I talk a lot about how Exposure and Response Prevention (ERP) Therapy is the frontline treatment for obsessive-compulsive disorder, but haven’t delved much into the actual therapy. For starters, I’m not a therapist, and certainly not an expert on ERP. But I think it’s important for anyone whose life has been touched by OCD to, at the very least, have a basic understanding of this therapy. Maybe the more knowledgeable we are, the less daunting treatment will seem.
The premise behind ERP Therapy is straightforward: face your fears repeatedly, and eventually they will cease to frighten you. Sounds easy (well, at least to those of us without OCD). But as we know, nothing related to obsessive-compulsive disorder is simple, and in fact, treating OCD sufferers with ERP Therapy can be quite complicated. Just as an example, I’d suggest taking a look at this great guest post written by Dr. Seth Gillihan, on mental rituals, OCD, and ERP. His discussion and the ensuing comments demonstrate how important it is to work with an experienced therapist who really understands the complexities of OCD and ERP.
Like OCD, ERP Therapy is often misrepresented by the media and misunderstood by the general public. Reality shows where patients are asked to do things like lick toilet seats (not sure if that really happened but you get my point) do more harm than good. An OCD sufferer who is already apprehensive about beginning treatment will surely stay away after seeing this portrayal.
And so we need accurate, quality information. While this article, written by Tom Corboy, MFT of the OCD Center of Los Angeles, focuses on ERP Therapy for the treatment of Harm OCD, it can easily be applied to the treatment of other types of OCD as well. I love the analogy he uses in the last sentences when explaining ERP Therapy:
The primary behavioral therapy tool used when dealing with Harm OCD is called Exposure and Response Prevention (ERP). While cognitive therapy challenges the content of our intrusive thoughts, and mindfulness addresses our perspective towards those thoughts, ERP directly confronts the behaviors done in response to those thoughts. While mindfulness and cognitive therapy set the table, ERP is the main course. This is where the real work gets done.
I recommend reading the whole article, but also want to share Mr. Corboy’s clarification of some basic ground rules of ERP Therapy:
- We won’t ask you to do anything we wouldn’t do ourselves.
- We won’t ask you to do anything illegal, immoral, or dangerous.
- We will never force you do anything.
Just as we need to spread the word as to what OCD really is and is not, we also need to provide accurate information about Exposure and Response Prevention Therapy. I believe all of you who have already successfully undergone ERP Therapy for OCD are an invaluable resource. Was it different from what you expected? Were there any big surprises? How helpful was it to you? What were some of your best/worst experiences? Demystifying ERP Therapy might be all that is needed to inspire some sufferers to commit to it. And as so many of us know, that can be the beginning of a dramatic change in their lives…for the better.
ocdtalk 
Though it was one of the hardest things I’ve ever had to do, it was also, HANDS DOWN, one of the very best. It was the key that unlocked my prison door.
When my exposure seemed too much for me to handle, my therapist helped me figure out a side-step, and that ended up being enough for me. I’m forever grateful to him.
Thanks for sharing, Jackie. You have a great way of putting things….”the key that unlocked my prison door.” So glad you are free!
Thank you for clarifying that we won’t have to lick toilet seats. I remember when I was trying to face my fears of public toilets, I was afraid that I would have to do something like that. And that’s really not what ERP is about. We don’t have to do things that even people who don’t have OCD wouldn’t do or that could be dangerous to our health. I think the idea that we do scares a lot of people off, as you say in your post. Thanks for bringing these links to our attention.
You’re welcome, Tina. Thanks for your comment….I’m going to reply to your comment below as well too.
BRILLIANT post, Janet. It’s true, my psychologist never forced me to do anything I didn’t want to. She strongly encouraged, coached, pushed, and challenged my cognitive distortions, but all with my permission. ERP was/is difficult for me (and for everyone else too, I’m sure!), but I know it’s essential to my mental health.
I particularly love the quotes you used in your post. They give a clearer picture of what good treatment looks like.
There are times when eating food off a toilet seat may be an ERP (though I’ve never done that!) as part of the treatment for someone with contamination fears, BUT, a patient would slowly progress to that point, only if they were ready and willing. I was never willing to go there, so I never did it. If I had been willing to go there, I suspect I would be much further along in my recovery. But that was a personal choice I made, and as I said, you are not forced to do things you don’t want to.
