7 Reasons Why ERP Doesn't Work
Let's talk about the impact of stress on the brain and Exposure Response Prevention (ERP) therapy as the gold standard treatment for OCD. Erin shares the differences between eustress and distress, the importance of changing your relationship with uncertainty, and the potential pitfalls of ERP therapy.
00:00 Introduction to Stress and OCD
01:00 Understanding Different Types of Stress
01:52 Facing Fears and Exposure Response Prevention (ERP)
03:21 Challenges of OCD and Intrusive Thoughts
05:23 The Role of Therapy in Managing OCD
05:53 Examples and Scenarios in ERP
09:57 When ERP Doesn't Work
12:24 Common Pitfalls in ERP
28:48 The Importance of Support Systems
30:49 The Impact of Stress on the Brain
32:13 Conclusion and Additional Resources
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You've heard all the things about what stress does to your body, but have you ever wondered what stress does to your brain? And do you experience those thoughts like, Oh, I'm too far gone. I don't think therapy can help me because I'm My intrusive thoughts are too much, or I'm a lost cause. Well, in today's episode of Bossing Up Overcoming OCD, I'm going, I'm going to be explaining exposure response prevention therapy, which is the gold standard treatment for OCD.
And you're going to be learning all about what ERP is, what it is not, and how it Can change, and how it can retrain your brain in the way you, well,
in a way that can help you live that value driven life. There we go. Intro done. Now we have the intro, and I'm going to get into the details of this episode.
Alright, so we've all been there. We've all experienced stress. to some degree. And there are those two different types of stress. There's the eustress, which is spelled e u stress, and then there's distress. The eustress is the type of stress that is helpful and motivates us, and that's what helps us get up and get ready for, like, work.
in the morning, or for school, or to follow through with that presentation, because we know that doing this thing is good for us, and the distress, which doesn't feel so good and makes us uncomfortable, is the one that,
the distress is the one that
brings us the doubt, and the uncertainty, and the discomfort.
And when it comes to discomfort, nobody enjoys being uncomfortable. And that's like the really challenging part when it comes to exposure and response prevention therapy and really with any fear or stressor that you have going on. We've all heard that phrase of face your fears. You're brave. You can do it. And like, that works if you're wanting to ride a roller coaster and it. likely doesn't feel as distressing if that's the end goal, just to go for a ride on a rollercoaster.
And depending upon the level of fear you have, and if it's fear of heights and this rollercoaster is really high, like, okay, that's one thing. And you can probably rationalize yourself into doing it or
so you can likely face your fears when it's something like riding a rollercoaster or doing, you know, love going to carowinds and at carowinds they have this really high swing and it is intense where you and one or two other people are strapped in they pull you all the way up to the top and they tell you like from a microphone right on the count of three pull the plug and it's like one two three and then boom you drop it's like that huge pendulum type swing that is such an adrenaline rush very fun And if you're going to carowinds this summer, I think it's a great way to face your fears if you have a fear of heights or just want to push outside your limits.
And I totally get that it's not for everybody. And what's challenging is whenever you're experiencing OCD .
What's challenging when you're struggling with intrusive thoughts and the compulsions and the fears is you feel like I don't want to face these fears. In fact, you're doing so many things to avoid the fear and avoid this bad thing happening. Possibly it feels like a, like a sense of responsibility.
Like it's part of your moral job or your, you know, role as a parent like you need to do these things to keep your kids safe or your family safe or to keep your mom from dying and the thought of Facing your fears. Well that translates like oh, do I need my mom to die so that I can get over this fear, right?
It sends all kinds of confusing messages because If you are that person who,
who let's say worries about your dog dying, you don't need your dog to die to get help or to get over that fear. Not really. And I don't even want to say to get over the fear, but to handle and manage the fear. Okay. Because a lot of times with therapy or, well, a lot of times with, Your loved ones and people who care about you.
They're giving you advice. They're like, oh, you'll be fine. Just face your fears Don't worry about it, and that feels very unsettling and invalidating. It's like, how could I not worry about my dog dying? How could I not worry about my mom dying or my kid getting sick or me accidentally hurting somebody?
There are all sorts of intrusive thoughts that like to trick you into believing These bad things are going to happen
and or that you are responsible for those bad things happening. That's a lot of pressure.
