Exposure & Response Prevention – How it works
Before one can understand how ERP works to battle OCD, it is a good idea to understand what is broken when it comes to OCD. With OCD, minor events and situations get blown out of proportion. Thoughts that should be sent to the brain’s trash bin instead get rerouted to the part of the brain that reacts to danger. Warning bells go off and suddenly a thought becomes catastrophic. OCD’ers respond by performing compulsions, which only serve to cement in the mind that something was wrong with the thought — that, in fact, the brain should be reacting strongly to the thoughts. This makes sure that the next time the thought comes up, it will sound the alarm bells even more loudly.
ERP works by changing the way a sufferer reacts to the intrusive thoughts. It is thought that new neural pathways can be created. We can learn how to not react so strongly to certain thoughts. This is done by controlling the one thing about OCD that we can control… compulsions. Every time a compulsion is performed, we reinforce the belief in our minds that there is something catastrophically wrong with the bad thoughts we get. This makes the situation worse. With ERP, we don’t perform compulsions while still having the thoughts, thus teaching ourselves that we can have the thoughts without reacting so badly to them.
Is a spike the same as an exposure?
No. When you get spiked, or triggered, and end up having an intrusive thought, you are usually caught off guard and you end up responding usually the same old way, by performing compulsions. With ERP, you are prepared ahead of time for the thought to come and you are prepared to not perform compulsions. It is a planned thing. You are planning to make the thought happen and you are planning on not performing compulsions.
Set a goal
There are several things you need to do before starting ERP. The first is to set a goal for yourself. This is the overall thing you are going to work toward. For instance, if you have contamination problems, you might set a goal of washing your hands after using the washroom, before eating and when visibly dirty only.
Establish a baseline
The next thing to do is to establish a baseline anxiety level for yourself. People with anxiety disorders are usually pretty good at rating their anxiety, because they are used to feeling it in varying amounts. Think of a scale of 1 to 10, where 1 is totally and completely relaxed and 10 is a full blown panic attack. Now think about what your background anxiety level is, usually. This means, what is your anxiety level normally, when you aren’t dealing with OCD intrusive thoughts and compulsions. This number, between 1 and 10, becomes your baseline. It will be used when you do the next step and when you actually perform ERP.
Let’s just say, for this example, that you decide your baseline is 4.
Establish a hierarchy
The first step here is to write down a list of obsessions you have and/or things that trigger your OCD. Try to be as precise as you can. Don’t write down something general like, I fear things I own are contaminated. Be more specific: 1) Dirt on bottom of shoe, 2) Touching a handrail, 3) Poop on bottom of shoe, 4) Dirt on pants, 5) Contaminated toothbrush.
Next, for each item on your list of obsessions, write down the compulsion you would normally perform. The list might look like:
1) Dirt on bottom of shoe Wash shoes
2) Touching a handrail Wash hands immediately
3) Poop on shoes Throw shoes out
4) Dirt on pants Wash pants immediately
5) Contaminated toothbrush Throw toothbrush out
The next step is to look at each item on your list and rate each item (on that same scale of 1 to 10) as to how much anxiety you feel it would cause you. Your list might look something like this:
Obsession Compulsion Rating
1) Dirt on bottom of shoe Wash shoes 4
2) Touching a handrail Wash hands immediately 5
3) Poop on bottom of shoe Throw shoes out 8
4) Dirt on pants Wash pants immediately 5
5) Contaminated toothbrush Throw toothbrush out 7
The last step is to rewrite your list from least anxiety provoking to most anxiety provoking. So the above list would look like:
Obsession Compulsion Rating
1) Dirt of bottom of shoe Wash shoes 4
2) Touching a handrail Wash hands immediately 5
3) Dirt on pants Throw shoes out 5
4) Contaminated toothbrush Wash pants immediately 7
5) Poop on bottom of shoe Throw toothbrush out 8
You now have a hierarchy of obsessions/triggers, from least anxiety provoking to most anxiety provoking. Now look at your list. Remember when you figured out what your background anxiety level is? If there are any items on you hierarchy that are at that level or lower, cross them off the list. There is no sense doing ERP on obsessions that don’t raise your anxiety level. It won’t work. Those items don’t cause you much of a problem, so work on the higher numbers. We already determined (for this example) that the baseline level is 4, so ‘Dirt on bottom of shoe’ would be crossed off the list because it is also at an anxiety level of 4.
