Alexian Brothers Behavioral Health Hospital
Center for Anxiety and Obsessive Compulsive Disorders (OCD)

Exposure and Response Prevention (ERP)

The Center for Anxiety and Obsessive Compulsive Disorders (OCD) at Alexian Brothers Behavioral Health Hospital is one of less than 20 like it in the country so it makes sense that many people are unfamiliar with Exposure and Response Prevention Therapy (ERP). ERP is one of the most effective and highly researched modalities for the treatment of anxiety disorders. The basic premise behind ERP is that if you are afraid of something, you must face that fear in order to learn that you can handle it. If you avoid what you are afraid of, or seek a lot of reassurance for it, it will only serve to maintain your anxiety and in fact often causes the anxiety to get worse instead of getting better.

ERP is based on Cognitive-Behavioral Therapy (CBT). The concept of CBT, the other most effective and highly researched therapy for anxiety disorders, is that there are three contributing factors: the way you think, the way you feel, and the way you behave. While many therapies will focus only on the way you think and feel, it is really the behavior that needs to be the focus when it comes to an anxiety disorder because behavioral change is the ultimate measure of whether or not a person is still anxious. If they continue to avoid and seek reassurance, they will continue to be anxious. If they face what it is they are afraid of, then they learn that they can handle it, and therefore, the anxiety decreases.

 

The Elevator Scenario: An Example

Imagine you are standing in front of an elevator. Now, you may love elevators, look forward to riding on them, and enjoy pressing all of the buttons. While this may annoy everyone else on the elevator, you do not care – you are happy. Or, you may be totally indifferent to elevators – you just use them to get from point A to point B and that is all there is to it. Or perhaps you are afraid of elevators and want nothing to do with them at all, so you just take the stairs everywhere you go to avoid the issue. Now, this may have no significant interference in your life, and you could live the rest of your life not riding on elevators, and that would be fine. But, what if like one of our patients you were invited to a family reunion in downtown Chicago, on the 37th floor of a high-rise building? What would you do now? Taking the elevator is not an option for you, so you may opt to take the stairs. However on second thought you realize that 37 floors is just too high up to walk, so what do you do?Our patient sat in the lobby for the entire duration of the party, only seeing relatives as they came or left the building, or those few who were nice enough to bring her down a plate of food and talk to her for a few minutes. She was so depressed after this event that she decided to really dedicate herself to treatment and we started to work with her initially focusing on her fear of elevators.

 

Cognitive-Behavioral Therapy gives us a few options in this scenario. First, we could talk to her about why she fears elevators. However, many therapists have tried to talk to clients about why they fear what they fear, only to have them continue to be afraid. So, a general talk therapy is really out of the question in this case – it is just not going to change her behavior. Or, we could try to change her feelings first, telling her not to fear the elevator because it is safe. Again, this will probably be futile – how many times have you tried to tell someone not to worry or be afraid of something, and they continue to feel that way anyway? This is just frustrating for both the anxious person and the person reassuring them. So, maybe we need to try to change the behavior first. Doing this in a gradual manner will accomplish our goal – getting them back on the elevator.

To begin, we need to get an idea of what the person is afraid of – this is called a functional analysis. This analysis let’s us know what the purpose of this avoidance behavior is. In this case, it could be not to die in a fall, or not to be trapped, or to avoid annoying relatives. If it is just to avoid relatives, we probably do not need to do any ERP with the elevator, but if it is to avoid a fall or to avoid being closed in, then we will need to do ERP with the elevator. We will also want to know any general fears our patient may have about elevators. So, let’s say that the person in our example generated the following list ranked from lowest level fears to highest level fears:

  1. I will sweat on the elevator.
  2. I will breathe heavily on the elevator.
  3. The doors might not open right away, and I will think about being stuck.
  4. I might faint.
  5. I might get stuck in the elevator for 5 minutes.
  6. I might get stuck in the elevator for 10 minutes.
  7. I might run out of air in the elevator and suffocate.
  8. I might get stuck in the elevator for more than 10 minutes.
  9. The elevator might fall one story.
  10. The elevator might fall more than one story.
  11. I might die on the elevator.

With this as our list, we have our work cut out for us. There are a few themes here: One is the idea that our patient will experience a panic attack or some panic symptoms, another is that of being stuck or even experiencing some claustrophobic like symptoms, and a third theme is that there could be injury or death from a fall.

Now that we know what the patient is afraid of, the themes of the fear, and the purpose of the fear (to prevent a panic attack, a feeling of being stuck, or a fall/injury) we can start to work on an ERP program tailored to our patient. Since most of the panic symptoms cluster toward the bottom and the middle of the hierarchy, we will start there. We will do what we call interoceptive exposures to deal with these fears. To do this, we need to create the very symptoms that a person fears in order for them to learn that they can handle those symptoms. We develop exercises that specifically address each of their fears.

To deal with her fear of sweating, we will have her wear several layers of clothing and sit in the sun or in her car with the heat on for 10 minutes to work up a good sweat. Once she has done this, here comes the real test of ERP – she will sit with the uncomfortable anxiety and let it pass on its own without doing any type of avoidance techniques. Instead of doing any breathing techniques or muscle relaxation, which only distracts a patient from their exposure, they are to sit with their fear and just let it pass on its own. This is all done to realize that they can in fact handle the uncomfortable feelings that they are experiencing. We measure the level of discomfort through Subjective Units of Distress (SUDS), and they are rated on a 0 – 10 (or 0 -100) scale. The levels of SUDS are assessed at constant intervals during the exposure, and when the levels reduce to around a two or three, the exposure can be stopped. The patient takes a bit of a break and then they do it again - back to focusing on sitting in the sun and getting sweaty, and starting the whole exercise over again. We will keep on repeating this exposure until there are two desired outcomes: First, the initial spike of anxiety is no higher than a three, and second, the time it takes for the patient to report a low level of anxiety is short.

As you can see from the graph, the spike, or initial experience of anxiety was high for this patient. It took quite awhile for their SUDS rating to get to a level where we could stop the exposure (we do not want to stop an exposure when a level is high, as that teaches the patient that escape is a good way to stop their fear). The second exposure also has a high spike, and the time to get down to a stop level is also significant, though less than the first time. But, by the seventh time of doing the exposure, there is almost no spike at all, and we are able to stop the exposure quickly, as it takes the patient only seconds to get to a level of reduced anxiety where we can stop the exposure. We will use this same technique for the fear of being stuck (we will work toward putting chairs on the elevator and sitting on it for at least thirty minutes at a time), and for the fear of falling and getting injured.

While a rather basic example, this scenario illustrates how ERP works. We can also use some CBT with this patient by testing the probability of elevators falling. For example, if we ask a patient what they think the probability of an elevator crash is and they say 20%, we tell them that would mean that twenty out of every 100 times an elevator moves anywhere in the world, it will crash. If that were the case, no one would ever ride elevators, as they would be banned for being a national health risk. But, they are not banned, because they do not crash that often. They do not even crash 10% of the time, or even 1% of the time. In fact, it is a safer mode of transportation than a car. Yet, many people would rather drive then take an elevator. Why? Because at least with a car, there is a feeling of control, while with an elevator, you are putting your life in the hands of a machine, and if it breaks, there is nothing that you can do about it. So, people often trade off a higher probability of dying in a car for a feeling of control, and we avoid a lower probability of dying in an elevator because we are not in control of its movements.

To learn more about Exposure and Prevention Therapy and the Center for Anxiety and Obsessive Compulsive Disorders, please call 1-800-432-5005.

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