And so with my approach of exposure response prevention, it's not so much about facing your fears. Yes, we are doing things that you feel fearful of or you're afraid of. But it's much more than that.
Exposure response prevention therapy is about changing your relationship with uncertainty. It's also changing the relationship you have with these thoughts.
So here's another example. Let's say you are afraid of having a heart attack and you are looking online to try to find help and you land on a therapist website that says, Oh, I'll help you face your fears. And you're thinking, Oh dear God, like, I'm gonna have to have a heart attack to get over my fear.
How horrible does that sound? And of course, that's not what the therapist is truly intending, yet. I can empathize and see how distressing that might feel to read that or to think like, Oh, do I need to have a heart? And maybe I'm being a little bit facetious, but that's okay. So it's like, Well, do I have to have a heart attack to feel like, oh, that wasn't so bad?
Like, no.
So when looking at it from
this other angle, and it's not even radical acceptance, it's not that we're accepting, oh, you're going to have a heart attack one day. No, it's sitting in a place of the gray area. You may or may not have a heart attack.
And the way we get there is through those scenarios where you are looking at scenarios about heart attacks, or reading about heart attacks, or watching videos, or just us having the conversation about the heart attack. Those are some examples of lower level exposures, and the exposures start wherever you feel you can handle them best.
But what I really want you to Here, especially if you're that person who feels like they are quote unquote too far gone or they're a lost cause or their intrusive thoughts are too much or too embarrassing, too shameful, you name it. There are a lot of things that your intrusive thoughts try to trick you into believing.
And ultimately, with the exposures, we are working towards your goals, okay?
And so we're going to have a conversation about.
What you want to feel and what you want your brain to experience when you think of the word heart attack or If something on the news comes up, well not even news I don't know how many people even watch the news these days. Maybe you do. I don't know It doesn't just the news doesn't seem very positive So let's say something on the TV or as YouTube, right?
Like that's more of our media use these days, but let's say you're flipping through YouTube or Instagram, TikTok, and someone says something about a heart attack. Instead of you feeling triggered and going down a rabbit hole of researching on Dr. Google and four hours later you're like, oh my gosh, I can't sleep because now I'm worried about a heart attack.
We're going to then have that conversation of what would you like to do if someone on TikTok Talks about a heart attack. Maybe you're in the camp of thinking like I would like to think so what and that is Money, that is the gold that we are after that is what you want And that's what you'll do in therapy.
We will help you reach that place of so what? Bring it on. I don't care.
And that marks your willingness to do these exposures. Because it sounds torturous, right? In a way. And so that's the, that's the goal of this episode. In Planning out this episode, I really want you guys to know and feel that exposure response prevention works.
Not only does it work, it works very well and it can work for you too. But guess what? I know there's always a catch. There are times when exposure response prevention doesn't work.
Yes, and I even got a question from, and I hope I'm pronouncing his last name correctly, um, but it's from Nicholas. Let me just do it like that, okay.
Alright, and so there are times when exposure response prevention therapy doesn't work. And let me, okay. And I received a question from one of the audience members. His name is Nicholas Furnari. He is a doctoral candidate
for, let's see,
for Pacifica Graduate Institute. And he is out of San Diego, California.
And his question was,
What are some additional methods that help get OCD patients asymptomatic? So basically,
well, no. His question was, besides exposure response prevention, what are some additional methods that help get OCD patients asymptomatic?
Because with Nicholas's experience, he was recognizing that not all patients were quote unquote successful after going through exposure response prevention therapy, and that they were still experiencing intrusive thoughts. And so he was curious how, you know, basically a majority of patients are successful, but then there's that portion that is not successful.
And so these are those times when ERP goes wrong. Or doesn't, and when ERP doesn't fully accomplish the goal of helping you reach that so what attitude or bring it on attitude or you're not as willing to
be in the same headspace with some of these fears.
And with the additional factors, Nicholas, that can help you in reaching a place of being asymptomatic. That looks like what I was saying earlier with changing your relationship with. These words changing your relationship with uncertainty and also remembering what your goals are in that You no longer want to to live a fear driven life but a value driven life.
So those are the additional factors. Now let's talk about how exposure response prevention can go wrong.
