Q: What is ERP for OCD and what are exposures?
A: ERP (Exposure with Response Prevention) is the gold standard OCD treatment (Foa, Yadin, & Lichner, 2012). ERP involves gradually exposing yourself to things that you fear (sometimes in person, such as touching public door handles and sometimes in your imagination, where we imagine a feared scenario and outcome). We do this slowly and gradually, and the idea is to build up your tolerance for anxiety and discomfort associated with that thing. In the same way that your body acclimates to a cold pool, your brain acclimates over time to the stimulus, and anxiety and discomfort come down, a process called habituation (Foa & Kozak, 1986). We call the act of doing this completing/ performing an exposure or exposure exercise.
Q: If I do therapy with you, am I going to be forced to do scary things/ exposures that I don’t want to do?
A: No. I practice a compassionate form of exposure therapy, wherein we partner and make decisions about exposures together. While exposure work is at the heart of any effective OCD therapy, there is no reason that it needs to be agonizing or painful. In fact, it shouldn’t be. We never do exposure without your consent, and we go at your pace, choosing targets that you are actually motivated to work on. Too often, exposure work backfires because targets that are too difficult are chosen too soon.
Q: Do you choose what exposures I do?
A: No. I offer many options of the types of exposures we might try. The ultimate choice of which exercises we do is up to you. I’m a firm believer that the client must be driving the process for therapy to be effective. If you imagine doing a particular exposure and are terror-stricken, that’s not the one we choose. If it makes you a bit anxious within a manageable range, and you can imagine having substantial relief at letting a particular compulsion go, that’s the one we pick. We choose treatment targets that you are most motivated to work on.
Q: What do you mean by a “compassionate” form of ERP?
A: Unfortunately, in the past, exposure-based treatments have suffered a high dropout rate. As someone who has undergone exposure therapy myself, I imagine this is due to a lack of collaboration, targets chosen by therapists, and a lack of compassion in the process. I was lucky enough to work with a therapist who I had a really strong relationship with and who worked collaboratively with me. What I mean by compassionate ERP is that exposure exercises are imagined collaboratively but ultimately chosen by the client, and the client’s pace of work is honored. There won’t be any shaming for not being ready- in fact, since reclaiming self-trust is an important aspect of OCD recovery, I believe that a client saying, “no, I’m not quite ready for that,” is evidence of progress. Your treatment, your pace. It’s important that we work just at the edges of your comfort zone, not miles past it.
Q: What does a typical exposure look like?
A: Coming up with exposure exercises is actually quite creative, which is why I enjoy coming up with them with clients. Sometimes it involves slowly moving toward something you’ve feared (touching a doorknob without washing hands or leaving the house and only checking the locks once!). Sometimes we use the imagination to play through a scary scenario, to imagine it without engaging in any reassurance or other rituals to get certainty that it won’t happen. Most importantly, when we begin exposure work, you aren’t doing it alone. My job is to hold the space within which you can approach the edges of your comfort zone, grounded by the presence of a partner in your recovery who is cheering you on.
Resources
- Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. org
- Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press. [1]
