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Over reliance on ERP - CBT the better approach


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22nd October Update:  I am just resurrecting this thread. We have a lot of non-UK users of our forum making a lot of what I consider unhelpful (to them and to others) references to the use of ERP therapy. OCD-UK is a UK based charity, and therefore because of NHS recommendations and our own general belief we do not advocate the use of ERP on its own. The treatment we recommend for OCD is Cognitive Behavioural Therapy (CBT).

 

Something that's becoming more apparent on the forum of late is the over reliance and references to the use of ERP for therapy. I want to state right off the bat now, if you focus solely on ERP you are almost certainly going to remain with OCD and put yourself through some traumatic experiences.

I am not saying ERP won't work, it may, but in my opinion it is unlikely if done alone.

I am not saying you don't need to do ERP, you do.

What I am saying is that ERP needs to be part of your treatment programme but it needs to a small/ish part of a much larger treatment structure.

To treat OCD all the evidence we have and all the successful experiences we have seen have been through the use of Cognitive Behavioural Therapy (CBT). So let's look at what CBT is:

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Cognitive Behaviour Therapy makes use of two evidence-based behaviour techniques, Cognitive Therapy © that looks at how we think, and Behaviour Therapy (B) which looks at how this affects what we do.

In treatment we consider other ways of thinking ©, and how this would affect the way we behave (B). Exposure and Response Prevention therapy (ERP) is used as part of the behavioural approach to help explore alternative ways to respond to the obsessional thoughts or doubts.


So if we try and do ERP (the B part of CBT) on its own then we are missing the key point, it is how we think that affects what we do so doing ERP in most cases is pointless. I once said doing B (or C) without C (or B) is like fish without chips!

In my case, putting my arm down the toilet (ERP) would have been unhelpful if I did not understand what I was doing, why I was doing and worked on the cognitive part of therapy. More than that, it would have been so mentally painful and anxiety provoking. Whilst doing cognitive work does not make doing ERP any less hard, it does make it a little more tolerable.

I use an analogy which is a tad simplistic but I think it makes the point about why I say ERP alone is usually unhelpful.... imagine someone with panic attacks afraid of heights.

The ERP approach

The dumb ERP therapist takes the patient up in a plane. Without really asking if it was ok straps a parachute to the patient and kicks them out of the plane as an extreme form of ERP (that we use to call flooding). If the patient pulls the right chord and survives, the chances are there anxiety will be even more extreme (if they don't splat into the ground)!

The CBT approach

The more enlightened CBT therapist asks the patient if they would like to try some extreme exposure to cure their fear of heights. So the therapist and patient head up in the plane, and the therapist explains the purpose of the exercise is to show that a fear of heights is rational but does not need to be debilitating. So with permission therapist straps the parachute to the patient, shows them what the main chord is and what it does. Shows the reserve chord and what it does and the purpose and shows the patient how to land. Finally, the therapist takes another parachute and straps it to their own back and says if you want to do this patient I am going to do it with you, would you like me to go first or shall we hold hands and go together? Facing the jump is still anxiety provoking for the patient but by going through all the lessons and explaining why doing it, what the chords do etc (a little cognitive work) then the jump is easier to face and once floating through the air the anxiety is almost certainly going to go within seconds because the patient chose to jump after the ground work (cognitive).

The above example is simplistic and there is far more to the cognitive side of therapy, but I think it explains why ERP on its own could work, but is more likely to not and cause further anxiety problems.

Now, all that said, again this is my belief rather than something I know to be fact. I suspect the type of OCD may be relevant to how much C and how much B work needs to be conducted. If the problem involves lots of physical compulsions then I would say you need to do a mix of cognitive work and behavioural (ERP) work, maybe 50/50 mix or maybe a tad more behavioural (40/60).

However if a person has primarily problems with intrusive thoughts then provided there are not lots of hidden compulsions going on (mental, googling or reassurance seeking) I think the spread of work needs to be far less ERP and more cognitive, perhaps 75% cognitive and 25% behavioural (ERP).

The point I am making in all of this (much longer waffle than planned) is that yes ERP is needed in our OCD treatment, but the cognitive is needed just as much if not more so.... in my opinion!

Ashley. :smile:

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I don't know. I don't think the forums are heavy on the side of ERP as the primary treatment for OCD. I see most of our posts being on the cognitive side.

