Perhaps the most common question I hear OCD therapists ask is what Exposure to do for a certain compulsion.
Unfortunately, such a question reflects a misunderstanding of how ERP works, because Exposure doesn’t eliminate compulsion. The only thing that eliminates a compulsion is the decision to stop doing it. This is the Response Prevention part of ERP. Exposure is never a replacement for Response Prevention.
Exposure is never a replacement for Response Prevention.
Even though people often refer to ERP as ‘Exposure’ for short, Response Prevention, or eliminating compulsions, is as important — if not more important — than Exposure.
Response Prevention is also an absolute prerequisite for Exposure: Doing an Exposure when the person is still doing a compulsion doesn’t accomplish anything. And that makes sense, since if you stop and think about it, Exposure without Response Prevention isn’t treatment; it’s just the everyday life of someone with OCD.
Exposure without Response Prevention isn’t treatment.
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. And in the vast majority of these cases, the primary reason treatment hasn’t been effective is that the therapist has done Exposure without Response Prevention.*
So the next time you hear someone ask what Exposure to do for a compulsion, here’s what you can tell them:
Don’t worry about Exposure, worry about Response Prevention. Work on helping the patient to stop doing the compulsion. Help them to understand why they are doing it, empower them with the knowledge that they actually do have control over it, help them to do a cost-benefit analysis of continuing to do it, and encourage them to take a calculated risk by letting it go. And don’t do Exposure until the patient is prepared to refrain from the compulsion.
In my experience, once a patient has eliminated compulsions, most of their symptoms are already gone, and the sense of control they have regarding their compulsions translates readily into quick and easy Exposure work.
*Most frequently, there has been no Response Prevention of compulsive rumination, either because the therapist wasn’t aware of this compulsion or because they didn’t know how to address it.