What Is It?

Exposure and Response Prevention (ERP) is an evidence-based treatment that is known as the gold-standard treatment for anxiety disorders and obsessive-compulsive disorder (OCD). ERP is a treatment that targets anxiety through the process of engaging in gradual and repeated exposure to anxiety triggers while concurrently reducing reliance on safety behaviors, methods of avoidance, and compulsions (Response Prevention).

ERP treatment is organized in accordance with an anxiety hierarchy, which is comprised of a list of the person’s anxiety triggers (thoughts, memories, body sensations, events, places, activities, people, etc.). The hierarchy serves as a roadmap for the treatment process and provides information about the various stimuli that have become associated with anxiety. It also provides information regarding the order in which anxiety targets will be addressed as well as some indicators regarding how much time may be required to work through items on the hierarchy.

There are three types of Exposure: Imaginal, Interoceptive, and In vivo. Often, a course of ERP treatment will utilize more than one type of Exposure and/or combine the types of exposure during sessions. More information will be provided about each type of Exposure in the following paragraphs.

How Does it Work?

ERP is employed to effectively treat anxiety disorders and OCD (among other conditions) because it helps to break down the experience of fear/anxiety that has become associated with various triggers. Individuals struggling with clinical anxiety tend to have two common beliefs: 1) Something bad will happen when they encounter their anxiety triggers and 2) When that bad thing happens, they will be overwhelmed and unable to cope with the outcome(s). Considering these two beliefs, it is no wonder that avoidance and other safety behaviors are enacted to prevent contact with feared stimuli. However, repeated reliance on avoidance strategies only serves to strengthen the fear response, as it unintentionally sends the message to the brain that: “This is too scary and the only way I can handle it is to avoid it!” ERP is intended to challenge these two beliefs, reduce reliance on safety behaviors and other avoidance behaviors, decrease distress, and improve functioning.

Exposure is conducted in a stepwise process, involving a measured and strategic approach to interacting with previously avoided stimuli and situations. Engaging in Exposure work allows for new learning and corrective experiences to take place. In order for this to happen, repetition of exposures must ensue to break down the association between the trigger and the experience of anxiety so that they are no longer paired together. In other words, ERP facilitates the person’s ability to break down the mental connection between the trigger and feelings of anxiety so that over time, the trigger no longer provokes the same distress. Through participating in ERP treatment, people learn that they can tolerate anxiety (and that the anxiety does not last forever) when the situation is broken down into smaller component parts. It is key that the component parts are sequentially experienced over time with repetitious practice. Exposure work will also help people to learn that the avoided situation is actually more manageable than they anticipated, and that anticipation is often more difficult than the actual event. Over time, people learn that the stressful situation becomes less distressing with repeated exposure, and that escape or avoidance is not needed to cope with the situation. Through this process, people learn that they are able to successfully face their fears and that doing so may open them up to having more positive experiences. Bottom line: ERP helps people to learn that anxiety no longer gets to call the shots!

An important note about exposures is that they are intended to challenge anxiety, but not to overwhelm the person. In other words, exposures should not be designed to flood the person with anxiety. Exposures are carefully constructed so that they are within the person’s current range of tolerance and so that the person is able to build his/her confidence as new challenges are mastered. Thus, exposures are strategically developed to increase the person’s anxiety tolerance while decreasing reliance on escape or avoidance strategies.

Circumstances and situations may cause people to encounter anxiety triggers in their daily life. While this is exposure, it is not therapeutic exposure, and there is a BIG difference between the two! Exposures that occur randomly in everyday situations are not strategically designed, appropriately staggered or paced, and are often not repeated. All of these variables (when not properly accounted for) can worsen anxiety, which highlights the importance of working with a mental health professional who specializes in ERP. A clinician trained in the provision of ERP facilitates therapeutic exposure work whereby the intensity of the exposure can be adjusted during the course of the session. Professionals know how to scale back or increase the difficulty of the exposure, as needed. Again, exposures should be orchestrated in such a way that the anxiety is challenged AND the person can be successful in completing the exposure. With this in mind, exposures should not be prematurely ended because: 1) enough time needs to be allotted for the anxiety to level off and/or be experienced as tolerable and 2) we do not want the person to end the exposure feeling overwhelmed and/or discouraged because then they will be far more reluctant to try again in the future. When engaging in ERP with a trained clinician, the difficult spots in the exposure can be worked through together and the clinician can provide support and encouragement to help the person challenge his/her anxiety and complete the exposure.

Types of Exposure Therapy

As previously mentioned, there are three different types of Exposure: Imaginal, Interoceptive, and In vivo Exposure.

