S3C3. The Second Pillar: Exposure and Response Prevention (ERP)—The Gold Standard

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The second pillar of recovery is ERP. ERP stands for exposure and response prevention. It is also sometimes referred to as Exposure and Ritual Prevention and/or notated as Ex/RP, but it is one and the same. ERP is the treatment of choice for all forms of OCD, as it is evidence-based and effective (Khodarahimi, 2009) and is associated with a long-term remission rate of 32% to 70% (Burchi et al., 2018). ERP has two key terms—exposure and response prevention.

Exposure means deliberately facing events that trigger obsessive thoughts so that fear gradually fades through habituation (getting used to the trigger). Like the horror movie losing its edge after being watched repeatedly, your triggers will also lose their edge if faced repeatedly. But while facing your fears, you need to resist the compulsions your brain urges you to do; that is, prevent the response OCD demands through compulsions.

For example, you may choose to expose yourself to the anxiety of hugging your parent. This may give rise to obsessions, which may give rise to the urge to do the compulsions. You may want to run away from the situation. You may want to avoid sitting with your parent or looking at them. You may get the urge to neutralize the thoughts by telling yourself that you are not sexually attracted to your parent. Or, you may get the urge to seek reassurance from others if you are a good person.

These compulsions are the usual responses you provide to your obsessions. The response prevention portion of ERP requires you to not counter an obsessive thought with the usual compulsive response. In this case, since the compulsive urge is to avoid sitting with your parent and looking at them, you sit with them and look at them. Since the compulsion is to neutralize the thought, you do not tell yourself that you are not sexually attracted to your parent. You stop trying to seek reassurance from others about this. In short, you learn to not do your compulsions to manage your obsessions and let the anxiety reduce on its own.

You wonder why you feel less anxious if you don’t do the compulsion. Shouldn’t your anxiety actually rise? Yes, it will rise in the beginning, but it will go down eventually. The reason is fairly simple to understand but difficult to implement. Think of an alcoholic who wants to give up drinking. When they try to give up drinking and stay away from alcohol, their body demands alcohol, as the body is used to having alcohol in the system. They will have withdrawal symptoms like headache, nausea, anxiety, or even hallucinations. They will have an intolerable craving for alcohol. That is, their anxiety WILL rise in the beginning. But eventually, if they resist it long enough, despite the increasing urges, the need for the alcohol begins to diminish, and soon, they do not feel the need to drink any longer.

Also think of learning a new skill. When you first want to learn driving and you sit behind the wheel, there is fear—of losing control of the vehicle, getting into an accident, hurting people, and damaging property. All these are valid concerns. Yet, if you decide not to get behind the wheel to learn driving, you will never overcome the fear. However, if you persist in spite of the fear, you not only get better at driving, but you also begin to lose the fear, as you get habituated to it by facing it often enough.

Similarly, in the case of OCD, not doing the compulsion will definitely increase the anxiety in the beginning. But if the compulsions are resisted, the anxiety will eventually subside. If you think you are doing something wrong when you do your exposures and find your anxiety increasing, you may stop doing your exposures altogether. You may miss the point that for the anxiety to go down, it has to go up as much as it can first before it can subside.

The premise in ERP for the treatment of OCD is graded exposures as opposed to flooding. In flooding, you face all your fears at once and get used to them, whether you feel ready or not. You are not explained why you have to do what you have to do. It is more like ‘I’m ordering you to do something’ rather than ‘Let us discuss what you can do.’ It is a more difficult form of exposure. It can get overwhelming and may also derail the recovery process if not done well.

In graded exposures, the approach is more collaborative rather than dictatorial, where you are expected to face your fears in a graded fashion, one after the other, and learn to manage your obsessions without doing your compulsions. When you face your fears, the anxiety that you experience should be high enough to make a difference but not so high that it overwhelms you into giving up. As you get better at handling the smaller fears, you progress to the larger ones. You decide which fears to pick first. You decide the pace. You decide the frequency. You decide when to start. You decide when to stop.

Think of it like resistance training at the gym. When you start off, the weights are small enough to lift without causing exertion or damage but also large enough to exercise your muscles well. When you adjust to those weights, you lift larger ones. Or, think of it like learning a new language. You start with the basics, like the letters, sometimes even the script, if it is different from English, like Mandarin or Hindi. You proceed to the more difficult lessons only once you have mastered the easier ones.

Can you think of other examples where you did not know how to do something in the beginning, but with repeated practice, you got better at it? Hint—your childhood. Even activities like brushing your teeth follow that process. There was no fear, but there was difficulty, which you managed and at which you got better. Fill in Worksheet 3.3 to understand how capable you are at learning new things.

The purpose of this worksheet is to recognize that if you put your mind to something, you can achieve it. You may not master it, but through repetition you can do it well enough to put it on your resume. The same principle works with anxiety. If we face the obsession without doing the compulsion, the anxiety rises at first. But after some time, through repeated exposure, the anxiety begins to fall. It is almost as if your OCD gives up on you because you are not giving in.

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