Exposure and Response Prevention (ERP) is an empirically supported, cognitive-behavioral intervention for OCD that has become the gold standard in OCD treatment. Through ERP, patients learn that their anxiety can be alleviated without engaging in compulsions and that their worst expectations don’t actually occur. For patients who may not experience a noticeable decrease in their discomfort during ERP, they still learn through the process that discomfort is tolerable and survivable. While guidelines for delivering ERP are straightforward, many clinicians struggle to deliver the intervention effectively to patients. This is particularly common among novice clinicians. A 2012 article1 in the Journal of Obsessive-Compulsive and Related Disorders identified the most common mistakes clinicians make when practicing ERP. The seven most common pitfalls (and recommendations for how to avoid them) are described below:
- Avoiding the extreme. Exposures to triggers at the top of the hierarchy are necessary to experience greatest symptom relief and reduce the likelihood of relapse. Avoiding these triggers allows patients to conclude that feared outcomes were prevented only because the most dangerous situations were not faced. Clinicians must design exposures to the most feared scenarios, even if it means asking patients to engage in somewhat extreme (and at times, unusual) behaviors.
- Choosing the wrong type of exposure. In vivo exposures involve directly facing feared objects or situations in real life, whereas imaginal exposures involve imagining feared consequences or catastrophes through a detailed narrative or story. Using imaginal exposures when in vivo exposures are possible will yield less powerful effects. Neglecting to use imaginal exposures altogether (which can effectively target underlying core fears), will similarly lead to less effective treatment. Ultimately, the appropriate use of both in vivo and imaginal exposures is imperative.
- Encouraging distraction. In order for exposures to be optimally effective, patients must be attentive and mindful during the exercise. Clinicians may inadvertently encourage distraction by engaging patients in conversation or asking them to shift attention to something less anxiety-provoking when discomfort increases. Distraction generally undermines the effectiveness of exposures as patients need to remain in contact with the trigger they are confronting. For this reason, clinicians must help patients to remain attentive to the feared stimulus during the exposure.
- Providing reassurance. Much like encouraging distraction, providing reassurance to patients can undermine the effects of treatment. OCD thrives on doubt and it compels patients to seek certainty. For exposures to work most effectively, patients must be able to retain some uncertainty around the consequences of the exposure exercise. Providing reassurances to patients interferes with this process and prevents the patient from fully confronting their fear.
- Treating only the peripheral symptoms. An essential part of OCD treatment is identifying patients’ core fears. These fears are the underlying driving force to the OCD and its compulsions. Imaginal exposures are extremely effective in targeting these catastrophic feared outcomes, however therapists sometimes focus only the overt symptoms of the disorder. By targeting the core fear directly, tolerance for distress can generalize to other triggers that share the same underlying fear.
- Not addressing mental compulsions. Mental compulsions include counting numbers, saying prayers, repeating affirmations, and reviewing or re-tracing past events, all designed to neutralize discomfort and stave off feared consequences. Because mental compulsions are not readily observable, they are often missed by clinicians. And because they are automatic, they are difficult to prevent. Clinicians must be particularly creative in helping patients to block mental compulsions or to replace them with a mental response that provokes additional fear.
- Forgetting to involve family members. Patients with OCD frequently involve their family members by having them perform rituals, by requesting that they engage in avoidance behaviors, and/or by seeking reassurance from them. Clinicians must help family members navigate such requests by patients and coach the family on how to be of support and comfort to patients without providing reassurances.
A commentary on these pitfalls by Dr. Seth Gillihan, first author of the 2012 article referenced in this post, can be found on the Psychology Today website at:
1 Gillihan, S., Williams, M., Malcoun, E., Yadin, E., & Foa, E. (2012). Common pitfalls in exposure and response prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1, 251-257.