Obsessive-compulsive disorder is a psychological disorder associated with obsessions (recurrent thoughts, such as about germs) and compulsions (repetitive actions, like cleaning).¹
In previous posts, I discussed the nature of OCD, consequences of obsessions and compulsions, the need for control, potential reasons compulsions appear to work, and why we need compulsions to work. Then, in my last article, I began discussing an effective treatment for OCD called exposure and response prevention (ERP).
Though other interventions (e.g., psychodynamic therapy, antidepressants) are also used in managing obsessive-compulsive disorder, research shows that ERP is one of the most effective treatments for OCD.²
What is exposure and response prevention?
Exposure and response prevention is essentially a behavioral technique (some versions also contain cognitive exercises which help identify thinking errors).
ERP has two components. The first component requires exposure to a feared situation that an individual with, say, germ worries, has been avoiding (e.g., shaking hands with strangers); the second component requires refraining from engaging in compulsive behavior during or after exposure (e.g., washing thoroughly after shaking hands).
Exposure and response prevention in practice
To explain how ERP works in practice, I use the example of a fictional person named Charlie. Charlie is a young man who has germ-related obsessions. He is highly disgust prone. So he often dreads doing anything that might trigger his intense disgust reaction. One such activity is taking out the trash.
His therapist suggests that Charlie begins with some cognitive activities which help identify his cognitive distortions. After a week of completing these exercises, it becomes clear to Charlie that he often commits a cognitive distortion called thought-action fusion.
Common in people with OCD, thought-action fusion refers to the mistaken belief that merely thinking about something increases its occurrence.
For instance, one night as Charlie is carefully taking out the trash, his right hand touches a piece of garbage that is very sticky, and he suddenly thinks he might catch a deadly virus. Something about the thought is so powerful that he engages in a lot of washing afterwards.
By doing cognitive exercises addressing thought-action fusion and other errors, Charlie slowly begins to think differently, learning that intrusive thoughts—as real as they might feel—are only thoughts.
As mentioned earlier, the first behavioral component of ERP is exposure. To do exposure, Charlie first needs to create a hierarchy of his fears (see picture), by ranking a list of relevant situations from least to most anxiety-provoking. Then, he will begin ERP with a situation that provokes moderate levels of anxiety and discomfort.
Key is starting with situations which provoke enough anxiety to engage us emotionally but not so much to make us feel powerless, reinforcing fear and avoidance behaviors. Choosing an activity associated with moderate levels of anxiety increases the likelihood of success, which then teaches us that anxiety can be managed. After completing that step, we feel more confident to move up the ladder and face more difficult challenges.
A few weeks later, Charlie is ready to move up his ladder of fears and touch a garbage can in a public place, like in the mall. As with previous rungs of the ladder, Charlie needs to remain in this anxiety-provoking situation (i.e. keep his hand on the bin) until his intense fear dissipates.
The second major component of ERP is response prevention. Having learned to identify compulsions and avoidance behaviors associated with his germ-related obsessions, Charlie now tries to apply his knowledge to identify and prevent his usual avoidance behaviors during his exposure sessions.
Identifying compulsions can be difficult since some avoidance strategies are very subtle. For instance, while Charlie has his hands on the garbage can, he constantly worries about his back pain. These distractions prevent him from being fully exposed to fearful thoughts and sensations about catching an illness from touching the bin.
If this step is too anxiety-provoking, Charlie may not be able to do without constant distraction and avoidance; if so, he may need to repeat the previous step before trying this again.
The same applies to you and your fears. As we come to the end of this post, I would like you to consider creating a hierarchy of your fears.
Some of you may have obsessions for which real life exposure does not exist. For instance, you may fear accidentally running over an animal while driving. I address how ERP works for these types of obsessions in my next post.
**Please note the information provided is meant only for educational purposes and is not intended to be a substitute for professional medical advice or treatment.
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
2. Strauss, C., Rosten, C., Hayward, M., Lea, L., Forrester, E., Jones, A. M. (2015). Mindfulness-based exposure and response prevention for obsessive compulsive disorder: study protocol for a pilot randomised controlled trial. Trials, 16, 167.