Imaginal Exposure

Imaginal Exposure consists of encountering anxiety triggers in one’s mind. As previously discussed, it is common for people to try to avoid their anxious thoughts. At times, there seems to be a fusion between thinking and acting, with concerns that if the thoughts occur, or are discussed, they may be more likely to happen and/or be acted upon. Consequently, most people tend to try to avoid their stressful thoughts. Research has consistently shown that thought suppression does not work and that avoidance of anxious thoughts actually tends to maintain and even increase the thoughts. Imaginal Exposure interventions help people to face their anxious thoughts and discover if the outcomes that they fear are true and/or likely to happen. With repeated Imaginal Exposure, the person becomes better able to tolerate the anxiety and the distress level decreases over time. Therefore, the use of Imaginal Exposure facilitates facing/experiencing the thoughts without trying to get rid of them. Imaginal Exposure is used when the anxiety-provoking stimuli/situations cannot be simulated in real life. It is also used to initiate exposure work before moving on to utilizing other types of exposure.

When Imaginal Exposure is used, the person’s worries and intrusive thoughts are targeted through verbal and/or written formats. Some Imaginal Exposure strategies include:

• Creating a list of statements, which will be used to develop a loop tape (a recording of the statements played on loop)
• Alternating worrying out loud with the therapist
• Adding more detail to the worries
• Role plays
• Writing scripts about feared scenarios
• Writing scripts about the worst-case scenario
• Writing uncertainty scripts pertaining to how the worry might unfold and a lack of clarity about how things will turn out

Interoceptive Exposure

Interoceptive Exposure is used to target physical/body symptoms that have become associated with anxiety. The primary goal associated with this type of Exposure is to increase the person’s ability to tolerate anxiety connected to physical symptoms. Typically, when a person experiences bodily sensations that they have come to associate with anxiety, they panic as they attempt to tamp down the intensity of the sensations. These attempts usually exacerbate their anxiety: the more they struggle with these symptoms, the more uncomfortable they become. Interoceptive Exposure is intended to help the person see that they are able to experience these symptoms and still be okay, even if they are not entirely comfortable. While the symptoms are bothersome and uncomfortable, interoceptive exposure helps the person to recognize that the symptoms are not dangerous and that the feared outcomes associated with these body symptoms are not as likely as they predict. Lastly, engagement in Interoceptive Exposure helps the person to learn that while the symptoms are unpleasant, they can be tolerated and accepted.

Interoceptive Exposure is often used when the following diagnoses are the focus of treatment: panic disorder, emetophobia (fear of vomiting), health anxiety, OCD (sensorimotor subtype), and social anxiety. Some Interoceptive Exposure strategies include:

• Engaging in exercises that will elicit the feared body sensations
• Using caffeinated drinks, carbonated drinks, and avoided foods to create feared bodily sensations
• Engaging in movements that will provoke the physical symptoms in situations where others might be present and may observe the person experiencing these symptoms
• Engaging in exercises that will elicit the feared body sensation while listening to content from imaginal exposures

In Vivo Exposure

In Vivo means “in life” and In Vivo Exposure means that the feared stimuli/situation will be simulated in real-life settings. Whenever possible, it is optimal to utilize In Vivo Exposure, as this type of exposure will likely bear the closest resemblance to situations that the person may encounter in real time. In other words, In Vivo Exposure consists of interacting directly with the anxiety triggers, or aspects of the triggers. In this type of Exposure, the feared situation is broken down into more manageable pieces and worked through with some variability in the conditions (locations, day/time, people involved, etc.).

In Vivo Exposure is used with all different types of anxiety and OCD. Here are some examples of In Vivo exposures with each condition:

• Generalized Anxiety Disorder
  • Trigger – making decisions
  • Exposure – flipping a coin to decide what movie to watch, picking options at random, not allowing enough time for careful consideration of options

• Social Anxiety Disorder
  • Trigger – being the last person to arrive at a social event
  • Exposure – showing up late to a family party on purpose

• Panic Disorder
  • Trigger – experiencing symptoms in a public place
  • Exposure – go into Target alone and continue thinking “What if my anxiety gets worse and I panic?”

• Emetophobia
  • Trigger – worries about having food poisoning
  • Exposure – listening to worry statements about food poisoning while eating food that was not prepared at home

• Phobia: Needles
  • Trigger – seeing a needle
  • Exposure – watch an episode of Grey’s Anatomy

• Perfectionism (not an actual anxiety condition, but perfectionism often accompanies anxiety conditions)
  • Trigger – worries about making an error when speaking or writing
  • Exposure – send an email without correcting the typos

• School Refusal (not an actual anxiety condition, but school refusal can be a behavioral manifestation of various anxiety conditions)
  • Trigger – being in the school building
  • Exposure – gradually increasing time spent inside the classroom instead of going to the counselor/nurse’s office

• OCD: Contamination
  • Trigger – touching items perceived as dirty
  • Exposure – handling money, mail, dog’s leash, etc.

