ERP Therapy Explained: The Truth About Facing OCD Fears

Why would anyone choose to walk toward the things that scare them most? Kristina talks with Natalia about what exposure and response prevention, or ERP, involves and how a therapist can build it step by step, with consent and compassion. They cover listing fears and compulsions, starting with something you are already willing to face, and slowing down when things feel overwhelming, and Natalia is clear that every therapist works differently. It is for anyone curious about how this approach works. This content is educational and is not a substitute for one to one professional care.

Transcript

Hi, Everyone. I'm Natalia. I'm so excited to be speaking with you about exposure response prevention. It's my favorite type of therapy. I love that. Okay. Yeah, So exposure response prevention therapy, It's not talk therapy. It's more along the lines of behavioralism. So we are trying to change our reactions to our fears. We're trying to change our behavior. So exposure response prevention is helping you get exposed. That's where that part comes in to the things you fear. And then response prevention means that we prevent our compulsions from happening. As possible. So we realize that when we have OCD or phobias, We tend to really avoid our triggers, Avoid the things that make us uncomfortable. And if we do encounter them in the real world, We're almost guaranteed to do something like a compulsion to self soothe. And so ERP therapy is basically in a safe, Gentle, And very structured environment, Slowly work our way up to being around the things that give us fear, That make us feel like something bad is going to happen. Wonderful. So this kind of makes me want to ask you a question. I definitely see this a lot, And maybe you see it in your practice. I certainly see it in my DMs, In my practice, Where people will also come and say, You know, Why would I unearth what I want to go into something that is already so scary to me, That I have so much angst, Anxiety, You know, Whatever the negative feeling state is, Right? Guilt, Shame, Et cetera. Like they can't even fathom having to quote unquote expose or go to that. So why on earth would somebody do that? Yeah, It's a great question. And I usually share my own personal experience when someone asks that because I have OCD or I have now subclinical OCD. But when my OCD was severe, I would have been that person that gave that really big pushback. So why I would have been afraid to do ERP, Because I actually believed my obsessions, My fears to be very scary, Very dangerous. That's usually where we want to start. We want to say, Well, What about your fears? Are you actually willing to push back on. What piece of your fears do you believe is the OCD's magnification? And that's where we'll start the ERP, In that little bit that you are not in alignment with. So whenever we start ERP, We don't have to like create the whole fear hierarchy for all the things. We actually want to start with something that you're already motivated for, And that you already seem to see is an overreaction to a stimulus. I see so 1 of the things you're saying, If I'm hearing, You're right is more that having a person understand for themselves that there is an exaggerated response to this, That this, This is a little bit extreme and perhaps even is getting in the way and somehow, And they're willing to work on that item. Yes, So whatever, If there's any piece of your OCD that you're willing to work on, That's where we might start ERP. If there's any one of your triggers that you are inherently willing to face even a little bit, We sort of build your buy-in to ERP by starting there. And so I, For example, Will share that I've definitely had some folks recently where they've talked about that they thought about ERP, But then they read all these stories about, Or even on Reddit, Right, About when people have done ERP that they often say things like, You know, I feel tortured. I feel sometimes like I'm getting traumatized. It's extremely difficult. You know, I don't ever want to do something like that. What would you say to that? Yeah, So I mean, I would first of all say that people who have had that experience, That is a valid experience. It is true that a lot of exposure therapists are not as compassionate as they need to be. This is something that I think that our field is working on and making sure that we start with compassion and then we move forward into the next phase. You know, Honestly, I think that the framing of like, I'm going to advocate for my needs with my therapist. And also, I'm going to remain autonomous and in control of my work. So when we build a fear hierarchy, I always say at the out, Around the outset, Like, We don't have to do anything on this list. We're going to build this list as a, You know, Wish list. A therapy wish list. And if we do none of these items, That's that's up to you. Every single time we level up on the fear hierarchy, We get consent, We get buy in, We check in to make sure that some other thing is not happening in your nervous system this week. That's Got it. So it sounds like one of the things I'm hearing is that people can, Can make sure that when they're working with a therapist, That they're looking for somebody who can do it kind of step by step. Um, And, And, You know, Hopefully build build up that muscle and the confidence to be able to do it. So let's talk a little bit about, You know, How would somebody just more like a big overarching bird's view, How would somebody