ERP Part 1: What is Exposure and Response Prevention for OCD?

---

Part 1: The Context

Exposure and response prevention treatment (ERP) is a specialized form of therapy and it’s the most well-researched treatment for those experiencing OCD.

Before explaining what ERP is and how it works (which will be reviewed in future posts), it’s helpful to make sure we understand ERP within the context of OCD. To get that started, let’s begin with a review of a central component of OCD: Intrusive thoughts.

Intrusive thoughts are unwanted, usually (but not always) scary or taboo thoughts, about something bad happening. Intrusive thoughts can be about anything: The only limit to our intrusive thoughts is our imagination. Most of us with OCD have our primary “theme areas” which are the sorts of intrusive thoughts that we experience the most (even if we also experience, from time to time, intrusive thoughts in other theme areas).

Common Intrusive Thoughts For Those Of Us With OCD:

Common intrusive thought themes include:

·         Germ contamination (e.g., Are my hands contaminated with a dangerous germ? What if I contract HIV? What if I contract rabies? What if I contact mold? What if I cross-contaminate and spread germs among my belongings or my environment?)

·         Emotional contamination (e.g., Am I going to get stuck with a gross or disgusting contamination feeling? What if I cross-contaminate my belongings or my environment and I then get re-contaminated and get stuck feeling contaminated forever?)

·         Harming others (e.g., What if I lose control and stab someone? What if I lose control and run over a group of pedestrians? What if I strangle my child? What if I sexually assault someone? What if I inexplicably yell a racial slur?)

·         Harming self (e.g., What if I somehow hurt myself? What if I inexplicably try to kill myself? What if I randomly jump off a building or into traffic?)

·         “Just right” (e.g., What if I get stuck with a thought or a feeling that gets in the way of me living my life unless I have a “just right” feeling after completing a behavior?)

·         Hit-and-run (e.g., What if I ran over a pedestrian without realizing it?)

·         Memory (e.g., What if I did something terrible and I don’t remember it?)

·         Scrupulosity (e.g., What if I somehow displease God? What if I’m a terrible person? What if I’m a sinner? What if I am somehow worshiping the devil? What if I go to hell?)

·         Relationship (e.g., What if I’m not with the right partner? What if I don’t love my partner? What if I somehow cheated on my partner or am being dishonest in some way?)

·         Sexual orientation (e.g., What if I’m gay and I don’t realize it? What if I’m straight and I don’t realize it? What if I’m bisexual and I don’t realize it?)

·         Pedophilia (e.g., What if I’m a pedophile? What if I sexually assault a child?)

·         Sensorimotor (e.g., What if I can’t stop noticing my breathing? What if I can’t stop noticing my swallowing? What if I can’t stop noticing my heartbeat? What if I can’t stop noticing my “eye floaters”?)

What Usually Happens When Those Of Us With OCD Have An Intrusive Thought?

When we experience intrusive thoughts, we believe we might be in danger and begin to feel anxious. We can feel anxious even if one part of us “knows” that the chance of us actually being in danger is very low (more on the difference between “very low” and “zero” risk in this post). Because we feel afraid and want to feel safe again (including making the intrusive thought go away), we are highly motivated to complete a behavior that helps us feel better. This behavior is usually our compulsion. Sometimes compulsions are physical actions, like washing your hands or checking your stove. Other times, the compulsions are mental actions, like memory-checking, analyzing, worrying, ruminating, counting, saying specific phrases, etc.

To make the relationship between intrusive thoughts and compulsions more clear, let’s review two examples.

Example 1: Eric’s Intrusive Thoughts About Contamination

Eric’s primary intrusive thought theme area is emotional contamination. Eric’s not overly concerned about germs. Instead, he’s concerned that he will get stuck with a “gross” or “not just right” feeling if he thinks he might be contaminated by something sticky, wet, greasy, or sometimes for no reason at all. This gross or not just right feeling is distracting and painful and gets in the way of him doing other things (activities he enjoys, spending time with family and friends, sleeping, etc).