Sunny and Janet, please help me understand this, because I’ve not had a lot of ERP from a therapist. When would it ever be necessary to eat from a toilet seat? That is not something that anyone would ever need to do to get through life, so why would that be something that someone would need to do to get over a harm contamination fear? To me, it borders on the bizarre. Of course, OCD is bizarre. 🙂
The examples that Corboy gives in his post on ERP seem to have the patient do things that other people do without thinking–hug your children when you’ve been avoiding it, or not washing hands compulsively before preparing food for your children. Those ERPs in his post make sense to me. A person without OCD would think nothing of doing these things. They’re terrifying only to the person with OCD who has the harm issues.
What person, with or without OCD, would want to do a therapy if possibly eating off of a toilet seat was part of it? I would guess that most people without OCD would never think of doing such a thing.
If you’re trying to get over a fear of public bathrooms, or bathrooms in general, wouldn’t it possibly be an effective ERP to just go ahead and use a public bathroom, to not avoid it? Or to not wash your hands compulsively after using the public bathroom? Or to clean the home bathroom once and not allow yourself to rewash it? Those seem much more in line with “normal” living, or living without OCD. At one point in my life, it would have been extremely difficult for me to clean the home bathroom once. I would have had a very, very hard time not giving in to the compulsion of cleaning it again and again, with bottles of cleaner. It would have been a very effective ERP to keep myself from rewashing the bathroom.
Anyway, I’m just a bit confused about what people should expect with ERP.
Thanks for sharing, Sunny, and I think it’s so important for people to realize that exposures are never forced, and the really tough ones are worked up to gradually. I know Tina already commented below on the “toilet seat issue,” and I’d also love to hear from any professionals out there regarding these types of exposures.
Tina, I’m sure a lot of people are wondering the same thing you are, and as I said in my reply to Sunny, I’d like to hear from some ERP Therapists regarding these “over the top” exposures. I am no expert, but from what I’ve read, one of the explanations for needing to do these things that most “normal” people would never attempt is to think of a bendable pole. Those with OCD have bent so far in one direction (fear of contamination, for example) that in order to have the pole stand straight up (which is the balance we want), it is necessary to bend extra far in the opposite direction (eating off a toilet seat). I have no idea how valid this is (experts, help!) but do know plenty of people who have had great success with ERP without doing these types of exposures. I’m guessing a lot depends on the therapist and the OCD sufferer???
Hey Tina and Janet. So, very similar to what Janet said in her comment above – my psychologist once told me that those of us with OCD are so far over on one end, that we need to go really far over the other end so we will sort of “snap” back to a reasonable middle ground. I remember my psychologist once taking me into a public bathroom, sitting on the floor, and rubbing her hands on the floor. I never did do that myself. But, she was showing me there was nothing to be afraid of. Again, a good therapist will never force you, and will never ask you to do something they would not do themselves. I know it seems crazy and outrageous, but I do get it now. Still haven’t done it myself though. Sometimes, I think I might just do something like that someday to go ahead and bury this stinking illness! But it will only be because I chose to do it and felt ready. I really don’t want to scare anyone off from pursuing ERP. I stupidly put ERP off for 13 years because I feared this VERY thing. But I never did end up doing it, and I got significantly better anyway (though again, I think my results would have been even better if I had just jumped in all the way). So I put it off for nothing!!! Ugh. As the patient, you are in the driver’s seat.
Anyway, hope this helps. Sorry to add confusion!
It helps me, Sunny! Thanks! And thanks for letting others know that there is no reason to put off ERP Therapy. The best time to do it is now! And you didn’t add to the confusion, you clarified it!
I’m happy to chime in here. First of all, thanks for another great post, Janet. You do an incredible service providing information that helps people with OCD get the help they need.
I appreciate all the very thoughtful earlier comments in response to this post. In terms of what people should expect with ERP, I think the short answer is “a therapist who’s willing to encourage the person to go as far as necessary in the exposures in order to recover.” The question, of course, is how far is necessary. I’ll be honest here–I’ve never licked a toilet seat, and I’ve never worked with someone in ERP where that was part of the treatment. I’ve done other things that we don’t usually do outside of the therapy setting, like eating food from a napkin that was on the toilet seat. If you’re like most people you’re probably thinking, “Gross!” A little, and probably less gross than stuff we do every day, like touching our mouths after shaking hands with people who may or may not have washed their hands after using the bathroom.
