OCD

ERP for OCD

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Exposure and Response Prevention (ERP) is an evidence-based treatment for OCD. It uses the principles below to extinguish the power OCD has over you. ERP is used to meet you where you are and gradually extinguish the compulsions, or "responses" to obsessions - setting you up for success rather than an unachievable mountain to climb. For example, if compulsive washing is an issue, you might expose yourself to "contaminated" things and then not wash your hands. If this feels too difficult, you might start by touching a chair which is less "contaminated" first, and then working your way up to the bathroom doorknob.

 

Exposure has rules that should be followed to ensure success, and should be applied within every exposure experience. Below are some of those rules:

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Frequency - Whatever you expose yourself to, and at whatever level you are in your hierarchy, it is essential that you engage in that exposure behavior frequently and regularly. It likely won’t be enough to practice leaving the house without checking the stove, or not washing your hands after touching the phone, only once a week or even once a day. These exposures have to be done frequently, often many times a day, to allow exposure to properly have its effect of desensitization.

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Duration – The amount of time you expose yourself goes hand in hand with how often you do exposure. A good guide is to engage in the exposure experience until your anxiety drops to at least 50% of what it was at the beginning of the exposure experience. This gives you the time necessary to experience desensitization. If you leave too early, you are actually reinforcing the "escape" response and training yourself to run from the anxiety, which strengthens OCD. Give yourself plenty of time whenever you engage in an exposure exercise - it is an essential part of applying the technique successfully. Rather than letting the clock tell you when you are done, let your anxiety be your guide. When it has dropped by about half, your exposure will have an effect.

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Intensity - How strong of an exposure experience should you be looking for? If you start too low on your intensity level and expose yourself to a thing or situation which does not create much anxiety (say, 2 on a 1-10 scale, where 10 is the highest imaginable anxiety), you won't get much payoff from the experience. On the other hand, going for a 9 or 10 right away may feel so overwhelming that you may decide to give up the whole effort. Aim for something between 4 and 7, and shoot for dropping it down to a 2 by the end of exposure (not zero), before moving to the next level.

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Methodology - There are many ways to manipulate the intensity depending on the methodology you use. Say the challenge is to leave the house without checking that the range is on. If you presently have a ritual of touching the range knobs a certain number of times and/or in a certain order, you might first change the order, the number of times you touch them (sometimes even changing to 5 if you always have to check an even number of times), or a combination of the two. Then you can graduate to shortening the amount of time you touch them, just waving your hand across the burners as a check, and then just visually inspecting them. Next, look at them for shorter periods of time, and from further distances from the range.  In all these ways, you are constantly "pushing against" the OCD and strengthening yourself.

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Monitoring - Observing, recording, and reporting your progress to your therapist is an essential aspect of ERP. Nothing helps motivate, encourage, and clarify the progress that has already been made than good record keeping.  

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Postponement – Also known as "delay." Here, the focus is on when you do it. Say you expose yourself to a contamination source, and your standard response is to take a ritualized two hour shower where you repeat certain behaviors and feel compelled to follow some specific rules. In postponement, you might practice jumping into the shower for a quick rinse and then out again in 30 seconds, drying yourself off, and then go right back in and take your two hour shower - no other changes. It is less difficult to do this when you have every intention of going right back in the shower and engaging in your full ritual. Next time you would do the same thing again, but wait 60 seconds after drying off from your 30 second rinse before beginning your two hour ritual. Next time, wait two minutes before going back in, then work up to 30 minutes, or even a few hours. You eventually find that you don't feel the need to go back at all. During this process, you could experiment with adding a few seconds and a few actual washing activities to the original 30 second rinse.​