Transcription
Today I'm talking about ERP exposure response prevention therapy for OCD. Hi, I'm Paige Brad cope. Welcome to therapy for a better life.
ERP exposure response prevention therapy is really the gold standard when treating OCD. What we do in ERP is we are exposing ourselves to different obsessive thoughts, images, urges, situations. We're exposing ourselves to what triggers our anxiety, and we're staying in that exposure. And the response prevention part is that we are not completing any compulsive or ritual behaviors in an attempt to bring our anxiety down.
Let me show you two graphs that help you understand what's happening during exposure response prevention therapy. In this first graph, you can see that on the vertical axis is our level of anxiety, and on the horizontal axis is time. And at the bottom here, you can see that this person just had an obsessive thought, or maybe they were triggered in an in an environment that began their obsessive fears. And when they had the obsessive thought, their anxiety spiked and sky-high. And at the top here, they began to do a ritualistic or compulsive behavior, and that behavior then their anxiety dropped. Now, what they just did was they reinforced their original obsessive thought. And so what happens is the next time they have this thought, their anxiety goes sky-high again. They compulsory enforce it, the anxiety drops, and now they're in their OCD pattern.
What we do with ERP is, if you look at this graph, when the person has the obsessive thought, their anxiety goes sky-high. But here, we are not going to reinforce that obsessive thought. And instead, we do not do the compulsive behavior, no ritualistic behaviors, and that anxiety over time drops on its own because it was not reinforced. And the next time we have the obsessive thought, it doesn't go quite as high as originally, and no compulsive ritual behaviors, the anxiety drops. And any time now that that obsessive thought happens, because we cannot control our thoughts, the obsessive thought may come, but it doesn't spike our anxiety quite as high. And and that anxiety drops on its own. Eventually, through enough practice of ERP, we really will not get much anxiety at all after we have done ERP successfully. And this is how ERP works.
So, what are the steps in doing ERP? The first thing that you have to do is identify your triggers. What are your triggers? What begins the obsessive thoughts? What are the triggers? Are they different situations? Are they avoidance behaviors, safety behaviors? Like, what is it that triggers your obsessive thoughts and and what triggers the anxiety?
Number two, I want you to assign each trigger a SUDs score. A SUDs score stands for Subjective Unit of Discomfort Scale, and it's from 0 to 100. So, for example, for a person that has contamination OCD, one of their triggers may be touching a doorknob, and they may assign the SUDs score of 80, which is pretty high out of a hundred, to touching a doorknob.
The next thing that you will do, number three, is that you're going to put these in order where you're going to put your most distressful trigger on top, and then at the bottom, you're going to have some of your less distressing triggers.
Number four, you're going to begin to practice an exposure. You pick one of your exposures off of your hierarchy, which is your list. And most people start at the bottom, they start with their easy ones. Sometimes they might start using imaginal, which is imagining their exposure if they can get enough anxiety through imagining the exposure to to actually do the exposure. But most people that I work with actually start in vivo, which is in real life, doing an exposure. If I go back to my doorknob situation, they might first start their first exposure with maybe just putting a finger on the doorknob and and doing that exposure. They're going to stay in that until their anxiety drops. Now, the ritualistic behavior, our compulsive behavior, was washing their hands. And so they they may touch the doorknob, but they are not going to wash their hands. As they practice more and more, they're going to get more parts. They're going to up the ante, which I'll explain a little later, but they're going to really put their whole hand on that doorknob. And eventually, they're even going to after touching the doorknob, they're going to touch their clothing, maybe touch their face, really upping the ante on that exposure.
We stay in an exposure for this person, it would be not washing their hands, that not doing the compulsive behavior, and we stay in it until our anxiety drops by at least 50%. I have people rating their SUDs scores at the beginning of every exposure and then every 10 minutes during the exposure. They're going to give themselves a SUDs score until that SUDs score drops by 50%. So if touching the doorknob was a SUDs of an 80, they're not going to stop their exposure until their they have given themselves a SUDs score of 40. For most people, that takes somewhere between 40 to 90 minutes, depending on how difficult the exposure is, whether it's an exposure you've done several times or whether it's your first one.
Now, we continue with the exposure. I like people to practice every single day and what their exposure is. And we're going to stay with that exposure until we can't really get any anxiety out of it anymore. The SUDs score just, you know, just is so low, we just can't really get any anxiety even when we give ourselves anxious thoughts. Then it's time to move up to our next exposure on our hierarchy.
