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ERP: One Step At a Time

When I first talk to my clients about ERP (exposure and response prevention), they have a puzzling and incredulous look on their faces. They seem to be thinking:   “You are telling me, I am paying you so you can make me more anxious?  I am here for you to take away my anxiety, not to give me more of it!”

Because I can “read” their mind I explain in detail what ERP means and I will briefly summarize it here:

  1. We clarify the bad reputation ERP has thanks to reality TV shows in which OCD clients are crying, screaming, and on the verge of a full-blown panic attack because they’re being “exposed” to that which they fear the most.
  2. ERP is about helping you “habituate” or get used to that which you fear.  However, it is by NO means like you’ve seen on TV!
  3. Before ERP occurs, several sessions are spent gathering information to “map out” the right treatment according to the type of OCD you are experiencing.  Education is an essential step.  We also determine what “cognitive distortions” (irrational beliefs) you may have.
  4. Once the work in preparation for ERP has been done, together we create the fear hierarchy.
  5. The exposure hierarchy will be done one step at a time.  There may be steps within each step on the “fear ladder.”
  6. We will write up several hierarchies depending on the triggers, avoidances, compulsions and your type of OCD.

How we determine what goes where on the ladder?

For example, if your OCD is fear of contamination and going to hospitals brings your anxiety through the roof, we will rate that exposure as the highest. We’ll get there once you’ve accomplished the exposures in the lower levels.

If touching a table after your spouse left the cell phone there gives you a low level of anxiety, we would place it as one of the first exposures.

You will be given specific instructions as to how to proceed with your exposure assignment throughout the week.  You will also have a chance to do some exposures in the office as well.

Taking small steps and following your therapist’s instructions is essential to succeed.  I am not saying it won’t produce anxiety, because it will.  Otherwise, the “exposure” you are doing is not targeting your fear. So yes, it will bring anxiety, but because we began with the lowest level, you will eventually “habituate” and move up to the next step.

Response Prevention:  As you do the exposures, you are taught the benefit of abstaining from doing the ritual.  This of course is challenging and difficult.  You and your therapist will talk about the guidelines you can follow in order to respond accordingly.

Why go through the trouble of ERP?

It has been found that CBT along with ERP is the preferred treatment for OCD.  OCD is not only a biological disorder it is a “learned” behavior.  You have been avoiding or ritualizing for months if not years and the only way “your OCD brain” will unlearn the “bad habits” is by teaching it to get used to anxiety and accept uncertainty.  Treatment requires that you give it time to practice the skills.  By the way, OCD is already consuming a lot of your time.  It will require a lot of effort (same here).  Yes, it will give you anxiety.  You are already experiencing a great deal of that also. In the long run, by doing CBT and ERP you will be better off than by doing what you are doing now –reinforcing and strengthening OCD with your rituals, avoidances, and compulsions.

What are your thoughts?  Do you agree?

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