Yay, you're finally ready to try
Exposure and Response Prevention!
Or like 70% ready
You’ve tried therapy with someone who doesn’t specialize in ERP, half-hearted ERP, medication, meditation, praying, crying, crystals, Reddit, willpower, workbooks, weed, yelling at yourself, and probably more.
Now let’s talk about real ERP.
Obsessive-compulsive cycles & your brain
You can think of us as having two brains: a reptile brain and a logical brain. Sometimes they play well together. Other times we feel “of two minds.” In obsessive-compulsive cycles, your logical brain works wonderfully as always, but your reptile “safety first” brain is over-reactive to a specific class of threats.
Here’s what happens:
1) Your reptile brain detects a threat from your set of fears and activates “fight or flight”
2) You become conscious of urges to flee or use “safety behaviors”
3) You comply with the urges and survive. Great!…But you don’t learn anything
4) Because no learning occurred, the next time you encounter the threat, the cycle repeats
In short: if you frequently use safety behaviors to deal
with your fears, you will stay stuck in the same cycle.
YOU GOT THIS
Think about how you handle situations that are indeed risky or uncomfortable but don’t spark big emotional reactions. In ERP, we take those brilliant risk-navigation and coping skills and apply them to situations that feel harder.
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 neat cycle?
2) One or more sessions practicing the “response prevention” part of “exposure and response prevention.” You learn how to mindfully acknowledge fears, make a rational decision about how to handle the situation, and move on. You don’t have to be perfect, but you do have to practice. Symptom relief usually starts when you start practicing consistently.
3) We collaboratively design experiments that let your brain figure out whether your fear beliefs are accurate. Collaboratively! I can’t make you do anything, nor does that sound fun. We make too-hard experiments easier and convert abstract, “untestable” fears to a concrete and testable format.
4) We run the experiments together in session and problem-solve any barriers to you doing them at home.
5) Once your brain gathers enough data points to decide for itself, your reaction to your trigger situations starts to look more like everyone else’s.
Common misconception: ERP = anxiety management skills
We do cover a few fun skills! But the real process of change is your brain learning that your feared situations do not require a fight or flight response. Consider past experiences in which you were super afraid of something and then got used to it. Voila! Same process of change brain-wise.
How many sessions will I need?
Twenty-two. Just kidding! I have no idea.
A lot of factors can impact the number of sessions standing between you and your treatment goals. The main one I see? How willing you are to give ERP a shot.
A lot of people learn the basics and then get creative, often with the pure-hearted goal of making treatment faster or less painful. In reality, ERP works surprisingly fast once you start doing it correctly, and if it feels painful, you are probably not doing actual ERP. It should feel more like a mindfulness exercise than anything else: you observe a fear, allow it to be present, and still mindfully decide for yourself how you want to handle it. If you do that, and if we’re treating OCD and OCD only, treatment is often about 20 sessions. Most of the other things I treat tend to take fewer sessions, and BDD usually takes more. Again, that number mostly depends on your willingness to try ERP as-is.
If you want to contain your time and costs, and you also want to get better, maybe try standard ERP at least once, without any additions or subtractions.
ERP doesn't work for every problem under the sun
But it does work for OCD &
obsessive-compulsive loops
Tons of people worry ERP won't work for them or will be too painful. Yet ERP actually works for a surprisingly wide range of fears, including every OCD subtype as best we know. Yes, even the most abstract, “untestable” fears known to humankind. Furthermore, embarrassment about taboo thoughts and irrational compulsions drops off sharply over the first few sessions as people get used to talking about it. Worried ERP won’t work because your compulsions mostly happen inside your head? That’s adult OCD for you! You don’t want to be weird and do them out in the open. Also, you have learned to multitask. You can do compulsions while also driving, watching TV, scrolling Instagram, “listening” to your partner or friends, walking the dog, cooking, eating, going to the bathroom, and on and on.
So many reasons to avoid ERP!
But I bet none of them are good