Exposure and response prevention (ERP) therapy is the gold standard for treating obsessive-compulsive disorder (OCD). By confronting obsessions without relying on compulsions or avoidance behaviors, people with OCD learn to sit with uncertainty and ultimately decrease the distress and anxiety caused by their obsessions.
Like OCD, phobias involve a vicious cycle of intense fearful reactions and avoidance behaviors done to neutralize distress. Since ERP targets similar symptoms and processes in OCD, one might wonder: can ERP be used to treat phobias too?
What are phobias?
People with phobias have an intense fear of a specific object, situation, or circumstance, known as a phobic stimulus. The fear is generally disproportionate to the level of harm posed by the feared stimulus and causes significant distress and impairment. Moreover, those with phobias may go to great lengths to avoid encountering their phobic stimulus or things related to it.
In principle, phobias can be about anything at all. Here are a few examples.
- Emetophobia (fear of vomiting)
- Atychiphobia (fear of failing)
- Aerophobia (fear of flying)
- Atelophobia (fear of cheating)
- Tokophobia (fear of pregnancy)
Can ERP Be Used to Treat Phobias?
Given that phobias and OCD are similar, involving strong negative reactions to obsessions or phobic stimuli and behaviors done to alleviate unpleasant emotions, one might wonder whether ERP works for phobias as it does for OCD.
“The answer is yes, absolutely, 150,000%,” says Dr. McGrath, Chief Clinical Officer here at NOCD. In fact, a recent meta-analysis, which examined 33 randomized controlled trials on the use of exposure therapy for phobias, found it to be more effective and produce longer-lasting results than non-exposure-based treatments.
How does ERP work?
ERP therapy is the most effective treatment for OCD, a disorder characterized by intrusive and distressing thoughts, images, and urges, as well as compulsions done to alleviate obsession-induced anxiety.
While compulsions provide short-term relief, they result in more obsessions and compulsive urges in the long run. Experts theorized one could short-circuit this process by having people with OCD trigger obsessions while resisting the urge to engage in compulsions to feel better. In the 1960s, British psychologist Vic Meyer tested elements of the theory in a groundbreaking study that experimentally verified elements of ERP in human subjects. Recent studies have shown that 80 percent of people with OCD find relief with the therapy.
Today, ERP therapy remains the gold standard in OCD treatment, and may also be used in treatment for a number of other mental health conditions.
What is the treatment process like?
ERP can sound daunting, especially if you expect to jump right into confronting what you fear most. Fortunately, that’s not how the treatment works. ERP is carefully designed so that people are able to face their obsessions and fears safely and gradually.
Ranking obsessions and triggers
To ensure that ERP runs smoothly and to avoid producing overwhelming distress, patients begin the process by listing and describing their obsessions and highlighting triggers. They then work with their therapist to rank these obsessions and triggers based on a subjective unit of distress scale (SUDS). Patients and therapists then work together to develop exposures for each obsession, starting with what produces the least amount of fear or distress.
Exposures
To better tailor exposures to a person’s obsessions and levels of distress, therapists can utilize different types of exposures. When starting out, it can be helpful to use imaginal exposures. For this type of exposure, patients think about the obsessions or feared scenarios. Consider Relationship OCD (ROCD); someone with this OCD subtype may write exposure scripts about being with the wrong person or never being sure they are with the right person.
In addition to imaginal exposures, there are in-person or in vivo ones. For example, someone with Contamination OCD, after progressing through less direct exposures, may be asked to physically touch objects they think are dirty or contaminated and not use hand sanitizer afterward.
Response Prevention
If patients rely on compulsions to feel better through the exposure process, they won’t achieve long-term relief. By preventing patients from performing compulsions and avoidance behaviors, it’s possible to break this vicious cycle. Over time, patients can better tolerate distress and accept uncertainty without relying on compulsions and avoidance, which only reinforce fears in the long run.
How does it work?
There are several processes that help explain why ERP works. The first is called habituation. When patients repeatedly confront obsessions without performing compulsions, they get used to feeling the resulting anxiety and allowing it to pass, which allows these responses to decrease over time.
Inhibitory learning is another important process. Inhibitory learning occurs when a previously fearful response is reduced as one gathers more knowledge about feared situations—new learning about feared situations interferes with the recall of old ways one acted in the same situations. In ERP, people who avoid engaging in compulsions or avoidance behaviors learn that they are able to sit with uncertainty and that feared outcomes won’t necessarily come to pass. New information gained through ERP can also alleviate anxiety by helping people realize that certain negative outcomes aren’t as intolerable as they thought they were, and that they can accept uncertainty about them.
Finally, through ERP, patients learn they can tolerate anxiety about their obsessions and fears, just the way they do in other parts of their lives, and don’t need to avoid it at all costs. This helps reduce the urge to engage in avoidance behaviors or perform compulsions to get rid of anxiety.
Is ERP different for phobias?
While ERP has been shown to be highly effective in treating all varieties of OCD and phobias, the specifics of treatment can vary widely between the two conditions, and even among different presentations and themes. It’s important to recognize that ERP therapy will always be variable and responsive, tailored specifically to a person’s triggers, fears, and compulsions or safety-seeking behaviors.
The main distinction between ERP for OCD and for phobias is in the types of behavior that are resisted: “The process for phobias is very similar to what we do with OCD. We purposely expose you to more difficult scenarios and situations gradually over time,” says Dr. McGrath. “The main difference is that instead of working on compulsions in response prevention, you’re trying to eliminate safety behaviors that people with phobias engage in to reduce their anxiety, such as avoidance of the feared situation, reassurance-seeking, or distraction.”