The Importance of Response Prevention

ERP treatment would be incomplete without the implementation of concurrent Response Prevention methods. As previously discussed, a common response to heightened anxiety is an attempt to evade the anxiety through the use of safety behaviors, avoidance, and compulsions. These behaviors include (but are not limited to):

• Checking behaviors
• Asking for reassurance
• Turning down invitations/making up reasons to not attend social events
• Carrying anti-anxiety medication with you
• Using substances to feel calmer and/or more outgoing
• Online researching about anxiety triggers
• Missing school/work
• Only virtually interacting with others

While engaging in safety behaviors may decrease anxiety in the moment, over time these behaviors exacerbate and lengthen the course of anxiety disorders and obsessive-compulsive disorder. Safety behaviors provide people with a false sense of safety (i.e. because I engaged in checking behaviors, I prevented _______ from happening), while preserving the fear and maintaining the anxiety cycle. Furthermore, as people come to increasingly rely on safety behaviors, avoidance, and compulsions, these behaviors become effective for shorter and shorter periods of time and people find that they are repeating the behaviors more frequently in efforts to compensate for briefer and briefer periods of relief.

In ERP treatment, Response Prevention systematically and repetitiously targets the safety behaviors that maintain anxiety. The reduction of safety behaviors is conducted over time in descending order, whereas exposure work is conducted in ascending order. In other words, both Exposure and Response Prevention are strategically paced in a stepwise fashion, but they progress in opposite directions. For example, in the case of Contamination OCD, Response Prevention for handwashing may target:

• The duration (decreasing the amount of time that is permitted for handwashing in consistent increments over time)
• The amount of soap used (decreasing the number of pumps from the soap bottle)
• The temperature of the water (gradually decreasing the water temperature over time)
• Reusing a hand towel to dry hands and increasing the number of times the same towel is used

The goal of Response Prevention is to help people realize that they can manage stressful situations without the use of avoidance behaviors and without trying to cancel out/undo the potential feared outcomes. Safety behaviors are usually extremely time consuming and stressful to perform. Safety behaviors need to be reduced in order for people to attribute their progress to their efforts to engage with and work through anxiety rather than side-stepping their anxiety. Employing safety behaviors, avoidance, and/or compulsions after engaging in exposure work, cancels out the effects of the exposure and prevents corrective learning from taking place. In other words, safety behaviors cancel out the hard work that was done during the course of interacting with anxiety triggers. Although safety behaviors may exert a strong pull and be difficult to resist, targeted Response Prevention work will help to dismantle a person’s reliance on these counterproductive responses. Consistent adherence to Response Prevention methods helps people to build the confidence to face their fears without trying to evade anxiety. Response Prevention also helps people to recognize that they can acquire the wherewithal to meet these anxiety challenges with committed practice.

Need help or support?

If you or a loved one are struggling with an anxiety disorder, OCD or any other mental health concerns, know that you are not alone. If you are a parent or a caregiver and are seeking additional information about these diagnoses and how you can best support your child, our office provides parent training with the SPACE program. Please see previous blog entry – SPACE- Supporting Parenting for Anxious Childhood Emotions — for more information on SPACE.

To seek help for these or any other mental health concerns, please contact The OCD and Anxiety Center at (630) 522-3124 or info@theocdandanxietycenter.com. We have offices in Oak Brook and Orland Park, Illinois and in Marietta, Georgia that specialize in helping individuals overcome anxiety disorders, Obsessive-Compulsive Disorder, and other co-occurring mental health conditions. We provide telehealth services that are available in Illinois, Indiana, Iowa, and Georgia.

At The OCD and Anxiety Center, we can provide treatment both in the office and at off-site locations (your home, mall, school, etc.). We will work closely with you to create an individualized treatment plan and discuss the appropriate frequency of appointments (once a week or more, if needed). We look forward to working with you!

Dr. Ashley Butterfield is a licensed psychologist at The OCD & Anxiety Center in Oak Brook, IL.  She specializes in Cognitive Behavioral Therapy and Exposure and Response Prevention Therapy for anxiety, OCD, and anxiety-related disorders. She is comfortable working with children and adults and is able to provide treatment both in the office and outside of the office, wherever anxiety happens.