I recently wrote about how exposure and response prevention (ERP) therapy, the evidence-based psychological treatment for obsessive-compulsive disorder, is anxiety-provoking. Many people with OCD are aware of this fact, and it is often one of the reasons given by those with OCD for not attempting ERP. It’s too scary. Who wants to deliberately expose themselves to intense fear and anxiety?
And the media doesn’t help. I’ve seen television programs that show distraught people with OCD being forced to engage in behaviors most of us would find repulsive; things such as sifting through garbage and then not washing your hands, or licking a toilet seat. Who would willingly expose themselves to such things?
The truth, however, is that ERP, when done properly, is patient driven. Nobody is forced to do anything, only encouraged when appropriate. In addition, most good therapists go by the adage, “I won’t ask you to do anything I wouldn’t do myself.”
That being said, ERP might sometimes include things that most of us don’t typically do. For example, if someone’s obsessions involve contamination, it is possible that as part of ERP therapy, they might go with their therapist to a public bathroom, sit on the floor, and touch the floor with their hands, or perhaps even have a little picnic. You might be thinking, “Isn’t just using a public restroom enough of an exposure?” Well, sometimes yes, and sometimes no. As I understand it, the reason these “over-the-top” exposures are sometimes needed can best be explained by envisioning a bendable pole. We are striving for the pole to stand straight up (which represents “normal” actions and reactions). 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, it is necessary to bend extra far in the opposite direction (hence our picnic in the bathroom).
Just to be clear, if you’ve never done ERP therapy, you will not walk into a therapist’s office and be whisked away to some public restroom to do exposures on the floor. Remember ERP is patient driven. So how and when is it determined what exposures those with OCD will tackle?
One of the crucial components of good ERP therapy is the creation of a hierarchy, which is basically a list of anxiety-provoking situations created by the person with OCD. At the bottom of the hierarchy will be the least distressing events and at the top will be the most triggering sources of anxiety. For example, someone struggling with fear of contamination might have “picking up a spoon that fell on the floor” lower down on his hierarchy and “using a public restroom” at the top. This hierarchy is used as a guide for the person with OCD and his therapist.
Typically therapists will start by having their clients tackle situations that cause mild to moderate distress and then work their way upwards. As you can see this is a very individualized approach, and good therapists will work closely with those with OCD – coaching and encouraging, but never forcing, until the top of the hierarchy has been reached.
So the truth about exposure and response prevention therapy is that it is not easy, but it is indeed doable if you are willing to commit to it. And it works. The pay off is huge – a life no longer dictated by obsessive-compulsive disorder. Seems like the way to go to me.