Always Start with Response Prevention

I see many ‘treatment refractory’ cases in my practice.  These are people who have seen a therapist (sometimes more than one) for ERP, but have not gotten better.  While there are several common denominators across these cases, I believe that one of the most important ones is that they have frequently seen therapists who did Exposure, but neglected Response Prevention (eliminating compulsions).

Many patients and therapists think that if they can just find the right exposure to do, they can make a patient’s symptoms go away, but that simply isn’t true.  Exposure is never a replacement for Response Prevention: If a person is engaging in compulsions, no exposure is going to change that. (And when a patient or therapist says they’re having trouble with a case and need help finding the right exposure, they probably need help with Response Prevention.)

So why do people neglect Response Prevention? I suspect that it’s because of the common perception (and to my mind, harmful misconception) that Exposure works via habituation to a stimulus or to the feeling of anxiety itself.*  From this perspective, as long as the patient is exposed to the stimulus and experiences anxiety, shouldn’t some sort of habituation take place — even if there are compulsions present?

But I don’t believe that ERP works via habituation.  Rather, as discussed in depth here, I believe ERP works by facilitating two types of learning, both of which are precluded by the presence of compulsions:

  1. Learning that you can choose not to do a compulsion and not to avoid, even when you’re scared
  1. Learning what happens, both practically and emotionally, when you let go of compulsions and avoidance

When you look at ERP through the lens of these types of learning, it’s relatively self-explanatory why compulsions prevent ERP from working:

  • If you do a compulsion, you obviously don’t learn that you can choose not to do a compulsion.  In fact, doing a compulsion with a therapist might even strengthen your belief that you lack control over your compulsions.
  • As long as you engage in compulsions, you don’t get to see what happens — practically or emotionally — when you let them go.

For the above reasons, I believe it is pointless to do Exposure until the patient is able to do Response Prevention.  (And therefore, if the patient engages in compulsive rumination, teaching the patient how to stop doing this should be the first priority in treatment).

In my experience, once a patient has eliminated compulsions, most of their symptoms are already gone, and the sense of control they feel regarding their compulsions translates readily to Exposure work.

I hope that patients and therapists practicing ERP will start seeing Response Prevention as equal in importance to Exposure, and as a prerequisite to productive Exposure work.  After all, Exposure without Response Prevention isn’t treatment; it’s just the everyday life of someone with OCD.

*Another factor that likely contributes to neglecting Response Prevention is the fact that many therapists aren’t aware that rumination is a compulsion; or mistakenly believe that it’s impossible to eliminate it; or simply don’t know how to teach someone to stop doing it.  Any of these might lead a therapist intent on doing ERP to begin Exposure despite the fact that compulsive rumination is still present.