Exposure and response prevention, or ERP for short, is an approach within cognitive behavioral therapy (CBT) where we literally expose ourselves to that which is causing us some kind of distress or impairment. It can be a public restroom for contamination fears or engaging in small talk with a stranger for someone with social anxiety. ERP is also exposure to our thoughts, feelings, and sensations themselves. While we are exposing ourselves to our fears we are also preventing ourselves from performing and engaging in unhelpful compulsive or avoidant behavior. In short, it looks like this.
E - Exposure = Encountering anxiety, disgust, or guilt-inducing stimuli (bathroom, spiders, unlucky numbers, stories, mental images, dizziness, etc.)
R/P - Response Prevention = Preventing ourselves from responding in our typical fashion (avoidance, checking, ruminating, reassurance seeking, etc.) that has contributed to the maintenance of our problem.
The research is very strong that ERP is a sound approach to OCD, anxiety, and phobias. While ERP may sound relatively simple, it can often be very challenging to perform. After all, who wants to voluntarily make themselves uncomfortable? When the common question “So what do I DO during or after my exposure?” is asked, it is often responded to with “Sit with the anxiety/discomfort/uncertainty.” I wholeheartedly agree this is useful, however, it is a bit nebulous. People often wonder how the heck to SIT WITH THE DISCOMFORT.
While I’m not introducing anything groundbreaking or new here, I just want to provide a slightly different way of thinking of ERP - and that is ERE - Exposure and response EXTENSION.
Truly NOT responding to any kind of stimuli is pretty difficult, if not impossible depending on how we define responding. In ERE we may still be responding to the feared stimuli but our response is extended beyond that of our prior response history. For example, instead of trying to just sit with discomfort, I may try to locate that discomfort in my body and describe it.
If you believe in evolution, a very similar process to ERE exists and it is called variation. Let’s look at an example. Imagine a bunch of rabbits living in a woodsy forest. As the rabbits reproduce over time, natural genetic mutations begin to occur resulting in some rabbits having different fur colors, in this case let’s say brown, white, and black. Now we have a lot of rabbits of three different colors, some white, some brown, and some black. Predators are able to identify the white rabbits with ease due to the color contrast with the forest. Eventually, the white rabbits die off in the woodsy environment and the brown and black rabbits continue to reproduce as they are more difficult to identify by predators. The genetic variation resulting in brown and black fur color is what we’re focusing on here. The brown and black colors worked in the woodsy forest but the white color did not (If this were a snowy environment it may be a different story i.e. context matters). If we think of this in terms of OCD and ERP, our typical avoidance/compulsive behaviors are the white-furred rabbits - they are not working effectively enough to be sustainable. Our new response to our trigger is the brown and black-furred rabbit. So what does this look like exactly? In short, it simply means doing something different than we did before. Ideally, this isn’t just something totally chosen at random but rather a varying way to respond to our obsessions and triggers. For example, let’s say I’m terrified of hitting someone with my car and not realizing it. Typically whenever I roll over a pothole (trigger activating obsession/doubt) I either check my rear-view mirror or turn around to make sure I didn’t hit a person (compulsion). In ERE I may just sit with my discomfort, OR I may do one of the following: remind myself why I’m willing to make myself feel so uncomfortable and take what seems like a large risk; listen to a podcast that I have been wanting to listen to but haven’t gotten around to it; say to myself “Yea, that’s possible. We live in an uncertain world”; tell myself I can’t do anything about checking for at least one hour; launching into another type of exposure; and/or breathing into the uncomfortable sensations in my body.
Okay, back to the rabbits. As time goes on and the white rabbits die off and the brown and black rabbits hang around, the variation in brown/black fur color has resulted in what we can call retention. This means that right now in this woodsy forest, these fur colors work to keep the majority of predators at bay so black and brown are here to stay for now.
As someone with OCD progresses through their journey with ERP they may come to find certain exposures and responses to those exposures work and others don’t. That is okay. Our aim is to start responding to our fears differently or not responding to them at all. In time we will see if these variations result in retention, if not, back to the drawing board.
There are some questions we can ask while considering introducing variation. Some are:
Does this new response feel like another compulsion? If so, we may try to make another selection.
What have experts suggested I try?
What has worked in the past?
What has worked for other people?
What’s my best guess?
Does this seem like a step toward recovery?
Is this more uncomfortable than doing my typical compulsion? There is a good chance that it will be. Remember, our aim is not to go without discomfort but to have a new way to respond to it that allows us to live a life more in line with our values and goals.
Again, none of this is new or groundbreaking; clinicians have been working like this with OCD and related afflictions for decades. This article is just meant to provide a slightly different way of looking at ERP, especially if one is stuck focusing on NOT DOING THE COMPULSION. A varied response may even be telling ourselves "I'm not going to do that compulsion because it would strengthen OCD and OCD has caused a lot of pain in my life."
I'll end with a metaphor. Imagine going to culinary school. You start off by learning how to make a basic dish. This dish is great for dinner, but not so great for breakfast or lunch. In time you start to learn new dishes that are good for breakfast and lunch. You eventually start to combine elements from one dish with another, creating brand-new dishes. Now, when you want to prepare a dish or entertain friends, your options in dish selection are greatly improved. Having one way to respond to an obsession is like being able to prepare one dish. This may work for a while, maybe even indefinitely, however, it's usually a good idea to have more than one option.