I don’t really think that “what people normally do” is a very good criterion in ERP, for the reasons Janet described. I often use this analogy: We don’t “normally” put chemicals in our bodies that make us violently sick and make our hair fall out. And if we have cancer, there’s a good chance we’ll do exactly that. In the same way, we sometimes ask people in ERP to do things that people don’t tend to do in their daily lives, in the service of helping people get their lives back. Also, it’s actually very normal to do abnormal things when we need to, like picking up feces with our hands (if a child had an accident in the bathtub), or sticking a hand in the toilet (to save a dropped wedding band).
I agree that it seems to be a bit trendy to go for the most extreme exposures possible. And in some cases what’s possible just isn’t necessary.
Finally, it’s good to emphasize what 71& Sunny mentioned about not being forced by her therapist to do things she wasn’t ready to do. Here’s a passage from a document about what to expect in ERP that I made for people I work with: “While your therapist will encourage you to do what you’ve planned, you will not be forced to do anything you’re not willing to do. You can think of your
therapist’s role as being like that of a coach—to help you get the most out of your treatment and to reach the goals you’ve set. A coach can encourage an athlete to do one more repetition while lifting weights, but obviously it won’t be helpful if the coach lifts the weight for the athlete! In the same way, ERP therapy is something that you do—it’s not done ‘to you.'”
Keep up the great work, Janet!
Thanks so much for taking the time to comment so thoroughly, Seth. You always put a fresh spin on things, and it’s great to hear your perspective as a therapist. You certainly clarified the idea of “extreme exposures” for me, and I appreciate all your insights!
Sunny, do you deal with contamination OCD? For some reason I was thinking that wasn’t a problem for you. I would sit on the bathroom floor with you for moral support of you ever decided to do that!
Pinned this. So important to share knowledge. Thank you for all you do. http://pinterest.com/pin/147141112798586616/
Thanks so much for your support, Katherine. I hope you’ve been well.
Thanks, Sunny, for your input. You didn’t add to the confusion. It’s a tough thing to deal with, figuring out what will and will not help with the OCD. It sounds to me like the ERP therapy you did helped you tremendously. I’m sure you did what was best for you at the time, and you are continuing to work on it. I’ve just followed a different path. I wish when therapy was first offered to me many years ago (I don’t remember the name of it, but was a type of cognitive beh therapy–may have been ERP) I had taken the opportunity. But I didn’t, and that can’t be changed. Other things have helped me. The ERP that I have done with and without a therapist has helped too. But it’s still difficult for me to truly know what it’s like because I wasn’t immersed in it. I feel like I understand it a bit better, though, because of your comments and the comments from Janet and Dr. Gilliam. So thank you, everyone! 🙂
@Tina: have you ever thought about going for sort of a “test-run” with ERP, just taking a baby step in that direction? When I first started true stupid intense ERP in January, sometimes I felt like I was driving myself to my own doom to do these exposures. After a while, I started to realize that almost everytime I went to my appointments, I left feeling better overall and healthier when I walked out. Nobody who has OCD wants to do ERP-I mean, think about it…why would you want to drive to see a specialist to PAY to do something that you specifically are hell-bent on avoiding? But, science is science and it works. I am living proof of that progress! 🙂
I’m not sure if this will add insight into what anyone else has said, but I feel like since I’m right in the middle of going through this treatment, it might be helpful to hear another perspective.
