Exposure and Response Prevention: An Analogy
Exposure & response prevention (ERP) is like an exercise program for your brain.
Exposure and Response Prevention (ERP)
Exposure and response prevention (ERP) is just like a fitness program for your brain. However, instead of shaking up your fitness level, it’s designed to shake up stubborn OCD symptoms. Let’s expand on this analogy.
Reasons for Doing Exposure and Response Prevention (ERP)
People don’t adopt fitness routines for no reason at all; physical exercise is not a random activity. We don’t accidentally buy gym memberships or wake up on treadmills. Exercise is always purpose-driven and typically is intended to improve one’s quality of life in some quantifiable way. Common goals for exercising are related to health, aesthetics, or the feelings it evokes.
Treatments like exposure and response prevention (ERP) are also intended to enhance your life in a meaningful way. Just like with exercise, your ERP efforts will be driven by your own personal motivators. Maybe you want to spend less time on your rituals so that you can be living more deliberately and less reactively. Perhaps OCD has caused your world to shrink, and you want to take it back. Maybe you’re motivated to fight OCD so that you can be a better parent or spouse. Maybe you simply want your days to be filled with more fun and less panic.
These reasons form the basis of your recovery plan.
If these reasons don’t exist for you…if you’re doing treatment for someone else rather than for yourself, the road will be difficult. In order to be able to sustain effort through challenges, you will have to identify personal motivators that are meaningful to you.
Just like with physical exercise, your ERP has to be purpose-driven or you will lose your momentum.
This analogy can be taken even further.
Exposure therapy is not a singular activity.
Physical exercise is often based around targeting a particular muscle group or certain aspect of health. People who want big biceps do different exercises than people who want to lose weight.
This is similar to exposure and response prevention therapy. People who want to be less bothered by unwanted thoughts (e.g., thoughts of hitting someone with your car) do different exposures than someone who is afraid of contracting a deadly disease. The form of the “exercise” reflects a specific therapeutic goal.
You can target your OCD symptoms in multiple ways.
People who want to work on their abs might consider crunches, leg lifts, push-ups, etc. In ERP, there is no one exposure that will help you get better. Instead, there is an array of options that might work for you. Develop your treatment plan deliberately and thoughtfully on the basis of your OCD symptoms.
Exposure therapy is based on a hierarchy that builds skills over time.
Physical exercise is hierarchical. If you want to get stronger, it’s smart to start with light weights and build up to heavier ones. It would be downright dangerous to attempt a 500lb bench press without proper training. In ERP, going for that “10″ on your hierarchy is ill-advised at the beginning of treatment. Before going there, you need to lay the proper groundwork first. A gradual approach might take more time, but it will get you to the destination without subjecting you to unnecessary injuries.
Like any exercise, ERP will make you “sore” at first.
If you’ve ever started a personal fitness program, you know that the first few days or weeks of a new routine can be downright painful. It’s common to feel aches and soreness in muscles that you didn’t even know you had. If you’re unaccustomed to exposure and non-avoidance, early exposures might feel especially challenging. However, like any exercise program, the soreness associated with exposure and response prevention will decrease with practice and give way to increased mental and behavioral flexibility.
Therapists, like trainers, have different styles.
Not everyone is a drill sergeant. The best trainers will listen to you, work with you, and try to understand where you’re coming from. They’ll then use their expertise to design an individualized plan for you that is based on your goals, preferences, and unique perspective. The best therapists I know follow this same approach to treatment. If you’re completing an exposure under duress, you’re unlikely to benefit from it. It’s the process of choosing to face your fear (and willingly embracing the uncertainty that comes with it) that leads to lasting recovery.
ERP is a personal journey.
Even the best trainer in the world can’t do the work for you. The success you will have in your therapy depends on the amount of time and effort you invest in the process. The right support system can be critical to your success, but ultimately there is no substitute for hard work. Own the process of treatment.
Progress in treatment requires consistent day-to-day effort in addition to your scheduled therapy sessions.
If you go to the gym only once a week, you will never look like a champion bodybuilder. Large investments of your time will result in significant gains, whereas small investments may yield little (if any) benefit. For you to reach your treatment goals, you must prioritize your recovery and keep exposure time from getting swallowed by life’s hectic pace. This means putting forth effort even when you don’t feel like it.
SSRIs can be helpful, but they are not a substitute for therapy.
Protein may fuel muscle growth, but it’s unlikely to yield any significant benefit if it doesn’t accompany behavioral changes like exercise. Similarly, “supplements” like SSRIs can be helpful, but you shouldn’t consider them a “magic bullet” that will eliminate your OCD with no effort on your part.
Treatment effects can generalize.
The squat is considered the “king” of lower body exercises, because it results in a flood of human growth hormone that can stimulate muscle development in other body areas. Exercises like squats have the potential to pay whole-body dividends. Similarly, solid exposure and non-avoidance skills transcend the specific symptom area you’re targeting. Once you understand the process of exposure and response prevention, you develop core skills that go beyond your immediate treatment goal and result in generalized improvement.
Exposure and response prevention (ERP) is based on human physiology.
If you visit your doctor and ask what you can do to build muscle and strength, he or she will recommend exercise. If you ask your doctor for alternative strategies for muscle development, he or she would be pretty hardpressed to come up with a list of effective alternatives. Exercise works because it’s based on human physiology. There’s no real substitute for exercise when it comes to muscle growth and development.
So, too, for exposure. Exposure is one of the only evidence-based treatments for OCD. Exposure and response prevention works because it capitalizes on human physiological processes like habituation. What causes ERP to fail sometimes? It’s often not ERP itself that fails but rather that the treatment wasn’t delivered in an effective way. For example, important factors might go overlooked when developing your treatment plan. This might cause you to select exposures that target the wrong “muscle” groups. Of course, other likely causes for treatment non-response are issues related to the consistency or form that exposures take. This is one of the reasons why it’s helpful to have a therapist oversee treatment and provide feedback.
Rituals are like junk food.
If you’re doing exposure in one moment and ritualizing the next, it’s a bit like going to McDonald’s after your workout. You might think you’re getting thinner, but you might actually be gaining weight. Rituals will sabotage your efforts. It’s important to adopt a philosophy of living that incorporates consistent response prevention.
Recovery is not an endpoint; it’s a lifestyle.
Although you might accomplish your specific goals related to fitness, in order to maintain the gains you’ve made, you need to figure out how to incorporate exercise in your daily life. The same principle is true for exposure.
Exposure therapy is not a strategy to be set aside after reaching your therapeutic goals. Instead, it’s a technique that you want to integrate into your day-to-day lifestyle. Moreover, just like exercise, there will likely be times when you’ll need to increase the frequency or intensity of your exposures. Just as many people up their exercise after the holidays, so too will you have to dial up your exposures during periods of stress or change.
Questions? Comments? What strategies do you use to maintain your fit brain?