do ERP? What are some of the components that go into this? Yeah, So I mean, The first thing that we would have to do is to create a complete list of obsessions, A complete list of compulsions, And that that can take some time. And then once we have that foundation, We're going to build something called a fear hierarchy. And now a fear hierarchy, Which needs to be renamed, But that's what the official name of it is, Is basically like a to do list or a wish list that you Find challenges to the OCD and then you rate them in a scale between 1 and 10. Some therapists do 1 in 100. As you go forward in the fear hierarchy, You only do things that are really achievable in the moment, But you have this full list of where you will be going if you so choose. Okay. Got it. And then what do you do for, I guess, How, How do you take the next steps? Like, Are you looking for then willingness? Are you looking for, Uh, Picking like what's, What's the lowest or highest level of distress that it's causing? Cause there's different information out there, Right? There's, There's some styles where we're using like our own internal measure to kind of say, Okay, These things are more low level difficulty. These are mid, These are high, Right? There's other therapy modalities that would say, Hey, We don't need to look at that. To do. So what would you say? Yeah, It's very much dependent on my client. We have this conversation at the first session to say like, How do you want to structure this work? Do you want to first tackle things that would have the most positive benefit to your parenting or to your relationship or to your wellbeing? What do you really miss that you want to bring back into your life? Do you want to go slow and steady just with the absolute easiest exposures and go up the list? Or do you want to make a call any given session as to like what you really feel motivated to work on? There's no right or wrong way to do this. There's the clinically, There's the classic way. And then you'll probably find that a lot of talented OCD therapists out there are innovating and having flexibility based on their clients' needs. And if the clients advocating for a certain approach, We definitely want to accommodate that. The only no-go area for us is talk therapy. Because sometimes clients will say, I'm not ready to do my fear hierarchy. I want to talk about, You know, My childhood or my week. And our job as as OCD specialists is to give that a little bit of a container. And then redirect to the core purpose of working with an OCD specialist, Which is to face the fears. Got it and so if someone's in session with you and, You know, Like you said, The 1st conversation will be something like this, Which is really collaborative and you're both kind of assessing and evaluating and creating a plan together. How would you help them then through this model move towards, If you're noticing that, Let's say a person just generally tends to stay in the lower area and really is not, Just not really wanting to really go towards other things because they just feel too scary. And now that they understand, You know, What they would have to do, Whether it's, You know, Exposed to a fear thought or an actual situation or a person or whatever it is, Right? So. . . How would you address that if they kind of get to that place? We're like, No I don't want to even though, You know, They can they've demonstrated they can but they're just not willing to Yeah, So I would probably utilize acceptance commitment therapy. So this is another modality that really focuses on your values and how your behavior is not in alignment with your values. So that might be a little side quest that I go on with my clients to sort of point out where the disconnect is between where they want to go and what they're willing to do today. But again, Like this, It can't be forced. It can't be coming from a place of like authoritarian therapy where I'm saying this is what's best for you right now and we're going to move forward because that, You know, That inherently is going to bring up a lot of feelings of, You know, As people on Reddit might say, Of being made powerless or feeling like they have to comply with the therapy. But then coming home and being overwhelmed by or flooded by the experience that they had in the therapy room. So I am very, As I keep saying the word measured, But that's how we want to show up in a therapy room is measured. We are going little by little because slow progress is more important than rushing through it and potentially risking a flooding event that will cause the client to be one of those posters on Reddit saying, I'm never going to do this again. So I see it as like, I've got one shot with this person, And we're going to take the time that we need to get where we need to go. Yeah, I love hearing that approach. And I mean, I think you're right at this point. It sounds like the other thing is that every therapist has their own personality and style. And the other thing, If you know, As we're talking about kind of the introduction to ERP in today, Today's episode, It's understanding the different ways ERP can be done, But that fundamentally we're still looking at kind of the same foundational pieces, Right. Which is creating like that skeleton or Roadmap of okay. What are we what are we even going to be facing and where are we going to be going? Then together designing and getting creative to think of ways of how we can expose and making sure we're clear What are we even exposing to? Right, What are we gonna do