Do you remember times growing up when you begged for permission to stay in bed and skip school to avoid a problem? Tough tests, fights with friends, heartbreaks, embarrassment, and disappointments are rites of passage few of us escaped. But instead of letting us hide, our wise parents told us to get up and face our fears. Unbeknownst to many of them, this sound advice plays a pivotal role in exposure and response prevention (ERP). ERP is a specialized type of cognitive behavior (CBT) therapy used to treat many mental health conditions, most notably obsessive-compulsive disorder (OCD) and the extreme fears that come with it.
Fear is an essential emotional response designed to keep us safe. It is the brain’s danger warning system. But for people with conditions like OCD, the fear is so extreme that false alarms are frequent, even in the absence of any real risks. But it is possible to temper this overactive physiological fight-or-flight response.
With repeated exposures to distressing stimuli and more controlled responses to them, the brain changes and learns to adapt in healthier, more normal ways. The result is less anxiety, fear, and distress.
A Brief Look at Exposure and Response Prevention
Exposure and response prevention was first discovered in the mid-1960s and perfected in the two decades that followed. It is widely used today to break the cycle of fear and avoidance.
Confronting things that we fear to reduce anxiety seems counterintuitive. Admittedly, exposure does intensify distress in the short-term, but it eases over time due to a process called habituation.
In psychology jargon, habituation is adapting to a stimulus through repeated exposure. In other words, familiarity and experience lower emotional, physiological, and behavioral responses.
If you have ever conquered a fear of public speaking or flying by doing it repeatedly or are unphased by a noise that once drove you crazy, that was habituation in action.
How Exposure Therapy with Response Prevention Works
Exposure therapy is a one-dimensional stand-alone treatment. Exposure therapy and response prevention, as the name implies, is a two-part treatment protocol.
Exposure is introducing people to anxiety-inducing triggers in increasingly longer increments as tolerance to them builds. Exposures can be through actual objects, people, places, and situations or imagined scenarios.
Intense fears often compel those who suffer from them to engage in unhelpful behaviors like extreme avoidance or time-consuming rituals to escape distress. But these behaviors only reinforce and escalate fear.
Response prevention, the second part of the ERP equation, is crucial. It refers to the practice of tolerating triggering stimuli without engaging in actions to neutralize distress. By withholding reinforcement of the fear through a mental exercise or physical act, the frequency, and intensity decline.
ERP addresses triggers one-by-one, working from the lowest end of the fear hierarchy to the highest. The fear is mastered once the patient experiences a dramatic reduction in anxiety and refrains from acting when exposed to the triggering stimuli.
Depending on the severity of anxiety and the number of fears, exposure, and response prevention typically takes 12 or more behavior therapy sessions. Initial sessions are 60-90 minutes but require less time as mastery builds.
Self-monitoring is an essential tool in exposure therapy. Between therapy sessions, patients record emotions, anxiety levels, and frequency of maladaptive behaviors. Therapists use these accounts to track and measure treatment progress.
The Difference Between Exposure and Response Prevention and Talk Therapy
Cognitive behavior therapy is among the most common forms of psychotherapy. CBT is effective in treating several disorders, including depression, trauma, addiction, and generalized anxiety.
While ERP is a form of cognitive-behavioral therapy, the two treatments have distinct and divergent goals. CBT works to change unhelpful thoughts to reduce symptoms, whereas ERP aims to change how to feel and respond to them.
Exposure therapy with response prevention is preferred over standard talk therapy for fear-based conditions like obsessive-compulsive disorder and phobia disorder because it addresses both fears and behavioral responses. Response prevention is not standard practice in cognitive behavior therapy.
Treating OCD with Exposure and Response Prevention
ERP is most commonly used to treat obsessive-compulsive disorder (OCD), a common and often debilitating condition that affects one percent of the population, including one in every 200 children.
The hallmark features of OCD include persistent unwanted and distressing thoughts, formally called obsessions, and repetitive and ritualized behaviors that follow, called compulsions.
