The Exposure in ExRP refers to being deliberately exposed to the thoughts, images, objects and situations that trigger anxious thoughts and/or obsessions.
While the Response/Ritual Prevention part of ExRP refers to choosing not to do a compulsive or ritualistic behavior once the anxiety or obsessions have been “triggered.”
OCD and Anxiety:
OCD and anxiety disorders take over the body’s alarm system. This system is designed to protect us, but instead of warning only of real danger, that alarm system responds to any trigger (no matter how small) as a true, terrifying, catastrophic threat. Thoughts, even irrational and/or intrusive ones, can also be triggers.
With OCD and anxiety disorders, the brain frequently signals danger. This happens even when the brain knows the probability of danger or something bad happening is very small.
Compulsive or ritualistic behaviors are attempts to keep oneself safe when that alarm goes off. Initial anxiety often decreases with compulsions/rituals (which can be behavioral or mental), or avoidance. When a person engages in rituals/compulsions or avoidance, they reinforce to the brain that the situation or thoughts are dangerous. Because the anxiety decreases with the compulsions/rituals or avoidance, a reinforcing loop of anxiety and/or OCD thoughts is maintained.
Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the client to the anxiety source or its context without the intention to cause any danger.
In classic exposure therapy, habituation is the primary principle in treatment. This is the process when a person’s behavioral and sensory responses decrease after repeated exposure to a feared stimulus. The belief is that once habituation occurs, then the fear will be extinguished.
Newer models of Exposure Therapy are abandoning the idea of habituation in exposure and embracing something called Inhibitory Learning.
(Brain Body Integrative Therapy integrates the Inhibitory Model of Exposure Therapy)
In order to be optimally effective, ExRP needs to help people learn safety in such a way that it is strong enough to block out (or inhibit) the original fear.
Elements of Inhibitory Learning
- Focusing on Anxiety Tolerance instead of Habituation
- Disconfirming Expectations
- The Element of Surprise
- Combining Fear Cues
Exposure therapy is conducted using a combination of in-vivo exposure (live), imaginal, and virtual reality.
This part of ExRP treatment is particularly important for people who have developed ritualized, repetitive behaviors or compulsions in response to the obsessions or fears. The compulsive behavior serves to “undo” or neutralize the anxiety that occurs when faced with an anxiety-provoking situation. Since compulsive behaviors serve to reduce or eliminate anxiety, they are intrinsically rewarding.
The elimination (extinction) of rewarded behaviors (compulsive rituals, escape, and avoidance) cannot be achieved unless these behaviors are prevented. Response prevention focuses on preventing these behaviors from being rewarded. Once a behavior is no longer rewarded, it stops.
The combination of exposure to anxiety-provoking stimuli, along with the prevention of rituals, escape, or avoidance leads to the most effective treatment response.
Fear of ExRP
It’s normal to feel anxious and fearful of engaging in ExRP therapy. It should be evident that exposure and response prevention therapies require the willingness to tolerate an initial increase in discomfort. ExRP is similar to physical therapy, whereas treatment is often initially more painful with the outcome of building strength, mobility, and decreased pain. Clients voluntarily choose to participate in this type of therapy. They are well-prepared in advance of the therapy. At no point is anyone forced or coerced to participate in the exercises.
Traditional talk therapy tries to improve a psychological condition by helping the client gain “insight” into their problems. Talk therapy can be a very valuable treatment for some disorders, but it has not been shown to be effective at treating the active symptoms of OCD. Many with OCD have deep awareness and insight into their fears and behaviors, but that alone is not enough to bring relief.
ExRP (combined with ACT) is the most effective evidence-based treatment for OCD.