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The San Mateo CBT Clinic provides therapy for anxiety disorders in children, teens, and adults. Jonah Lakin PsyD is a licensed clinical psychologist specializing in Cognitive-Behavioral Therapy (CBT) for Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agorophobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

San Mateo CBT Clinic blog about anxiety treatment

Anxiety Blog. Describes CBT principles involved in treatment for anxiety disorders in children and adults. Conditions discussed include: Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agorophobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

Exposure with Response Prevention (ERP) for Obsessive-Compulsive Disorder (OCD)

Jonah Lakin

Exposure with Response Prevention (ERP) is the gold-standard of treatment for Obsessive Compulsive Disorder (OCD). ERP refers to treatment in which clients intentionally put themselves into situations that trigger anxiety (exposure) and then they practice resisting the urge to engage in compulsive behavior (response prevention). 

What is Exposure and how does it work?

In exposure therapy people repeatedly face anxiety provoking situations so that they can learn through direct experience that their fears won’t come true. Many people already know their fears aren’t quite realistic prior to treatment, but they don’t usually feel better until they actually experience it. So if you’re afraid of touching doorknobs, it’s not enough to tell yourself that doorknobs are safe, you would want to practice touching doorknobs repeatedly so that you can learn directly that nothing bad will happen.

Exposure therapy relies on a gradual approach in which people practice facing mildly anxiety provoking situations first, and then they move up to a slightly more challenging task. For instance, a person might first practice touching the doorknobs in their home. At first, touching these doorknobs will cause mild-to-moderate anxiety but with repeated exposure, touching these doorknobs will no longer elicit any anxiety. Once touching doorknobs in the home becomes easy, this person will begin touching doorknobs at their office and once those are no longer scary they may move on to touching bathroom doorknobs. As this example illustrates, people are usually only taking small or medium steps along the way, but over time they add up to very large gains. 

Exposure therapy works due to the psychological process of habituation. Habituation refers to the finding that we get used to things as we are exposed to them repeatedly. A classic example of habituation occurs when getting into a cold pool. At first, the water seems freezing, but after a little while, we get used to it and it feels comfortable. In this example, we habituate to the cold water because we stayed in it for a few minutes. Likewise, if we find touching doorknobs to be highly scary, we can touch doorknobs repeatedly and eventually we will get used to it (habituate). 

The tricky thing about habituation is that it takes a little while to take effect; it’s not immediate. So, it’s not enough to get in the pool for 30 seconds and then jump out, and it’s not enough to touch one doorknob and wait a few seconds before washing.  We need to stay in the pool for several minutes and we may wait a while after touching the doorknob before we feel better. This piece is really important: for habituation to take place, you must remain in the anxiety provoking situation long enough for you to get used to it.

Why do you need Response Prevention?

Response prevention means that people practice resisting their urges to engage in compulsive behaviors during exposures (they “prevent” their compulsive response”). This is necessary for two different reasons. The first is that we have to remain in the anxiety provoking situation long enough for habituation to occur. When anxiety is high, it may take 30-60 minutes for habituation takes effect. When we engage in compulsive behavior, we are quickly exiting the anxiety provoking situation and thus will never get to experience habituation. If after touching the doorknob you feel intense anxiety and then you wash to feel better, you are effectively exiting the situation before habituation can occur. The second reason that response prevention is needed is more complex and has to do with our beliefs. 

To better understand this second reason, let's imagine that you have contamination OCD and are just like the person we’ve been describing who has fears related to touching doorknobs. You are terrified that if you get the germs from a doorknob on your hands, they’ll eventually get into your body and you will become very sick. Therefore, any time you touch a doorknob you become highly anxious and you immediately wash your hands (compulsion). This practice of immediately washing your hands brings you immediate relief, but unfortunately it also prolongs your fear. To help clarify this point, let's review the situation and pay special attention to your beliefs about touching doorknobs.

• Before exposure: you believe “Germs on doorknobs are very dangerous and will get me sick if I ingest them"

• You practice Exposure without Response Prevention: You touch doorknobs daily but always wash your hands immediately afterwards.

• After exposure without response prevention: You believe that, "the reason I haven't gotten sick is that I always wash my hands.” Thus, you continue to believe “Germs on doorknobs are very dangerous and will get me sick if I ingest them.”

• As a result of the compulsive hand-washing, the belief that germs on doorknobs are very dangerous remains unchanged. The lack of response prevention has rendered the repeated exposures ineffective.

This happens with all sorts of compulsions and is not unique to contamination fears: when exposure happens without response prevention, the individual attributes their continued safety to the compulsion rather than learning that the situation is objectively safe.

Summary

Exposure with Response Prevention (ERP) is the most effective treatment for OCD. It involves gradually facing anxiety provoking situations and resisting urges to engage in compulsions. This allows individuals to habituate to a variety of situations that previously caused anxiety. ERP also alters people’s beliefs about what situations are dangerous. 

The goal of treatment is not to learn special ways to avoid feeling anxious as this will only strengthen OCD. ERP works by repeatedly feeling anxious and allowing the natural process of habituation to occur. Habituation takes time and doesn’t happen right away. This makes ERP difficult work and it becomes much more manageable when it is done in a gradual manner. 

With patience and hard work, people with OCD can weaken the power of their obsessive anxiety and eliminate their compulsive behaviors.