Those exposures can go, the exposure response prevention therapy, or we'll call it ERP for short, it can go wrong because the therapist may not push you to reach that most distressing situation. It can be It's tough, right, to be in that place where you're very afraid, and
if your therapist is not skilled enough to recognize your attempts at distraction, or honestly, the cop outs, right, like, you could be in an ERP
exercise and then you're like, Hey, where did you get your degree again? Hey, where did you get your training? And Hey, when are we meeting again? And so your therapist may not pick up on the distractions or you could very easily talk in tangents and your therapist may not be as skilled to detect, Oh, they are talking away from the main idea, and that main idea is that fear we were working on.
And so it can be very easy for your therapist to not bring you to that most distressing situation.
And, and that could be a lack of trust in the therapeutic relationship. It could be that your therapist is also uncomfortable with that particular fear.
And if that's the case, The therapist can, if you are that therapist, then seek your own cons, no, don't even get into that.
Another way ERP can go wrong is if you're doing imaginal exposures. So,
is when you're doing imaginal exposures, when you actually need to do like a live practice type of exposure. Or vice versa. But it's basically saying that the exposure is not really hitting the nail in the head kind of situation. Let me look at an example.
And the imaginal exposures are great, especially if, like,
you're imagining things that are hard to recreate, right? Like, we can't create hell on earth, even though it feels like it sometimes. Uh, and, and we can't, you know, conjure up cancer. So. That's when the imaginal exposures are, are helpful. There are times like, let's say you struggle with panic and you have a fear of having a panic attack.
All right, so us imagining that you're having a panic attack works, but that's very different you breathing through a straw or doing rapid breathing for a minute and being in those physical sensations of what feels like panic.
Or if we're imagining you eating something dirty that has fallen off the floor. Like, again, with our imagination, we can, we can do all sorts of things. The difficult part is that your brain is not truly learning that that experience is not dangerous or that you can handle that experience. So in that example, if something falls on the floor and you eat it, yeah, we can imagine it to start.
All right. But then the next step would be to do it. And in doing that,
you're not allowing your brain to distract you from, from the activity, because it's very easy whenever you're doing imagination based exposures, that your brain is going to very easily jump to the next topic. It's going to jump to the next, scenario or tangent distraction and it's gonna be like do do do I am not wanting to be here
or if you're having the other thing like watching
watching videos about car crashes for example like yes you can watch it, and your imagination may go there for a minute, but it's not the same as actually sitting in the driver's seat, no, I'm not going to tell you to get in a car accident, but I am going to encourage you to drive to that new part of town where you're afraid of getting in an accident because Imagine that relief you're gonna feel like once you are driving by yourself, you're going to the store by yourself on the other side of town and you no longer feel anxious about it.
And it's not that we want a car accident to happen, but we want to change your relationship with that anxiety and with that uncertainty and that unknown. It's like, I mean, I hope I don't get in a car accident. And I need to go to the store. So what? And even if I did have a car accident, it doesn't mean that it's going to be fatal.
It doesn't mean that I'm going to lose my life just because I am in a car accident. It wouldn't be fun,
and it wouldn't be something that I want, but I do need to go to the All
right. Number three in how exposure can go wrong is when Either you or your therapist or maybe a loved one are encouraging you to be distracted during your exposure. Raise your hand if you always have a fidget cube with you or you always use your phone as a fidget item. Right? I bet there's a lot of you out there raising your hand.
If not both hands, you're like, oh boy, that's me through and through. It's easy to do. And in our
day to day life, we are so full of distractions. I mean, and it It's bananas how many distractions we have, and it only leads us down this path of
one tangent to another, and by the end of it you're like, now how did I get here?
And so, when you're doing an exposure, and if, let's say you're that parent who's helping your child
not worry about germs,
no, hang on,
no, what's
another one,
yeah, let's say you're that parent whose kid is worried about throwing up or contamination type of fears, it can be very easy for, for us to say like, oh, don't worry about it, just go call your friends, go out, have fun, go outside. And don't worry about it. All right. Well, some of those are good coping strategies, right?
Like call a friend, go outside, get exercise, get fresh air. Yes, those are good coping strategies, but But they are also distractions, and they are not helping your child get to a different relationship with that anxiety. They're still going to be afraid of the germs
or that contamination of whatever that, of that contamination.
