ERP Therapy and Increased Anxiety

by artur84

by artur84

When my son Dan was first diagnosed with obsessive-compulsive disorder, he, like so many others, did not receive proper treatment. Wrong therapy, wrong drugs. His OCD spiraled out of control and less than a year later it was so severe he could not even eat.

So when he entered a top OCD residential treatment program, my husband and I finally breathed a sigh of relief. Dan was on his way!Β  The therapy used in this program was exposure and response prevention (ERP), the recommended psychological treatment for OCD.

By all accounts from his social worker, Dan settled in quickly at the program and was already working hard: facing his fears (exposures) and refraining from engaging in his compulsions (response prevention). And from what we were told, he was making good progress.

We were so pleased and excited! We couldn’t wait to see Dan and almost ran into the clinic for our first weekly meeting. How wonderful it would be to see him not so tormented by this horrible disorder!

Well, what we found was not what we imagined. Dan had lost more weight and had black circles under his eyes. He was noticeably nervous, anxious, and jittery, and appeared to be in even worse condition than when he first entered the program.

What went wrong?

Actually, nothing.

What my husband and I didn’t realize at the time is that ERP therapy, by its very nature, raises anxiety. Our son was being asked not only to face his greatest fears, but to refrain from engaging in the thoughts or actions that he believed (at least on some level) kept him, or those he cared about, safe.

Let’s take an example. A common obsession in OCD is worrying about the possibility of hitting someone while driving. Maybe a person with this obsession might avoid driving, but if he has to drive, he makes sure to go back and check every time he thinks he might possibly have hit someone. This compulsion temporarily reduces our friend’s anxiety, but actually strengthens his OCD.

Enter ERP. Now he not only has to face his fear of driving, he has to force himself not to turn the car around to make sure he hasn’t hit anyone. This causes a spike in anxiety, which is actually an integral part of ERP therapy. While the anxiety will be intense, it always resolves at some point. It might take a long time at first, but each time this person drives without checking, the anxiety will typically take a little less time to dissipate until finally, the person with OCD is no longer tormented by this obsession. He has learned to live with the uncertainty of the situation.

Back to Dan. So while we didn’t know it at the time, my husband and I should have been happy to see him so anxious. As he himself told us, “I feel horrible, but that’s good.” That meant he was truly immersing himself in his ERP therapy, and it was working. It’s a tough battle, but as I’ve said many times before, I’ve never met anyone who has regretted doing ERP therapy. The only regret is not having done it sooner.

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33 Responses to ERP Therapy and Increased Anxiety

  1. Thank you for explaining this crucial point, Janet. It can be frightening to the OCD sufferer and those who love them when they consider or experience an increase in anxiety. You’ve explained why this is actually an important part of getting better. ERP helps those with OCD learn to tolerate anxiety rather than avoid it – and that makes all the difference in the quality of life. πŸ™‚

    • Thanks for your comment, Angie. When Dan entered the residential program, I believe we were told things such as “He’ll get worse before he gets better,” but nobody ever explained “how much worse,” why this was necessary, and how it would manifest. More information and education would have been helpful. Thanks for your expertise!

  2. Anne says:

    Hi Janet,
    I have a question about the IOCD conference. Do you think this is a useful conference for parents to attend? I am thinking of going this year but want to feel confident that it will be worthwhile for me to make the trip. Any thoughts? As always, thanks for all you do. You have made a big difference in my life and in that of my daughter. Anne

    • Hi Anne, Thanks for your kind words! My own personal opinion about the IOCDF conference is that is it definitely worthwhile for parents to attend, and maybe even more worthwhile for children, teens, and adults who have OCD to attend. Aside from the great sessions and activities, parents and those with OCD connect with people who truly understand what they are going through. It is like spending a weekend with a wonderful, supportive community who “gets you.” I’m planning on being in Chicago this summer!

  3. Nicole says:

    This is a perfect explanation of ERP! Thank you – I want to do a follow-up to my OCD post, but couldn’t find the right words to really describe ERP. Could I reference your post?

    • Hi Nicole, Glad you liked the post. Feel free to reference any of my posts or articles as long as they’re linked back to my post or attributed to me. Looking forward to reading more of your blog!

  4. Anne says:

    Thanks for your quick response Janet! I am seriously thinking of coming to Chicago too. At this point Eliza (who is now 13) would have absolutely no interest meeting other kids who have OCD, so she would not be joining me (at least this year – maybe in future). I am mostly interested in the sessions, but I think I would enjoy meeting other parents too. Thanks so much for your input. It would be great to meet you in person!

  5. Paul says:

    I would just like to share (having been in ERP therapy for 26 years next month) that describing the the anxiety induced by ERP needs to be worded carefully. The amount of anxiety experienced by the patient no doubt varies greatly as he/she goes through ERP treatment. It depends on how severe the OCD is and on how difficult the particular “exposure” is for the patient. Using phrases like “spike in anxiety,” “increase in anxiety,” and even “intense anxiety” may not adequately convey the struggle involved. For people like myself with severe OCD, Dan’s description: β€œI feel horrible, but that’s good.” hits closer to home.

    I have had very mixed success with ERP because the fear I experience is SO severe that “horror” is actually an appropriate word to use. I often am unable to “prevent the response” to a difficult exposure because I simply cannot tolerate the severity of the anxiety. The anxiety induced by ERP can by TERRIFYING and paralyzing. I say this from experience even when there’s a “weak” 2nd voice inside me that says “OCD is lying to you…all is OK.” (And in my case, that second voice is ALWAYS there, so I feel very guilty when I “fail” an exposure attempt, and that “failure” also
    erodes my self esteem. None of that is healthy for me obviously (feelings of failure, guilt, and lowered self esteem.))

