Exposure and Response prevention (ERP) is the most effective treatment for OCD. However, it remains under-utilized by therapists even though it is preferred by people with OCD who are educated about treatment options. Therapist avoidance and lack of understanding about exposure remain major reasons that more clinicians do not use exposure, but access to appropriate training and supervision is also a problem.
In my experience, compared with exposure for other problems (e.g., panic), using exposure for OCD requires greater fluency in developing appropriate exposure exercises that precisely target a client’s particular constellation of obsessions, and in identifying and disrupting any avoidance behavior. In sum, ERP for OCD is tricky. Consequently, I read with interest a recent article in the Journal of Contemporary Psychotherapy: “When Exposures Go Right: Effective Exposure-Based Treatment for Obsessive-Compulsive Disorder.”
The article provides a nice, readable summary of the OCD literature on how to create an effective ERP plan. They write:
In our opinion, the most effective CBT-E/RP clinicians deliver treatment in a flexible manner and remember the overall goal is for the patient to step out of their comfort zone, experience anxiety fully, feel successful at managing their anxiety, and then leave the session with a sense of accomplishment.
One emphasis I liked in the article is the use of humor in exposure. Humor in exposure can bring a sense of playfulness to the exposure work, and there is evidence that positive mood before and after exposure is associated with lower risk of relapse. Additionally, talking to clients about their experience of and increasing contact with exposure can gently undermine avoidance (e.g., distraction).
The article also outlines various issues around using ERP in outpatient settings. These include the logistics of in vivo exposure outside the therapy office, as well as legal and ethical issues to conducting out-of-session exposure.
I did not agree with absolutely everything in the article. For example, the authors emphasized habituation to feared stimulus even though recent research on inhibitory learning has provided compelling evidence that habituation is a poor indicator of learning during exposure. However, I overall found the article interesting and I picked up a few tips. I think any OCD specialist could benefit by reviewing it.
If you’d like to read the full article, I found a link to the pdf.