And so that leads to number four of when ERP doesn't work. And whether this is falling on the therapist's shoulders, your shoulders, or the loved ones, Please hear me out when I say do not give reassurance. Reassurance only feeds the fear. So for example, going back to your kid has a fear of germs. If you say, Oh, it wasn't that dirty, you're fine.
If you've washed your hands three times, you're fine. That's enough. You've already washed your hands plenty, or you didn't really touch it. There's no germs on you. All of that is reassurance.
And again, it's not helping your child change the way they feel when they're afraid. So here's another way, because right, like that, that's a lot to take in. And I know it's hard as a parent, whenever your kid is going through stuff or they're asking you to give them comfort, right? And that's what, I mean, as a parent, that's what you feel like your main job is, is to help your kid be comfortable.
Which, speaking of, who says that we're entitled to comfort?
You know? I mean, yes, it is pleasant to feel comfortable, but who says we have to feel that way all the time? I
think that's another misconception that our, that Americans have. We don't always have to be comfortable. We keep hearing these messages of do what makes you happy, live your best life, and it's like, well, your best life can also be dealing with being uncomfortable and doing that well.
And we know that happiness is an up and down roller coaster, it's another emotion on our feelings wheel, so we don't want to discount all the other feelings on our feelings wheel. Happiness is not the only one on there.
So, let's say You've been giving reassurance. Guilty as charged. It happens. In fact, up to 60 percent of kids with OCD,
In fact, kids with OCD, up to 60 percent of the time, their family members are reinforcing the fears. You're not meaning to. I get it. So, I'm sorry.
Let me tell you a, let me give you a quick rundown of information seeking versus reassurance seeking. Alright? Because if they're asking for reassurance, they're typically asking the same question multiple times or in different ways. They could also be asking that question so that they don't feel as stressed out.
Or they're seeking out a particular answer,
or they're asking for more definitive answers. That's all like what a reassurance seeking cycle looks like. Now, if you're looking for information, you ask the question once, or you're only asking the question so that you can be informed. Like, hey, what's the weather today? Oh, okay, so it's gonna be mostly cloudy, high of 80s.
Okay, like that's enough. It doesn't have to be like. Now, when's it going to storm?
What's the wind speed? Right? Like, none of that. The other piece when someone is just seeking information is they accept the answer that's given.
They're only seeking truth
and they're only pursuing the information if it's necessary for them to make a decision on something. Right? Like, I'm asking you what the weather's going to be today so I can decide, well, do I need to wear a jacket today or do I need to take an umbrella?
And so basically with the information seeker, it's a one and done, but reassurance, it's like, you know, when they've asked one too many times
and when it's kind of one of those feelings like, well, I know they know better, right?
Well, not that they know better, but they should already know the answer to this question. Because you've answered it a gazillion times, or they somehow should know this by now. So, anyway, that's how exposure response prevention therapy doesn't work, because whenever you're doing the exposure, someone is giving you reassurance.
And so let's say you are afraid of being violent and we're looking at a movie scene that has murder in it or something. And a loved one says, Oh, you're not a murderer. You would never kill anybody. Like that sounds nice and thank you for that, but it's giving reassurance. And so it's not allowing you is not allowing.
That sufferer of intrusive thoughts to deal with the harm thoughts or the violent thoughts. So it's kind of like, and while even just talking about it, it can feel like somewhat troubling. So it's like, so are we saying like we have to be okay with violent thoughts? No, but what we do have to do is get to a place that you want, right?
So it's like, all right, if violent thoughts pop in there, what do you want to do about it? What do you want your brain to experience? And if it's that, so what attitude, that's what we're after. That's what we're going to do. So. You have a thought about,
well, and I've heard so many examples over the years, but let's say you're at the top of an escalator at the top of the stairs and you get an intrusive thought about pushing people down the steps. Okay. Well,
you can get to that place of thinking. So what if I think this? Right? It's not, so what if I do this? It's, so what if this thought comes up? I don't have to do anything with this thought. It's just my brain trying to trick me or whatever language, phrase, story you want to use.
And according to one research study, ERP doesn't work because it's failing to address the core fear. Now in OCD work, we don't Need to truly understand why you're afraid of having a heart attack.