Some people are in a good place cognitively and should be doing ERP and they can get advice on that. Others are much farther behind and they tend to get advice that leans more toward the big C rather than the big B.

I think maybe the bigger problem is the possibility that sufferers may be advised to do ERP before they are ready for it. I know I'm thinking back and wondering if I've done that. We all need to remember that not everyone is in the same, advanced position to be able to do ERP.

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I think there is a lot of reference to ERP across OCD features at the moment (not just here), but a thread did mention it this week which is what prompted me to post.

I think maybe the bigger problem is the possibility that sufferers may be advised to do ERP before they are ready for it.

This is important too, but down to therapists failing to get to know their patients fully. But yes this was an issue I had on the phone today with a gentleman reluctant to go back for therapy because the previous therapist had tried to rush them into exercises far too soon.

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I think that's a great post and explanation of how the therapy should look, Ashley.

One thing I've found beneficial in my ongoing recovery is also a more systematic approach--not just random cognitive or exposures applied when you are feeling in the throes of a really bad obsessive time. But doing the homework every day on both the cognitive and behavioural side of things.

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Also I think you can think that you're doing an exposure but you're only halfway there - as a simplistic example of this, for the person with a fear of heights, you can take them up to the top of a tall building and let them sit there for an hour. However there is a huge difference between sitting, clenched, with your eyes half closed thinking how high and awful it is verus sitting and actually looking out, looking around and seeing fully what it is that you're actually afraid of.

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CBT is a package concept; and picking on just part of it without the whole, for me, is unlikely to lead to significant overall improvement.

In other words, as well as ERP there are a number of other key elements - all essential to the success of the therapy model.

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Guest SurfRider

ERP has always been very tricky for me. As I have said, my obsessions are very difficult to do ERP for. When I was a devout Mormon, religious obsessions and compulsions occupied much of my thoughts. But ERP was very tricky, because doing it would require me to do things that I believed that God and my religion would punish me for. Scrupulosity is very difficult to do ERP for. Are you really going to tell a Mormon that they need to start swearing and drinking alcohol, and are you going to tell a Catholic that they need to take a picture of the Virgin Mary and pee on it? Some therapists would say yes, but I would never have done that as a devout Mormon. As a result, I was never able to beat scrupulosity when I was a devout Mormon. I had to leave the religion. ERP for relationship and sexual obsessions has proven to be equally tricky for me.

I believe that people pushing ERP is a result of the fact that ERP is often overlooked in CBT because it's the most difficult and painful part, so people were talking about it because it is often overlooked. It's much easier to sit around and engage in metacognition than to face the things that you're afraid of.

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It's much easier to sit around and engage in metacognition than to face the things that you're afraid of.

I think this is a key point and a trap I fell into. The cognitive aspect is very, very important - but equally, it is easy to sit around and analyse things to death, which I have been guilty of doing. Both need to be done together - and as surfrider has said, ERP is easier to avoid. Ashley, you say that there is an overemphasis on ERP - but actually I see a lot of people attempting to gather information about OCD (often which they already know) as a way of avoiding proper exposure.

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ERP has always been very tricky for me. As I have said, my obsessions are very difficult to do ERP for. When I was a devout Mormon, religious obsessions and compulsions occupied much of my thoughts. But ERP was very tricky, because doing it would require me to do things that I believed that God and my religion would punish me for. Scrupulosity is very difficult to do ERP for. Are you really going to tell a Mormon that they need to start swearing and drinking alcohol, and are you going to tell a Catholic that they need to take a picture of the Virgin Mary and pee on it? Some therapists would say yes, but I would never have done that as a devout Mormon. As a result, I was never able to beat scrupulosity when I was a devout Mormon. I had to leave the religion. ERP for relationship and sexual obsessions has proven to be equally tricky for me.

I believe that people pushing ERP is a result of the fact that ERP is often overlooked in CBT because it's the most difficult and painful part, so people were talking about it because it is often overlooked. It's much easier to sit around and engage in metacognition than to face the things that you're afraid of.

but then a devil worshipper has to face the fear of going to a religous after death, how does one deal with that ...cbt and erp.

good religous leaders can interact with cbt and erp and guide and support one through a ocd manifestation

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ERP is useful but it does not do the why of OCD. So it attacks the symptoms not the cause.

No therapy attacks the cause. In fact, we don't care what the cause is because we can deal with OCD as it comes and people can get better from it, without ever knowing the cause.

