ERP Therapy – An Analogy

One of the reasons I became an advocate for OCD awareness was to spread the word that Exposure Response Prevention (ERP) Therapy is the therapy of choice for treating Obsessive Compulsive Disorder. Unfortunately, I sometimes come across first-person blogs where OCD sufferers equate this therapy with torture, and therefore refuse to try it. Others feel it may be helpful but are just too afraid to attempt it.

On his blog, Dr. Steven Seay compares ERP Therapy to an exercise program, and using this analogy, really sets the record straight as to what this therapy involves when dealing with a competent therapist:

I often think about ERP as an exercise program for your brain. Why do people exercise? Typically to improve their quality of life in some way — be it related to health, aesthetics, or the way it makes them feel. People don’t take up exercising for no reason at all–it’s always purpose-driven. This is just like ERP. Why would you do it? Because it’s going to enhance your life in some way.

The analogy can be taken a bit further, though.

Exercise is not a singular activity. It’s something that’s often based around targeting a particular muscle group or certain aspect of health. People who want big biceps do different exercises than people who want to lose weight. This is similar to ERP. People who want to be less bothered by unwanted thoughts (e.g., thoughts of hitting someone with your car) do different exposures than someone who is afraid of contracting a deadly disease. The form of the “exercise” reflects a specific therapeutic goal.

Moreover, there are multiple ways to target the same muscle group. People who want to work on their abs might consider crunches, leg lifts, push-ups, etc. In ERP, there is no one exposure that will help you get better. Instead, there is an array of options that might work for you.

There’s also the hierarchical nature of exercise. If you want to get stronger, it’s smart to start with light weights and build up to heavier weights. It would be downright dangerous to attempt a 500lb bench press without proper training. In ERP, going for that “10″ on your hierarchy is ill-advised at the beginning of treatment. Before going there, you need to lay the proper groundwork first. A gradual approach might take more time, but it will get you to the destination without subjecting you to unnecessary injuries.

Finally, the world is full of different types of trainers. Not everyone is a drill sergeant. The best trainers will listen to you, work with you, and try to understand where you’re coming from. They’ll then use their expertise to design an individualized plan for you that is based on your goals, preferences, and perspective. The best therapists I know follow this same approach to treatment.

My position is that if you’re completing an exposure under duress, you’re unlikely to benefit from it. It’s the process of choosing to face your fear (and willingly embracing the uncertainty that comes with it) that really makes the difference.

Thank you, Dr. Seay.  Here’s hoping your words inspire all OCD sufferers to “hit the gym!”

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17 Responses to ERP Therapy – An Analogy

  1. Lolly says:

    Great post, and so true.

  2. douglaslisa says:

    Thank you for the excellent analogy. It really make a lot of sense. You comment, “My position is that if you’re completing an exposure under duress, you’re unlikely to benefit from it. It’s the process of choosing to face your fear (and willingly embracing the uncertainty that comes with it) that really makes the difference. “ is a critically important one. One must wonder what can be done if the sufferer is unwilling, for whatever reason, to take the necessary steps towards an exercise routine.

    • ocdtalk says:

      That last sentence of Dr. Seay’s post really rings true to me also……I wish I had more answers for you and hope you can find someone to help you out soon.

  3. ocd3timesocd3timesocd3times says:

    Great post. I had difficulty with ERP, but for a different reasons then you discuss. My obsessions are not contamination based, so it is it difficult to recreate a scenario which triggers my fears. I always assumed that contamination fears (while they must be awful) are easier to replicate for ERP, because it is easy to create an environment that is dirty.

    My OCD is based on fear that people close to me will be injured. My compulsions revolve around touching objects a set amount of time, counting, and obsessive thoughts. I am sure that the right therapist can help me, but unfortunately I have the preconceived notion that it will not help. For now, I am using Meds, but hopefully I will smarten up in the near future and try it again. Thanks.

    • 71 & Sunny says:

      Hi ocd3times. I am not a mental health provider, just a person who has lived with anxiety for all of my life. I’ve been in CBT using ERP for my OCD for the last 2 1/2 years. I am really improving. I’m sorry you’re struggling so much. I really do believe that ERP can help you. The trick is to ratchet up the anxiety (with the help of a psychologist) and then NOT do whatever it is that relieves the anxiety. Jonathan Grayson, Ph.D., in his excellent book “Freedom From Obsessive-Compulsive Disorder” talks about how to treat these types of obsessions in Chapter 11 titled: Ordering, Symmetry, Counting and Movement: Rituals of Perfection and Magic. I highly recommend this book. Even more so, I very highly recommend you contact the International OC Foundation for a listing of treatment providers in your area that are experienced and knowledgeable in using CBT & ERP to treat OCD. Truly, there IS hope for you. The work is very hard, no doubt, but very worth it. My own experience confirms that. Best wishes.

