with obsessive thoughts that cause anxiety, such as a fear that touching things will make us sick (contamination type OCD), or the uncertainty about whether we might be going to hell (scrupulosity type OCD), or the fear that maybe we hurt someone in the past (harm type OCD). Then we come up with creative ways to deal with the intense fears and uncertainty, like washing our hands after touching something, or saying repeated prayers, or seeking reassurance about our past behavior. But it is exactly those creative ideas that become the compulsions that take up increasing effort and time in our lives, and which edge out more and more of the things that give us pleasure. Also trying to avoid the kinds of experiences that trigger our fears can gradually make our lives smaller. Going to therapy with people who are untrained in working with OCD can also make OCD worse since well-meaning therapists will teach coping skills, offer reassurance, or help analyze and reality-test past experiences using methods like Cognitive Behavioral Therapy (CBT), but those actions can also worsen compulsions or become compulsions themselves.
So what makes ExRP different?
ExRP may initially seem very counterintuitive, but once we understand ExRP it becomes clear why it works so well. Let me start with a useful analogy. Imagine you (like me) can't stand horror movies. I made the mistake of watching the Blair Witch Project when I was a teenager and struggled to sleep for weeks. Then I watched The Ring as an adult thinking I was maybe able to experience horror movies better, but you know what they say about doing the same things and expecting different results. Even Ghostbusters gave me nightmares as a kid. So I avoid watching horror movies. Now even doing things that remind me of horror movies (going into the woods for instance) tend to make me nervous. However, if I wanted to desensitize myself to a horror movies I could set up a project where I watched the Blair Witch Project every day for a couple of weeks. Initially I imagine my anxiety would go up ahead of watching it, and it would be pretty scary. But the likely outcome of watching it daily for a could of weeks is that, by the end of the two week period, I would become bored of watching it. It would no longer provoke anxiety in anticipation, and most of the scenes would no longer scare me that much. Then I could do the same thing with The Ring, and work my way through a few other horror movies. Probably after watching several different kinds, horror movies would no longer scare me that much any more, at least not to the point that I'd need to avoid them.
ExRP works in a similar way. Our brains tend to become anxious in anticipation of something that will trigger our obsessive fear. Let's say we were working with a fear of contamination. If you imagine a 10-point scale that measures anxiety, perhaps we would usually be at a 2 or 3 on the scale, and then if we have to touch something that would trigger some medium level of contamination fear, like touching a table top, it might elevate to a 5, and then afterwards it would go up to a 6 or 7 while we are wondering if we might have exposed ourselves to some kind of serious bacteria, and that may continue until we can wash our hands. However, if we were to touch a table and not wash our hands, and not implement any kind of "coping skill" to deal with the anxiety, but simply watched it on the scale in our minds, we would discover that it would not stay at a 6 or a 7 for very long. After several minutes it would begin to taper down by itself, without any kind of intervention on our part. If we repeated the exercise a few times a day for a couple of weeks, eventually the anticipation of touching the table top and the experience itself would no longer cause the anxiety to taper up - it would become "boring" like watching the horror movie on repeat.
What is happening in our brains is that our brain initially thinks that our obsession (getting sick) will come true unless we resort to the compulsion (washing hands). This causes our anxiety to taper up before we even touch the table in anticipation of our fear. However, our brains cannot generally sustain that level of anxiety endlessly, so if we simply don't do anything then it will generally begin to taper down by itself. When that happens repeatedly for a week or two, our brain learns that it is not necessary to implement the compulsion (hand washing) to make the anxiety come down, so it stops tapering up in the first place. Once that happens we can approach touching things that cause more anxiety (doorknobs / shoes / toilets) and gradually work through increasingly difficult levels of fear until they all begin to taper off.
What we are left with after working through each level of fear is significantly reduced anxiety, and gradual elimination of the impulse to enact a compulsion. The underlying fears will likely still remain to some extent (horror movies will always be at least a little scary), but it no longer becomes necessary to resort to compulsions to deal with them, or avoid actions or thoughts that trigger the fear, since exposure to the fear no longer results in the anxiety tapering up past a point that we can deal with.
The goal is the elimination of the compulsions and avoidance so that we can get back to living our lives without having to avoid the things that caused us fear, or resort to the compulsive behaviors or thoughts that took up so much of our time. Exposure Response Prevention for OCD and phobias is one of the most satisfying kinds of therapy out there since it's relatively short-term and effective.
If you're interested in therapy for OCD or phobias then check out our Exposure Response Prevention program here.
