Yay, you're finally ready to try
Exposure and Response Prevention!
Or like 70% ready
You tried regular therapy, half-hearted ERP, medication, meditation, praying, crying, crystals, Reddit, willpower, workbooks, weed, yelling at yourself...let’s talk about actual ERP.
Obsessive-compulsive cycles & your brain
You can think of us as having two brains: a reptile and a logical brain. They each have their strengths (speed / accuracy) and sometimes play well together. Other times we feel torn or “of two minds.” When we encounter threats, each brain runs a risk assessment, and sometimes come to different conclusions. If you have an untreated obsessive-compulsive disorder, your logical brain works normally, but for whatever reason, your reptile brain over-responds to a specific set of threats. When you encounter one of these threats, you feel a powerful urge to engage in “safety behaviors” that are supposed to protect your short-term and long-term survival. If you are an adult, your safety behaviors include a lot of behaviors you can hide from other people, such as frequently monitoring the threat while pretending you’re not. You survive the threat, which is awesome! But your reptile brain never gets a chance to learn that you would have survived even without the oversized physiological reaction or safety behaviors. Because no learning can occur under these conditions, the cycle tends to repeat itself throughout your entire lifespan. Yes, the behaviors take different forms in different situations, and change quite a bit as your brain develops. But underneath any surface-level changes, the same fear cycle is running. That is, until you decide to address it directly.
What does treatment look like?
1) A few sessions of information gathering. What are your exact feared outcomes and safety behaviors? What is the logic that ties them together into one simple cycle?
2) At least one session practicing the “response prevention” part of exposure and response prevention. You learn how to mindfully acknowledge fears, make your own decisions about the best course of action, and move on. Symptom relief usually starts when you start practicing these skills consistently.
3) We collaboratively design experiments that let your brain figure out whether your obsessive-compulsive fears are accurate. We make too-hard experiments easier until they meet the “challenging but doable” metric. We convert abstract, “untestable” fears (what if I go to hell after I die?) to concrete, testable predictions (I will/won’t be filled with extreme anxiety about going to hell in x situation, y situation, and z situation; I will/won’t move on and continue to enjoy my life a few minutes after encountering x trigger, y trigger, or z trigger). I know your fears don’t feel testable or feel too dangerous—otherwise you would have tested them already!—but so far all fears I have seen so far have been completely convertible, so ERP can be effective and not feel like torture.
4) We run the experiments together and problem-solve any barriers to you repeating them at home.
5) Once your brain gathers enough data points, your reaction to your trigger situations starts to look more like everyone else’s.
10% skills
90% chilling out
True, I said it on the home page, but…it’s still true! We do cover a few cool anxiety management skills, but the real change is your brain learning that “fight or flight” isn’t necessary. Consider past experiences in which you were super afraid of something and then got used to it, reaching as far back as learning the big slide was tolerably safe (and fun!) when you were three. Voila! Same process of change brain-wise.
How many sessions will I need?
22…Just kidding! I have no idea.
A lot of factors impact the number of sessions you will need to cross the finish line. The main one I see is conveniently under your control: whether you are willing to give ERP a try without any modifications.
People often learn the ERP basics and then get creative, often with positive intentions of making treatment faster or pain-free. In reality, ERP works surprisingly fast once you start doing it right. If it feels painful, you are probably doing something ERP-adjacent, and we need to adjust your form so you’re doing actual ERP. Think good stretch, not bad stretch. Switching analogies for a second, ERP is basically a mindfulness exercise: observe a fear, acknowledge you are not 100% sure whether or not it is true, make a best logical guess, and take what you think is the best course of action. If you are doing ERP, and we’re treating OCD and OCD only, treatment is often ~20 sessions. The other things I treat usually require fewer sessions, and BDD usually requires more. Again, that number mostly reflects average willingness to try ERP.
If you want to contain therapy time and costs, and you also want to get better, I recommend giving ERP a solid try. If you don’t like it, you are totally free to get off the ride whenever you want. You can also try life without your compulsions and then go back! I haven’t seen that yet, but life is long and I’m not a fortune teller, so I’m down to be surprised.
ERP isn’t the answer for everything under the sun 🌞
But it’s great for obsessive-compulsive stuff!
Tons of people worry ERP won't work for them. Yet it works for a surprisingly wide range of fears, including every OCD subtype as best we know. Worried ERP can’t help because your compulsions mostly happen inside your head? That’s adult OCD for you! You don’t want to seem weird and do compulsions out in the open. Besides, you can multitask now, so you are a checking / planning / catastrophizing pro even while driving, watching TV, scrolling social media, “listening” to people, walking the dog, cooking, eating, going to the bathroom…which is how some of us manage to do compulsions 16 hours a day. Efficient! The only downside is that it sucks.
So many reasons to avoid ERP
A few extra important reasons not to