What to Expect in Starting ERP Therapy for OCD and Anxiety
I have noticed a common, and completely normal, response from my clients over the years when I begin to teach them about Exposure and Response Prevention Therapy. The response usually goes something like this: their eyes widen, their muscles tense, and they express uncertainty about moving forward.
This response is absolutely understandable and to be expected. The essence of ERP Therapy is for you to be willing to purposefully approach your fears in a structured and planned way, without engaging in your typical behaviors to make the fear response go away, so that you can learn to sit with it and tolerate uncertainty. As a Therapist, I know that approaching this subject and starting ERP Therapy is a tough ask because who wants to feel afraid purposefully?
Beginning ERP Therapy is tough, and getting stuck in the cycle of OCD and anxiety is tougher. Once you realize this, everything can change. This realization has helped the same clients go from “there is no way I can do that,” to “even though it was hard, I’m so glad I did it.”
Knowledge of what to expect in ERP Therapy can help overcome one obstacle to getting started. This week, I am going to share my process of supporting a client getting started with ERP so you can better understand what to expect. We will review what to expect in the first session, explore what an exposure hierarchy is, and what the process of creating exposures can look like.
What to Expect in Your First ERP Therapy Session for OCD and Anxiety
Often, attending the first session of ERP Therapy can feel like an exposure in itself. You might have overcome many “what if” thoughts and urges to avoid the appointment before you (virtually) step into my office. You might even wonder, “Is she going to make me do an exposure in the first session?”
The answer is a resounding “No!” There is groundwork to cover before you start doing exposures in session. It may take a handful of sessions to focus on preparation before you begin working on exposures.
In the initial session, you can expect us to review the therapeutic relationship, assess your current symptoms, set treatment goals, and begin psychoeducation on OCD, Anxiety, and Exposure and Response Prevention Therapy.
From Psychoeducation to Planning: Starting Your ERP Hierarchy
An exposure hierarchy is a list of fears and triggers related to OCD and anxiety that are ranked from least to most distressing when thinking about eliminating compulsions or safety behaviors. This list serves as a roadmap for exposure planning, starting with the less distressing items and gradually building up to the more distressing items over time.
There is no hard-and-fast rule about what session you should begin developing your exposure hierarchy. In the sessions between the initial session and the one where we start creating your hierarchy, we will focus on a few key points to help you prepare: thoroughly reviewing the psychoeducation of ERP, identifying and clarifying your values, and, in the case of OCD, reviewing the Y-BOCS (Yale-Brown Obsessive Compulsive Scale).
The Y-BOCS is a rating scale used to identify common obsessions and compulsions that clients can experience and symptom severity. I use this often with clients as a starting point for the hierarchy. In a later post, I will review the hierarchy and its development in greater detail.
From Hierarchy to Practice: Creating an Exposure Plan in ERP Therapy
The hierarchy is the last piece of the puzzle before exposure planning can happen. After the hierarchy is complete, I support my clients in collaboratively brainstorming exposures to do in session and for homework that align with their values.
There are a few things to consider when exposure planning. First, it is really about understanding what you’re afraid will happen if you engage with the trigger without the compulsion or safety behavior. This is what we call the feared outcome. This helps make sure the exposures we plan are targeted and specific to your goals. It also helps in the reflection time after the exposure to begin comparing what you were afraid would happen and what actually happened to facilitate learning new insights about your capabilities to tolerate uncertainty and how accurate anxiety is at predicting the future.
Second, we will discuss what to do about compulsions or safety behaviors during the exposure. The ultimate goal is to refrain from compulsions entirely, but this is often unrealistic to start with. If this is the case, we will discuss whether to delay or reduce the compulsion during the exposure.
Third, we will ensure the exposure plan is specific and measurable. This will help structure it so you know exactly what the plan is, and it can be repeated in future sessions or for homework.
Lastly, it is essential to make sure the exposure is what I call a doable challenge. This is important so that the exposure is not too much, too soon, and does not flood you with high distress and anxiety. Even though the purpose of ERP is to expose you to anxiety, to learn to tolerate it, it is important that the anxiety felt is at a challenging yet manageable level so that you can complete it. This helps build your overall confidence in your ability to do exposures, and over time, we will gradually increase the intensity at a pace you agree with.
Final Thoughts from an ERP Therapist: Encouragement for Your OCD and Anxiety Journey
ERP Therapy can be intimidating to consider. It asks you to do what might feel unimaginable, to approach your feared outcome without safety behaviors. The good news is you are not alone. Your ERP therapist is there to guide you and to work with you, and ERP is an evidence-based practice that is highly effective in treating OCD and anxiety.
You will not be thrown into the deep end of exposures during the first session, or even at all. Your therapist will take time to get to know you in your initial session, provide psychoeducation, help you prepare to engage in ERP for several sessions, support you in creating an effective hierarchy aligned with your values, and then collaborate with you to develop specific, measurable, and planned exposures.
If you’re struggling with OCD and anxiety and are interested in starting ERP Therapy, then let’s talk! I offer a complimentary 30-minute consultation so that we can discuss what you’re going through, your goals, and assess if we would be a good fit to work together. If you’re ready, click the button below to schedule an appointment.
Lauren