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...now 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 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 planning and re-planning how you will manage your feared situations. 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 repeats itself throughout your whole life. Yes, the behaviors take different forms in different situations, wax and wane over time, and morph as your brain develops. But underneath surface-level changes, that single fear cycle is running until you decide to address it directly.
What does treatment look like?
1) 1-3 sessions of information gathering. What are your exact feared outcomes and safety behaviors? What is the logic that ties them together into one integrated cycle?
2) 1+ session practicing the “response prevention” part of exposure and response prevention. Learn how to mindfully acknowledge automatic thoughts, make your own decisions about the best course of action, and move your attention to the next thing. Symptom relief usually begins when you start practicing these skills consistently.
3) Collaboratively designing experiments that let your brain learn whether your feared predictions are accurate. We modify too-hard situations until they feel challenging but doable. We convert abstract, “untestable” fears (what if I go to hell after I die?) to concrete, testable predictions (my anxiety will be about 5/10 if I watch this film clip about the afterlife, then will drop to 4, then 3; I will not regret having watched the clip). I know your fears feel murky, untestable, or dangerous, but all fears I have seen have been (safely!) convertible to ERP format. Importantly, you will only practice doing what you genuinely want to do—your experiments are intended to help you live your life more in line with your values, not less.
4) 20+ sessions running the experiments together and problem-solving barriers to you repeating them daily at home. Once your brain gathers enough data points, your external and internal reactions to your trigger situations look a lot like you never had OCD.
5) Feel free to graduate, stay in therapy to work on something else, schedule a future session to double-check that you’re still doing well, or come back for booster sessions anytime in the future.
10% skills
90% chilling out
I said it on the home page and 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 super used to it. 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 as is.
People often learn ERP basics and then get creative. They have fully positive intentions of making treatment better or faster. In reality, ERP is surprisingly fast and effective once you start doing it right. If it feels painful, slow, or unhelpful, you are probably doing something ERP-like, and we need to adjust your form back so you’re doing actual ERP and getting actual results. We all did homegrown ERP for a long time before starting treatment and are creative thinkers, so pretty much everyone runs off the track a few times during a course of therapy (me too!). We will absolutely tailor ERP to you, together, but modifications on your own at home have, say, a 90% chance of slowing you down.
If you are staying the course and doing ERP, and we’re treating OCD only, treatment is often around 20-30 sessions. The other things I treat usually require fewer sessions, and BDD usually requires more. Again, that number mostly reflects willingness to try ERP, as is.
If you want to contain therapy time and costs, I recommend giving ERP a solid try. If you don’t like it, you are totally free to stop whenever you want—starting treatment does not obligate you to cross the finish line. You can also do a full course of ERP, see how you like life that way, and then decide to go back to all your old compulsions! I haven’t seen that yet, but life is long.
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. I have a whole list on the next page! 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. ERP specialists know that, and we will design your exposures to fit your actual fears and your actual compulsions, including and especially the ones in your head.
So many reasons to avoid ERP
A few extra important reasons not to