Exposure and Response Prevention (ERP)
Exposure and Response Prevention
Exposure and Response and Prevention (ERP) is typically used alongside another therapeutic modality (e.g., Cognitive Behavioral Therapy or Acceptance and Commitment Therapy) in the treatment of OCD, phobias, anxiety, and eating disorders.
What are Exposures?
Exposures are activities where you will be asked to “expose” yourself to situations, objects, people, places, things, thoughts, or feelings that create urges to avoid and intense feelings of anxiety.
What is Response Prevention?
Response Prevention means that during (and after) the exposure activities, you will be asked not to engage in behaviors that nullify the anxiety or urge to avoid.
*It is important to note that you will not be asked to engage in an ERP activity that you and your brain are not ready to confront or that is inherently dangerous.
How does ERP work?
By slowly exposing yourself to distressing activities and not engaging in avoidance behaviors, you are teaching your brain that that particular activity is not as dangerous as previously believed. In essence, your brain will develop the ability to tolerate these activities. This is called increasing your “distress tolerance.”
Consider this situation:
The purpose of a car alarm system is to let you know that someone is trying to break into your car.
Imagine, you hear your car alarm going off outside of the store. You run to your car, phone in hand ready to call for help, when… you see a pigeon sitting peacefully on your car’s hood and there are no intruders in sight.
Sometimes, our brains can act like this car alarm. It starts sending off panic signals when there is only a mere pigeon. ERP helps to recalibrate your alarm system so that it is not going off for birds.
How do I do ERP?
With the guidance of your therapist, the ERP treatment progresses with a hierarchical approach. Meaning, you will begin with activities that bring about small amounts of anxiety/urges to avoid, and slowly work your way up to more intense levels.
It is typical that by the time you are ready for more high-intensity exposures, the activities themselves will no longer carry the same weight as they once did. This is due to the progress that you and your brain will have made by that point.
Here is a brief example of the process:
A client comes to therapy due to their intense fear of spiders. This fear has led them to avoid doing any outside activity, which has meant that they recently gave up several of their hobbies. Giving up their hobbies has led to them not spending as much time with their friends. Now, in addition to their fear of spiders, they are also feeling lonely and sad.
If this client were to engage in ERP, the first step would NOT be to have them hold a spider! That is way too much, way too soon.
Instead, the client and therapist will first create a list together that includes everything the client avoids or is afraid of as it is related to spiders.
Next, the client will identify their top fear (the fear that would cause the most anxiety/panic). This fear is placed at the very top of the hierarchy and is used as a comparison tool for the other items.
Then, the client and therapist will start to categorize each of the other items as low levels of distress, medium levels of distress, or high levels of distress. This can be tricky but the therapist will have ways to aid the client in sorting out each item.
Once the hierarchy is created, the therapist will help the client identify all the ways they typically nullify their anxiety (e.g., telling self “It will be okay,” washing hands after touching something that a spider may have been on, spraying lots of bug spray, asking someone to clean the area for them, etc.). This list will aid the client in remembering what they will NOT be doing during or after an exposure.
Once ready, the therapist will guide the client through their first exposure checking in with their ratings of discomfort along the way. This may be looking at a toy spider ring that is sitting on the coffee table in front of them for one minute.
(Remember, everyone’s hierarchies will look different. A low-level exposure for you may be someone else’s high level).
Afterward, the client is encouraged to identify their thoughts and feelings while processing their experience.
The therapist and client then create a homework plan for the week. ERP skills must be practiced outside of the therapy room in order for a client to make progress. Worksheets and other tools may be provided to the client to aid them in their homework.
If you have any further questions about ERP or wish to start your ERP journey today, please reach out to us!
Reference
American Psychiatric Association, Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., & Simpson, H. B. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007. Available online at PR_OCD.book (psychiatryonline.org)
International OCD Foundation. (2023). Exposure and Response Prevention. International OCD Foundation | Exposure and Response Prevention (ERP) (iocdf.org)
National Collaborating Centre for Mental Health (UK). (2006) Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society. (NICE Clinical Guidelines, No. 31.) 5, PSYCHOLOGICAL INTERVENTIONS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56465/
Written by Rebecca Athanason, LCSW
Exposure and Response Prevention (ERP) at Austin Anxiety and OCD Specialists
Rebecca Athanason is a licensed clinical social worker at Austin Anxiety and OCD Specialists. She specializes in teletherapy, obsessive-compulsive disorder (OCD), trauma/PTSD, eating disorders, grief-related issues, anxiety disorders, and depression. She enjoys working with teenagers, adults, seniors, couples, and families. If you are interested in learning more about exposure and response prevention (ERP) or if you would like to schedule a therapy appointment with Rebecca please contact us at hello@austinanxiety.com or 512-246-7225.