Because To me, even when we are going down that path of, or let's say if we're trying to go down that path of figuring out why you're worried about having a heart attack, all we're really doing is still trying to give you clarity so that you can get the results. And we can get those results without addressing your core fear.
Okay? So, if we were to zoom out from the core fear, really what it is, is you're afraid of the uncertainty. So it's not that we're going to zero in on the heart attack fear, we're going to zoom out on the fear of the uncertainty and the unknown. So that's what we will ultimately address.
And number six for an ineffective, well, and number six for where exposure response prevention goes wrong, is when the uncertainty Either you or your therapist is not coaching you to help you handle those mental compulsions. So compulsions, again, guys, are those things that we do
to help address the fear. So in the case of mental compulsions, they are extremely challenging and it may be something that you're doing during an exposure, but you're certainly doing it in your normal day to day stuff. So, for example. If you are that person who's afraid of violence, and you watch a scary movie, you see a horror scene or murder scene play out, and then you've got this intrusive thought of, Oh, what if I become a murderer?
What if I kill somebody? Then your compulsion then is giving yourself reassurance. Or Yeah, is giving yourself reassurance. So that may sound like, well, I'm a good girl. I don't do that. I have a faith, a religion that I, that I believe in. I know I love, let's see, I know I love myself. So I wouldn't do that to myself.
So all of those are giving yourself reassurance and AKA they are a compulsion and AKA they don't help you.
And number seven, why Exposure response prevention therapy doesn't work.
I'll see where I'm at with time. Oh, I'm doing pretty good.
Is because the loved ones in your life are not understanding and helping support the therapy work. So if you or your loved one are experiencing OCD, the family members need to be involved with the treatment as well. Now to what degree? Honestly, it may only take one, maybe two sessions. with the therapist, but there's definitely a lot of resources and support out there on the internet as well and support groups too.
And what you can learn as the family member is how to not give reassurance. You can understand more about exposure response prevention therapy and why it works. You can also air out those questions of like, Oh, if my daughter's worried about it. being violent, should I remove all the knives? So you're going to get those questions answered.
And you can also learn how to coach your loved ones through those exposures or how to help prevent them from doing some compulsions. And like one tip is put a notebook on your dining room table. All those questions that Your loved one asks you repeatedly, go ahead and write those in the notebook, so then next time they ask, you can say, go check the notebook.
All in all, exposure response prevention therapy works, and it works when you have the right therapist,
when you have the right therapist, and
all in all, exposure response prevention therapy works, and it works when you have the right therapist.
And the right support system. Well, not really the right support system, but a support system that is going to help you further that progress that you need so that you can be living in your values and no longer living in fear. And when it comes to stress, we know that, or you've heard so many things about what stress does to the body, right?
Like it creates all the sleep problems, joint problems, heart problems, et cetera, et cetera. And so the question I asked you guys at the beginning of the episode, when it comes to the brain, stress can actually make your brain smaller. And then, on top of that, the fight or flight part of your brain, the amygdala, that part gets bigger.
On average, the amygdala is the size of an almond. And that almond sized amygdala is the one releasing the cortisol and the adrenaline. That gets you so worked up. And what's fascinating is that all of those impacts that stress has on the brain, they are reversible. And so through therapy, your amygdala can get smaller and,
and you can stimulate better brain chemicals. So
ERP is definitely worth it because it can change your brain, not only in how you think, physiologically too. Isn't that incredible? I think that's what's so exciting about this type of therapy. You can retrain and change your brain.
All right. Well, recording. Well, all right. So this was a lot of fun telling you about ERP and the brain and how all of these things work so that you can get to a place where you're living Living the way you want to living in a place of freedom or whatever that version of living you want to live
be sure to check out my Mindfulness podcast called soul sync. It is now live and out there for purchase. You can purchase on a monthly basis or monthly a yearly basis
and click on the link in the show notes to get directly linked out to the soul sync podcast where you can start listening to the mindfulness episodes because mindfulness is another way to help retrain your brain and help you focus on the things
it will help you focus on the things that you want all right y'all take care and come back next week
and come back next week where I'm going to be talking about the differences between OCD versus ADHD. Happy Friday!
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