ERP is simple.

But simple doesn’t mean easy.

Exposure and response prevention (ERP) is a specialized form of therapy designed for those experiencing OCD.

I recommend ERP to almost all of my clients because it’s the most well-researched and effective treatment for OCD.

Before starting ERP, we’ll complete several steps.

The first step is comprehensively reviewing how your OCD is showing up for you. And this begins with reviewing your intrusive thoughts.

Perhaps you’re having thoughts about contamination, or that something terrible will happen to you (or someone you care about), or that you might be a bad person (or that you might do something awful), or that something isn’t “just right”.

Whatever intrusive thoughts you’re having (and many experience OCD have a variety of intrusive thoughts), there are at least three parts of them:

1. The intrusive thought is about something bad happening to you or someone else

2. You don’t know 100% for sure that the bad event will not happen

3. The intrusive thoughts get stuck and cause anxiety
   

Let’s break these down.

Intrusive thoughts aren’t typically pleasant. I’ve never worked with a client who reported, “William, I just keep getting stuck with the thought that I’m probably going to win the lottery.” No. Instead, intrusive thoughts are almost always about unpleasant, bad, even terrible events occurring.

Most of us with OCD suspect that the bad things predicted by intrusive thoughts are unlikely. But unlikely doesn’t mean impossible. Those of us with OCD are often, what clinical research describes as, intolerant of uncertainty.

Those of us with OCD like to know 100% for sure that something bad won’t happen. 99% might be nice. But we want an absolute guarantee.

And since we don’t know practically anything 100% for sure, we find ourselves getting stuck with thoughts about the possibility of the bad things happening.

When we get stuck with thoughts about these bad things happening, we become afraid. When we’re afraid, we’ll do something, anything, to try to get the thoughts to go away so we can feel safe again.

To illustrate what this looks like, imagine someone whose OCD theme area is “hit-and-run” OCD. Hit-and-run OCD shows up when someone frequently (even constantly) intrusive thoughts while driving that look like: “What if I hit someone with my car without knowing it” and/or “I might have killed someone and that makes me a bad person” and/or “I might have police show up to my house and they’ll take me to jail and everyone will think I’m a terrible person”.

For someone with a hit-and-run theme area, these intrusive thoughts can become especially prominent when they hear or feel “bumps” while driving. The intrusive thoughts then typically look something like, “What if that bump I just felt was me hitting someone with my car?”.

Note how these intrusive thoughts relate to “intolerance of uncertainty”. Most individuals with hit-and-run OCD often try to reassure themselves with phrases like “I didn’t see anyone in front of my car, so I probably didn’t hit anyone” or “I would surely notice if I hit someone with my car” or “My family tells me that I would definitely know if I hit someone with my car”.

But no matter how many times she tries to reassure herself, the intrusive thoughts just keep coming back: “But, what if somehow I hit someone and I didn’t realize it?” or “What if I somehow didn’t notice that I hit someone?”

Even though she thinks she probably didn’t hit someone with her car, she doesn’t know for sure. And not knowing for sure usually means the intrusive thoughts stick around, causing her to be terrible anxious.

Given all of this, it’s entirely understandable what she does next: She turns her car around and drives back to the street where she felt/heard the bump. By doing this, she can check the area to see if she hit someone.

Unfortunately, often, even after driving back to check, another intrusive thought will arise, “I don’t think I saw anyone laying injured on the side of the road, but maybe I didn’t look carefully enough and someone was, in fact, injured.”

This thought causes more anxiety and motivates driving back again…and again…and again.

It's not uncommon for those with hit-and-run OCD to spend hours each day driving back to check that they didn’t hit someone.

Frequently, they’ll give up driving altogether.

Driving back again and again and again is a form of checking behavior. Checking behaviors are a form of compulsive behaviors.

Compulsive behaviors are the behaviors those with OCD complete to try to get rid of intrusive thoughts, get rid of anxious feelings, and keep themselves and others safe.

Sometimes checking behaviors are checks in the physical world, like checking that the door is locked, the stove is off, the pet is in the living room, your baby is safe, etc. Other times, checking behavior is internal, including checking for the presence of certain thoughts or feelings / sensations in the body.

Whatever form of checking shows up, even if these checks help to reduce anxiety in the short-term, in the long-term, they increase the power of OCD.

Using compulsions to manage OCD is like throwing a log on a fire: It might dampen the flame for a moment, but soon enough the log will catch and the fire will be bigger than ever.

ERP short-circuits this never-ending cycle of intrusive thoughts, painful feelings, and compulsive behaviors.

To short-circuit OCD, we’ll explore the core fears related to your compulsions. Are you afraid something terrible will happen to you or a loved one? Are you afraid you’ll do something terrible to someone else? Are you afraid you’ll be stuck with a feeling or thought forever? Or are you afraid you’ll be a “failure” or that deep down you’re “not enough”?

Whatever the fear, we’ll assess the objective, realistic risk.

We’d never do something in treatment that is realistically dangerous.

But “knowing” something isn’t realistically dangerous doesn’t get rid of the intrusive thoughts or the anxious feelings.

To reduce the intrusive thoughts and anxious feelings in the long-term, we need to go beyond “knowing”. To do this, we’ll discuss ways to modify your compulsive behaviors, primarily related to participation in exposures.

Exposures are the bread and butter of ERP treatment. During exposures, we’ll slowly but surely engage with the situations, thoughts, and feelings that scare you. We start with exposures that are only the smallest bit uncomfortable and then work our way up. We always make sure the pace and intensity of the exposure process is not overwhelming you. Slow and steady.

Our primary goal during exposures is new learning.

We want to show your body that although it feels very scary to be around triggers (either events / objects in the world or intrusive thoughts), you can tolerate the intrusive thoughts and anxious feelings. In fact, we’ll work together to prove to yourself that you can function well and engage in your life even while experiencing intrusive thoughts and anxious feelings.

This process is rooted in developing the skill of distress tolerance and, like all skills, it improves with practice. So, just like lifting a muscle improves a muscle’s strength, tolerating intrusive thoughts and anxious feelings improves your ability to be with and manage them (like a weight getting easier to lift as your muscle becomes stronger).

Another goal we’ll often reach during exposures is habituation. An exposure is like jumping into a cold swimming pool. It’s uncomfortable at first, but that discomfort goes away over time. This transition from discomfort to comfort is called habituation. Habituation isn’t about “knowing” you’re safe. Habituation is about feeling safe.

One of the best aspects of ERP is that it emphasizes learning new skills. You keep the skills we learn long after our work is over and the improved feelings and functioning you have typically last long after therapy.