Exposure Therapy for OCD: Exposure and Response Prevention (ERP)

Learning to gradually face your fears is one of the most effective ways to break the OCD cycle. For OCD, the technique for facing fears is called exposure and response prevention (ERP).

ERP is done by:

  • Exposing (E) yourself to situations that bring on obsessions (triggers)
  • Not engaging in the unhelpful coping strategies that include compulsions or rituals, and avoidance (Ritual Prevention- RP)

Step 1:  Get to know your OCD better

  • To face your fears, it is helpful to know what you are thinking (your obsessions) and identify the triggers that bring on your obsessions and compulsions.
  • You can do this by keeping track of the triggers on a daily basis for 1 week by using the Obsessive Fear Monitoring Form.
  • Because obsessions can happen frequently, writing down 3 triggers per day (e.g. 1 in the morning, 1 in the afternoon, and 1 in the evening) will be enough to give you a good overview of your obsessions and compulsions.
  • In the column labeled “Fear”, rate how intense the fear was in the specific situation. Use a 0-10 rating scale, where 0 = no fear and 10 = extreme fear.
  • Finally, record all the compulsions/coping strategies you used in response to the obsession. Be sure to include both behavioural and/or mental strategies you used to manage the obsession and fear.

 

Here's an example to help you out

Date

Triggers for Obsessions
(specific situations, objects, people, or thoughts that provoke obsessive fears)

Obsession

Fear 
(0-10)

Compulsions/
Coping Strategies

Nov. 30

Used the grocery store pen to sign the credit card receipt.

This pen is covered with germs from strangers. I could contract some terrible disease and pass it on to my children, causing them to be sick.

8

Scrubbed each finger carefully and washed for 3 minutes.

Try to make an entry as soon as possible after the episode as this will help you to be more precise. You may want to keep a small notebook with you that you can easily carry around.

Step 2: Build a fear ladder

  • After about 1 week of tracking your obsessions and compulsions, you will be ready to make a list of all the different situations that you fear.
  • Build a fear ladder by rank, ordering your triggers from least scary to most scary. For example, if you have contamination fears, being at a friend’s apartment may be a situation that is low on the fear ladder because it only evokes a fear of 1/10. But using the bathroom in a shopping mall may be a situation that is very high on the ladder because it evokes a 9/10 fear. See Examples of Fear Ladders for some ideas about building your fear ladder.

 

TIP: Build a separate ladder for each of your obsessive fears. For example, you may need a separate hierarchy for all situations related to your fear of contamination. You may also need a separate ladder for all situations related to your fear of causing something terrible to happen.

Step 3: Climb the fear ladder – ERP

  • Once you have built a fear ladder, you are ready to face your fears by putting yourself in situations that bring on your obsessions (exposure), while resisting doing anything to control the obsessions and the anxiety associated with them (response prevention).

KEY POINTS TO MANAGING YOUR OCD (see Facing your Fears: Exposure for more tips):

 

  • Bottom up. Start with the easiest item on the fear ladder first (i.e. fear=2/10) and work your way up.
  • Track progress. Track your anxiety level throughout the exposure exercise in order to see the gradual decline in your fear of a particular situation. Use the Facing Fears Form to help you do this.
  • Feeling anxious when you try these exercises is a sign that you are on the right track. If you’re not anxious you might be too low on your ladder, and if you are feeling flooded with excessive anxiety, chances are you started too high up on the ladder. Remember that regardless of how intense your fear is, it will peak and then level off. What goes up must come down! Even if you do nothing about it the fear will eventually go away on its own.
  • Don’t avoid. During exposure, try not to engage in subtle avoidance (e.g. thinking about other things, talking to someone, touching the doorknob only with one finger instead of the whole hand, making mental promises to de-contaminate later on, etc.). Avoidance actually makes it harder to get over your fears in the long term.
  • Don’t rush. It is important to try to stay in the situation until your fear drops by at least half (e.g. from 6/10 to 3/10), or until you notice a significant reduction from your fear at the start (e.g. from 7/10 to 4/10). Also, focus on overcoming 1 fear at a time. It is a good idea to do the exposure repeatedly until the first item on the hierarchy no longer causes much of a problem for you.

Engaging in Response Prevention

  1. Resist the urge. In order for exposure to work, it is important that you try to resist, as much as possible, carrying out your compulsions during or after the exposure. The whole point of ERP is to learn to face your fear without having compulsions.
  2. Modeling. If you have been performing compulsions for some time, it may be difficult to know how to face a feared situation without doing them. In this case, it can be helpful to ask a family member or a close friend who does not have OCD to show you how to, for example, wash hands quickly or leave home without rechecking appliances, and then model, or copy, their behaviour.
  3. Delaying and reducing ritualizing as an alternative. You might find it very difficult to completely resist a compulsion, especially the first time you are facing your fears. In that case, you can try to delay acting on the compulsion rather than not doing it at all. For example, after touching the floor (exposure), wait for 5 minutes before washing your hands, and wash for 1 minute instead of 3 minutes. Try to gradually prolong the delay, so that you can eventually resist the compulsion altogether.
  4. Re-exposure. If you do end up performing a compulsion, try to re-expose yourself to the same feared situation immediately, and repeat the practice until your fear drops by half. For example, Practice 1: touch the floor and wait for 5 minutes before washing hands for 1 minute. Practice 2: touch the floor again immediately after washing, and wait for another 5 minutes before washing for 1 minute. Repeat this process until your anxiety drops from, say, 6/10 to 3/10.

 

How to move on. Once you experience only a little anxiety when completing an exercise, you can move on to the next one. For example, after several practices, you might feel very little anxiety when you wait 5 minutes to wash your hands after touching the floor. You can then challenge yourself to wait for 8 minutes before washing your hands after touching the floor. Again, repeat this practice until your anxiety drops by half or is significantly reduced from where it was at the start.

REMEMBER: It is OK to ask for help. Talk to a supportive person when you have the urge to perform a compulsion and are afraid that you can’t resist. Ask this person to stay with you or to go somewhere with you until the urge decreases to a manageable level.