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The thing I don't understand is.... If erp is about putting yourself in a situation intentionally what happens if it goes wrong? I can't commit to erp for this reason

What do you mean if it goes wrong?

There are two parts to ERP: exposing yourself to the obsession and practicing not performing compulsions. That's it.

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Where's the 'LIKE' button when you need one. :)

Well said, Ashley.

Just one point I disagree with :-

I suspect the type of OCD may be relevant to how much C and how much B work needs to be conducted. If the problem involves lots of physical compulsions then I would say you need to do a mix of cognitive work and behavioural (ERP) work, maybe 50/50 mix or maybe a tad more behavioural (40/60).

While it may seem intuitive to group action with action and thought with thought, I believe it is incorrect to do so. Perhaps without intending to, this equates physical compulsions with a behavioural problem and mental intrusions with a cognitive fault. :wontlisten:

Sadly, all too many psychologists subscribed to this belief when I was a child (40 years ago) and the result was parents being told OCD was 'deliberate bad behaviour'. Thankfully the field of psychology has moved on!

It is now well recognised that thoughts drive behaviours. Challenge the thought and the behaviour changes by itself without needing to control it or intervene directly.

But many people still fail to grasp that thinking patterns are also a behavioural response. Rumination is a behaviour, it's not just random thoughts going round your head over which you have no control.

Cognitive therapy is about changing the way you think, choosing different mental tools to deal with the world. And it applies equally to intrusive thoughts and physical compulsions.

I think it's unhelpful to categorise physical and mental compulsions as 'types' of OCD, just as it is counterproductive to segregate OCD into different themes (HOCD, POCD etc.)

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Snowbear, you're so wise :) Great points from you and Ashley.

In the past, Flooding was the worst thing I could have done and I got the idea and incentive to do it from an American OCD forum I used to practically live on. That forum held flooding and extreme exposure as the only way forward for recovery. Everything else was considered 'reassurance' or 'avoidance'. So Using that philosophy, I totally disregarded 'Brain Lock' (the book which actually helped me regain my life back when I actually opened my mind to it, read it and applied it). It was actually considered 'reassurance' on the forum when we know now that mindfulness helps OCD recovery!! Definitely, the wrong advice can set you back YEARS. It took me ages to realise that the cognitive side was just as important if not more important than the behavioural side. Only really when I joined OCDUK did I begin to realise than the majority of people who weren't suffering as such had trained themselves to not respond to their intrusive thoughts in the moment or reframed them when not anxious. And I'm still learning about emotions and their relationship with OCD and how to deal with them in a therapeutic way whereas in 'flooding' and exposure mode, I did not listen to my feelings at all and psychologically damaged myself. Good advice can go a long way to helping and bad advice can set you back so much. I'm glad I found this forum.

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The thing I don't understand is.... If erp is about putting yourself in a situation intentionally what happens if it goes wrong? I can't commit to erp for this reason

The way it goes wrong is if you compulsively do exposure over and over again each time you get an intrusive thought, which is exhausting. Then you wonder are you doing the exposure right and expose again. This goes on and on. No time limits, no graded hierarchy. It's self torture!! And sometimes if your body is in such a high state of anxiety as a result of these endless flooding exposures, it can take days or weeks for the anxiety to quell and for physiological responses (sweating, heart racing, light headedness, out of body experiences) to settle. In other words, flooding is bad and impulsive exposures can become compulsive (as you are doing them to avoid 'avoidance' and in a way by doing the exposure it reassures you that it's not real (this reassurance makes it all worse so the cycle begins again) and to be 'doing the therapy right').

CBT and ERP go hand in hand and the therapist should do detailed cognitive therapy with you before the behavioural exposures begin, otherwise, you won't be ready for it and the experience might be too jarring. With flooding or compulsive exposures, the brain won't learn from the experience either, you will just become more afraid as you have been sensitising yourself further to the thoughts rather than desensitising.

Edited by Orwell1984
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I think for ERP to be done effectively it needs to be done in a graded way. To use a simple example - for someone with a fear of water/ drowning, the thing not to do is throw them into the sea and say to them 'well it's sink or swim mate'. A first step may me paddling into the sea from the beach until they are visibly anxious and then getting them to stay there and face that initial anxiety.