If I had to break ERP down into three parts, It would be 1)tools/knowledge/how to healthily deal with situations 2) hierarchy 3) coaching through this. My doctor is one of the leading experts on OCD. In the beginning, I went through all my obsessions and compulsions-basically, telling a complete stranger all this personal information that most of us want to keep hidden. Then, I created a hierarchy of these obsessions. For example, when I first started I couldn’t eat at a restaurant or touch my phone without washing my hands. Touching my phone was easier than eating out, anxiety-wise, so touching my phone WITHOUT washing my hands helped me build up a repertoire of successes and also showed me that I was capable of changing this and attaining more freedom. Once you master the easier obsessions and compulsions, you move on to ones that are more difficult, ideally gaining momentum and confidence along the way. The “coach” (I literally refer to my doctor as ‘Coach’ on my blog) helps you plan exposures (performing the avoided situations) by teaching you the tools to “get through it” and for me, being a moral support, cheerleader, and confidence booster. It’s also helpful to be able to talk to your coach when you have an unexpected “setback”, if you have completed something on the hierarchy that is really difficult or is still bothering you, or if you need to be held accountable (like me). The idea is not so much that doing the exposures will eventually make the anxiety go away, but thinking about it from the perspective of knowing that you can get through it. That’s something that I think about often and helpful to know. Also know that you will be doing the hard-lifting…but having a Coach there truly makes it easier…but it’s the hardest thing I have gone through and the road is a long one, but I AM SO THANKFUL that I chose to go in the ERP direction. My blog is chronicling my ERP if anyone needs specific examples. 🙂
Also, I didn’t mention the most crucial thing! The exposures are what you do to move up the hierarchy. It is an exposure because you do what you have been avoiding, but do not do a compulsion to negate it. The therapy helps you work up this exposure ladder, while you refrain from compulsions and are helped and encouraged by your “Coach”.
Hey C! I love what you’ve added to the conversation. Really good stuff. Yes, I do struggle with contamination. It is my main symptom along with hyper-responsibility/accidental harm/hit-and-run OCD symptoms. I have a smattering of other symptoms, but those are my main struggles. I try to talk about all OCD symptoms on my blog because I know others struggle with all kinds of things, and really, ultimately, we all struggle with the exact same thing when it comes down to it: uncertainty and doubt.
Hi C, Thank so much for all your contributions. How great you are doing ERP Therapy now, and I really appreciate you sharing your insights and knowledge. I look forward to reading more about your journey on your blog!
Can I just say that I truly LOVE these types of exchanges in comments?! A real conversation, with really helpful input by everyone. I learn so much through this. Thanks everyone.
I totally agree, Sunny. I’ve always felt that comments are the best part of blogging! And thanks to you too. Your contributions are always so thought-provoking and helpful.
A shine On Award for all of your hard work! http://wp.me/p2E0IW-cQ
Thank you so much for thinking of me, grannyK! I really appreciate it. I don’t usually participate in the blogging awards for the simple reason I don’t have the time, but you sure made my day!
I don’t always accept either because of the whole time issue, but I always appreciate the thought and I do love to pass on good things to good people!
I’m honored that you consider me “good people.” 🙂 Thanks again!
Janet, I am writing a post about an ERP session we went through with Blake. I’d like to link back to this post. Would that be alright? Thanks, Angie
Hi Angie, I’d be honored to have you link to any of my posts at any time………I look forward to reading what you have to say.
Thank you. 🙂
1. “We won’t ask you to do anything we wouldn’t do ourselves.”
This is so important. I’m a CBT therapist and I have decided that I must always be prepared to match (and sometimes exceed) what I ask patients to do in their ERP.
I licked a boot last week and I’m still standing!
Good for you, Jane! Now that’s what I call an interesting job :). Thanks for sharing!
my son was asked by a very reputable
psychologist on his first experience with treatment
to lick a toilet yes it actually happened 9 years in we cant get him to have treatment
Hi Vincenza, Thank you so much for sharing. I’m so sorry this one bad experience had such a negative effect on your son.It’s a shame. A good therapist would work with him to develop appropriate exposures and not expect too much too soon. I hope your son will agree to treatment in the near future. I’m wishing him and you better days ahead.
I have also had OCD for 26 years, but for about six of those (13 years ago) I was much much better and could do pretty much everything normally. I let it slip back and always thought that I would be able to push myself again to get well but now I am worse than ever and really need professional help.
I also have contamination OCD and have feared ERP due to the reasons given above. When I was well even after having OCD seriously previously, I would use a public bathroom, and use the toilet paper provided, but I still wouldn’t sit down on the seat etc. because I wouldn’t do that if I was normal, just as no one I know in my family would do. This includes putting things on the floor, including myself. I would be happy just to be able to enter a public toilet and use it without issue as of right now I can’t even walk within 15 feet of one.
The issue is, my OCD is so bad right now that the idea of going into a therapist’s office who may have been doing these things with other clients is too much for me as a first step, so what do I do? I would like go to a therapist and work out which steps would be first and as some of my OCD almost feels like PTSD (my fears are often of certain people after certain events) I would also like talking therapy too to see if that can help somewhat, but what do you do when the very thought of this therapist gives me anxiety that is greater than what would normally be expected at the beginning of treatment?