Furthermore, if Eric has a contamination experience, he becomes very scared about cross-contaminating other objects in his environment. He’s concerned about cross-contaminating other objects in his environment because he’s predicting that, if he cross-contaminates, he might later touch the cross-contaminated object and then have another distracting and painful contamination experience (as well as threatening even more cross-contamination).

As a result, if Eric touches something he believes is contaminated (or even has a contamination thought “for no reason” or because he “just felt contaminated”), he will have the thoughts “My hands might be contaminated” and “I might cross-contaminate”. When he has the thoughts, he feels uncomfortable and anxious (sometimes severely so). So, he’s highly motivated to wash his hands to get rid of the current distracting thoughts and painful feelings as well as protecting him against cross-contamination which might cause future distressful contamination experiences.

In the past, Eric has washed his hands but then not “felt” like he actually decontaminated. As a result, he takes longer and longer washing periods to get the clean, decontaminated, “just right” feeling he needs to feel safe.

Frequently, Eric finds a lot of relief when he finally gets a good wash in. But the intrusive thoughts and the related painful, anxious feelings always come back. As a result, Eric spends more and more time washing, being careful about contamination, and trying to protect himself as much as possible from future contamination experiences.

Example 2: Jessica’s Intrusive Thoughts About Her Front Door

Jessica’s primary intrusive thought theme area is that she’s left the front door to her house unlocked. After completing her nightly ritual, which includes unlocking and locking the front door 20 times while repeating out loud “Locked. Locked. Locked. The front door is locked. I’m now locking the front door”, she begins to walk to her bedroom to go to sleep.

Unfortunately, while on her way to her bedroom, she has the thought “I think I just completed my locking ritual, but what if what I’m remembering was my locking ritual from last night and I actually forgot to check the door tonight. This might mean that the door is unlocked. If the door is unlocked, someone might come in and terrible things might happen.” These intrusive thoughts activate anxious feelings. These anxious feelings motivate Jessica to do something to make the thoughts and feelings go away. And I bet you can guess what Jessica does: She goes back to the front door and completes the locking ritual again.

Sometimes these rituals might take hours for Jessica to complete. One part of Jessica “knows” what she’s doing seems “crazy”. But that “knowledge” doesn’t make the thoughts or feelings go away. So, Jessica completes her compulsion. The compulsions are not fun and are often quite time-consuming. But, at least some of the time, they make the thoughts and feelings go away. Unfortunately, the thoughts and anxious feelings always come back the next night. As a result, Jessica begins to dread bedtime because she confidently expects she’s going to have many intrusive thoughts, lots of anxiety, and have to participate in lengthy and frustrating rituals.

The Endless Cycle Of OCD:

What these two examples show is that most of us with OCD do, momentarily, feel better after completing our compulsions. Unfortunately, the intrusive thoughts and anxious feelings come back again later (and sometimes not very much later at all). Each time the intrusive thoughts and anxious feelings return, we again complete our compulsions. We get momentary relief. But then the next intrusive thought comes. And the cycle continues.

Part of us knows the compulsions are “crazy” or “irrational” but, if we don’t complete the compulsion, we can’t get the thought out of our mind, feel so scared, and are worried something terrible might happen. And so, even if this cycle is “crazy” to others, we continue participating in the repetitive pattern of intrusive thoughts, anxious feelings, temporary relief via a compulsion, followed by another round of intrusive thoughts and so on. 

It's this trapped cycle that ERP helps us overcome.

ERP helps us have far less intrusive thoughts and, when those intrusive thoughts do arise, to feel far less anxious. This results in far less compulsions. The end goal of ERP is to help us feel safe so that we can get out of our heads and back into more freely living our lives.

In part two (which you can access here), we’ll review some of the preliminary steps before actually beginning ERP, including identifying core values and the willingness to take calculated risks.