What is Exposure Therapy with Response Prevention (ERP)?

Often when I talk to individuals about ERP, I get some pretty common questions:

1. What is exposure therapy with response prevention (ERP)?

2. Why do you do it?

Before we get into the nitty gritty; there are a few key components you probably want to know about.

First, exposure therapy is principled around prolonged exposures. Prolonged exposures, in short, are times in which individuals in therapy are encouraged to sit with their physiological response to certain stimuli. By doing this, we are able to build physiological and psychological resiliency regarding those stimuli. Due to the nature of our physiology (mainly the fight or flight response, also known as the sympathetic nervous system), we have intense reactions to feared stimuli. By allowing these naturally occurring responses to subside in the presence of these feared stimuli, our reaction becomes less intense. We habituate to the new situations and the feared situations become more manageable.

Exposure therapy with response prevention introduces individuals to these feared situations or stimuli, and do not allow individuals to avoid or placate these emotions. Avoidance behaviors reinforce these fears and we, inadvertently, condition ourselves to have those intense physiological reactions anytime we have feared thoughts or situations. The neural pathways implicated in OCD (and other presentations that we address with ERP) are both excitatory (activated at the sight or thought of an event or stimuli) and inhibitory (pathways that inhibit behaviors and responses). In extreme cases, we have individuals who have conditioned the excitatory neural pathways by engaging in avoidance behaviors without allowing inhibitory neural processes to occur. This is why the response prevention aspect is so daunting, but necessary.

Which is the second portion that is important to understand about ERP: By inhibiting their ability to avoid or engage in behaviors that aim at alleviating their anxieties or stressors, we condition our pathways in such a way that lead to adaptations to difficult situations instead of maladaptions of compulsory or avoidant behaviors. This portion of the exposures is most difficult due to the fact that we are inviting our clients to stare their fears in the face; and not blink.

When would you use and prolonged exposure paradigm? You can see it utilized in many ways. For instance, Trauma Focused Cognitive Behavioral Therapy (TFCBT) utilizes prolonged exposures and reprocessing in the form of trauma narratives. We ask you rank, in hierarchical fashion, traumas into Hard, Harder, and Hardest categories. We master one level of these ”exposures” before graduating to the next. During that time we have habituated and reprocess those reactions to trauma in a safe and empathetic environment. A Written Exposure Therapy Protocol (WET Protocol) also utilizes similar tactics.

Dialectical Behavioral Therapy (DBT) also utilized an prolonged exposure-esque process in the form of distress tolerance. Individuals are asked to increasingly introduce themselves to situations that test their tolerance and invite them to develop more adaptive ways of behaving in those trying situations through ACCEPT and TIPP skills. By successes in these situations, they are reappraising those situations as less difficult or scary which allows them to adapt instead of collapse in certain situations.

This is not an exhaustive list of the ways prolonged exposures can be utilized, but only a few of its common forms. In the form of Exposure Therapy with Response Prevention we utilize it to often address and overcome severe phobias, illness anxiety, obsessive compulsive disorder, social anxiety, and many others.

Exposure therapy is one part psychoeducation (Education on topics related to disorders and the treatment of them), one part hierarchy construction (gradual desensitization guide for a disorder particular to each individual), and the rest is exposures. Post psychoeducation and hierarchy creation, you would follow the structured hierarchy, that is a living document changing with the needs of each individual, until you sufficiently develop adaptive skills to overcome your intrusive thoughts and compulsive behaviors. These exposure are aimed to overtrain our reactance so that we can be prepared for most common presentations of our fear.

A good exposure therapist is one that is creative and willing to walk with you during your exposures. I have two rules when it comes to exposure therapy:

1. I will never ask you to complete an exposure that I myself would not complete.

2. Have fun.

Just because we are exposing ourselves to our most feared situations, doesn’t mean we can’t have a few laughs along the way. I could probably concern you with some of the contamination fear exposures I’ve engaged in many clients. That’s before we begin to talk about individuals who present with violent/harm OCD. We can often take very serious situations and inject a little bit of humor. If you’re curious of those presentations, I encourage you to take a look at www.IntrusiveThoughts.org .

A third rule I have has to do with respecting your moral and value system during exposures. That not just an exposure rule, but a way of conducting myself with anyone I work with; but I digress.

You should also expect exposure to be hard. Very hard. All therapies are difficult by nature. You are given the proverbial mirror to inspect all the gritty problems from your past or present. With exposure therapy, you are not just emotionally drained, but also physiologically exhausted; however, if you find the right exposure therapist, we will walk you through the process gradually to help you overcome these fear with as minimal distress as needed.

Exposure therapy, along with medication, is a great avenue to overcoming many different types of anxieties, phobias, and obsessive compulsive related struggles. If you’re a therapist looking to know how you could add some exposure therapy to your practice or refer somebody for ERP, or somebody looking to overcome the aforementioned struggles, don’t hesitate to call me at 405-513-0282 or email me at Info@ChadMcCoy.com