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5 Must Do's in ERP for OCD & Anxiety Exposures

5 Must Do's in ERP for OCD & Anxiety Exposures


Today, I am going to share with you five must do's for ERP, exposure and response prevention therapy. Ted is a client in his fifties who has contamination OCD and about six months following his therapy, he noticed that he had lost most of his progress. Ted's not alone about 40 to 50 percent of people that go through ERP and exposure therapy actually fail therapy, or they lose their progress. So what's happening here? Well, I dove into the research and I changed my methods so that I could be more effective in treating people with ERP and exposure therapy. I want to share with you what you need to do to make sure your therapy is more effective. Hi, I'm Paige Pradko. Welcome to Therapy for a Better Life.

Now you can see that I'm not in my normal office. I am constructing a new office and we are going to put a window in where the ladder is. And Ollie decided to join me in the construction zone today. Doing E R P and exposure therapy is a little bit like construction. You are laying down new neuropathways in your brain and you are rewiring your brain. It is a bit messy, but you can be excited about what's to come.


I am going to help you get the best exposures and ERP as possible. After reviewing research about the old method and the new method, I have shifted methods. I used to follow the habituation model, the emotional processing model, but after reviewing the research of Michelle Craske and Abramowitz and Deacon and, Joseph LeDoux, I have learned that inhibitory learning theory is more effective in treating people with OCD and people needing exposure therapy. I am going to review the highlights with you today.

If you know me, you know that I love to use acronyms when I explain difficult things, and this is no different. I'm using the acronym savvy S. A. V. V. Y. Because you are going to be so savvy with your ERP and exposure therapy. The first letter in savvy is S and that stands for surprise yourself. It's very important with ERP and exposure therapy to constantly surprise your brain. You want to set up new, exciting exposures. You want to challenge yourself. You want to do things that you don't think you can do. You want to continually surprise your brain. There's research that that's how your brain learns the best. In our old model of habituation, we used to do many of the same exposures over and over again. We are not doing that anymore. We are going to be surprising you as much as we can. It's also why we no longer do, cognitive therapy before we do exposure therapy or cognitive restructuring. We no longer do that.

The second letter in savvy is A, and that stands for anxiety tolerance. In the habituation model, we used to track our anxiety and want our anxiety to go down. We thought we were successful once the anxiety went down. Research has shown that tolerating anxiety is not a good indicator of success in ERP and exposure therapy. We are no longer doing that in the ERP.

We all have anxiety and we want your confidence to build at handling anxiety and coping with it at whatever level it is. If anxiety is high the whole time it doesn't have to come down. If it does come down, that's fine. The exposure still works. It even works if you have what people may call a bad exposure that anxiety or discomfort was high the whole time. If your anxiety isn't there at all, it means you may not be challenging yourself or your fear has habituated.

The third letter in savvy is V and this stands for violate expectations. So we think something's going to be very awful and dangerous. We tend to avoid it. But with exposure therapy and ERP, we expose ourself to that trigger or fearful situation or thought, and we stay there. We don't avoid it. We don't do any compulsions. And we find that we get through it. That's called violating your expectation. You thought you wouldn't be able to get through it, but you did get through it. And so that's a mismatch. Now, Deacon's research has shown that the greater that mismatch, the better the learning. So what that means is that the more you challenge yourself, the better the learning. We want to have a big difference between what you expect. "Oh, geez, I don't think I can do it", versus what you actually experience. The bigger that mismatch, the better the outcome.

The fourth letter is another V and this V stands for vary. We want to vary everything. We can vary in exposure therapy. For example, we want to vary the context or the situations and the environment. We want to practice our exposures in as many different places as we can do ERP in as many different situations as you can. For example, if somebody is doing an exposure on driving, I want them to drive during the day, during the night, during high traffic situations, low traffic situations, bad weather, good weather, with people, and without people. I want them to vary it as much as possible. The same with ERP we want to vary those exposures. Now we also want to vary and combine the actual feared triggers, the fear cues. We want to combine those. And for example, if somebody has contamination OCD, I might have them contaminating the whole house. And at the same time, giving themselves fearful thoughts or listening to a script on a recorder.

The last letter in the word savvy is Y and that stands for YOU. I want you to do some tracking of your exposures including what exposure is planned and what actually happens. What do you feel before the exposure? Are you scared? Are you hesitant? Are you worried? What do you feel afterwards? Did you feel like, "oh, I did a pretty good job", or, "oh, maybe that didn't go quite as well as I wanted to", or, "oh, I'm really proud of myself". And what did you learn during the exposure? Did you learn that you could do it? How are you going to change this up next time? So these are questions that consolidate the learning of your ERP and exposure therapy. And there is evidence that if you consolidate this learning, after every exposure, that your exposure outcome will be better and you will learn more. So learning is the key in the inhibitory learning model.

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