If you live with OCD, being exposed to your triggers may sound counterintuitive. But research shows that it may actually help — a lot.
People with obsessive compulsive disorder (OCD) may experience two main symptoms: obsessions and compulsions.
Obsessions are significantly distressing and persistent thoughts. Compulsions are repetitive behaviors and rituals that you may engage in to decrease the fear and anxiety these obsessions cause you.
In other words, for many people with OCD, a typical response to fear and anxiety is engaging in compulsions. Because manifesting these distressing thoughts is another common fear, compulsions feel like a way to prevent this from happening.
But what if you could learn to override this anxiety and tolerate your triggers in a new way without engaging in compulsive behaviors?
ERP gradually exposes you to triggers that typically cause you obsessive thoughts. Then, it works with you to prevent a compulsive response to that trigger. That way, you stay in the distressing situation long enough to realize you’re safe even when you don’t follow a ritual.
“By doing this, you learn that the situations that feel unsafe aren’t actually unsafe — you will never do an exposure that is actually unsafe,” says Dr. Suraji Wagage, a licensed clinical psychologist in Los Angeles, California.
In this controlled environment guided by a trained therapist, you’d face situations, images, sounds, and thoughts that typically prompt fear and anxiety. You’d then resist the need to neutralize those fears with a compulsion. Eventually, you could break the cycle of obsessions and compulsions.
Specific goals of ERP will look different for everyone. The main goal is for you to learn how to tolerate the uncertainty around your fears without engaging in compulsions.
“This means that when an OCD trigger comes up, you are able to sit with the ‘maybes’ related to your trigger and then make a choice to not engage in any compulsions,” says Kristel Roper, a licensed marriage and family therapist in Sacramento, California.
ERP therapy isn’t about canceling your distress but about learning how to accept it without following the need to neutralize it.
Another goal, by extension, is to help you live your life in the way that you want to, rather than OCD or anxiety making those decisions for you.
Once you’ve identified your specific triggers, obsessive thoughts, and compulsive behaviors, an ERP therapist will guide you with several techniques. These may include:
This aspect of ERP therapy includes learning about OCD and its symptoms, traditional treatments, research, and other related information.
You’ll also hear more about how the cycle of OCD works, and how ERP can effectively interrupt it.
This technique involves purposely being exposed to triggers in a gradual way.
“For example, if a client has an obsessive fear of getting a severe mosquito-borne illness, we will look at pictures and videos of mosquitos, read about Dengue fever, and practice going outside in the summer with shorts on,” says Grace Dickman, a licensed clinical social worker in Chicago, Illinois.
An important aspect of the obsession-compulsion cycle is the low tolerance to uncertainty.
When you have a distressing thought, you believe this thought may become a reality. You engage in a compulsion to neutralize it and prevent it from becoming real.
You need to engage in the ritual almost immediately because you have a difficult time dealing with the possibility it may become true. This uncertainty is what leads you to act on the thought.
In ERP, you’ll face your fear and then wait, instead of acting on it. Eventually, you may develop the ability to tolerate the uncertainty around your fears or the “maybes” it brings up.
For example, you may have an obsessive thought about your sibling getting hurt. You then move your hands in a specific way as a ritual to decrease the distress.
In ERP, you’d face this same thought but you wouldn’t move your hands right away. With time, you can see that your sibling remains safe even though you don’t engage in the compulsion.
In the future, whenever you have the same thought, you might not have to interrupt what you’re doing to follow a ritual. You’ll be able to tolerate the thought knowing your sibling will be safe.
Tolerating uncertainty is about learning how to say, “Maybe this will happen, maybe it won’t.”
If you find it difficult to face a particular trigger, your therapist may instead use a recorded script. This script will guide you through an imaginary scenario where you’d be exposed to, and face, that fear.
This is the key intervention in ERP therapy.
This technique refers to the intentional practice of refraining from engaging in compulsions or avoidance behaviors when exposed to a trigger.
Delaying the ritual
You’ll start by delaying your responses to triggers. Your therapist will ask you to increase the time between your obsessive thought and the behavior you usually do.
“For example, if a client has to say a prayer after every time they have a thought about harming a child, I would ask the client to wait 30 minutes before saying the prayer,” says Dickman. “This can be a good way to build up to refraining from the compulsion altogether.”
