Types of Exposure You Might Experience in ERP Therapy for Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is characterized by recurring intrusive thoughts and repetitive behaviours that attempt to alleviate distressing thoughts. Exposure and response prevention (ERP) is a therapy technique that has been found to be effective in treating OCD, which involves in part working to safely expose the patient to feared stimuli in a way that supports them to build up their tolerance to that stimuli, and reframe their related thoughts and fears. This exposure can be done in two ways: through in vivo exposure and imaginal exposure.
What is OCD?
OCD involves two components of distress: obsessions and compulsions. Obsessions refers to a difficulty in managing persistent thoughts, ideas, and images that induce anxiety. Compulsions refer to a push to act on these distressing thoughts in attempt to reduce them through repetitive behaviours. Compulsions can also be referred to as rituals and are similar to avoidance, such that, they prevent an individual from disconfirming their erroneous beliefs. Particularly, when exposed to a feared stimulus, one believes they are in a harmful situation.
Symptoms that can be connected to a diagnosis can include the following: the individual attempts to resist any unwanted cognitions and/or urges either through suppression or compulsions; the individual intends to use compulsions to prevent or thwart fear, yet, the behaviour occurs in excess and are unrealistic in preventing a perceived threat; the obsession or compulsion is time consuming, causes vast distress and/or impedes with functioning on an individual and/or social level; finally, symptoms are not attributable to substance use or other mental disorders
Types of Exposure in ERP
ERP can help people suffering from OCD recover through two forms of exposure: in vivo exposure and imaginal exposure.
In vivo exposure begins with exposing the patient to the feared stimuli to disprove their erroneous beliefs and recognize the anxiety they are experiencing will not continue indefinitely. Exposure then disproves the patient’s belief that catastrophic consequences can occur if a ritual is not performed in anticipation of encountering the feared stimuli. Finally, patients learn to tolerate the uncertainty of future catastrophic consequences. An example could be supporting a patient with contamination OCD to build up to touching things like door knobs, trash cans or light switches without then following up with engaging in rituals (such as hand washing or getting immediate reassurance).
Imaginal exposure is the second form that is typically used when there are legal and ethical considerations, or perceived real danger in the situation. This can also be used if in vivo exposure is too activating of a place for a patient to start. Imaginal exposure helps modify fear structures by having the patient repeatedly imagine the feared events and disconfirming the belief that the fear and anxiety will pro-long, like in vivo exposure. Next, patients recognize, as the tendency to think about catastrophic events increases and anxiety reduces, they are less likely to participate in fear evoking behaviours. Finally, patients are taught to challenge the belief that thinking about disastrous consequences will result in them coming true. In this case the patient with contamination OCD might instead imagine touching the contaminated surfaces, and sitting with the discomfort or fear that comes up without imagining or acting out their safety rituals after.
The final component to these interventions will be the emotion processing that occurs during or after both types of exposures. This helps patients reflect on the stimuli they have been exposed to and modify any other resulting unhelpful thoughts or interpretations that come up for them in relation.
If you or someone you know is looking for more information on treatment for OCD or wants to explore ERP, reach out to our office to see if we have a clinician who can fit with your needs. We have therapists with a variety of specialties available, including use of ERP for OCD.
About the Author
Kirusana Ravindran is an Intake & Administrative Assistant at GWTC, while also completing her Bachelor of Science in Mental Health Studies at the University of Toronto with plans to pursue graduate school in psychotherapy.