ERP and ExRP are kinds of psychotherapy used to treat obsessive-compulsive disorder (OCD). ERP stands for Exposure and Response Prevention. Innovations in this psychotherapy over the past ten years resulted in its being given a new name: Exposure and Ritual Prevention (ExRP). The two therapies are similar, and both build on core behavioral therapy concepts. The purpose of this article is to provide information about what these therapies involve, and how they might be helpful to people suffering from OCD.
OCD is a psychological disorder that has been documented for thousands of years. OCD is characterized by the presence of either obsessions, compulsions, or both. Obsessions can be thought of as intrusive thoughts that cause anxiety. They are difficult to get rid of, despite one’s best efforts. Compulsions are activities, often performed repetitively. We often experience anxiety when we are not able to perform the compulsion.
For several decades after the early psychoanalysts wrote about obsessions (starting in the late nineteenth century), treatment for OCD would typically involve psychoanalysis that strove to root out the unconscious cause for an obsession. More recent thinking in the field conceptualizes obsessions and compulsions a bit differently. Recent research has shown that obsessions and compulsions respond to treatments that do not focus at all on unconscious causes; successful psychotherapeutic treatment will typically focus on developing new ways of responding to the obsessions and compulsions in the here and now, regardless of their cause. While there has been much theorizing and speculating about the origin of obsessions, there has not been a research-supported consensus in the field about what causes OCD. However, therapies like ERP and ExRP have been shown to treat OCD successfully without focusing on the cause, whatever it might be.
When an obsessive thought occurs, feelings of anxiety will usually occur as well. The anxiety is very uncomfortable, and as a result, people with OCD typically engage in an activity that they have found will relieve the anxiety. This can take many forms. For some, a behavior like washing one’s hands will relieve the anxiety. For others, seeking reassurance from a loved one or other source will relieve the anxiety. In the past several years, the internet has become an increasingly popular resource for people with OCD who seek to reassure themselves, and thus lower their level of anxiety. Still others with OCD would love to find something that would relieve their anxiety, but have not been able to. Whatever the strategy used to deal with the increased anxiety, the unpleasant feelings are seen as scary and as something to get rid of, if possible.
Cognitive-behavioral therapies like ExRP try to change one’s reaction to these unpleasant feelings. By doing so, one can experience obsessive thoughts and the need to perform compulsions a bit differently. This kind of change is a difficult one to enact, and takes some hard work. Much of this hard work will come in the form of “exposure” exercises that will be discussed by you and your therapist. Through these exercises, one can gradually learn to tolerate feelings of anxiety better. The OCD sufferer is “exposed” to feelings of anxiety during the exercise, which helps break some unhelpful patterns that have been established. These patterns have often taken shape over several years of OCD.
It is often said that we are creatures of habit. This is certainly true in a brief examination of how OCD can become entrenched in our thoughts and behavior. People suffering from OCD have often developed habitual ways of dealing with feelings of anxiety when they arise. If these habits result in a quick lessening of anxiety, then each time we do it, the habit becomes a bit stronger. This is a basic principle of behavioral psychology called negative reinforcement. Negative reinforcement is when the removal of a negative stimulus follows performance of a certain action, thus making us more likely to perform that action again next time.
Sara (not her real name), a young woman living in New York, experienced anxiety whenever the thought of AIDS came into her mind. She found that she could reduce this anxiety by checking on the internet to confirm that nothing she was doing in her life right now put her at risk for contracting HIV. Sara was rewarded for her internet research with reduced anxiety. While she had found a short-term fix for her anxiety, she found that over time, she had to spend more and more time on the internet. This began to impact her personal life and her work life.
One centrally important aspect of therapy for OCD is exposure. This will take different forms depending on the nature of the obsessions or compulsions. For Sara, the woman described above who had obsessive thoughts around HIV and AIDS, the exposure exercises would address her reaction to those thoughts. If Sara found herself thinking, “what if I got HIV when I was at work yesterday,” then when she was ready, her therapist would probably recommend an exposure exercise addressing her reaction to that thought. Sara might try to “expose” herself to the idea that it is possible that she did, in fact contract HIV at work yesterday. Often, such an exercise will have very little appeal to the person with obsessions about HIV contamination. If one has already invested so much effort in steering clear of the risk of infection, why go out of one’s way to contemplate the possibility of infecting oneself?
