Organized Chaos - Volumes 1 & 2
What Is Exposure & Response Prevention?
by Lisa Jo Bertman, Ph.D.
Assistant Professor of Psychiatry
Tulane University Health Sciences Center School of Medicine
Exposure and Response Prevention (E&RP) is a behavioral technique that is most effective for treating OCD symptoms when combined with medication. E&RP has two components: exposure involves confronting fears; response prevention involves not engaging in the response that makes you feel more comfortable. The goal of E&RP is "habituation." Habituation refers to getting used to something that formerly produced a very strong emotional response. It is not enough to do just exposure or just response prevention; you must do both in order to experience habituation.
Where Do I Begin?
Below are five steps to beginning E&RP:
- Write out a complete list of situations, thoughts, images, impulses that make you anxious or uncomfortable (call this obsession list).
Examples: Thoughts that I hit someone while driving; thoughts about shaking hands with others. - Write out a complete list of all the things you do to reduce or help manage your anxiety (call this compulsion or ritual list).
Examples: checking oven to make sure it's off; washing hands after touching certain items that are “dirty”; repeating movements; replacing a bad thought with a good thought. - Write out a complete list of all the things you completely avoid because they make you too anxious (call this avoidance list).
Examples: trying on clothes in department stores; driving; doing laundry; stepping on cracks. - Or a SUDS Meter Rank each item on your compulsion and avoidance Lists using a SUDS (Subjective Units of Distress Scale). This is a 10 point scale with 1 = no anxiety, calm, cool, collected and 10 = worst anxiety ever; panic attack. Please rank each item using what you anticipate your SUDS would be if you were asked to resist doing the ritual or to do what you avoid doing.
Examples: if you check the locks five times before going to bed or you wash your hands after putting your laundry in the wash, record what you think your SUDS would be if you did not do these rituals. Or for avoidance situations, if you avoid sitting on the floor in a public place or handling dirty laundry, record what you think your SUDS would be if you were to do these things. Be sure you don't rank all the items 10 even though the thought of all these things may be very distressing to you. If you have a variety of rankings from 1-10, you will be in a better position to begin E&RP. - Generate a fear hierarchy by recording the items you ranked from lowest to highest. Set aside two hours for E&RP. Begin with the lowest item on your fear hierarchy. Expose yourself to the trigger and follow the directions Throughout the remainder of the day, you should follow the suggestions please under the special tips for time outside E&RP. Once you have experienced habituation to the lowest item, move to the next item, and so on …
Special Tips Regarding What Not To Do During E&RP:
Don't Distract: Distraction is just another way to avoid anxiety and won't allow you to habituate to your anxiety. You must focus on your anxiety and the exposure task you are doing.
Don't Over Expose Yourself: Sometimes people expose themselves to too much during an exposure session which can be counterproductive. Once your SUDS reaches an “8” or “9”, you should not expose yourself to anything else until your anxiety comes down.
Don't Need Rituals To Reduce Anxiety: Resist rituals and you will learn that you do not need to do rituals to reduce your anxiety. That is, your anxiety/discomfort will abate naturally within a period of time. (i.e. usually 2 hours.)
Don't Take Anti-Anxiety Medications Or Use Relaxation Techniques: It is important to focus on the anxiety so that you do not attribute your gradual reduction in anxiety to something else. If you take an anti-anxiety medication, or use relaxation techniques during E&RP, you will attribute your reduction in anxiety to these things. You will continue to feel uncomfortable with the idea that you can bring your anxiety down without doing rituals or anything else.
Special Tips For Time Outside E&RP (throughout the rest of the day):
- Plan Pleasant Activities Daily
- Learn Relaxation Techniques
- Exercise
- Adopt Coping Statements
- Stay Busy
- Eliminate Rituals and Avoidance Behavior Whenever Possible
Lisa Jo Bertman, Ph.D. is an Assistant Professor of Psychiatry at Tulane University Health Sciences Center School of Medicine, Dept. of Psychiatry and Neurology (TB 53), which is located at 1440 Canal Street, New Orleans, LA 70112-2715. Dr. Bertman's phone is 504:588-2201 and her e-mail address is lbertman@tulane.edu
