When Traditional ERP Doesn’t Help

Traditional ERP is a well researched intervention that has helped relieve symptoms for many people with OCD. When it doesn't help, however, practitioners often have limited or misguided views on the reasons, pointing to gaps in treatment efficacy.

What is traditional ERP?

Exposure and response prevention (ERP) is a therapeutic intervention for OCD that involves confronting a feared outcome, while preventing the compulsive response.

I am using the term “traditional exposure and response prevention” to refer to a technique that generally uses more observable stimuli (e.g. a door knob, or a stove) and responses (avoiding the door knob, checking the stove), with the belief that the person “habituates” to their anxiety over time if they are exposed to the stimuli without doing their compulsive response. Therefore, the goal of traditional ERP is to spike the person's anxiety as much as possible while preventing the compulsion.

When it doesn't help, what do these practitioners say?

Rather than systematically addressing the limitations and misguided beliefs within traditional ERP practice, I think it's appropriate to critique a representative example of what these practitioners think is going on when it doesn't help.

Have a look at the following article: Eight Reasons Why Some Patients Fail in OCD Treatment

General thoughts

I spent 20 years, on and off, frustrated by therapists who strongly believe that traditional ERP is the only possible intervention for OCD, which I have found to not be true for myself. If you detect some bitterness, that's why.

First, while this article is purportedly about ERP, there is no mention that RP (Response Prevention) might not have been taught adequately. This is probably a huge factor, since most practitioners don't teach patients about rumination and how to stop.

Second, underlying emotional components are absent. This is an unfortunate problem, but is very common with strict behaviorists, as most I have met tend be wary around psychodynamics in OCD treatment. All I will say is that I'm more concerned with what helps people than which theory or point of view is correct.

Point by point critique

I'm going to address most of the author's points in no particular order.

Lack of Insight

Basically, OCD is classified as one of two types: with insight, meaning the individual understands that the OCD beliefs are irrational or untrue; and without insight, meaning the individual thinks the OCD beliefs are probably true. In some cases, insight can be totally absent, making the OCD beliefs rise to the level of delusional intensity. Obviously, good insight carries a better prognosis than poor or absent insight because delusional beliefs are much more stubborn than irrational ideas. That is, irrational beliefs can usually be reduced with behavioral evidence that disconfirms them while delusions are extremely resistant to change even in the face of overwhelming evidence they are wrong.

While I think this classification is oversimplified and frankly kind of patronizing, the real issue is that this point does not matter too much, and that it says much more about the therapy than the patient.

I'll be brief on why this is oversimplified. First, people with OCD have a spectrum of insight (not a binary level), just like everyone. Someone can know one obsession is rational while another one is not. Second, some OCD is perfectly rational, such as sensorimotor OCD or so-called "Pure-O". See Greenberg's Type 3 OCD. Third, irrationality is a common feature of OCD because it serves a defensive purpose. Addressing the defenses first, and then compulsive rumination, can change a person's insight.

Because many practitioners are hyper-focused on getting the patient to learn and unlearn certain behaviors, they hand-wave any blockers as lack of insight (and lack of motivation, which I'll get to at the end). IF ONLY the patient could come to understand that their beliefs are irrational, then we'd be able to get this ERP stuff going.

Strict behaviorists might not understand that only the patient can know exactly what is obsessive and compulsive for them. This interferes with the reliance on objective truth in treatment. The therapist's job is not to define reality for the patient, or even to define what is obsessive or compulsive. It's to hold the patient while they find their feelings, help them understand what compulsion is, how to choose to stop doing it, and work with them on any justifications they have that may prevent them from making that choice. Then they can help the patient stop avoiding things they want to do (in other words, exposure).

As far as insight is considered in therapy, the main thing that matters is whether or not they are experiencing symptoms and want to get better. If so, for the most part, they can be treated. If not, for example, if they are there because someone else wants them to go, such as a spouse, that's much more difficult.

As a practitioner, if you work with feelings and rumination, you don't have to worry about objective reality too much. If you care a lot about the patient's rational insight, you're going to unnecessarily filter out a portion of highly distressed people who are perfectly treatable.

Inability to Tolerate Therapeutic Distress

As suggested above, since ERP involves deliberately triggering intense anxiety and discouraging patients from engaging in maladaptive OCD actions to neutralize it, ERP requires real grit and well as strong motivation. Unfortunately, many people with good insight and high motivation believe they lack the psychological strength or fortitude to withstand the necessary distress of doing ERP. Here, again, facilitating people along the spectrum of readiness for change is often needed so they can connect with their inner resources and see for themselves that they do indeed have the right stuff to successfully combat their OCD.

Exposure does not necessitate distress. It's practice to see if you can do something you want to do but are avoiding, while not ruminating. If your anxiety is spiking during an activity, then response prevention is the thing that needs to be practiced more first. This doesn't really take grit the way the author means it, just practice.

Response prevention is primarily about stopping rumination, which can be learned before exposure. That's the main behavioral factor that decreases the anxiety, not spiking the anxiety itself. As Greenberg says, we don't habituate to anxiety. People can live with spiked anxiety their entire lives as long as their undigested emotions remain unconscious, and their compulsions are geared toward avoiding their feared emotional state.