instead of our Typical compulsive urge to as you said self-protect Try to prevent, You know something bad from happening And then really building it out step by step from there with that But can you give us, You know, For anybody listening, A little bit of a layout, Like what are some of the different ways that ERP can be approached? Into today's day because I think, Like you said, There's kind of the classic. Standard. Process, But I think there's been some evolution, So would you mind speaking a little bit to that? Absolutely. So one of the really great things that has happened to ERP in the last 15 years is the advent of YouTube. And we have a lot of ways to expose people to their fears without actually exposing them to danger. So we will probably start work rather than having you drive on a bridge, If that's your fear, But watching a YouTube video of cars driving back and forth on a bridge. And we can ultimately trick the nervous system into feeling the same feelings and maybe in a in a less activated way that we would feel if we were actually in that situation. So that would be one place where we would start is by trying to create fictional or immersive experiences that remind the body of the fear. We can also create imaginal scripts where we write stories and use narratives to bring us deeper into our fears. And we can bring family members in and role play or bring up certain fears in a more lighthearted way. But we have many different ways that we can involve the person, Bringing them into some safe exposures to the things that they are dreading, The things that are keeping them up at night. Yeah. So it sounds like there's a little bit of a kind of setup that you, You create. Um, And then one of the things is that you, You want to look at the different ways of how to basically just start in the least kind of threatening way, If you will. Right. That feels the most kind of comfortable. Um, Just like, I guess a person kind of adjust, Get used to it a little bit and, And then kind of go from there. Yes, Exactly. And it depends on the person for what is the most gentle approach to begin. But I think one of the trickiest is if something that we do early on in exposures is overwhelming to their nervous systems, Then we need to go back and do some distress tolerance work. We need to take a quick pause and figure out what they are capable of doing to re-regulate and how they can be in a very receptive place coming into our therapy room. So we have little detours that we can take if those early exposures don't seem to be going well. Yeah. Can you talk a little bit more about that? Like what, What would be an example? Because I, I certainly know I've heard a lot of different mixed, Mixed input about, You know, Oh, We want to practice feeling discomfort at the same time you're talking about, Well, If the discomfort is so high that you're kind of starting to, You know, Almost like clock out a little bit from your body or you're not even fully there, Or, Or, You know, You're starting to feel like you're going to just kind of shut down. Right. Too much and we're not, We're not anywhere near there. So how would you, How would you have figured that out? Like when, When would it be appropriate to do something like distress tolerance and not have that be counted as a, You know, Compulsion or avoidance, Right? Cause this is like such an interesting nuance in OCD. Yeah, It's really tricky. And I think this is the divide between the classical ERP practitioners and what, For lack of a better word, What like sort of the next gen ERP therapists. I think that it really is about having balance, Like honoring the structure of exposure response prevention, But also individuating it. So creating something that is meeting the person where they are that moment, We're still taking the same path. But if we see someone come into our therapy room, And they're vibrating at like an eight out of 10, Just as their baseline, I'm not going to bring in exposures. For me, That person needs to be down at a two or three at a more regulated level before we can even commence. Not all exposure response prevention therapists believe that, But that's my personal philosophy. Okay, And so what would you do? What would be an example of how you would do some exercise that would be a distress tolerance exercise? So we might begin our session with some tones, With a visualization. We might begin the session by increasing our comfort with the space. I work with a therapy dog and a therapy Maine Coon cat for certain clients, And sometimes it's just that animal-focused time in the beginning. Sometimes we do need to to check in with our bodies, As you mentioned. We might need to do a body scan. We might need to do some letting go of other stressors that we're bringing into the therapy room. But this sometimes will be 15 minutes at the beginning of a session, And sometimes we don't need to do it at all. So it really depends on the person. And if they are asking to do it the entire session, Session or every session and they want to do the same thing every session, That's when I start to, You know, Be like, Ooh, Is this an avoidance compulsion? Is this potentially in service of the OCD? And so we would switch gears then. I love that. So I just want to say personally, I think that's really creative and you have the capacity sounds like to, You know, Have an animal. Um, And I find that, Yeah, Therapists who are open and able to be flexible and really keep striving to be the client where they're at are, You know, I think it's