A BRIEF INTRODUCTION TO EXPOSURE WITH RESPONSE PREVENTION (ERP)
by Mark Chrisinger, LCMHC
A BRIEF INTRODUCTION TO EXPOSURE WITH RESPONSE PREVENTION (ERP)
by Mark Chrisinger, LCMHC
Introduction
What is exposure with response prevention (ERP)? In brief, ERP is a structured approach for learning how to experience and tolerate feared experiences. “Exposure” means being exposed to a feared internal or external experience, and “response prevention” means not responding to that experience with avoidance.
First let’s go into how fear works. In phobias (any kind of specific fear), there is a threatening stimulus (for instance, heights) that activates the sympathetic nervous system (which we experience as anxiety or fear), which then leads to an attempt to escape (e.g., run away, hide, etc.). If there is no way to escape from the threatening stimulus, the sympathetic nervous system response may turn into a panic attack due to an overload of energy activated toward escape. This in turn may result in the parasympathetic nervous system applying an emergency brake to the sympathetic system, shutting you down in what is known as freezing or death-feigning.
Now all of this is fine if the thing you’re afraid of is life-threatening. If you experience this reaction in being pursued by a bear, it works very well: You see the bear, your sympathetic system kicks into gear, and you run. If the bear gets too close to you, you will attempt to fight it, and if it neutralizes your abilty to fight, you’ll flail in panic. If flailing doesn’t allow escape, you’ll then play dead, and if playing dead works, the bear may lose interest in you as prey for long enough to allow you to go back into flight and escape, or the bear will eat you, in which case being in a dissociative, shutdown state no doubt minimizes the horror of the situation.
But, putting the remote possibility of bear attacks aside, suppose that the thing you fear is not so tangibly life-threatening—like, for instance, the sight of blood. If your brain has categorized the sight of blood as threatening or very dangerous, your response to a photograph of blood will be the same as your response to a real bear in front of you. First, you will try to escape. If you can’t escape, you’ll experience panic. If the panic persists for long enough, you’ll experience shutdown. In this case, you’ve spent huge amounts of energy trying to escape, and you end up exhausted—and all of this will take place for no reason, because that photograph of blood was never going to hurt you.
The goal of ERP is is to reset your relationship to this kind of fear response. It is a gradual approach to exposing you to the feared thing and letting you experience it for a length of time without resorting to escape behaviors. This process teaches your nervous system that the feared stimulus and accompanying sensations of fear are tolerable and don’t require the previously conditioned life-or-death reaction, allowing you to have a more flexible emotional and behavioral response to the stimulus and to the fear.
Here are the steps:
1. Identify what you are afraid of and in what context. Usually the feared thing seems obvious, but sometimes it is more subtle than the surface level, and it is also important to take into consideration the context. If you’re afraid of blood, does that mean your blood, other’s blood, blood in front of you, videos of blood? The context is important to make the exposure most effective. In obsessive-compulsive disorder (OCD), identifying the feared object can be difficult, because the feared thing is usually, though not always, something internal. For instance, someone might have an obsession about his family member being injured, and so it might appear that he is afraid of his family member being hurt, but really he is afraid of the thought “what if someone in my family were injured?” I’ll be adding more information to my website about OCD later.
Example: “I’m afraid of heights, mostly when I have to go into a tall building or fly on an airplane, but I also get really anxious when I anticipate having to do those things or watch movies showing people exposed to heights.”
2. Identify the problems the fear has caused you and your motivation to work on it. Before going more into the details of what you are afraid of—which is itself an exposure exercise—you need to focus on why the fear is a problem that you really want to work on. Does fear keep you from doing things you need or want to do? Does it make it difficult to sleep or eat? Does it impact your relationships? Think about what you would do if the fear wasn’t there. It’s important to focus on your positive goals first rather than just on wanting the fear to go away. This shifts you away from fear-based avoidance, which is what sustains the fear in the first place.
Example: “I want to visit my mother more, and I need to fly in planes to do that. I also want to be able to walk and drive over bridges and get around normally.”
3. Identify any historical factors that contribute to your fear. Why are you afraid of this thing in particular? You might not be able to answer this question, and it’s okay if you can’t. Sometimes fears are really random, but sometimes they have a clear historical origin. Exploring the issue with therapy, journalling, or conversations could be helpful in identifying the cause.
