Please note that Rumination-Focused ERP is a new and evolving approach to ERP. It has not yet been researched, and therefore to the extent that it differs from classical ERP, it is not evidence-based.
How you conceptualize OCD and ERP affects not only how you do exposure but also what you do as exposure. By discarding the role of habituation, and focusing instead on restoring agency and eliminating symptoms, RF-ERP significantly limits the targets and rationales for exposures. It thus provides a simple framework for designing a precise ERP protocol. The purpose of this article is to outline that framework.
RF-ERP is based on the following model of OCD and ERP:
- OCD consists of compulsions and avoidance
- OCD is treated by eliminating these behaviors
- ERP facilitates the elimination of compulsions and avoidance by restoring a person’s sense of agency, or choice. This is accomplished by:
- Showing a person that they are in control of these behaviors. (The person must then use this restored sense of agency to consistently eliminate them.)
- Showing a person that they can control their experience of anxiety by controlling rumination. (This makes the prospect of eliminating compulsion and avoidance much less threatening.)
Discarding the role of habituation, and focusing instead on restoring agency and eliminating symptoms, yields only two types of exposure:
- Doing anything avoided*
- Confronting any trigger in order to practice not doing a compulsion
And only two** rationales for any exposure:
- To show you that you can do something avoided, or confront a trigger without doing a compulsion
- To show you that by controlling rumination, you can control your anxiety
It’s important to highlight that according to this model, the goal of confronting a trigger is to practice not doing a compulsion. In other words, the goal of the exposure is the response prevention. That means that if the person can confront the trigger without engaging in a compulsion (including, obviously, compulsive rumination), the goal of the exposure has been accomplished.
If this model sounds boring, it is. Exposures are not creative and the person is not asked to do anything extreme. This model has a number of advantages:
- It’s precise. It accomplishes its goal without wasting time or causing unnecessary distress.
- It’s simple. A list of triggers and forms of avoidance is a list of all targets for exposure.
- It’s a really easy sell. It’s self-explanatory, relatively painless, and doesn’t require any extreme behavior.
RF-ERP also rejects some common rationales for exposure. According to this model:
The goal of an exposure is never to feel anxious.
RF-ERP sees anxiety as evidence of rumination, so asking someone to feel anxious would mean asking them to engage in a compulsion. Thus, according to this model, feeling anxious would never be the goal of an exposure.
(And anyway the rationale for such an exposure would probably be habituation, the role of which this model rejects.)
The goal of an exposure is never to habituate to anything.
The goal of an exposure is never to feel the Core Fear
(The goal of exposure is not to feel the Core Fear. Rather, the goal is to stop protecting yourself from it with compulsions and avoidance, and thus to stop living in fear of it.)
Notably, RF-ERP also rejects the use of imaginal scripts. Imaginal scripts are not used in RF-ERP because they do not align with the above rationales for exposure.
I believe the framework above can help therapists and patients to home in on the most effective elements of ERP. Whether or not you adopt this framework, I hope this article will encourage you to think critically about what you’re doing as exposure and why you’re doing it.
A worksheet for the RF-ERP approach to exposure can be found here.
*Notably, some important forms of avoidance, such as avoiding setting boundaries or expressing anger, are less concrete than others.
**While an exposure may also provide an opportunity to disconfirm an expected negative outcome, this model does not see this as the central goal of the exposure. The central goal of such an exposure would be to learn that you have a choice, regardless of the outcome.