One thing I do have disagreement with is not looking at the cause of OCD and just the current problem. For some people traumatic early childhood experiences or traumas at other stages of life can contribute to the development of OCD (as well as other disorders). Sometimes those affected have never been able to open up to anyone about these experiences because it's been too painful to do so. Just the process of talking through these difficult life events can be cathartic and can give a person an insight into why they've arrived at the point in their lives where they are at, and what has been fuelling their intrusive thoughts and behaviour. This may then help the sufferer engage more effectively with CBT.

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Cognitive therapy is about changing the way you think, choosing different mental tools to deal with the world. And it applies equally to intrusive thoughts and physical compulsions.

I think it's unhelpful to categorise physical and mental compulsions as 'types' of OCD, just as it is counterproductive to segregate OCD into different themes (HOCD, POCD etc.)

I absolutely agree, cognitive therapy is important, dare I say vital, for all aspects of OCD regardless of intrusive thoughts of physical compulsions.

You are also right about it being unhelpful about categorising, and now I have read it back perhaps a better way to word that part of the topic might be to say that regardless of the type of OCD, at different times of your therapy (partly based on patients understanding) there may be more of a focus on different aspects of CBT, i.e. more of an emphasis on cognitive work much earlier in therapy. I believe cognitive works needs to remain even when the focus shifts more to behavioural work, but perhaps less so at that stage of treatment.

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Ashley, you say that there is an overemphasis on ERP - but actually I see a lot of people attempting to gather information about OCD (often which they already know) as a way of avoiding proper exposure.

I guess what prompted my thread is this week I have been covering email and phone support and reading stuff online and I have had people ask me about accessing ERP therapy, I think the final straw came when someone on here wanted to find a place for ERP treatment on here last night.

But you are right, on the forum at least we see far too many people throwing the 'what if' question. Partly though their own lack of understanding, partly through avoidance as you rightly point out which of course perfectly demonstrates the need for that person to A) need more cognitive work and B) at some point needs to 'choose' to give the behavioural work a go.

I think it is ok to be scared and afraid of doing exposure work, it is ok to not to know how to do it, but we have to choose to 'try' even if that is simply asking the therapist to help prepare us to give it a go further down the line.

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Guest Cerisa123

OK. So, how would ERP work for me? I've just transferred from my non-BABCP qualified REBT practitioner to an OCD specialist CBT psychologist at Mindworks, by the way, who I am hoping can help me.

My main worries are:

1. Pretty much every time I have a memory from the past (anything - and I mean a real memory, no matter how trivial) my brain goes 'are you SURE that happened?' and it drives me bonkers and makes me doubt myself. So I feel like I can't really talk to people about the past in case I've 'got it wrong'. Or if someone remembers something I don't, it really freaks me out.

2. Did I do something wrong anyway and not remember? So even if I babysat a child on my own, e.g. how would I know I had not molested it and forgotten? So how would the ERP work anyway?

Please, someone, help.

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The thing I don't understand is.... If erp is about putting yourself in a situation intentionally what happens if it goes wrong? I can't commit to erp for this reason

I think I slightly disagree with some of my friends on here (partly). I think if the cognitive work as been done right, and the preparation work then chances are any behavioural exercise whilst being hard, is unlikely to go wrong, especially if you choose to participate (rather than being forced by a therapist). As others have said, if you do the CBT work correctly and the therapist is preparing you to 'choose' then it can't really go wrong.

Where I slightly disagree is that yes there is a risk that doing an exposure exercise may increase our anxiety and may leaving us feeling horrid for a time, maybe even more so. We can not deny that, but that generally happens where the CBT as not been done or not been done right by the therapist/patient. In fact a forum friend did the arm down the toilet exercise with me at the Nottingham conference as a spur of the moment thing. Whilst it is amazing they pushed themselves to do that, it was a spur of the moment thing down without any preceding therapy work so for a few weeks she felt contaminated. But, by the token of the fact she chose to give the exercise a go, I know she is now making progress with her full CBT work.

So this brings me back to your point Liberty I can not promise that it won't go wrong, but I can 100% promise that if you don't commit to doing the work (C and B) then OCD will be with you for a very long time and overall it will cause you far, far more anxiety and difficult moments. It's a choice, and not a fun choice but ultimately there is only one choice we have to find a way to choosing to take.

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I think to answer Liberty effectively we need her to clarify exactly what she means by "Going wrong"

I have a sneaking suspicion that she may mean 'what if she's made to expose herself to a situation and she loses control and does the thing she fears' (like harming someone)

I may be wrong though, maybe Liberty can clarify :)

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