wonderful and it can help to keep break, Break this down so that if somebody really wants to use ERP as a first line treatment for their OCD, That, You know, They can hearing this, I hope understand that there is flexibility, That it doesn't have to be Like you just said this kind of you know, Like we're gonna beat you down with this that that's not the goal here That's it's like it's not for us, Right? This is for you You know and I will say even for myself, I mean I have OCD and when I was learning ERP, You know I actually liked imaginals because I had a what you know knowing of course now for a while but pure oh like a lot of mental activity and then a lot of reassurance seeking and internal checking and reviewing and Tracing and stuff but like, You know, That's the kind of stuff once you figure out what what things are and then you learn the strategies and you try the different strategies you also I think get to for yourself assess and evaluate oh which one of these really works for me or maybe which one of these do I like or what's a pacing or what can I set up so it's helping folks to also learn how to think through the ERP mindset. Yes, Yes, Absolutely. And, You know, Also to start from a place of self compassion. We, When we go into exposure response prevention, Like sort of like, In this like grin and bear it energy of like, I have to push through this. I have to like get it out of the way. We're not going to, We're sort of stealing ourselves for impact. So we do want to, You know, Be in touch with ourselves and continue to remind ourselves that this is an act of self-love. To be brave enough to do exposures is an act of self-compassion and energy. That's how I want people to approach it. So is that something you do on the front end in terms of helping people get into a good mindset around doing this work? Or what do you do? What would you suggest? Is like really desired that this is something that is welcomed, Not just by the family system, But by the OCD experiencer themselves. So yeah, I do spend, You said one session to set up, I probably spend three or four of like really like building out the ERP foundation. And the one error I think I continually make is when I get families coming in who are, Very anxious and feel like it's very urgent to jump into ERP. Sometimes I get swept up in it because, Yeah, I know how to do it. I could do ERP starting the very first session in the first 10 minutes, But that doesn't mean that that's the right thing to do. Yeah. You know, As you're saying that, I mean, That hits home for me too, As a, You know, Educator, But also as somebody who has a private practice. Similarly, I sometimes have clients or family members that come in and it's just like, Okay, We need this done like today, Tomorrow. Okay. The next session, Session number two, Let's go. Let's are we fixing it today? Can we fix it now? You know, And you feel this pressure. It sounds like, Okay, Like I understand what we need to do to get you there, But. We can't always jump in like that. And you're right. We have to learn how to slow everybody down for a second and ask, You know, I mean, I think as for that openness and willingness to. Have a little patience because it's a process and you know, It's like you didn't get here overnight and You know, Even if you want this to be done and over with now like a little bit of time You might still have to kind of manage and accept that you're gonna have that internal Uncomfortable state that's not gonna feel resolved, Right? We're not gonna kind of zap it all and magically make it all go away But what do you do with time, Right? So, Can you talk a little bit about you know, How much time an hour? Would you say a person would in the beginning kind of be asked to accept a little bit of being in that uncomfortable seat they've been in before they start to get a little bit more into doing the work and starting to relearn and actually start to get some relief? Yeah, So by the book ERP, It is supposed to be concluded within 12 to 20 sessions. I personally have only successfully done that in a few cases. I still aim to be very time efficient, But I think that the first like four or five sessions are definitely laying a foundation. We have our entire structure. I would say five to 15 is going to be really doing the work, Getting focused on the exposures at hand. Around 15 is when we're sort of upping the ante a little bit. We're doing harder, More challenging exposures, Those five through eights, Those nines. And that's usually where I can see, Is this client receiving relief from this process? Or are they not reaping the benefits quite yet? And By 15 sessions in, I really want the client to feel better. And so sometimes I sacrifice moving forward into the hardest parts of the fear hierarchy in order to allow that person to just enjoy the relief and enjoy the progress that they've made. I would say well-orchestrated OCD treatment can be probably well-completed by session 30. Again, Every ERP therapist is different. I know that a lot of ERP purists will try to condense it more than that, But that's my personal pacing. Yeah, I love that. I mean, I second that. I think, Yeah, You're right. Like, The literature says one thing and you can, And depending on the person, What other issues are coming up or they're at, I mean, Yeah, There's other variables. I mean, If it all goes. Beautifully well, Then yes, It can all kind of stay in this. But, You know, This is real life and real folks and real issues. So sometimes it can take a little bit more.