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Exposure with Response Prevention
Exposure with response prevention (ERP) is a form of behavioral therapy that involves gradually confronting a feared situation while resisting compulsions. Compulsions are behavioral responses aimed at getting certainty about an obsession and relief from discomfort. An obsession, such as “I might be contaminated” could be responded to with a compulsion like excessive hand washing. ERP for this would involve engaging in behaviors that make the sufferer feel “contaminated” (e.g. touching a public surface) while resisting the urge to wash. Over time, two things occur. The compulsive hand washer in this example begins to habituate to the discomfort (meaning, the pain associated with feeling contaminated diminishes), and the brain learns to separate the feeling of contamination from the demand to wash.
ERP begins by establishing a hierarchy of triggering situations, with exercises addressing the easiest first and then working up to more challenging exposures during the course of treatment. Many exposures can be “in vivo,” meaning they involve literally being in the presence of a fear (being near or touching a triggering item, visiting a triggering environment, engaging in a triggering behavior). When in vivo exposures are not feasible, imaginal exposures can be employed, which involve writing exercises that elicit the feared state of mind combined with resisting reassuring or neutralizing mental compulsions.
ERP is a collaborative process wherein the therapist and client work together to establish a treatment plan that runs at a pace that will be challenging, but tolerable and effective. An OCD therapist will never ask a client to engage in a behavior that is dangerous, that they themselves will not engage in, or that violates religious or moral beliefs. However, exposures are designed to be challenging and induce discomfort, so part of ERP treatment involves the therapist and client working on motivational issues as well. Exposures are typically practiced first in the therapy session and then assigned as daily homework.