Golden Gate Psychotherapy

John "Andy" Bradshaw

Exposure and Response Prevention

People with OCD perform compulsions to temporarily relieve themselves of the anxiety they feel about their obsessions. A person with contamination fears, for example, may wash their hands repeatedly and perform other cleaning rituals. While this temporarily reduces their anxiety about germs, in the long run it causes their OCD to get worse.

One approach shown to be effective in helping people overcome this cycle of obsessions and compulsions is called “Exposure and Response Prevention” (ERP). Considered the “gold standard” for OCD treatment, ERP is fairly straightforward: The person with OCD exposes themselves to situations that trigger obsessive thinking and doesn’t allow themselves to perform a compulsion in response. While this sounds simple, it does require the person with OCD to face their fears and tolerate a fair amount of anxiety and uncertainty to overcome their OCD.

“In vivo” Exposure: With this approach, the client confronts situations that trigger their obsessions in real life. A person who has to have their desk arranged in a certain way, for example, may be asked to keep their desk in disarray. A person with fear of germs may be asked to use a public toilet or keep their hand on a dirty doorknob for an extended period of time. In vivo exposures will likely cause the client’s anxiety to increase initially, but with time and repetition, their distress level and urge to perform a compulsion in response will decrease.

Imaginal Exposure: With this approach, the person with OCD imagines in detail any thought or situation they find distressing. A person who repeatedly checks the locks on their front door, for example, might imagine a scenario in which they accidentally leave the door unlocked and their house is robbed. Many therapists ask their clients to make a short recording describing the situation (1 – 2 minutes) and have them listen to it over and over again. While listening to the recording will trigger the client’s anxiety initially, the more they listen to it, the more the client will learn they can tolerate the ensuing distress. As the client becomes habituated to their fear, their anxiety about it and need to perform a compulsion in response will drop.

Fear Ladders: Many therapists ask their clients to create a “Fear Ladder”, listing all situations or thoughts that cause them distress. The client rates each situation/thought on a scale from 1 to 10, with a 1 being the least anxiety-provoking and a 10 being the most anxiety-producing. After reviewing the list with their therapist, the client starts at the bottom of the ladder, facing their least-anxiety provoking fears first. Once they’ve learned they can tolerate the distress associated with those situations, they slowly move up the ladder, exposing themselves to increasingly challenging thoughts and situations.

Some tips while doing ERP:

Practice mindfulness: Mindfulness means being aware of and accepting what’s happening right now in the present moment. This can be very useful during exposure exercises. By acknowledging and accepting the distress you feel when facing obsessive fears (without fighting it), the easier it can be to resist performing your compulsions.

Avoid reassurance seeking: When you’re anxious or fearful, it’s natural to want someone to reassure you and tell you that everything is OK. While that reassurance may reduce your anxiety in the short run, in the long run it makes your OCD worse: You’re sending yourself a subconscious message that your fear is too much for you and that you must be reassured when faced it. Rather than seeking reassurance, remind yourself that you can tolerate the anxiety that comes with facing your fears, and that by doing so, you’re becoming healthier and stronger in the long run.

Lean into the anxiety and discomfort: Don’t resist it. Embrace it if you can. The more you fight anxiety, the stronger it gets.

Tap into your values: Think about what’s truly important to you and remind yourself of those values when practicing ERP. For example, if being a good granddaughter is important to you, remind yourself of that and don’t let your fear of germs and public transit keep you from visiting your grandmother. You can use your values as motivation when exposing yourself to obsessive fears.

Pay attention to your thoughts and feelings and process them afterwards: Discuss what came up for you during your exposures with your therapist afterwards. This can lead to important insights that will be useful for future exposures (e.g., “My anxiety was high for the first 10 minutes, but it dropped after that.” or “It wasn’t as bad as I expected.” or “The more I did it, the less scary it was.”) You can also journal about your ERP experiences or talk with a trusted friend about them.

John “Andy” Bradshaw, Licensed Marriage & Family Therapist #121313, focuses on the treatment of OCD and anxiety at Golden Gate Psychotherapy. You can contact him at (510) 599-9845 or andybradshawtherapy@gmail.com.

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