“ERP (Exposure and Response Prevention) is not working.” “I’ve tried ERP before- it doesn’t work for me.” I have many current and past clients who said this once. You might think, given my practice focus, that I would simply respond by offering more ERP. Not necessarily. Let me say what I don’t do, first. I don’t automatically say, “MORE ERP!” What I do is dig deep in assessment, first. Your outcomes are highly connected to whether you have done a few crucial things in your Exposure and Response Prevention for OCD. Here are common reasons you aren’t getting the most benefit you could.
#1: You haven’t given ERP a real chance.
Let’s just start with the obvious- you can’t get the benefit of a treatment if you haven’t tried it. Have you tried another approach instead that is NOT ERP?
- SNRI’s, TCA’s, Mood stabilizers- without trying an SSRI first
- Supportive psychotherapy (Talk therapy)
- Psychodynamic or psychoanalytic therapy
- Essential Oils
- Supplements and vitamins
- Relaxation and/or mindfulness
- Trauma processing
- Distracting myself or avoidance of triggers
- Talking to others about my problems
- “CBT” that only talked about the irrationality of thoughts
Please note that at any given point, all of the approaches listed above (EMDR, talk therapy, etc.) can be useful for a variety of things; they are just not the clinical first option for OCD!!!
Hear me loud and clear, because it needs to be said: if you’re serious about getting better and have access to it- go for the gold standard Exposure and Response Prevention. The rationale and research is extensive- you can find it in my ERP for OCD presentation and ERP for OCD Brochure.
#2: You tried and “failed.” You might need to increase the quality of your ERP or attempt another trial.
If we sit down in assessment, and you say anything like the following, the quality of ERP may have been lacking, and we need to “up your game.”
Use this handy checklist ✅:
- I did ERP once- I touched the trash/wrote a scary script/didn’t check a door/fill in the blank.
- I didn’t do homework, or at the level recommended.
- I gave it less than 12 sessions, or 16, or 20 depending on severity.
- I scheduled appointments with long periods in-between (weeks or more).
- I saw someone not trained in CBT.
- I saw someone not trained in ERP.
- I saw someone who claimed they work with OCD but only told me to replace negative thoughts, snap a rubber band on my wrist if I have a negative thought, or to “though-stop.”
- I didn’t consider SSRI medication
- I used a workbook without a therapist
- I was “white knuckling” exposures (forcing them without integrating acceptance)
- There were obsessions and core fears I didn’t or couldn’t tell my therapist about
- I was compulsing during exposures
- I was compulsing right after exposures
- I didn’t “hold the line” with exposures but bounced around to try different things before getting one thing down well
- I did ERP successfully before but relapsed
- I only talked about exposures but never did them with my therapist
- Exposures were always overwhelming
- I regularly had panic attacks and/or continued to have panic attacks during the exposure process
- I have other untreated mental health / physical conditions
- I have expectations about never getting anxious or avoid getting anxious.
Though this is a very thorough list, it’s not even cumulative. There are even more! All of this to say, ERP is a very deep and powerful tool. Don’t give up too soon.
#3: You gave up without considering many viable OTHER treatments.
Now that we’ve covered many reasons that ERP quality may have been lacking, there are certainly those who receive solid treatment from a trained clinician, but they still are having problems. It happens in my practice; it happens with the world’s foremost experts, too. OCD is a formidable foe, and we are complex as human beings- no one size fits all. OTHER OPTIONS EXIST!!! As you consider with your clinician what’s not working, consider the following:
- Cognitive Therapy (Cognitive Therapy with Behavioral Experiments- which is crucial to incorporate the behavioral component- is also a first line treatment, so if you don’t feel you can tolerate ERP to start or just don’t want to, this is another evidence-based starting point).
- Medication add-on or changes. There are multiple options beyond the first line SSRIs (and Clomipramine, which is an SRI).
- Intensive Treatment
- Monitor for detours and/or comorbid conditions. Panic attacks often interfere in progress and have to be addressed. Depression, substance abuse, Eating Disorders, Trichotillomania (and all BFRB‘s), Autism, Tics/Tourette’s and many other conditions often co-occur. Though OCD is often a first priority disorder (meaning it can tend to create the most emergent problems), this is not always so. Sometimes something else must be addressed first- or simultaneously.
- After trying variations of first and second line treatments, a person can also consider the following:
- Brain Surgery
- Gamma Knife
- Access issues- the following reasons and many more can lead to missing out on effective therapy.
- Inability to find a trained provider who is available to see you
- Financial barriers
- Cultural and discrimination barriers
Though the answers aren’t easy with these barriers easy, you can stay apprised through my dedicated OCD page and OCD newsletter as to new resources, free training, discounted groups, and more. The IOCDF is also the premier location to find out more of how to get help.
#4: Though it’s uncommon, you may have tried many options above. Keep pressing on.
This is part of the uncertainty we have to accept- and work towards. A generation ago the tools we have today didn’t exist as they do (ERP got full steam in the 80’s and wasn’t available in your average practice until later)!!! OCD, especially severe cases, was seen as largely difficult to treat or untreatable by many providers for most of the 20th century.
I have seen personally- and the experts attest- there is usually hope for those who keep pressing on, even in the most severe of cases. Check out Dr. Liz McIngvale’s personal story to to be encouraged.
So if you have doubts and fears about ERP, have tried it and it hasn’t worked for you- or have avoided it, I have good news- there likely exists options for you. And even those who seem to run out of options can typically find many if they keep persevering. You are valuable and significant, no matter how you feel today. I hope to be an encouragement in your journey.
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