Now, what about the ones we already completed? I don't like my clients to lose ground. So I have them touching all of those things if they were contamination OCD clients, or if they're checkers, I'm going to have them doing, you know, kind of exposing themselves very briefly every single day to those situations. They might not stay in the exposure because there's no anxiety, but I want them to continue to have them in their life so that they don't kind of recreate fears again.
Now, I want to talk a little bit about the ways to make ERP the most effective that you can. The first thing is, if if there's an opportunity for you to work with a trained therapist, of course, do that. But I know that there are not very many trained therapists in ERP around. And also people around the world live in places that there just is there there are different areas that there are not very many mental health providers. It's just that is not something that's available to them. And that's one reason why I do these videos to help you learn about it.
Also, if someone can combine ERP with cognitive therapy, really challenging those thoughts, it it helps make it more effective. Also, there's a therapy called Cognitive Bias Modification, CBM. And there is a certain kind of bias that people with OCD have, and it's called interpretation bias. They interpret very benign situations and environments and thoughts, and they interpret them as being dangerous. And they also interpret themselves as being more responsible. And so we really kind of work on those different interpretation biases in therapy.
The next way to make ERP more effective is being very committed, committed and accountable to do those exposures every day. It is so difficult, very, very difficult. And you have to be committed. You have to remind yourself why you're doing this, really to get your life back again.
The next way to make it more effective is is again looking at any kind of avoidance or escape behaviors. What are you avoiding? What are you escaping? These avoidance behaviors are also compulsions, and we want to make sure we do exposures on them. I like my clients to watch for secondary gain. I talked a bit about it in the last video. Secondary gain can be unconscious, or it can be conscious. But anyway that you your brain might be somehow getting something out of OCD. For example, are people doing things for you that have because you have OCD? Are you out of work, or not going to school, or not leaving your home? Are you doing something because you have OCD that your brain might like and get some kind of benefit out of? We have to make sure that we are not doing any of these behaviors that that if people are helping you because of OCD, that they stop doing that. If they're part of your ritual, we have to stop that. Secondary gain can really reinforce OCD.
The next item that can help make ERP more effective are medications. I want to refer you to your physicians to get information about this. But medications, as certain types of antidepressants, can be very helpful. There are there's quite a bit of research on an amino acid called NAC, and that seems to really help people with OCD and to make ERP more effective. I might do a video on that in the future. Again, I like people to know that benzodiazepines make exposure therapy completely ineffective. So you will want to work with your physicians on going off of those if you happen to take any benzodiazepines.
The next are safety behaviors. Safety behaviors are things that we are doing that our brain knows some way that we have this little thought that it's keeping us safe. For example, if we have a medication in our pocket, if we are instead of touching things full on, you know, we're touching with our finger, or we're using gloves or things like that. Just just to be aware that safety behaviors make ERP less effective.
I want to say one more word about upping the ante. When we're doing an exposure, we have to keep a very anxious brain. Exposures do not work if we are doing something to cause ourselves to be less anxious. Going back to that doorknob example, if the person just touches like this, that might be okay for the very first exposure. But they have to up the ante. They have to really touch it. And then how do they up the ante and make themselves even more anxious? Oh, let me touch my face now. That's gonna make somebody even more anxious. That's how we get an effective exposure is that we up that ante as much as we possibly can. Our brain has to be as anxious as possible for this exposure to work and for our brain to put down a new neural pathway that touching that doorknob is not dangerous.
Relaxation techniques make ERP less effective. And so we want to make sure we are not doing things like deep breathing and those type of relaxation exercises during the exposure. Again, our brain, our amygdala has to be active, very fearful, activate to generate. And so we have we need a fearful amygdala to make these exposures more effective.
And the last item, this is especially for therapists. The reason ERP is not effective many times is because the therapist is not challenging the client enough. And as a therapist myself, I know sometimes I feel like I am torturing my clients with exposures. We have to do that to help people. It's part of the process. We have to really challenge our clients. So I want to encourage you to challenge and stay with it. Sometimes when I'm working with my clients, I actually am negotiating with them. We're picking out exposures for the next week, and we're negotiating. I'm pushing them, and sometimes they're pushing back, and we come upon agreement about what the client is willing to do in that next week.
So I hope that you learned about ERP today, at least a few more helpful hints. And if you have any questions for me, please go ahead and put them in the comments section. I love hearing from my subscribers. And if you have any for any suggestions on future videos and what you'd like me to talk about, please list those in the comments as well. The next in the in the series is going to be a video on strategic exposure therapy. It's also used for OCD and different anxiety disorders, and I think you'll find it very interesting. So don't forget to subscribe and and click on that bell next to the subscribe button so that you'll be notified when the next video comes out on Mondays. So until then, I will see you in session. Take care. Bye bye.
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