    It’s very difficult to adequately describe the level of anxiety an OCD sufferer feels when practicing a very challenging ERP to someone without OCD.

    I would suggest imagining the following: Think about what it would be like to: Have a terrible fear of high places and attempting to FORCE yourself to go bungee jumping or sky diving. THAT is how hard it can be for the OCD patient to “feel the fear and do it anyway.”

    When practicing ERP, I have tried literally hundreds of “self talk” phrases to help myself succeed. A couple of my current favorites are: “OCD is lying to you,” and “the fear ALWAYS goes away.” I like these because they apply to any type of exposure.

    I apologize for rambling. I’m simply trying to convey that ERP can be VERY VERY hard to succeed at. However, ERP IS THE WAY OUT (of OCD). Personally, I will never quit using ERP to the best of my ability.

    • Thank you so much for sharing Paul, and I appreciate your honesty. As someone who doesn’t have OCD, I know I can never really understand how it feels, though I certainly know the fear is real – and I can relate to the feeling of being forced to sky dive (something I would NEVER choose to do).
      I guess what I keep coming back to, again as someone without OCD, is that those with severe OCD are suffering terribly anyway, so why not “suffer” some more if you can in the form of ERP therapy which at least has a payback. I know it’s not easy and I applaud you for not quitting. I’m always rooting for you!

      • Thank you for your reply Janet. Your comment: “…so why not suffer some more if you can in the form of ERP therapy which at least has a payback.” is an EXCELLENT point. I agree with you 110% and I believe that statement may very well help me to tolerate more anxiety during ERP therapy. Thank you (as always!) for sharing your wisdom! – Paul

      • Glad you found it helpful, Paul!

    • I am new to this blog and devouring all it has. My child is in a serious relationship with one with severe OCD. I adore this boy but will be the first to admit it comes with knowing this will be a great uphill battle forever if it is the choice she makes. I want to support her in this either way, fully and committed. But as I am not the parent, so being new and thrust into this with limited knowledge makes it challenging, thus needing to find and educate myself as much as I can. He has gone to top treatment centers for stays for ERP but they report they seem to be the one that doesn’t habituate to the response. I see how difficult it is for him. I see the fear and terror he feels with his triggers. My daughter actually went for a short time to the center as his ” support coach” but he had to cut his stay short for family reasons. I have been reading all I can find. So is ERP possibly not effective for some? Or is it that they need to do it longer or more intense? My child says the hard part of the ERP is you know the trigger is coming and out in the world it doesn’t work like that so he reports it doesn’t cross over for him. I was almost over the impression it was something you had to do as a inpatient? I apologize for my lack of knowledge. So do some people go as outpatients weekly or monthly for how long? I gather that the family who has done everything they can for this boy feels there is nothing left. Is this the case?

      • Thank you for sharing and I think it’s great how supportive you are being for your daughter and her boyfriend. The support of others is so important for those with OCD. I also think it’s great that you are trying to learn whatever you can about the disorder.
        I can’t really comment as to why ERP has not yet helped this young man, as I don’t know details and I am also not a therapist. ERP can be done in a variety of settings including but not limited to a residential program, a partial hospitalization program (which is intensive but you don’t sleep there), or weekly. In general, greater benefits come with more ERP.
        I cannot stress enough that I believe there is ALWAYS HOPE for recovery from OCD, no matter how severe. I base this on my son’s experiences and the countless stories I have heard from others. No matter how bad things are at this moment, recovery is possible. Unfortunately one of the hardest things about OCD is finding the right treatment. I don’t know where this young man was treated, but perhaps a different therapist or program would be a better fit to help him with the roadblocks he is facing in his therapy. I wish you all the best and hope to hear from you again.

      • India says:

        Hi Willing and ready to learn. I am sorry that your family is struggling. I am not really sure what would work for your daughter’s boyfriend. Treatment plans vary for different people and some people take longer than others to learn to live with this. I have heard some people say that ERP doesn’t work for them or that they are treatment resistant. It is very individualized. Has he tried acceptance and committment therapy? That is what has really helped me. ERP has been important for me too but I really believe that it was ACT that helped me and helps me to continue managing it. You might check out the International OCD Foundation. They have a ton of resources and information. He might be interested in that too. There are also support groups through yahoo that are lead by experts. In the two I know of one is for everyone and one is for sufferers only.

  6. India says:

    This is a great article. It is so true! ERP is really hard but it is so worth it. I really believe that the addition of Acceptance and Commitment therapy is what helped me to do it. I love ACT. And like your son, it took me forever to get the proper treatment. It makes me sad that it took me so long to find someone who actually knew how to treat this but it changed my life. I hope your son is doing really well. Is he managing the OCD better now?

  7. India says:

    Sending you good thoughts, Paul. Have you heard of Acceptance and Commitment therapy? I love it. It is so good for OCD. I truly believe I could have not done ERP without it.

  8. I just reviewed Janet’s 2012 post on ACT. I have done some work in the past on mindfulness and actually recently restarted those efforts via meditation. I am also familiar with The Serenity Prayer. I will do some more digging! Thank you India and Janet!

  9. Anne says:

    Hi Paul and India,
    I am a parent. My teenager has OCD and is doing ERP therapy. I recently discovered ACT on a podcast I watched through OCDStories. I suggest watching the interview with Steven Hayes. He wrote an ACT workbook “Get Out of Your Mind and Into Your Life” which I think is amazing. Adding ACT to my daughter’s ERP therapy has made a big difference. The therapy is not directed at OCD specifically, however, I believe it’s a life changing addition to ERP therapy.
    All the best to you both.

  10. Anne says:

    No worries Paul. I sometimes call her my son too!
    All the very best to you.


  11. If I have anything useful to share I absolutely will do that! – Paul

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