The answer to that is that beating OCD involves changing your habits. Sara, from the above example, had gotten herself in the habit of checking on the internet whenever she became anxious that she had become contaminated. If a website could convince her that she was not infected, she would feel at ease once again. With the assistance of her therapist, Sara began doing exposure exercises that involved purposefully refraining from going on the internet when she was anxious about contamination. She exposed herself to the anxiety that accompanied thoughts of HIV infection without responding in her habitual way. When done correctly, this type of exposure exercise has the effect of helping achieve a long-term reduction in obsessions, and in the anxiety they cause. Sometimes these exposure exercises will last only a few minutes, sometimes significantly longer. These exercises are not designed to make you feel better in the short term; they are designed to help you in the long term by helping you build a different relationship with your obsessive thoughts.
Some people with OCD find that they have to do certain things in order to make their anxiety go away. These are called compulsions, or compulsive behaviors. Sometimes these actions are relatively simple, as Sara’s habit of going on the internet to get information about HIV infection. Other examples of compulsions can be even quicker, such as washing one’s hands, or checking to make sure the stove is off before leaving home. However, some compulsive behaviors take a long time. Some compulsive patterns actually involve a series of behaviors. For example, many people with OCD describe taking long showers. They describe having to wash themselves in a particular way, sometimes washing the same area a set number of times. This is an example of something called a ritual, which is a series of compulsive behaviors. It is possible for these rituals to have a significant impact on the life of the person suffering from OCD.
It is this type of ritual referred to in “Exposure and Ritual Prevention.” The example of Sara refraining from checking on the internet discussed above describes one type of “ritual prevention.” Another example can be seen in the example of Robert:
Robert (not his real name) came to see me because he had been arriving later and later to work. This had caused him to be reprimanded by his supervisor on three different occasions, and he was concerned about his job security. Robert had OCD, and was engaging in rituals at home in the morning which made him late for work. In the beginning, he was able to just stop them when he had to leave the house, but eventually he was unable to do even that. His ritual began with trying on every pair of shoes in his closet to see which one felt the best. This was not so time consuming. Eventually, his ritual became more complex and he described needing to try on every shirt, pair of pants, and jacket he owned before he left his NYC apartment. This left Robert feeling exasperated; he knew that it was unnecessary to try on so many different articles of clothing, and was especially frustrated at his felt need to try on jackets even in the summertime, when he wouldn’t wear one anyway.
This example illustrates two important characteristics of rituals. For one, this ritual started out seeming harmless, but eventually became complicated and time-consuming. Secondly, Robert described knowing that his behavior was excessive and unnecessary, but eventually found himself feeling powerless to stop the ritual. This is often the case, and a very frustrating part of OCD. Fortunately there is hope for people suffering with this type of ritual to get some help.
Robert was able to effect lasting change through his work in Exposure and Ritual Prevention. Once he understood how OCD had put him in this situation, and how he could make some changes, he began to use exposure exercises to gradually change his ritualizing. First, he was able to experience the anxiety that came up when he decided to limit his trying on of jackets to three. Through the exercise he began to retrain his autonomic nervous system – he taught himself how to tolerate the unpleasant feelings that accompanied leaving something incomplete. After a while, he was able to skip the jackets altogether, and eventually was able to get dressed in only five minutes’ time. Robert described this process as a challenging one, but one he was ultimately very pleased about.
Can ExRP bring about lasting change?
One advantage of ExRP and other cognitive-behavioral therapies over medication is that you can use the skills you learn in therapy to change how you deal with anxiety and OCD. This is often a long lasting change. While medication is often helpful to reduce symptoms of OCD, many patients report that they are again vulnerable to obsessions and compulsions once they come off their medication. Many of the patients I have seen tell me that they feel better equipped to handle OCD because of therapy, although they often say it remains a challenge after therapy is over. Some describe having few to no symptoms of OCD after ending therapy. Others describe having persistent obsessions and compulsions, although these have a lessened impact on their lives. It is very difficult to predict what kind of an outcome someone will have in therapy. However if someone is willing to learn “new tricks,” and willing to put in the effort required of the exposure exercises, there is every reason to be optimistic about their ability to benefit from therapy.