Example: “When I was a kid I went hiking with my dad, and at the top of the mountain there was a cliff with a vista. I went to the edge and looked over, and I suddenly felt like I was going to fall or jump off, and I tried to step back, but my dad was standing right behind me. I think he was trying to hold me to make sure I didn’t fall, but I felt trapped between him and the cliff, and I got really scared. Since then, I’ve been afraid of heights, and it’s just gotten worse over the years.”
4. Identify any secondary fears. Distinguishing between primary and secondary fears is important. For instance, you might be afraid of dogs, but you also might be afraid of feeling anxious or panicking when you are around dogs—the fear of fear is the secondary fear. In many cases, the secondary fear is much more dominant than the primary fear of a thing or condition. The reason the secondary fear is often more powerful is that people can usually rationalize and acknowledge there is nothing to be afraid of from the stimulus (e.g., most dogs aren’t going to bite you), but they struggle to accept that high anxiety and panic are things that can be tolerated and not avoided.
Example: “I’m afraid of panicking on a plane and not being able to escape or get help.”
5. Identify escape behaviors. This includes anything you do to avoid or get away from the anxiety and fear. The basic escape behavior is literal escape: running away, leaving, etc. Every other escape behavior is a variation of that. Common escape behaviors include: leaving the situation, distraction, hiding (as in agoraphobia), self-soothing (e.g., deep breathing, eating, etc.), limiting sensory input (e.g., closing eyes), and compulsions (e.g., checking locks, etc.). Identifying escape behaviors is really important, because these are the behaviors that sustain the fear and anxiety.
Example: "I stop watching a show when heights are involved. I avoid talking to my mother about visits. I close my eyes when we're driving over a bridge. I don't look out of windows above the first floor."
5. Be willing to entertain the hypothesis that your fear is excessive or even unfounded. If you think your fear is 100% justified, there’s no way you’re going to work on changing it. You’ll never convince me, for instance, that I shouldn’t avoid walking off cliffs. Why? Because I 100% believe that doing so is life-threatening. If you believe being around blood or needles or elevators is as bad as walking off a cliff, you’re not going to be able to do the work. The best way to evaluate your fears is to categorize outcomes as “likely to result in physical injury or death” or “not likely to result in physical injury or death.” If the outcomes are not in the injury or death territory, the fear is excessive and maybe unfounded. The answer to this might vary by context. For instance, seeing a picture of blood is zero threat to life or limb. All fear of photos of blood is excessive to the goal of survival. But seeing blood pouring from your own body is 100% threat to life and limb, and your fear associated with this is probably equal to the survival task at hand.
I’d like to note that it is perfectly natural to experience fear that is excessive to the survival task. We are designed to be this way. If I’m afraid of venomous snakes, that is good from a survival perspective, because I’ll avoid them and be less likely to be injured or killed by one. If I am afraid of all snakes, that is even better from a survival perspective, because then I won’t make the mistake of not avoiding a venomous snake I thought was safe, and I’ll be even more likely to survive. Unfortunately, that also means I’ll be more likely to experience fear and anxiety in general. So more anxiety and fear than is absolutely needed is adaptive, but that doesn’t mean it is comfortable or unchangeable.
Example: “I know that 99.999% of the time being exposed to heights while in an airplane is not going to hurt me. I know other people can be fly without fear.”
6. Be willing to entertain the hypothesis that feelings of anxiety, fear, and panic are tolerable experiences that are not harmful. This is difficult, because these sensations are literally designed to motivate us to escape and not tolerate whatever is happening, and by definition we are going to feel uncomfortable and at risk of harm when we feel these sensations—but, that does not mean that the sensations themselves are intolerable or harmful to us. In fact, if we accept these sensations are designed to help us to survive—to save us from harm—they are by definition not harmful. It’s important to recognize that the fight-or-flight response is not going to kill you: an increase in your heart rate does not indicate you’re dying; shortness of breath does not indicate you are going to suffocate; weakness in your limbs does not mean you are going to lose all motor control—all of these sensations just indicate your body is activating energy to escape. It’s important to be onboard with this, because ERP is all about getting anxious on purpose—more anxiety during the exposure equates to more effectiveness.
7. Decide if you want to procede with ERP. Do you have the motivation to change, the willingness to challenge your fears, and the willingness to face and experience your fear? Are you ready to do this now? If you’re not sure, go back to your motivations and reflect on those. Reflect on the power the fear has over you and how much you really want to be free from that fear. You need to really want it before you start; otherwise, it’s going to feel like someone throwing you into a lake and telling you to sink or swim—that is, it’s probably going to make you more afraid.
