Exposure and Response Prevention for OCD
Exposure and Response Prevention for OCD
Authored by: Christiana Louisa Ticoalu, M.A., Psychology & Management
Language Editor: Alda Belinda
Clinical Editor: Dr. phil. Edo S. Jaya, M.Psi., Psikolog
A Quick Refresher
What is Obsessive-Compulsive Disorder?
Obsessive-Compulsive Disorder is a mental health condition in which individuals experience the presence of intrusive, seemingly ubiquitous obsessions. Obsessions may be defined as persistent, unwanted and intrusive thoughts and mental images that usually induce feelings of anxiety and distress.
To escape or neutralize the discomfort initiated by these intrusive thoughts, individuals with OCD engage in compulsions. Compulsions may be defined as repetitive, ritualistic mental acts and/or behaviours that individuals feel as though they must perform in response to an obsession. These compulsions typically follow strict rules, or are performed with the intention of achieving a sense of “completeness”.
Some Examples of Obsessions and Compulsions
Obsessions and Compulsions are idiosyncratic in nature. Some examples of obsessive thoughts include:
- I’m supposed to go on holiday next week, yet I have a terrible feeling. I should cancel my trip.
- What if my stomach ache is indicative that I have cancer? What if my previous doctors did not detect my illness?
- Something terrible will happen if I don’t count to a certain number.
- What if I did something awful and I can’t remember I did it?
- Why is he not replying to my text? Does he not love me anymore? Am I not his priority? Has he been in an accident?
- If I go to the kitchen and see a knife, I worry I might lose control and stab myself.
- If I go into the kitchen, there’s a chance I may stab my family.
As previously mentioned, these compulsions are performed to neutralize anxiety-provoking thoughts. Nevertheless, compulsions may or may not relate to the nature of an obsession.
- Repeatedly counting up to a certain number, so one’s mother does not fall ill.
Other examples of compulsions include
- Excessive, ritualistic cleaning, including washing one’s hands, showering or brushing one’s teeth.
- Repeatedly checking and rechecking appliances, switches or locks.
- Arranging and rearranging items several times until it feels “just right.”
- Constant seeking out reassurance that one’s partner loves them.
- Refraining from completing an assignment until it feels “just right.”
Obsessions and compulsions are time-consuming and typically take over an hour of an individual’s day. Otherwise, the condition commonly leads to considerable distress or impairment in everyday functioning. Notably, the symptoms of the condition are not better attributed to other medical or mental conditions, and are not the byproduct of medicine and substances on the central nervous system. Furthermore, these are not symptoms are not better attributed to the effects of withdrawal.
Symptoms of OCD
For a comprehensive list of obsessive-compulsive disorder symptomatology, we recommend you visit the ICD-11 webpage.
What is Exposure and Response Prevention?
Exposure-Response Prevention (ERP) is a form of therapist-guided behavioural therapy that involves systematic, repetitive, and prolonged exposure to things, be it tangible or situational, that provoke obsessional fear.
Importantly, ERP does not remove the anxiety-inducing situation but serves to provide individuals with the necessary skills to confront and cope with the situation, thus diminishing and eventually negating the need to engage in compulsive behaviours.
As such, the habitual cycle of relying upon compulsive behaviours to overcome obsessive thoughts and situations is gradually broken.
In vivo exposure: ERP works through measured, repeated exposure to real-world, low-risk, situations that have historically caused anxiety in individuals. As an example, someone with Contamination OCD, who would ordinarily not be comfortable utilizing public seating without an excessive amount of sanitizing beforehand, is instructed to sit in a public arena without performing any acts of deep cleaning prior to being seated. Another example includes individuals who feel compelled to double or triple-check that their door is locked upon leaving the house, may be tasked with locking it once, and directed to walk away.
Imaginal exposure: ERP may also work through imagined confrontation with feared consequences. For instance, someone with Morality OCD who is not comfortable with lying may be asked to write exposure sentences regarding lying. Imaginal exposure triggers may include “I have lied so many times, I am a liar. People hate me”.
