The Importance of Exposure
Exposure and ritual (response) prevention (ERP) is a carefully studied and proven effective treatment for OCD. The research is clear in showing that this method produces important reduction in obsessions and compulsions. The benefits of doing ERP also tend to last for a long time. This makes ERP a prime treatment for OCD. There is a drawback and that is that ERP is very hard work and in particular doing exposure is at best uncomfortable and usually very anxiety producing. If we look at the component parts there is evidence that exposure has its primary effect on obsessions and ritual prevention has its primary effect on compulsions.
Even though the effects of ERP tend to last there is often some slipping and people with OCD may drift some after treatment so that they are more troubled by obsessions and compulsions than when they finished treatment. As a result modern treatment for OCD includes something we call relapse prevention. The basic idea is to teach the individual how to handle the problem situations which will probably arise. In the case of OCD this means something will probably trigger obsessions and the urge to engage in compulsions in the future. Part of the treatment process is to learn how to apply ERP to the individual’s obsessions and compulsions. Part of relapse prevention is to help the person learn to apply the same skills in the future. In simple terms if people will apply what they learned about using ERP during treatment when OCD symptoms show up they can expect to maintain their gains from treatment and perhaps even continue to improve.
Like a lot of ideas which sound simple, the actually practical application may be somewhat more difficult. When I talk to someone who has been through treatment using ERP about how they are doing and what skills they are using it seems that the thing they can remember to do is the ritual prevention. More often than not however they are not engaging in active exposure and on closer examination they are often engaging in avoidance, albeit often rather passive, of triggers to their obsessions. An easy example comes from a person who has harm obsessions triggered by seeing or hearing about harm. They may report that news stories in the paper or on TV, violent movies and other descriptions of people being hurt trigger obsessions. As a result they simply don’t watch the news and are selective about movies. They may not recognize this as avoidance and note that they are just not interested in such things. They may further rationalize that it is reasonable to not like violent movies and there is no reason to watch movies you don’t like. There is an embedded distortion that the goal of exposure is to get to the point where you like something rather than get to the point where the thoughts it triggers are unimportant.
A similar rationale for not doing exposure is the argument about the fear being realistic or the compulsions necessary. For example someone might argue that since there really are germs that could make you sick it is just plain good sense to avoid touching some things. The same person may report they are keeping up with their ritual prevention because they don’t do the ritualized washing that they used to do, but they are also not taking any “unnecessary” chances.
What is the problem with doing things this way? It set a person up for a little slip and each little slip can lead to another. Pretty soon OCD has managed to sneak back and take up more of your time and energy. The answer to this problem is reasonably simple. When you find yourself thinking it is only reasonable to avoid something that is time to do some exposure. When you think you would rather not touch something, or rather not hear about violence or not pump the gas etc. remember that you are really avoiding and it is time for a quick exposure. Then congratulate yourself for taking the risk. In the long term this practice will solidify the gains from treatment and stop OCD from slipping back into your daily routine.
While ERP is commonly included in CBT for OCD it is not always prominent and sometimes may be presented in different ways or with different rationals. Some forms of CBT for OCD may not include ERP per se but do tend to include some techniques that serve the same purpose. Some forms of CBT such as Acceptance and Commitment Therapy (ACT) may include ERP but present it with a different rationale.