Fears are normal. But for those who suffer from OCD, these fears are so extreme and intense that the brain has no adequate response to manage the stress. Compulsions are a futile attempt to defuse the fear.
There are many subtypes of OCD, but they share common themes like contamination, doubts, forbidden thoughts, and violent and sexual ideations.
These disturbing thoughts drive urges to engage in rituals like handwashing, checking, counting, and reassurance seeking. Behaviors can be physical actions or mental exercises and ruminations.
But instead of reducing the anxiety, compulsions only empower the fears and OCD-driven behaviors; the more people participate in them, the more frequent, time-consuming, and disruptive they become.
The effects of the disorder can be debilitating and severely impair normal functioning, relationships, and even physical health.
While difficult to treat, the obsessive-compulsive disorder does respond well to exposure and response prevention.
ERP is the first-line, gold-standard treatment for the condition and more effective than standard practices in psychology that include thought stopping, relaxation techniques, and talk therapy.
In fact, ERP is the most important treatment for OCD; no other therapy method adequately breaks the cycle of repetitive, unwanted thoughts and the need for repetitive and disruptive rituals to escape them.
The effectiveness of ERP is welcome news since OCD was once considered an untreatable disorder.
ERP: An Evidence-Based Treatment for OCD
The science behind exposure and response prevention's effectiveness is backed by decades of research studies, patient accounts, and data.
Leading organizations like the American Psychological Association recognize exposure and response prevention as an evidence-based treatment for several anxiety- and fear-based conditions.
While cognitive-behavioral therapy alone may help treat OCD, ERP is far more effective in reducing symptoms, improving sleep, and quality of life.
A large body of research supports the efficacy of exposure therapy and response prevention as a treatment for obsessive-compulsive disorder. Approximately two-thirds of people with OCD treated with exposure and response prevention improved their symptoms. And up to one-third were considered recovered.
A Real-World OCD Exposure and Response Prevention Success Story
Janine suffered from a clinical level of fear over contamination from germs, illness, and disease. To relieve her distress, she avoided public spaces and suffered from painfully chapped and raw hands from frequent washing and sanitizing. But the more Janine resisted touching doorknobs and railings, the more afraid she became. And the more she washed. Getting to work became a harrowing, time-consuming experience.
Janine touched various items like doorknobs and garbage cans for increasingly longer intervals during ERP therapy without engaging in her normal excessive washing and sanitizing routine.
“It was so hard, particularly at first,” she admits. “I wanted to quit. But each time got a little easier. While I am still careful, I can go out in public without suffering a major anxiety attack. And my hands look and feel much better.” she said.
The Future of ERP to Treat Other Mental Health Conditions
Phobias are a common anxiety disorder, particularly among women. According to the National Institute of Mental Health, over 12 percent of adults in the U.S. suffer from phobia disorder, characterized by extreme and irrational fears. Common phobias include agoraphobia, social phobia, and specific phobias like spiders, flying, and public speaking.
Because phobias are fear-based like OCD, they respond well to treatment with exposure (physical, visual, or imagined) and withholding the normal behavioral response to the trigger—most commonly extreme avoidance.
Without question, ERP is the treatment of choice for phobias and OCD, but can it treat other mental health conditions? Scientists are taking a closer look at exposure therapy with response prevention for managing other disorders that involve anxiety and avoidance.
While research is limited, ERP shows excellent promise in initial studies for treating eating disorders like anorexia, bulimia, as well as body dysmorphia, Tourette's syndrome, and post-traumatic stress disorder (PTSD).
The Challenge with Exposure and Response Prevention
Exposure and response prevention is more complex than standard talk therapy. Confronting fears is an unpleasant, sometimes terrifying experience. It’s hard. According to research, over 18 percent of people fail to complete ERP therapy.
But starting and staying with exposure and response therapy can deliver dramatic improvements for OCD and other fear-based conditions in a relatively short period. And the benefits are backed by decades of scientific studies.
Freedom from extreme and irrational fear is possible. Hope Therapy and Wellness can help. Talk to one of our trained behavioral therapists today.