Exposure and Response Prevention (ERP) Therapy is a technique that grew out of the behaviorist school of psychology and the cognitive behavioral paradigm of therapy. The technique is specifically used for individuals who experience disorders that are driven by high levels of anxiety, and this anxiety results in the individual using some type of repetitive behavior to decrease their anxiety.
It is important to understand that ERP is a specific technique that requires specialized training to implement. Individuals should not attempt to try to use the principles of ERP unless they are licensed mental healthcare professionals and trained in the technique. Anyone who wishes to benefit from ERP should contact a trained, licensed, mental health profession.
What Is ERP?
The first component of Exposure and Response Prevention Therapy is exposure. Exposure therapy comes from the behaviorist school of psychology and is based on the notion that individuals who experience high levels of anxiety as a result of exposure to some stimulus or event will experience a peak of their anxiety if they remain exposed to the stimulus or event for long enough period of time. Once the anxiety peaks, it has nowhere to go but down; in other words, once the individual experiences a peak level of anxiety, the anxiety will slowly dissipate.
Individuals can learn to confront fear of anxiety-producing objects or situations by being exposed to them and allowing their anxiety to peak and then decrease. Once individuals learn that there is no danger involved in the exposure to the situation or object, their anxiety will eventually dissipate altogether or least to a level where they do not need to engage in dysfunctional behaviors to avoid these situations.
The issue with exposure is, of course, that it can be very uncomfortable for individuals in the initial phases of treatment. In cases where individuals are unable to allow their anxiety to peak and then dissipate, the technique may actually increase the person’s tendency to avoid the feared situation or object. Moreover, individuals who are not properly supervised may also resort to drastic measures to deal with their anxiety, such as engaging in dangerous or potentially self-harming behaviors to avoid anxiety. Thus, exposure therapy should only be implemented by individuals who are trained in the technique and who understand how and when it should be used.
In addition, if the exposure therapy process is not implemented at a pace that is comfortable for the client, there is a very good chance that the client will discontinue their treatment. For this reason, many exposure therapists first teach individuals very thorough methods of progressive muscle relaxation, diaphragmatic breathing (which also results in relaxation), and other techniques to manage stress and anxiety before implementing exposure protocols.
Once an individual has learned to control their stress and anxiety, they can then participate in exposure training while practicing their anxiety and stress control techniques (e.g., muscle relaxation, breathing, etc.). Exposure therapy often initially occurs via imagery; the individual imagines being exposed to the anxiety-producing or feared object or situation. Therapists also learn to use graded exposure techniques to help the individual become accustomed to dealing with their anxiety and gradually develop their skills as they confront the feared situations.
Graded exposure can work something like this:
- The client and therapist develop a hierarchy of related anxiety- or fear-producing situations or objects. Objects that produce the least amount of anxiety are at the top of the list, and those that produce the most anxiety are at the bottom of the list.
- The client and therapist work on developing skills to control stress, anxiety, and fearful responses through progressive muscle relaxation, diaphragmatic breathing, and mental imagery.
- Once the stress and anxiety management techniques have been practiced and the individual is relatively competent with them, the therapist exposes the individual to the situations at the top of the list (those that are least fear-producing).
- As the person becomes comfortable with exposure to objects or events at the top of the list, they slowly work down the list until they reach the more fearful or anxiety-producing situations or objects.
- This allows the individual to slowly and comfortably manage their anxiety and fear.
The use of the hierarchy and the elements of exposure during relaxed states is a type of therapy also known as systematic desensitization.
The response prevention element of ERP is used when individuals develop dysfunctional behavioral responses to anxiety-provoking situations. For example, individuals with obsessive-compulsive disorder (OCD) engage in compulsive behaviors to deal with anxiety that is produced by obsessions (recurrent thoughts).
A common manifestation of OCD is an individual who is obsessively concerned with dirt and contamination. These individuals may have obsessive thoughts regarding being dirty or contaminated that produces severe anxiety. One way to deal with the anxiety is to repeatedly wash one’s hands to rid them of dirt and potential contamination. This cycle of repeatedly obsessing over being dirty or contaminated and repeatedly washing one’s hands can interfere with the person’s ability to function. In ERP, the therapist would expose the individual to the feared situation (literally put dirt on their hands) and then prevent the individual from engaging in the repetitive hand washing. Because the individual’s anxiety will peak and then dissipate once they are not able to engage in hand washing, the individual eventually learns that there is nothing to fear about a little dirt on their hands. The use of relaxation training as mentioned above can be implemented in this technique to assist the individual in comfortably dealing with the exposure and response prevention part of the therapy.
ERP can be used with both imagery (imagining having dirty hands and then not washing them) and with actual stimulus production as mentioned above. A number of other components of ERP can be included depending on the therapist. While this treatment may seem rather cruel to some, it is highly successful in the treatment of certain psychological disorders that are driven by anxiety. When used properly by trained therapists, it results in minimal discomfort for the client.
The success of exposure therapy and ERP is based on the notion in both classical conditioning and operant conditioning of extinction. When individuals perform a behavior to reduce their experience of anxiety, they are continually reinforcing that behavior through a mechanism known as negative reinforcement. When behavioral responses are not reinforced, the responses decrease until eventually they halt or become extinct altogether.
Why Is ERP Used?
However, it should be noted that ERP must be used with discretion in trauma and stress-related disorders like PTSD and with personality disorders. ERP can also be used for individuals with certain types of substance use disorders, such as a tobacco use disorder where the individual smokes cigarettes primarily in response to stressful conditions. By not allowing the individual to smoke when experiencing stress, the individual can learn to control their smoking behavior to some extent.
Principles of ERP can certainly be applied in some instances in the treatment of substance use disorders; however, substance use disorders represent very complicated behaviors and are not just behaviors designed to reduce anxiety in the same way that the behaviors associated with anxiety disorders and OCD are. Thus, ERP may have some utility in the treatment of substance use disorders, but it is not considered a primary treatment approach for these disorders. Instead, more intense forms of Cognitive Behavioral Therapy that address global dysfunctional thinking patterns, attitudes, and beliefs are required in the treatment of substance use disorders.