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Key points
- To master ERP, therapists need to have a solid understanding of OCD and how it functions.
- Tailor treatment to meet the individual needs of clients and incorporate values into ERP work.
- ERP has a high learning curve! Stick with it, practice self-compassion, and seek support as needed.
Exposure and response prevention (ERP) is the leading evidence-based therapy for obsessive-compulsive disorder (OCD). For therapists who are new to ERP, it can feel both exciting and intimidating to learn and implement a new treatment modality. Mastering ERP can lead to life-changing outcomes for clients living with OCD, but it requires a solid foundation of skills and knowledge to build off of. Here are some tips for therapists who are looking to thrive in this specialty.
1. Understand the Basics of OCD
Before getting started with ERP, it is imperative to have a solid understanding of what OCD is, as well as how it operates. OCD is characterized by obsessions (intrusive and unwanted thoughts, images, or urges) and/or compulsions (repetitive physical or mental acts that are performed to alleviate distress or discomfort).
The driving force for compulsions is the anxiety or distress caused by the obsessions. Performing compulsions provides temporary relief and negatively reinforces the OCD cycle. ERP aims to break the OCD cycle by targeting the compulsions. When clients lean into their distress without compulsions, they learn to face their fears and tolerate distress.
2. Get Comfortable With Discomfort
ERP involves clients facing their fears without performing compulsions that would typically alleviate distress and discomfort in the short term. For therapists, bearing witness to clients’ distress in session can be challenging, especially if they are used to offering reassurance or other coping skills. Leaning into this discomfort is essential.
For ERP to work, clients have to be provided with a space to feel uncomfortable so they learn that they can handle these challenging experiences and work through them and that their distress will go down if they do not engage in compulsions. In ERP, distress is a sign of progress!
3. Start With Psychoeducation
Providing thorough and individualized psychoeducation at the start of treatment is vital in ERP. Key components of psychoeducation should include a clear and concise explanation of OCD, the OCD cycle, and how ERP works to break the OCD cycle.
This is the groundwork from where everything else in ERP is built. If a client doesn’t have a firm grasp of these concepts, there will likely be issues down the road. Adequate psychoeducation also helps with the buy-in and willingness of clients to do the hard work of ERP.
4. Create a Tailored Hierarchy
Exposures need to be individualized to clients’ presentations and core fears. Conducting a functional assessment during this phase of treatment will provide the therapist and client with the information necessary to proceed into the next stages of treatment. This includes spending time gathering information about the client’s obsessions and compulsions, utilizing a downward arrow to get to their core fear, and then collaboratively building the hierarchy.
Start with lower-level exposures that are done in session, and then move through the hierarchy. Working through the hierarchy can sometimes feel like a balancing act of finding ways to challenge clients while making the exposures feel manageable. Input and collaboration with the client are important for setting clients up for success.
5. Emphasize Response Prevention
Response prevention is the most important ingredient in the ERP formula. Response prevention goals should be individualized to clients and should make sense for where they are in their ERP journey. These goals can look like resisting, reducing, or delaying compulsions. Without response prevention, the distress will not subside, and the OCD cycle will continue. Remind clients that the goal is not to eliminate anxiety completely but to learn to tolerate it without needing to engage in compulsions.
6. Incorporate Values-Based Exposures
Values-based exposures can help increase motivation and willingness to engage in treatment by encouraging clients to face their fears in the context of what matters most to them. For example, if a client is avoiding social situations due to their fears, but community and relationships are core values, then incorporating exposures involving social situations or relationship building can help make ERP work more meaningful. This can enhance commitment and move clients toward accomplishing tremendous quality-of-life improvements.
7. Seek Supervision and Consultation
OCD cases can be complex, and ERP can feel challenging to implement at times, especially as therapists are first starting out. Seek supervision or consultation with a seasoned ERP therapist who can act as a guide through challenging cases or provide feedback. This can give a confidence boost and ensure that therapists are providing ERP in a way that aligns with best practices and is most helpful for clients.
8. Practice ERP With Self-Compassion
ERP can have a big learning curve. It's normal to feel uncertain or anxious about leading clients through exposure. Therapists should practice treating themselves with compassion as they’re learning and know that mistakes are a part of growth. Seeking out consultation and guidance and learning from mistakes are strengths and will only be of benefit in the long run. Willingness to face discomfort and modeling how to handle it sets an example for clients.
9. Continue Training and Learning
Ongoing training in ERP, just like any other treatment modality, is key to staying up-to-date with best practices. Enroll in workshops or continuing education to keep new and gained skills sharp. As therapists gain experience and confidence, they’ll find that ERP is a powerful tool that can profoundly impact the lives of their clients.
10. Trust the Process
Finally, trust in the process of ERP. Observing and experiencing clients’ discomfort may bring uncertainty or anxiety about being on the right treatment path, but stick with it and see how clients go on to handle future situations with confidence. The goal is to help clients develop a healthier, more productive relationship with anxiety and learn to manage their OCD effectively by becoming their own ERP treatment expert. Progress is not perfectly linear, but as clients grow in their recovery, they’ll have the tools they need to handle the challenges they are confronted with in the future.
Starting with ERP can be both challenging and rewarding for therapists. By becoming equipped with knowledge, skills, and the support of others, therapists will be better prepared to help their clients reclaim their lives from OCD. Keep learning, stay curious, and embrace the growth that comes from stepping into the world of ERP.