  4. ocdtalk says:

    Your obsessions and compulsions sound very similar to my son Dan’s OCD, and ERP Therapy literally saved his life. I have no doubt that the right therapist can help you…….now you just have to believe it!

  5. Thanks so much for sharing this! I actually thought a bit more about the analogy and expanded it in a new post. @ocd3times, both you and Sunny are right. ERP can be adapted to pretty much any symptom area…but it can be more complicated when someone’s triggers are internal rather than external. It’s definitely do-able, though. I also second the Grayson recommendation. His book is incredible.

  6. Tina says:

    Some of this echoes what my new therapist told me in our first session. We’re not going to start working on the 10s, but those that cause anxiety at about a 6 or 7 level. And he said sometimes therapists doing ERP are more like drill sergeants.

    I’m not going to be doing ERP, but what I will be doing (CBT as outlined in “Brain Lock”) has some similarities. It’s definitely going to jack up the anxiety, and the emphasis is on refocusing on another activity and NOT doing compulsions to try to relieve the anxiety.

    I think CBT is going to be key, and is probably advisable for most people with OCD. But I don’t think that because I’m not going to be doing ERP that I’m not doing what is best for me now or ever. I don’t think I have to do ERP or I’ll never get better. That is a decision that I will make with my therapist, who is keeping up with the medical literature too.

    Thank you, as always, for keeping us abreast with what is being said out there about OCD. I appreciate it, and I know you are helping a lot of people.

    • ocdtalk says:

      Thanks for commenting, Tina. I think the bottom line is if there is a therapist and therapy out there that can help you, it doesn’t matter what it is called as long as it works for you. And as you said, approaches can always be adjusted as time passes and you and your therapist work together to find the best direction for you to go. I really look forward to keeping up with your progress with CBT!

    • 71 & Sunny says:

      Hey Tina. That’s interesting, because my doc also says to concentrate on stuff that’s like a 6 or 7 on a scale of 10. It’s hard enough that you definitely “feel the burn” as Jane Fonda was in the habit of saying (ok – I totally just dated myself – but I think it’s a good exercise analogy ha ha), but not so hard that you couldn’t go through with it or become too traumatized by it. I say a 6 or 7 is hard enough. Although sometimes life presents a 10 (like my basement) and well, I’ve just gotta deal with it!

      • Tina says:

        Oh, I absolutely will have to deal with the 10s too. This is the way my therapist explained it: we’ll work on the 6 and 7 levels. As they come down, sometimes that can help the 10 levels come down too. And we’ll then work on those.

        I realize some things may remain a 10. I will deal with that when I come to it! 🙂

        Schwartz likens the work done in the CBT as “like having exercise equipment in your head. It makes you strong” (p. 18, “Brain Lock”). I guess I am exercising too!

        Wow, people in CBT therapy work hard! But it will be so worth it. . . .

  7. I read Dr. Seay’s post too and thought it was awesome. The part that I particularly liked was the fact that he points out that ERP is truly a way of life, required in order to stay “recovered”. So often I hear people say that they did ERP and now they are fine. I think there are probably different levels of recovery for people, but in reality, being truly OCD free probably isn’t that realistic for everyone and certianly – in order to obtain this goal – an attitude of regular ERP is required. I like to look at the intense ERP time as training for the rest of our lives.

  8. Jennifer Hedberg says:

    My position is that if you’re completing an exposure under duress, you’re unlikely to benefit from it. It’s the process of choosing to face your fear (and willingly embracing the uncertainty that comes with it) that really makes the difference.

    My daughter is 5 and has OCD. It has been heartbreaking for and me. She is so young that the exposure therapy has been very difficult. She doesn’t want to participate. She can’t ‘willingly embrace’ it because shes only 5 and only knows she hate to touch certain things. She can’t tell us why. Do we continue with this or wait till shes older?

  9. ocdtalk says:

    I’m sorry to hear you and your daughter are going through such a rough time. The good news is she has been diagnosed and has you to help her. Certainly dealing with a child so young presents different challenges in treating OCD. Do you have a therapist who specializes in treating children with OCD? I would recommend contacting the IOCDF for referrals and suggestions. There are also some great children’s books out there about OCD. As difficult as it may be for you to believe this right now, please remember that OCD is definitely treatable, and your daughter has a wonderful life ahead of her. Good luck and please keep me informed.

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