Also, I don’t fear germs or that anything bad will happen from contamination. I just don’t like the idea of having other people’s (certain strangers or people who I have had bad experiences with) bodily fluids on me (urine, sweat, grease etc.).
Hi Rachel, Thanks for sharing your story and I’m sorry things have become so difficult for you. I think your question about how to get over the fear of going into a therapist’s office is a good one. Basically it sounds like you need ERP to do the ERP! I’m not a therapist, and don’t have any great answers, but maybe others will chime in. Perhaps even connecting with a good therapist by phone (or possibly even home visits?) to come up with a plan to eventually make it into the office might be a good idea. Good luck as you move forward and please keep me posted.
Hi, Rachel. What you’re describing is not at all uncommon among people with OCD who want to start treatment. It’s a Catch-22: I need therapy to feel better, and I need to feel better to start the therapy. I’ve never worked with anyone who wasn’t at least a little anxious to start ERP, and many people are quite anxious, so the fear you’re describing doesn’t sound abnormal to me.
So how to get over the hump, when getting better means feeling worse at first? I like Janet’s idea of connecting with a good therapist by phone, or finding one who’s willing to come to a person’s house if necessary. Talking with someone can help the person develop some tools that can help him or her to take the next step. For example, a person might work with the therapist on cognitive strategies that can make treatment more approachable. While I expect there will always be some anxiety about starting good treatment, it doesn’t have to be overwhelming.
An experienced therapist will also evaluate for PTSD to see if that’s an issue that needs to be addressed in therapy, as well.
All the best to you, Rachel.
I have Contamination OCD and its increasing day by day.I wash my hands frequently whenever I feel I touches some germs.Earlier I was a non veg lover.Now I am scared to even touch the eggs.If I want to boil it I do wash my hands some 3/4 times in between the process.
I am scared of Toilet seat germs at home.I wash it with soap water very frequently.Whenever my daughter comes back and goes to toilet..after that I feel like she might have gone to school toilet so when she sits here this would be contaminated.Same thing with my husband too.(This case I get scared of office toilet seat germs that he might carry home ;-().I am scared of bird poops which might be there in my balcony.I dont take my kids for playing in the sand and all.Examples are many.But please somebody help me to get a right way to avoid ocd.
Hi Naj, Thanks for sharing and I’m sorry to hear you have been having such a difficult time. Obsessive-compulsive disorder is treatable. ERP therapy is hard work, but it works, and I hope you can find a competent therapist where you live. You can also get started on your own with some good workbooks. Check out the resource sidebar on my blog, or the resource section of my blog for suggestions. Please do not lose hope as you CAN get better. I wish you all the best as you move forward.
My son is a prisoner to his thoughts. I need help finding a good therapist…desperately. I have often heard that expensive in patient programs are not helpful. Is there a good one that you could recommend?
Hi Susan,
I don’t know where you live but the important thing is to find good exposure and response prevention (ERP) therapy. There are therapists your son could see weekly, there are also more intensive programs, and then there are three residential programs in the US specifically for OCD. I’d advise checking out the IOCDF website for more info or you could email me privately at ocdtalk@yahoo.com if you’d like.
Throwing this out there as someone who went undiagnosed for a long time and only figured out it was OCD when the ERP (which I found online) started to work–the point isn’t just to do the thing you fear; it’s to do it WITHOUT THE NEGATING COMPULSION. I’d been “facing my fears” literally for decades trying to become desensitized to them, and it never worked because I was only triggering myself, not completing the whole “response prevention” half of ERP. I basically became a lot worse for no reason with the best of intentions. So anybody who tries this on their own, keep in mind that it’s not just about facing down your fears. The fears are just the mechanism by which you trigger the compulsion. The whole point is to resist the compulsion, go through the inevitable anxiety, and recognize that, yes, the anxiety is manageable and actually goes away when you stop trying to reassure it into oblivion.
Thank you so much for your comment DC and of course you are right. This post focused on the exposure part of ERP, but I absolutely should have at least mentioned the “response prevention” part of the therapy as well (actually you’ve given me an idea for another post:)). So glad ERP helped you and thanks again for sharing!