Family Members Enabling OCD Behaviors

In most cases, it is important to enlist the cooperation (if not the actual involvement) of the OCD sufferer’s family or significant others. Otherwise, kind and well-meaning people can inadvertently undermine the therapy’s effectiveness. Hence, at a minimum, this means encouraging them not to provide anything that could be anxiety relieving to the sufferer. So, not providing reassurance or doing specific actions to prevent the sufferer from experiencing naturalistic anxiety. For instance, not repeating an answer to a question; not answering any questions that are being asked to gain reassurance; not avoiding touching things the sufferer doesn’t want touched; not buying extra cleaning supplies for the sufferer; and basically not doing anything to help the suffer avoid or escape from anxiety.

One of the primary purposes of adult OCD therapy is to help the patient restore a sense of agency. This means that family members should be able to do whatever they want around the (adult) patient without tip-toeing or acting as an adjunct therapists. It's the patient's internal sense of choice and overall sense of agency about compulsion that matters. Controlling other people's actions can reinforce the belief that those actions have control over them.

Co-occurring Depression or Other Complicating Conditions

If a person with OCD is also struggling with clinical depression, psychosis, substance use disorders, PTSD, panic, or various medical illnesses (e.g., IBS, immune deficiencies, etc.) treatment can be much more challenging. While these common difficulties will not necessarily render ERP ineffective, they can be serious complications that, if not appropriately managed during therapy, can result in poor outcomes

This is a much more complicated subject, so without addressing it directly, I'll say my belief is that while OCD has neurobiological underpinnings which can make someone predisposed to it, it is largely learned, so it can be unlearned.

Therapists Not Doing Effective ERP Because of Their Own Anxiety or Lack of Experience

A common “rookie mistake” is when OCD therapists under challenge their patients during ERP. Failing to evoke adequate anxiety during treatment will lead to weak results and ultimately suboptimal outcomes. This happens either because of mere inexperience but also, ironically, because of therapists’ own anxiety preventing them from engaging their patients in more robust and effective exposures. If therapists won't “eat their own cooking,” it dilutes the efficacy of ERP as well as the therapists’ credibility. For example, if a therapist won’t model for a patient touching a toilet handle, a community trash receptacle, a bathroom floor (etc.) without washing his or her hands, how is the patient likely to interpret that information? It sure won’t inspire confidence, right? So the “do as I say, not as I do” approach is usually lethal for success whereas the “do as I do” approach is often vital for it. (While some OCD experts might see therapist modeling as providing reassurance, it is more likely that it enhances the therapist’s credibility and emboldens the patient to take the emotional risk of doing the modeled exposure.)

This is generally misguided. Again, the purpose of exposure is to test response prevention. It should not need to spike anxiety.

Behavioral modeling is also tricky territory. The therapist could just as well be providing compulsive reassurance to the patient that the activity is OK and therefore defeat the purpose of taking a risk. This would depend on the nature of the fear and compulsions, of course.

Lack of Motivation

Despite sincerely wanting to beat their OCD, many people are not adequately motivated to succeed. As I’ll discuss below, ERP requires that people deliberately trigger their anxiety and wait for it to diminish or resolve without doing any discomfort reducing or safety seeking actions (i.e., rituals). Obviously, facing some of one’s greatest fears takes a lot of drive and determination. Simply put, if a patient tells me “I’ll try,” I’ll reply “You will almost certainly fail.” If he or she says “I’ll do my best,” I say “You will probably not succeed.” It is only when people commit to “Doing whatever it takes!” that I say “You will very likely succeed.” Hence, the requirement of deep, intrinsic motivation to “do whatever it takes” is vital for success. In fact, in many cases, working with patients to strengthen their motivation and readiness for positive change is part of the art of CBT. In other words, helping them move from “I’ll try” to “I’ll do whatever it takes!”

Traditional ERP often asks patients to do things that are both scary AND unwanted. This can cause resentment and confusion, much less lack of motivation. It's also unnecessary. Making someone do something they actually don't want to do is part of obsessional fear, because it's not something are avoiding. Uncovering emotional conflicts and learning how to not ruminate as precursors to ERP, coupled with exposures that engage the patient in things they want to do but are compulsively avoiding, create a more amenable environment to motivation.

Another layer is that strict behaviorists often project that doing their exposures is good, and not doing their exposures is bad. This can create a lot of conflict, especially if the patient has issues with being controlled by authority. It can also reinforce additional layers of compulsive rumination about being a good and bad patient.

I think that if someone is showing up for therapy, most “lack of motivation” for change is really justification against change. There are many forms that justification can take, and that's something that can and needs to be addressed in therapy before exposure starts.

It may go without saying that if the therapist has a conceptualization of OCD that doesn't help or resonate with them, it's likely that many of their patients won't have the motivation to continue treatment.

Final notes

It's likely that ERP is not effective for people because many well-credentialed strict behaviorists are practicing with a misguided conception of OCD and its treatment. This is not to say that traditional ERP has not helped people. It has helped me! But practitioners who insist that traditional ERP is the only thing we can do need a wider perspective in order to help more people.