Exposure and response prevention therapy is the most effective treatment for obsessive-compulsive disorder. Working with an ERP specialist to design an individualized treatment plan is key to the therapeutic process.
While exposure and response prevention (ERP) therapy is without a doubt the most effective treatment for obsessive-compulsive disorder (OCD), succeeding at ERP requires structure and commitment. That’s why it’s crucial to create a plan for how you will approach your goals and challenges.
This strategy is known as a treatment plan, and it’s a way for you and your therapist to outline what you’re looking to get out of therapy—so you can make the most out of your time together.
You may be eager to jump into ERP, but setting time aside for these intentional first steps will help you engage better in therapy, so you can learn to manage your symptoms with more ease. Read on to understand how to build your treatment plan.
Step 1: Set your treatment goals
When we talk about treatment goals, we’re talking about what you hope to get out of therapy. This might include the ability to regain the time you spend on compulsions, or an overall reduction of a certain symptom.
If you’re struggling to envision your goals, consider these questions:
- Why did you want to seek therapy in the first place?
- How does OCD make you feel stuck?
- What would be different about your life, without OCD?
- If you’ve done therapy before, what do you hope to be different this time?
In your first session, you and your therapist will set goals, exploring the various aspects of your life—including work, school, relationships and your social life—to better understand how you hope to improve your quality of life.
Taylor Newendorp, MA, LCPC, the Network Clinical Training Director at NOCD, says to be specific and realistic when goal-setting. For example, don’t aim to eliminate anxiety forever. “People can certainly learn how to manage anxiety very, very well and not react to unwanted thoughts,” Newendorp explains. “But, it’s not realistic to get rid of all negative thoughts or feelings.”
SMART goal planning
Breaking down bigger goals into smaller achievable actions and timelines can help you further track your progress. The SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goal-planning template may be helpful for this. See the example below:
- GOAL: Reduce compulsive handwashing by 50% in two months.
- SPECIFIC: I aim to wash my hands only 5-10 times a day.
- MEASURABLE: Record a log of when you wash your hands.
- ACHIEVABLE: My therapist will teach me response prevention techniques to do when I have the urge to wash my hands.
- RELEVANT: This will help me gain back time previously spent on compulsions.
- TIME-BOUND: Two months.
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Step 2: Identify your symptoms
Remember that OCD is marked by two main symptoms: obsessions and compulsions. Obsessions are repeated intrusive thoughts, sensations, images, feelings, or urges that cause anxiety or distress. Compulsions are repetitive behaviors or mental acts performed to neutralize the obsession, prevent something bad from happening, or try to reduce distress. Even though everyone with OCD experiences these two symptoms—and there are some common themes—your experience of the condition will be unique, so it’s important to spend some time identifying your specific symptoms.
ERP therapy teaches you to learn to resist compulsions—which in turn tends to reduce the distress you feel from obsessions. But, in order to do this, you need to get used to identifying the situations and obsessions that cause distress, and the behaviors you rely on to manage these feelings. You’ll also want to start noticing what you fear will happen if you don’t perform a compulsion.
An easy way to start identifying your obsessions and compulsions is to jot them down as they arise in real time. The goal here isn’t to capture a comprehensive list of every single symptom. It’s to become practiced at noticing them, so you can eventually learn to disrupt the OCD cycle. Keep in mind that some compulsions are more obvious than others. While compulsions like checking or handwashing may be easier to spot, avoidance or rumination may take more practice to notice.
Step 3: Develop an ERP hierarchy
Once you’ve spent time identifying fears, you can start to consider ways to face them. Don’t worry—you won’t be asked to dive in without support. In fact, your therapist will start by asking you to rank your fears (and potential situations for facing them) by how much distress they cause you, before you consider any actual ERP exercises.
In ERP therapy, this ranking is called a hierarchy, and it’s a crucial part of the treatment plan, because it helps you and your therapist address your fears in a gradual and intentional way. It’s also a list you can return to over time to track and anticipate progress.
ERP hierarchy example
Here’s an example of an ERP hierarchy, if your fears center on fire, and your main compulsions are related to checking OCD. You’ll see that the list uses the subjective unit of distress (SUDS) scale to rank each fear and potential exposure from 1-10.
- Leaving your home without checking that the stove’s off (9/10)
- Looking at photos of house fires (7/10)
- Watching a movie where there is a house fire (6/10)
- Reading news articles about house fires (4/10)
- Writing a scenario where your own home catches fire (3/10)
Note that while your therapist will have you note your compulsions as part of your general symptom identification process, we don’t create hierarchies for compulsions, because we know they’re going to show up as responses to the fears we confront in ERP therapy, regardless. If you engage in multiple compulsions in response to a single obsession, rest assured that your therapist can help you get practiced at resisting them all. The most important thing is knowing what your compulsions are, and starting slowly when it comes to triggering these responses.
Step 4: Do ERP exercises
Now that you have your hierarchy (which is probably a bit longer than the example above), you have some idea of which fears you’ll be facing first. At this point, you’ll learn response prevention strategies for resisting compulsions. That might mean learning to sit with uncertainty or using non-engagement responses, like telling yourself: “Maybe my fear will come true, maybe it won’t.”
The goal of ERP therapy isn’t just to put yourself through distress; it’s to target specific obsessions and triggers that have been bothering you, and learn new responses. This process of becoming more comfortable with discomfort can only occur if you aren’t relying on compulsions as a coping mechanism—which is why it’s so key you fully understand all of your compulsions before you start engaging in ERP exercises.
Step 5: Keep doing the work
ERP can be very effective in a relatively short amount of time, but it takes work to continue progress on your own. “Even when people are doing really, really well managing all their symptoms, stress can exacerbate OCD,” Newendorp explains.
Maintenance is key.”
Taylor Newendorp
“Our recommendation is that someone remain in therapy, even if it’s just checking in with their therapist once every two to three months,” he adds.
ERP therapy equips you well to handle the exposures that come up in daily life, but there’s no shame in seeking help for a symptom flare, or checking back in with your therapist as a way to maintain progress. As you move through life with your new ERP skills under your belt, Newendorp recommends prioritizing other healthy lifestyle habits—such as physical activity, decent sleep, and meaningful social interactions. “All that stuff does add up, and is really important,” he says.
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Bottom line
If you’re ready to jump into ERP therapy, you’ll thank yourself later for taking the time now to set up a plan. Making goals with your therapist can help you feel less overwhelmed when you face challenges, and will keep you on a path to success. If you’re able to master these steps, you’re already well on your way to taking your life back from OCD.
Key Takeaways
- The most effective treatment for OCD is ERP therapy, but everyone’s treatment plan is specialized.
- Your treatment goals should target your unique obsessions and compulsions.
- Setting goals early on in treatment can help you feel more resilient in the face of challenges, stay committed, and see more obvious progress.