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In almost every podcast episode, I mention the therapeutic intervention Exposure and Response Prevention, or ERP.
This is the evidence-based treatment proven to be effective in helping people get freed from the tyranny of OCD.
In this podcast series I would like to help you understand what ERP is, how to works, and why it’s so effective. I’ll share a touch of neuroscience, but you will easily follow along!
I recently spoke with a man Joe who was telling me his OCD story. He said that for years he lost hours each day to his obsessions and compulsions. He was sick of it. He wanted to do the things that he missed—like the simple pleasure of getting together with friends. He wanted to get his life back.
He told me he spent years going from therapist to therapist, and even tried taking medication. He said that nothing helped. He thought that some of his treatment just made things worse.
Then I noticed a smile cross Joe's face. His body visibly relaxed. He said, “Then I found ERP. It changed my life. Here’s the best way I can describe ERP. I play basketball. I had spend years playing defense with OCD. ERP has me playing offense—and winning! For years OCD talked trash to me. With ERP, I’m talking trash right back. I l f’ing love ERP. It works.”
Human Brains and OCD
Before we talk about ERP, let’s review what we know about human brains and OCD.
In a sense, people get imprisoned by OCD because of how they draw the line between what’s safe and what’s dangerous, and how they respond to perceived danger.
Our human brains are obsessed with the question, “Am I safe?”
When homo sapiens first walked the planet 300,00 years ago we were both predator and prey.
We have an ancient sophisticated system for identifying danger and taking action to get back to safety.
Here’s an example that shows how this plays out in real life.
One day I was on the couch reading a book when I heard my cat growl. I look up to see him standing near the glass back door “Making Halloween” He was standing sideways, and his his fur was up. His ears were flat against his head, and his swishing tail reminded me of the rattle of a rattle snake.
I looked outside to see what who or what was in the yard. I saw the neighborhood stray cat near the planter of catnip near the back door. My guess is that she came to the yard for the catnip, and the two cats saw each other.
Let me just say that these two cats have bad blood. They’ve literally gone at each other and drawn blood before.
At this moment, the stray cat was hunched down and motionless. It’s like she was trying to make her small and maybe even invisible.
My cat saw her, all right. He swatted at the glass door with his unsheathed claws. Then stray unfroze and ran away.
My cat watched her climb up and over the fence.
Once he was certain that the interloper was gone, his hair went down and her ears stood up. He shook his body like a dog shaking off water after a bath. Then my cat groomed himself and settled back in for his nap.
These two cats both detected danger. Their amygdalas, the danger detector, sounded and their bodies reacted to return to safety. All of this happened without a single conscious thought.
The autonomic nervous system is always active. It controls all the functions that keep you alive like your heart rate, respiratory rate, digestion. When you’re running, you don’t need to tell your heart, “Speed up and deliver more oxygen” it does it automatically. The nervous system has a gas pedal to rev things up and a brake to slow things down.
The nervous system creates three distinct physiologic states, and the cats demonstrated all three.
Before the stray came into the yard, my cat was enjoying a nap in the sun. He knew he was perfectly safe. The is where he spent most of his time. The gas and the brake of the nervous system were balanced. He’s balanced. That’s the first nervous system state.
The sight of the stray cat triggered my cat’s danger response. The nervous system changed to a revved up state to prepare to fight—and win. I could physically see his body’s changes. I could not see his hear rate quicken, or his blood being diverted from this digestive tract to the muscles that would help him fight.
The stray began in the balanced zone of safety. The sight of my cat making halloween triggered the stray’s danger alarm. Initially this cat decided to put on the brake instead of the gas. She crouched and froze. When she saw that was not working, her nervous system put on the gas and ran away.
These are the three physiologic states determined by the autonomic nervous system: balanced in the zone of safety, revved up and slowed down.
Let’s get back to Joe and see how this applies.
Joe remember his first obsession. He said that as he was crossing a floating bridge on his commute to work, he thought, “I’m going to drive my car off the bridge.” He said, “You know those bouncing lotto balls that spits one out. It’s like my brain spit out this thought. I wasn’t\t depressed or suicidal. I knew I wouldn’t drive off the bridge intentionally”
Many people have thoughts like this. Most people say, “That’s a crazy thought” dismiss it and go on with their days.