How it works
According to a review by Abramowitz (2006), three mechanisms are involved in breaking the vicious, self-perpetuating, cycle between obsessions and compulsions: behavioural mechanisms, cognitive mechanisms, coupled with a change in self-efficacy.
Repeated exposure to anxiety-inducing situations promotes habituation: a decrease in conditioned obsessional fear.
ERP also promotes the extinction of conditioned anxiety. This occurs when the distress-provoking thoughts, images, or urges, are repetitively paired with the non-occurrence of feared consequences.
ERP challenges the prevalent dysfunctional beliefs that underpin obsessions and perpetuate compulsive symptoms (for instance, responsibility for harm or overestimating threat).
For instance, once an individual is exposed to a situation of escalating anxiousness, yet chooses not to engage in compulsive behaviours in response, gradually, the urgency and need to rely upon compulsive behaviours to overcome the initial anxiety diminishes. This, optimally, will eventually negate the need for reliance upon compulsive responses altogether.
After repetitively observing that initially feared consequences do not eventuate in the absence of compulsive responses, the patient becomes more equipped to handle any future anxiousness. Over time, the patient realizes that the compulsions are redundant and no longer necessary.
Improvement in self-efficacy
ERP facilitates patient self-efficacy. Individuals develop the ability to gradually and consciously exert control over their feared thoughts. Further, they develop the ability to endure intrusions without feeling the need to resort to the former coping mechanisms or safety behaviours (compulsions).
Tailored Treatment Plans
At IndoPsyCare, we formulate treatment plans on a case-by-case basis. Contingent upon your condition and situation, your therapeutic journey may or may not include a variation of the following components:
Your therapist may administer assessments at various points throughout your therapeutic journey. This is done as a way of assessing your improvements and thus the effectiveness of the treatment plan. When treating obsessive-compulsive disorder, our clinicians typically administer the Yale-Brown OCD Scale II (YBOCS-II), the Obsessive Compulsive Inventory-Revised (OCI-R), and the Florida Obsessive-Compulsive Inventory (FOCI). Nevertheless, we ask that you please keep in mind that assessments may vary depending upon your specific condition.
During this stage, your therapist may provide you with information regarding your condition including its prevalence within the population, and the symptoms other individuals with the condition commonly experience. Further, they may seek to enhance your understanding of the way in which the condition is treated including the rationale of the therapy and its components. Additionally, your therapist might inform you of the reasons why this therapy is undertaken and how it is an important aspect of your roadmap to recovery.
You and your therapist might collaboratively develop an “exposure hierarchy” or “anxiety ladder” that comprises a list of anxiety-provoking things, places and situations. Further, you might collaboratively rank situations based on SUDs (Subjective Units of Distress) from least to most distressing.
This technique allows therapists to identify safety-seeking behaviours that are only situationally activated. During this stage, your therapist might guide you through the process of graded exposure. This means you might be required to systematically confront your items on your exposure hierarchy, commencing with those that provoke minor anxiety and working your way up toward those that provoke the most anxiety within you. Depending upon your situation, this may involve the incorporation of both in-vivo (in real life) and imaginal exposure.
Successful therapy requires active participation on your part. Your therapist might ask you to complete homework assignments between sessions, wherein you will typically be tasked with self-exposure. Specifically, you might be assigned tasks designed to provoke obsessional anxiety whilst attempting to abstain from compulsive behaviours to the best of your ability. In the sessions that follow these assignments, you will discuss the extent to which you were able to resist compulsions, and how you felt when doing so.
Breaking the Vicious Cycle
Through repetitive and prolonged exposure, it will hopefully become increasingly apparent that any anticipated, harmful consequences do not occur as feared. Thereby, this will hopefully disconfirm your dysfunctional beliefs. Further, this will lead to the aforementioned extinction, wherein the association between obsessions and compulsions is gradually broken. Over time, the need to perform compulsions in response to intrusive thoughts will be greatly diminished or, hopefully, altogether negated.
