Exposure & Ritual Prevention (ERP)

EXPOSURE & RESPONSE PREVENTION
(ERP)

WHAT IS ERP?

Sometimes called Exposure and Ritual Prevention, ERP is a type of behavioral treatment for OCD and Anxiety. practiced as a part of Cognitive Behavioral Therapy (CBT). ERP involves two components. First, people gradually expose themselves to experiences that provoke anxiety. For instance, someone with Harm OCD might start by saying certain words like “snap” or “stab.” In some cases, people face things they have been avoiding completely. In the example of Harm OCD, someone might start using kitchen knives again. The second step is to prevent compulsions or safety behaviors after doing exposures. This is the response prevention. For the person with Harm OCD, this could involve refraining from seeking reassurance about if they seem capable of harming someone.

WHAT IS ERP HELPFUL FOR?

ERP is the “gold-standard” treatment for OCD. ERP is also a treatment for Generalized Anxiety Disorder, Social Anxiety Disorder, Illness Anxiety Disorder (or Hypochondria), Panic Disorder, Specific Phobias, and Body Dysmorphic Disorder. Treatment varies for each based on the diagnosis. For example, worry exposures are a form of imaginal exposure exercise used to treat Generalized Anxiety Disorder. Interoceptive exposures, or exposures that target physical symptoms, are often used in the treatment of Panic Disorder. 

Many people are nervous about ERP. Please keep in mind that through the therapy process, people typically experience increased willingness to feel anxious. They also learn how to open up to and accept anxiety through Mindfulness and Acceptance & Commitment Therapy. Ultimately, it is always an individual’s decision to do exposures or not, even within the context of this therapeutic approach. An ERP Therapist is respectful of their Client’s experience and will never force a Client to do anything.

HOW DOES ERP FOR OCD AND ANXIETY WORK?

ERP helps in a number of ways. First, when a person avoids triggers or performs compulsions or safety behaviors, they teach themselves that they are in danger, even if they rationally know they are not. For instance, each time a person with OCD checks a lock repeatedly, they teach themselves that there is a high risk that they forgot to close the door. They are training their brains.

More than that, when a persons avoids, they do not learn what happens when they face their fears. Often, the outcome they are afraid of doesn’t come to pass. Even when feared outcomes happen, people generally find that they are able to handle them. For example, if someone has Social Anxiety and a fear of public speaking, they may avoid public speaking. As a result, they never see what happens when they do speak in public and thus remain convinced that they are not capable of handling their stress.

Also, by facing fears without doing safety behaviors or compulsions, people get to experience their ability to tolerate anxiety and distress. Instead of just understanding their ability to feel things theoretically, they have proof of what they can face and survive. They learn to feel their feelings so that their feelings do not limit them. For example, people who are afraid of the symptoms of panic in Panic Disorder learn about their resilience and ability to feel panic symptoms first hand. As a result, their panic is no longer in charge.

WHAT IS THE GOAL OF ERP?

Over time, people tend to become less fearful of triggers. People “habituate,” that is to say they get used to the things that used to cause fear. So the first time that you drop rumination about whether your thoughts are signs of a problem yet to come, you may be deeply afraid. As you continue this practice, however, it usually becomes progressively easier to tolerate the unknown.

That being said, habituation isn’t the goal of ERP. In recent years with the advent of the Inhibitory Learning model, the focus has shifted from habituating to triggers to building distress tolerance. Habituation is a side effect of learning to be unconditionally accepting of thoughts and feelings. When you use ERP to try to get rid of your anxiety, you’re now trying to avoid feelings again which was the problem in the first place. The goal is to be with thoughts, anxiety and uncertainty and to make space for these experiences.

Ultimately ERP is an exercise that builds the response prevention muscle for its use in daily life. Exposures are everywhere. They are the triggers that people regularly face. The key is to help individuals face their triggers without doing the compulsions and safety behaviors that consume their lives.