There are several parts to ERP. Some people think exposing themselves to an obsession/trigger is all that is needed. That is not true. All parts need to be completed in order to have a successful ERP session. They are:
1) Expose yourself to an obsession/trigger.
2) Purposefully do not perform compulsions for the duration of the exposure.
3) Allow your anxiety level to rise to its full height then wait for it to return to your baseline level.
One last step before ERP
Get prepared. A normal ERP session will typically take from 30 minutes to several hours. Set aside time for your ERP session when you will not be disturbed.
You are now ready for your ERP session. The lowest item on our hierarchy list from above is ‘Touching a handrail’. The exposure part will involve touching a handrail. Better would be running your hand all over a handrail.
Think about what would normally happen if you touched a handrail. Would you run to wash your hands immediately? Well you’re not going to do that during your ERP session. You are going to purposefully not perform compulsions, like washing your hands.
Touch a handrail for a good length of time. Hopefully your anxiety level will rise to the level you wrote down when you rated that item on the anxiety scale (from 1 to 10). You actually want your anxiety level to rise.
Stop touching the handrail. Now, where you used to wash your hands, you will sit and wait. You will not perform compulsions. You will not wash your hands. You will not sit and ruminate about what could be on your hand. You sit and wait.
How long should you wait? Hopefully you can wait long enough that your anxiety level falls down on its own to your baseline level. With the handrail example, the baseline is 4. After touching the handrail your anxiety rises to a 5. You sit and wait for your anxiety level to fall down to a 4. At that point your exposure is over. You have succeeded!
What if my anxiety level doesn’t drop to the baseline?
If you’re dealing with an obsession/trigger that is not too far up the anxiety scale from your baseline, you can probably wait it out until your anxiety level goes back down to your baseline level. But what if it doesn’t? Does that mean you failed the exposure? Hardly.
Set a time limit for the exposure. Maybe at first you set the time limit to 30 minutes. Over time you extend the time limit by 15 minutes each time until you are waiting a couple of hours. Basically you are giving yourself more and more time to allow for your anxiety level to lower back down to your baseline level.
Repetition is the key
Exposures should be done multiple times. The ultimate goal is to get to a place where exposing yourself to an obsession/trigger doesn’t raise your anxiety level at all. This is where you want to be. To get there you need to repeat an exposure as many times as it takes to get to that place.
With our example above, you would do the handrail exposure repeatedly until you no longer get a rise out of your anxiety. Then it’s time to move on to the next highest item on your list.
You are going to start exposing yourself to the lowest item on your hierarchy first. Then you move to the next lowest item and then the next lowest item. This is on purpose. You don’t start with the most anxiety provoking item because it would simply be too hard. You start on the lower items first, gaining practice and gaining confidence as you proceed higher up the list.
How often should I do exposures?
Exposures can be hard. You need time to recharge between exposures. You set the pace. The faster you do exposures, the faster you can conquer your obsessions. At the same time, do it too frequently and you will not have a big enough break in between. A good frequency would be one ERP session per day.
Watch out for compulsions
The whole point of exposing yourself to that which you fear/obsessions/triggers is that you won’t perform compulsions. You want to teach yourself that your anxiety level will return to normal without performing compulsions.
Watch out for ruminating. It’s the sneaky compulsion that can sneak on in and ruin a good exposure.
Chart your progress
As you do your exposures you should chart your progress so you gauge how you are doing over time. All you need is a piece of paper divided into four columns. For each exposure you do, write down the date of the exposure in the first column. In the second column you write down what your anxiety level was (on a scale of 1 to 10) at the start of the exposure. The third column is for you to record how high your anxiety level went during the exposure. The last column is to record how long it took for your anxiety level to return to a more normal (your baseline) level.
What you should notice after repeated exposures is that your anxiety level rises to a lower and lower level and the length of time it takes for your anxiety level to return to a normal level becomes shorter and shorter. If you’re seeing this, then you’re doing ERP right!