8. Design your fear hierarchy. Once you’ve decided to proceed, you need to design a hierarchy of situations that create fear or anxiety. It’s important to recognize that this is the beginning of your exposure work, and just writing the list might cause you some anxiety. Remember that you have decided to entertain the hypothesis that the anxiety is tolerable and the fear is unfounded, and you’re determined to go forward with the exercise even if it causes discomfort, because you really don’t want this fear to have so much power over you.
Go ahead and begin by just writing down anything that triggers the fear you are targeting (a thought, sight, sound, environment, thing, etc). For example, if the fear is heights, you might write: flying in a plane, buying a plane ticket, thinking about visiting my sister, driving over a bridge, watching people climb in movies, seeing skyscrapers, etc. Once you’ve written down all of the things that trigger your fear, go back and rank them from 1-10, with 1 causing the least anxiety and 10 the most possible. For instance, from the list above, you might put flying in a plane at 10 and seeing skyscrapers at 2.
9. Plan the exposure. For each of the items on the fear hierarchy, you need to plan an exposure. This means for each item you need to define the target exposure and the response prevention. For the most part the target exposure is obvious—it’s the same as the trigger—but sometimes you need to imagine the thing in order to practice the exposure (for example, imagining flying in a plane versus actually doing so). The response you are preventing is any form of escape from the target. So for seeing skyscrapers, you might say “exposure = looking at image of skyscraper and talking about it” and “response to prevent = getting up from seat, looking away from the image, looking at less disturbing parts of the image, pushing the image further away, changing the topic.” This gets tricker when you are dealing with OCD, because most of what is going on is internal. If the exposure were, for instance, thinking the thought, “Maybe I drank poison,” the response prevention might be “not mentally recalling everything I drank today to confirm I didn’t drink poison.” Once you have defined the conditions of the exposure, you also need to set a time length you are committed to. If it is with a therapist in a therapy session, it will be for a set duration of the session (30-50 minutes most likely). If you are doing it alone, you should do each exposure for 30 minutes or until you are experiencing 0/10 of anxiety on a scale where 0 = no anxiety and 10 = panic. You should have multiple exposure exercises ready so that you can keep the exercise going for the intended duration. For instance, if you end up at zero after looking at a skyscraper for 10 minutes, you should imagine buying a plane ticket and work on that exposure until the end of the session.
10. Do each of the exposure exercises. Theoretically, you start with the lowest item on your list—the least anxiety-provoking—but sometimes doing things out of order can help the exposure be more exhilarating! And it’s important for it to be exhilarating—that is, productive of a lot of anxious energy—for it to be effective. Before you begin, make sure you clearly understand the exposure task (e.g., looking at a picture, thinking a thought, imagining something), and make sure you understand the specific escape behaviors you are preventing (looking away, performing a mental compulsion, distracting oneself, etc.). Then check in with your subjective units of distress scale (SUDS) and ask yourself on a scale of 0-10 (where 0 is no anxiety and 10 is a panic attack) how much anxiety you feel going into the exercise. Keep in touch with your SUDS level throughout the exercise. If you are doing the exercise with a therapist, they will check in on your SUDS for you. If your SUDS gets to 0, double-check to see if you are performing any avoidance behaviors (e.g., maybe you are less distressed because your mind was wandering). If you notice any, stop them and return to the exercise. If you get to 0 and there aren’t any avoidance behaviors present, go to the next exposure exercise and keep it up until you have finished the intended duration of the session.
11. Do the exposure exercises again—and revise as needed. Even when you think you are done with a particular exposure, you should try it again. The reason for repeating it is that you might be using subtle escape behaviors. For instance, you might be using the end of the exercise as an escape, or you may be utilizing an escape behavior subconsciously (e.g., not really paying attention, anticipating something pleasant in the back of your mind, dissociating from your body, etc.). Repetition, like with any kind of new learning, is important for us to work out all the kinks.
There you have it: a definition of ERP and how to do it. Most of the time it is helpful to have someone guide you through the process, but it is also possible to do it on your own, particularly if the fear is very limited and not too intense.
Please feel to be in touch with any questions or comments at mark@markchrisingercounseling.com.