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ERP for OCD: A Complete Guide

ERP for OCD: A Complete Guide


Exposure and Response Prevention (ERP) is an evidenced-based treatment for OCD. Hi, I'm Paige Pradko.  Welcome to Therapy for a Better Life. 

Exposure and Response Prevention, ERP is often used when treating OCD. In ERP, we expose ourselves to different triggering obsessive thoughts, images, and situations. We are exposing ourselves to what triggers our anxiety, and we are staying in that exposure. The response prevention part means that we are not completing any compulsive or ritualistic behaviors in an attempt to bring our anxiety down while we are in that exposure and even after that exposure.

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Let me show you two graphs to help you understand what's happening during exposure and response prevention therapy. In this first graph, you can see that on the vertical axis is our level of anxiety. And on the horizontal access is time. And at the bottom here, you can see that this person just had an obsessive thought, or maybe they were triggered in an environment that triggered their fears. And when they had the obsessive thought, their anxiety spiked sky high. And at the top here, they began to do a ritualistic or compulsive behavior.

And after that behavior, then their anxiety dropped. They reinforced their original obsessive thought. The next time they have this thought, their anxiety also goes sky high. Again, they compulse, they reinforce it, and the anxiety drops. Now they are in their OCD pattern or cycle.


What we do in ERP, if you look at this graph, when the person has the obsessive thought, their anxiety goes sky high. Next, we are not going to reinforce that obsessive thought. And instead, we do not do the compulsive behavior, no ritualistic behaviors. And the anxiety drops on its own because it was not reinforced. And the next time we have the obsessive thought, it doesn't go quite as high and after no compulsive ritual behaviors, the anxiety drops. And anytime the obsessive thought happens, because we cannot control our thoughts, the obsessive thought may come, but it doesn't spike our anxiety quite as high. And that anxiety drops on its own. Eventually through enough practice of ERP, we will not get as much anxiety after we have done ERP successfully. And this is how ERP works.


What are the steps in doing ERP? The first thing that you must do is identify your core fear and your fear triggers. What are your triggers? What begins the obsessive thoughts? What is your core fear? Do they involve different situations? Are there avoidance behaviors? What is it that triggers your obsessive thoughts and what triggers the anxiety?


(Note: In this video, I discussed SUD scores and hierarchies. I no longer recommend using those steps and now follow the Inhibitory learning model as I have discussed in more recent videos.)


They're going to stay in that until their anxiety drops. Now, their ritualistic behavior or compulsive behavior was washing their hands. And so they may touch the doorknob, but they are not going to wash their hands before, during or after the exposure. They may up the ante, which I'll explain a little later, but they are going to really put their whole hand on that door up. And eventually they're even going to, after touching the doorknob, they're going to touch their clothing, maybe touch their face, really upping the ante on that exposure. To stay in an exposure for this person would be not washing their hands and not doing the compulsive behavior. And we stay it until they have the feeling that their brain had learned new safety learning. our anxiety drops. By at least 50%. I have people rating their SUD scores at the beginning of every exposure. And then every 10 minutes during the exposure, they're going to give themselves a SUD score until that SUD score drops by 50%.

If touching the doorknob was a SUD score of 80, they're not going to stop their exposure until they have given themselves a SUD score of 40 for most people that take somewhere between 40 to 90 minutes, depending on how difficult the exposure is, whether it's an exposure you've done several times, or whether it's your first one. Now we continue with the exposure. I like people to practice every single day on what their exposure is, and we're going to stay with that exposure until we can't really get any anxiety out of it anymore. The SU score just, you know, just is so low. We just can't really get any anxiety. Even when give ourselves anxious thoughts, then it's time to move up to our next exposure on our hierarchy. Now what about the ones we already completed? I don't like my clients to lose ground.

I have them touching all those things. If they were contamination, OCD clients or if they're checkers, I'm going to have them exposing themselves every single day to those situations. They might not stay in the exposure because there's no anxiety, but I want them to continue to have the exposures in their life so that they do not lose ground and recreate those fears again.