Doing the ritual differently
Besides delaying your responses, a therapist may also ask you to tweak your rituals.
For example, if your compulsion is to disinfect your kitchen, they may have you move things around instead.
That way, you’re acting on a thought, but since it’s not quite the ritual you’re inclined to do, you may find out that your obsessions don’t become true when you don’t do that particular ritual.
When you start therapy, an ERP professional will help you create a list of triggers. This is called a “hierarchy” and your triggers are ranked in order from least to most distressing.
From there, the two of you will work together to help you face your fears gradually, so that the process is not too overwhelming. You’ll go at your pace.
You’ll begin with the least distressing triggers and work your way up from there.
A typical ERP session, in order, may include:
- agreeing on a agenda for that day
- checking in on homework progress, like exposure you did outside of therapy
- discussing your progress since the last session
- talking about any new triggers that have come up
- problem-solving about any challenges during homework
- practicing exposures and rating them on a scale
- debriefing on the exposures and reflecting on what you learned
- discussing homework to do outside of therapy for the following week
Most of your time in session will likely be spent on practicing exposures.
A practical example
Joe lives with OCD. One of the most distressing obsessions he has is the concern that he might hurt his daughter. Joe fears that if he were to pick up a knife to cut up vegetables, he may hurt his daughter with the knife instead. His response to this fear is to repeat a prayer for a while.
“Joe might start with looking at a picture of a knife, then work up to holding a butter knife, then a steak knife. While he does each of these exposures, he will practice resisting the urge to pray that he won’t hurt his daughter,” says Roper.
“Over time, Joe’s brain stops associating knives with danger, as his feared consequence (i.e., hurting his daughter) never actually happens.”
Yes, studies suggest ERP is highly effective in treating OCD.
Research shows that those who live with OCD have something called impaired extinction in the brain, which is an inability to block out obsessive information.
The brain of a person with OCD also has difficulty with safety signaling in the prefrontal cortex, which means that they have a hard time telling the difference between a safe and a threatening stimulus.
While researchers are still trying to dissect how it all ties together, both of these factors appear to be related to the amygdala, the “fire alarm” in your brain that signals the fight, flight, or freeze response.
ERP therapy may work because it overrides an overactive amygdala, especially in conjunction with other CBT techniques.
In fact, some studies suggest ERP effectivity is on par with antidepressant medications.
A 2021 pilot randomized trial of 37 participants also found a significant reduction in OCD symptoms after individual sessions of ERP therapy. Researchers also found metacognitive therapy (MCT) provided the same results.
An older review of 45 studies also concluded that ERP therapy and CBT are the most effective treatments for OCD symptoms
In general, between 50 to 60% of people who complete ERP treatment see an improvement in their OCD symptoms.
ERP and psychotherapy share a few benefits:
- taking time to build a client-therapist rapport
- working at a comfortable pace of treatment
- processing each experience together
Beyond that, they may feel very different to someone with OCD.
Psychotherapy is usually focused on talking about how you feel and how you act.
ERP, on the other hand, is focused on “doing.” It purposely exposes you to an anxiety-triggering environment, so that you can face your fears. Also, homework is routine.
“In many ways, ERP is much more challenging than traditional talk therapy,” says Roper. “The clients that I have worked with who have been willing to engage in ERP and face their greatest fears are some of the bravest people that I know.”
ERP and psychotherapy aren’t mutually exclusive, though. You may use both of them for your treatment and find they provide you with different benefits.
You may find it helpful to use the International OCD Foundation (IOCDF) to find a therapist that’s trained and certified in ERP.
You may also want to find someone who will celebrate your successes with you and instill a sense of hope when the going gets tough, adds Wagage.
“Choose a therapist who is, above all, compassionate and supportive,” she says. “ERP involves doing things that are stressful, frightening, and may seem counterintuitive. You want someone who will explain everything carefully, possibly repeatedly, be understanding and patient, and serve as an encouraging guide.”
ERP is a specific type of cognitive behavioral therapy that’s often used in the treatment of OCD. It involves gradually exposing you to your triggers so that you can learn how to tolerate the anxiety and refrain from compulsions.
If you’re interested in this treatment, a trained ERP therapist can help you face your fears in a safe environment.