Understanding OCD and the Benefits of ERP Therapy

Author: Hannah Curley, LPC-Associate

Have you been struggling with upsetting thoughts that won’t go away? What about an urge to perform repetitive behaviors or rituals that you find difficult to resist? Obsessive-Compulsive Disorder is a diagnosis that brings with it lots of anxiety, distress, and discomfort that can make it difficult to function in everyday settings.

But what is OCD? 

Obsessive-Compulsive Disorder (OCD) has two major parts: the presence of obsessions and the presence of compulsions. Obsessions are defined as thoughts, images, or urges that are unwanted, distressing, and recurrent, meaning that they are repeated and can occur persistently. In contrast, compulsions are defined as repetitive behaviors or mental acts that are performed in response to obsessions in order to reduce anxiety or stop a dreaded thought from occurring (American Psychiatric Association, 2022). 

However, this does not mean that any anxious thought may be a sign of OCD. As an example: a young woman is afraid of touching doorknobs, worried that she might get sick, so she avoids touching doorknobs with her bare skin and washes her hands diligently. The core fear in this situation, that she may pick up a bacteria or virus and get sick, is not necessarily irrational or excessive, so it is also likely that this woman is experiencing anxiety. In contrast, if this woman were afraid of touching doorknobs because of the persistent fear that she could contract a life-threatening illness and spread it to her family and loved ones, leading her to avoid making contact with doorknobs and washing her hands for minutes at a time or completing other rituals like mentally checking for symptoms to alleviate anxiety, then there is a greater likelihood that what she is experiencing is OCD.

This example is only one of many ways that OCD may appear. At the core of it, OCD cannot be self-diagnosed, and the line between OCD and anxiety can be difficult to determine on your own. By working with a mental health professional, you can work to discover what might be OCD and what might be other forms of anxiety or stress.

If I have OCD, how can I treat it?

OCD is a disorder that can be treated through therapy with a mental health professional trained in anxiety and obsessive-compulsive disorders. While it can be scary to reach out for help, especially as OCD is very good at making the idea of breaking the cycle of obsessions and compulsions seem catastrophic, there are treatment options backed by research that can help.

According to the IOCDF, the first-line treatment for Obsessive-Compulsive Disorder is Exposure and Response Prevention (ERP). This treatment takes place in two parts: exposure, where client and therapist introduce exposure to feared situations to reduce anxiety over time and promote new learning, and response prevention, where the goal is to reduce and eliminate compulsions and ritualized behavior. Therefore, during exposures in therapy, the goal is to allow for new learning, increase your tolerance for uncertainty, reduce anxiety to feared situations, and help you feel more in control by disconfirming those fears in real time. As a note, while it may be scary to face what you fear, safety is always the number one priority. Real risk will never be involved.

Why ERP?

ERP views OCD as an anxiety cycle. When a trigger occurs that summons an obsessive thought, anxiety spikes. Compulsions then occur in response in order to soothe and reduce that anxiety, bringing you back towards baseline more quickly. However, compulsions may reduce stress in that moment, but by repeatedly engaging in them, not only will the anxiety continue to come back as the core fear is not addressed, but the obsessive thoughts are being continuously legitimized and reinforced every time it’s taken seriously. Therefore, the first goal of stopping compulsions is to interject in that cycle and stop the continued reinforcement and rollercoaster of anxiety spikes and soothing.

In the short-term, that does mean that anxiety can increase and last longer than it might after performing a compulsion, but this is where the new learning can occur. Over time, through repeated practice and exposure, the goal is to reduce both the duration and intensity of anxiety by allowing you and your nervous system to re-learn how to self-regulate and return you to your natural baseline.

Common Questions:

Is ERP dangerous?

No. Exposure and Response Prevention involves collaboration between the therapist and the client. All exposures are co-created, so everything is both expected and tailored to you. The exposures might feel scary because they are intended to help you face your anxiety, but there is nothing actually dangerous. Your autonomy is important!

What if it makes my anxiety worse?

As mentioned, in the short-term, it can. The process includes goals of learning distress tolerance and breaking the habit that is keeping you stuck in your anxiety in the long-term, with the overarching goal of allowing you to live your life with the freedom OCD may not have been allowing you. ERP sessions also include talking through and processing feelings and emotions that come up during the process to help you better understand yourself in a supportive, empathetic environment.

Is it a lot of work?

It can be. ERP is intended to be a shorter-term therapy completed in a few months, from initial session to moving to relapse prevention. During the process, homework will be assigned to practice exposures and track compulsions, so progress can certainly depend on work completed outside of session. Habits can be difficult to reshape, especially ones that have been reinforced by OCD for some time, but that does not mean it can’t be done! Persistence and repetition can be very beneficial.

Are there options other than ERP? What if ERP doesn’t work for me?

Yes! While ERP is currently the only front-line treatment recommended by the IOCDF, there are other options that can be completed alongside or instead of ERP. Alongside ERP, therapists can include treatment modalities like ACT, DBT, CT, or MBT. Options you and your therapist can try instead of ERP include ACT, I-CBT, CT, or Metacognitive Therapy. You have options and you are not alone, so if you’re struggling, your therapist can work with you to figure out what option might be best for you.

If you’ve been struggling with anxiety or OCD, you are welcome to reach out and schedule a free consultation call with me to start the first steps towards the goal of reclaiming your life from anxiety. You can read more about me and my work HERE!