I want to talk about the ways to make ERP more effective. The first thing is, if there's an opportunity for you to work with a trained therapist, of course do that, but I know that there are not always trained specialists in ERP available, and there are different areas that there are not very many mental health providers period. That is one reason why I make these videos to, to share this information.

You must remind yourself why you're doing this. For most, it is to get freedom and peace of mind in their life back again.


The next way to make it more effective is looking at any kind of avoidance or escape behaviors. What are you avoiding? What are you escaping? These avoidance behaviors are also compulsions, and we want to make sure we do exposures on them as well. I like my clients to watch for secondary gains or accommodating behaviors by others. I talked a bit about it in the last video. Secondary gain can be unconscious, or it can be conscious. It includes ways that you might be somehow getting some benefit out of having OCD.  For example, are people doing things for you because you have OCD are you out of work or not going to school or not leaving your home? Are you doing something because you have OCD that your brain might like and benefit from? We must make sure that we are not doing any of these behaviors. If people are helping you because of OCD that they must be aware that this is feeding the OCD cycle and stop. They are part of your ritual. We have to stop that secondary gain because it can reinforce your OCD.


The next item that can help make ERP more effective for some people is certain medications. I want to refer you to your physicians to get information about this. But certain types of SSRI antidepressants can be very helpful. There is also quite a bit of research on an amino acid called NAC. And that seems to help people with OCD and also make ERP more effective. I might do a video on that in the future. Again, I like people to know that benzodiazepines make exposure therapy less effective. You will want to work with your physicians on a plan to reduce your dose in certain cases if you happen to take daily benzodiazepines.


The next are safety behaviors. Safety behaviors are behaviors and things that we are doing that our brain believes in some way is keeping us safe. For example, if we have a medication in our pocket, if we are instead of touching things full on, we are touching with our finger or we're using gloves or things like that. Just to be aware that safety behaviors make ERP less effective.


I want to say one more word about upping the ante. When we are doing an exposure, we recommend allowing the anxiety to be there. If we are doing something to cause ourself to be less anxious, going back to that doorknob example, if the person just touches like this, that might be okay for the very first exposure. But eventually they have to jump all in and up the ante. They have to really touch it.

And then how do they up the ante and make themselves even more anxious? Oh, let me touch my face. Now that's going to make somebody even more anxious. That's how we get an effective exposure is that we up that ante. Our brain has to be as anxious as possible. We want your brain to create a new neuro pathway that touching that doorknob is not dangerous.


Also, relaxation techniques make ERP less effective. We want to make sure we are not doing things like deep breathing and those type of relaxation exercises during the exposure. Again, our brain, our amygdala has to be active, very fearful. Think of “activate to generate”. We need a fearful amygdala to make these exposures more effective.

And the last item, this is, especially for therapists, the reason ERP is not effective many times is because the therapist is not challenging the client enough.


(Note: In this video, I discussed SUD scores and hierarchies. I know longer recommend using those steps and now follow the Inhibitory learning model as I have discussed in more recent videos.)


As a therapist myself, I know sometimes I feel like I am torturing my clients with exposures. We have to encourage exposures to help people. It's part of the process. We must challenge our clients. I want to encourage you to challenge and stay with it. When I'm working with my clients, I am negotiating with them. We are picking out exposures for the next week and we are negotiating, I'm encouraging them. And sometimes they're pushing back. And we come upon an agreement about what the client is willing to do in that next week.


I hope that you learned about ERP today, at least a few more helpful hints. And if you have any questions for me, please go ahead and put them in the comments section. I love hearing from my subscribers. And if you have any suggestions on future videos and what you would like me to talk about, please list those in the comments as well. The next in the series is going to be a video on strategic exposure therapy. It's also used for OCD and different anxiety disorders. And I think you'll find it very interesting. So don't forget to subscribe. Until then I will see you in session.


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