During this phase, your therapist will likely reinforce your understanding of the strategies you have learned, including when and how they should be implemented. Furthermore, your therapist may equip you with the skills to recognize your own personal warning signs. It is essential that you understand these warnings so you can seek timely assistance from your therapist who will re-address your recovery treatment plan.
How many sessions will I need?
Every patient is unique, thus it depends upon your personal situation.
The number of sessions you require is typically influenced by:
- The severity of your symptoms
- Existing comorbidities (co-existing conditions)
- The length of time you have been experiencing your condition
- Your personal motivation and progress
- Your social support network
Making the Most of Therapy
Asking for help is commendable
Asking for help is understandably difficult, thus reaching out is a testament to the strength of each individual who does so. A call for help should never be seen as a sign of weakness, as it is the first step in your journey to recovery. Although sometimes uncomfortable, sharing your vulnerabilities with the right people may provide an appropriate, timely, and forthright avenue through which your problems can be assessed and addressed.
Be open and honest
Think of therapy as a journey in which you are steering the ship; your therapist is your guide, navigating the journey based on your account of what you see and experience. Reaching your desired destination and goals will be acquired with more proficiency when you share your feelings and fears. As your therapist acquires a clearer understanding of the intricacies of your situation, he or she will be in a better position to guide you in the right direction.
You will not see change overnight. True, lasting, cognitive and behavioural change takes time. Therapy is not a “quick fix”, rather it requires patience, consistency and tenacity on your part. Allow yourself time, communicate with your therapist, and share your feelings if you feel you are losing sight of your destination.
Trust the process
More often than not, improving your condition requires you to go beyond your comfort zone, letting go of your maladaptive coping strategies. Trust that, whilst this process may inevitably become uncomfortable or difficult at times, temporary discomfort may bring long-term and lasting benefits.
A Gentle Reminder
We sincerely appreciate your dedication; you have made it through this page of our library. We trust that you have gleaned valuable information from this page. Before we part ways we would like to reiterate that each treatment plan will be uniquely tailored to you, your situation and your requirements. Your personal treatment plan may or may not include the elements on this page.
If you feel as though you require professional assistance, please refrain from self-diagnosis. IndoPsyCare has professionals who are here to help.
Resources and Recommended Readings
We would like to emphasize that the information presented herein was derived from external sources. IndoPsyCare does not claim ownership of any information or research within these pages. For your convenience, our team has constructed a list of the sources utilized and included further research and reading.
Abramowitz J. S. (2006). The psychological treatment of obsessive-compulsive disorder. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 51(7), 407–416. https://doi.org/10.1177/070674370605100702
Franklin, M., & Foa, E. (2011). Treatment of Obsessive Compulsive Disorder. Annual Review Of Clinical Psychology, 7(1), 229-243. doi: 10.1146/annurev-clinpsy-032210-104533
Pérez-Vigil, Ana; Mittendorfer-Rutz, Ellenor; Helgesson, Magnus; Fernández de la Cruz, Lorena; Mataix-Cols, David (2018). Labour market marginalisation in obsessive–compulsive disorder: a nationwide register-based sibling control study. Psychological Medicine, (), 1–10. doi:10.1017/S0033291718001691
Pérez-Vigil, A., Fernández de la Cruz, L., Brander, G., Isomura, K., Jangmo, A., Feldman, I., Hesselmark, E., Serlachius, E., Lázaro, L., Rück, C., Kuja-Halkola, R., D’Onofrio, B. M., Larsson, H., & Mataix-Cols, D. (2018). Association of obsessive-compulsive disorder with objective indicators of educational attainment: A nationwide register-based sibling control study. JAMA Psychiatry, 75(1), 47–55. https://doi.org/10.1001/jamapsychiatry.2017.3523
Schwartzman, C. M., Boisseau, C. L., Sibrava, N. J., Mancebo, M. C., Eisen, J. L., & Rasmussen, S. A. (2017). Symptom subtype and quality of life in obsessive-compulsive disorder. Psychiatry Research, 249, 307–310. https://doi.org/10.1016/j.psychres.2017.01.025