Joe would have loved to move on, but that’s not what happened. Joe’s his brain kept on returning to the thought he would drive off the bridge.
Intellectually Joe knew that he would not drive off the bridge.
Still he had a nagging doubt. One day could he or would he drive off the bridge? Maybe he reaches for his glasses in the cup holder and drives off the bridge. Maybe one day the bridges would be ice and he would slide off
The obsessive thought, “I might drive off the bridge” created high levels of anxiety. He went into the revved up state.
He noticed his body’s changes—the racing heart and the sweating pals—and used that as evidence that it really was unsafe to drive on the bridge. this reinforces the thought that he is at risk of driving off the bridge,
His big fear was that he would leave his wife a widow and his children fatherless.
The anxiety he experienced when he had this thought was so intensely unpleasant he needed a break. He said, “it feels like I am going to die.”
He learned that he would get temporary relief from the anxiety by saying a specific poem forward and backward. But then the cycle would repeat. His obsession popped into his heard and he experienced the high level of anxiety.Each time he went to the high level of anxiety . However, to get relief he needed to repeat the poem two then five then 10 times. Some times he wasn’t sure if he said the poem exactly right, so he stared from zero again.
Joe got tired of the obsessions and compulsions. He decided to avoid them by driving around the lake instead of taking the bridge. This added an extra half hour to his commute.
Someone with OCD needs the certainty of safety. Short of the absolute certainty of safety, danger lurks.
Joe could not tell himself with absolute certainty that he would not drive off the bridge. Maybe one day it will be ice and he would drive off.
He estimates that his obsessions and compulsions consumed between two and three hours each day.
He wanted that time back.
ERP is the therapeutic intervention that finally helped do just that.
ERP stands for exposure and response prevention.
Here’s what it’s about. Within the context of a trusting therapeutic relationship, a person with OCD agrees to set up situations in which they feel the intense anxiety. Instead of performing the compulsions, they agree to stay present and fully feel the anxiety while resisting the urge to do the compulsion.
Over time, with repeated exposures to the same circumstances, the anxiety decreases.
ERP is not about making anxiety better by practicing relaxation techniques. In fact, anything that treats the anxiety can make ERP less effective. Instead it gives the person the experience that the anxiety wil subside on its own. The feeling of anxiety is nothing to fear.
The first few sessions with a trained therapist can be planning session. The therapist and person with OCD make a list of the things that set off the anxiety. These will become the exposures. Then the person with OCD assigns an anxiety score to each exposure. The exposures are then ordered based on the anxiety score. The first exposures that are taken on have the lower scores. As the exposures are repeated, the anxiety score decreases.
You might be wondering, “Why would somebody intentionally put themselves in situations in which they KNOW they will feel anxious.
The answer is that ERP gives them their lives back. They don’t want to invest the hours with their obsessions and compulsions. They want to skip the thirty minute rituals before they leave the house. The3y want to drive over a bridge, or even recapture the freedom to travel because they learned it’s safe to use bathrooms that are not in their homes.
The truth is that the obsessive thoughts and the anxiety will always be there. However, once treated, a person with OCD learns to tolerate obsessive thoughts and low levels of anxiety. It’s like being able to enjoy a summer day even thought there are mosquitoes buzzing around your ears.
Over time obsessions can change themes. Compulsions change. However, in the end, OCD is caused by the same common pathway: where is the line between safety and danger? ERP can be used, no matter what the thought.
Why is ERP so effective? This still being studied, but I have some ideas.
ERP requires that the person with OCD witness their thoughts and feeling and sensations in their bodies. There’s a difference between saying, “I’m so anxious I think I will die” and “My anxiety score is 3 out of 10.” When you witness your feelings, they have less power.
The zone of safety —one of the three physiologic states created by the autonomic nervous system—may be increased over time.
The amygdala, the body’s danger detector, recognizes patterns. I wonder if the repeated exposures to anxiety-producing circumstances train the amygdala that patterns are safe. After all, the brain is neuro-plastic. It can grow and change.
I don’t kneed to know how my smart phone works to do the things I want it to do.
In the same way, we know ERP works.
Here’s the best news. If you are interested in learning more, you can go to NOCD and find and ERP therapist. I’ll leave a link.
Please feel welcome to leave your thoughts or comments.