ERP stands for Exposure and Response Prevention. ERP aims at desensitizing the OCD sufferer to his anxieties. This is done by systematically exposing him to these anxiety inducing stimuli and preventing him from indulging in the compulsions to relieve the anxiety. ERP pulls the OCD from its roots and enables the sufferer to live as close to an OCD free life, as possible.

But ERP is a discipline. It is not a shot in the arm or a pill that one can pop and get better. It is not a magic wand either where you mutter a spell and poof! No more OCD. No! It isn’t that at all. ERP is a long and often painful process for the sufferer and apart from the skill of the therapist, depends largely upon the willingness of the sufferer to go through with it. I say willingness and not ability because if the therapist is skilful enough, he can customize the process to suit the sufferer’s speed, thereby neutralising the ability parameter.

The therapist is the coach and the sufferer the fighter. The therapist can guide the sufferer, very much like the coach guides the fighter, but the fighter has to fight the battle himself. It would not do for the fighter to say, he doesn’t want to get hurt while fighting the battle, but he wants to be an expert at it and hence, the coach should fight for him. No sir! Doesn’t work. It is your battle (even though you haven’t asked for it), and you need to be ready to get your feet wet.

Why is willingness so critical?

Willingness in ERP is essential because ERP is a paradoxical way of approaching OCD. In order to make sure that the sufferer rids himself of his anxiety, ERP gets him to face his fear first and gets him to deal with the anxiety by facing it and not running away from it. Like being afraid of a spider and being asked to face the spider. But this is a simplistic example and does not do justice to the fear experienced by the sufferer to face even relatively small and sometimes inane (for others) fears. The sufferer’s normal reaction would be to indulge in a compulsion when faced with his fear. That compulsion temporarily alleviates the anxiety that the sufferer feels. But it does not allow the sufferer to overcome the fear. Sort of like shutting his eyes when he sees a spider. Not being able to see the spider may reduce the anxiety, but it does not help him get over his fear. The Response Prevention part of ERP disallows the sufferer to ‘close his eyes’, metaphorically speaking when he is face to face with his fear.

When the process of ERP is explained to the sufferer, the sufferer may not feel up to the task of facing his fears because the thought may seem overwhelming. That is the reason, willingness is critical.

What is the process?

The therapist will ask the sufferer to explain his entire history, and understand the compulsions first. The therapist will also try and understand if there are any hidden compulsions that mimic constructive habits. Rumination is one such compulsion. Sometimes, praying is another such compulsion. Then there is Proxy Compulsion, Avoidance and Reassurance Seeking. There is talking to oneself, getting angry and venting too. These are different from the overt compulsions and may go unnoticed unless the therapist extracts them out of the sufferer.

Then the therapist will ask the sufferer to prepare a hierarchy chart that lists down all the obsessions and compulsions that the sufferer is engaging in, and grade them on the basis of their severity in an anxiety grading sheet. For example, in contamination OCD, the sufferer may have the urge to wash hands and if not washed, the anxiety may be 8 out of 10. And the same sufferer may also need to use a tissue to open the main door and if a tissue is not used, the anxiety may be 4 out of 10.

Once the anxiety grading sheet is ready, the therapist picks up the lowest anxiety inducing compulsion first. He would try to explain the irrationality of his thought and explain to him that the probability of his fears coming true is either minuscule or zero. After that, he encourages the sufferer to face the obsession and not do the associated compulsion for anxiety relief. Let’s say the sufferer suffers from Contamination OCD. And the sufferer finds it difficult to touch the toilet door knob. And if the sufferer touches the toilet door knob, he has to wash his hands thrice and rub them vigorously in order to deal with the anxiety. The therapist will encourage him to touch the toilet door knob. The therapist will then invite the sufferer to tolerate the anxiety by disallowing him to wash and scrub his hands, which he is normally used to doing.

If this gets too much for the sufferer to handle, the therapist may allow the sufferer to wash his hands twice instead of thrice. Or he may try to get the sufferer to delay the compulsion, if the sufferer cannot completely avoid it. The therapist would also explain the Anxiety Graph to the sufferer, to let him know that the anxiety will peak to begin with but with repeated exposure and delay in performing the compulsions, the anxiety will eventually subside and the compulsion will be said to have been controlled.

Once the lowest fear is tackled, the therapist moves upwards in the grading sheet and takes up another fear. And works his way upwards till all fears are controlled.

It is important to also note that the possibility of relapse is very high in OCD, and as such, the sufferer needs to keep practising the exposures to make sure he is not tormented by them in future. Once the fear is tamed, it turns from a bully to a beggar at the traffic signal, who is very much present but is a minor irritation. The objective of ERP is to turn all bullies to beggars and live a functional life.


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