Today’s blog is by Sam Kramer, PhD, a clinician at Anxiety Specialists of St. Louis who specializes in working with adults and older teens who struggle with anxiety, OCD, and related disorders.
Are you feeling confused and discouraged because your ERP is not working? You’re putting in the effort to do exposure therapy for anxiety, yet you are staying stuck.
Before throwing in the towel and labeling exposure therapy ineffective, it is worth considering these six barriers that may be getting in the way of Exposure and Response Prevention (ERP).
This blog post covers barriers to the process of doing Exposure and Response Prevention (ERP) and it assumes you are already somewhat familiar with some of the terms and rationale for ERP. If you are new to ERP, it may be useful to first explore other informational blogs about ERP on the International OCD Foundation’s website, or on this website linked here and here.
1) The ongoing use of avoidant coping/safety behaviors makes it seem like ERP is not working
There may be sneaky avoidant coping happening that make it seem like your ERP is not working. Think of it as doing the exposure with one foot in, one foot out. To understand this, you need to know about primary and secondary avoidant coping.
What are primary and secondary avoidant coping?
- Primary avoidant coping: when someone avoids a feared trigger altogether. For example, you completely avoid eating at a restaurant for fear that you’ll have a panic attack at the restaurant.
- Secondary avoidant coping: when you no longer avoid the trigger but you still treat it like a threat by doing something more subtle to keep an imagined bad consequence from happening. For example, you go to the restaurant, but only under the condition that you are able to sit on the end of the booth and nearest the door for quick escape.
Other common examples of secondary avoidant coping include:
- Checking your pulse to reassure yourself that it’s not too high
- Carrying a blood pressure or oxygen saturation monitor with you when not medically necessary
- Using the phone as distraction
- Always carrying a quick acting anxiety medication such as Xanax
- Only driving in the right lane so escape is easier
- Excessive loops of trying to mentally figure out what happened or what will happen
When these avoidant coping behaviors are used during exposure, you never overcome your fear. Instead, your safety is linked to the fact that you have an escape route, rather than understanding that your fear was unfounded or that you could cope better than expected.
What if I’m not doing any avoidance behaviors?
One tricky part here is that some of these behaviors might be happening in your mind. Safety behaviors that take place in the privacy of your head are less obvious to spot. However, they can slow down recovery significantly so are important to identify.
Exposures bring up negative thoughts. When those negative thoughts are met with desperate efforts to make the thoughts go away, the anxiety remains.
Examples of mental safety behaviors include:
- Trying to analyze or figure out again and again
- Arguing with the thought, trying to prove it wrong
- Staying on guard for the unwanted thought/feeling
- Repeatedly replaying a memory of what happened
- Playing out feared scenarios of what could happen.
They may seem harmless, but these mental acts teach the brain that thoughts and feelings are threats to be fought. This keeps the anxiety response alive and runs counter to the learning purposes of exposure therapy.
2) The exposures tried so far have been missing important contexts
Another reason your ERP is not working might be because the exposure situation does not adequately include the circumstances that cue the anxiety response.
I’ve seen people start therapy confused as to why their anxiety when driving persisted despite years of continued driving. They already force themselves to drive, so they wonder why driving exposures in therapy would be of any added benefit. Often they can drive under certain conditions, but they don’t seek out driving experiences that provoke their driving fears. For example, they may avoid passing in the left lane, driving during rush hour traffic, driving at night, etc.
Fear and fear responses are associated with specific circumstances. If you want to overcome a fear and change those associations in your brain, you need those specific cues to be present in the exposure. If nausea triggers your fear of vomiting, then exposures should eventually include inducing feelings of nausea and not just other common vomit triggers. Lastly, it’s important to incorporate varied contexts to help the brain master anxiety in many scenarios rather than a specific few.
3) The exposure is exited too early before necessary learning has occurred
Your ERP might not be working if you’re stopping the exposure too soon.
If anxiety were a pull-string doll, its one-trick phrase on repeat would be “You won’t be able to handle it…”. When faced with an uncertain or uncomfortable situation, we all desire to feel confident we can meet the challenge. That feeling of confidence in our abilities develops through experience. Exposure can provide the necessary experience so that you develop a sense of mastery.
An important component of exposure is expectancy violation. Expectancy violation refers to the gap between what anxiety expected was going to happen versus what actually transpires. Research shows that greater expectancy violations lead to greater therapeutic benefit from exposure.
Frequently individuals struggle to allow themselves to experience a feared scenario or their anxiety long enough to see that their anxious expectations didn’t match reality. Leaving an exposure too early reinforces the belief that the only reason you feel better is because you left. Staying in an exposure long enough gives your brain the necessary opportunity to reevaluate mistaken conclusions about the fear cue and update a new understanding that is more in line with reality.
Sometimes patients have all the tools to know what to do and how to do it, but progress is stalled by an unwillingness to stay with the discomfort/situation long enough to re-evaluate their preconceived expectations. Unfortunately, this deprives the brain of opportunities to update its assumptions. Part of the joy and difficulty of the therapist’s role is to collaboratively find ways to help the patient stick it out long enough to let the natural learning process happen.
4) ERP is being hijacked for the purpose of trying to control thoughts and feelings
Another factor that may contribute to thinking your ERP is not working is your using it for control. It’s important to have a mutually agreed upon plan for what the intended purpose of an exposure is ahead of time, but that does not prevent the allure of attempting to control emotions from hijacking the process. When reviewing exposure homework, one of the things I’m looking for are problematic expectations that successful recovery is equated with being able to do an exposure with no discomfort whatsoever.
Patients do indeed reach the point where previous triggers no longer elicit anxiety, but if the mere occurrence of unpleasant thoughts, emotions, or sensations is interpreted as failure or a problem then anxiety will continue to be a problem. What you resist will persist. The more you try not to feel or think something, the more the brain will focus on it. No intervention can eliminate the occurrence of thoughts, emotions, and sensations. A better route that can be achieved via exposure is to change your relationship with thoughts, emotions, and sensations such that their presence is no longer a point of concern.
5) Improper dose of exposure means ERP is not helping
It’s also possible that your ERP is not working because a higher level of care and higher frequency of exposure are necessary. The more immersive the experience, the more opportunities there are for the brain to update new safety learning required for lasting recovery. Patients who complete several or even daily exposures between weekly sessions generally reach their recovery goals faster. Doing one exposure per week is typically inadequate. In some cases, intensive outpatient or residential treatment may be necessary.
6) Counterproductive mindset toward the exposure process leads to ERP not working
Finally, it could be that your ERP is not working because of your mindset. Nearly all of the previously listed barriers could be explained as problems of mindset. One of the most common problems that slows down or completely halts progress is when a patient is willing to do the exposure but then does so with a mindset of resisting or pushing away what is felt during the exposure. If you are familiar with Acceptance and Commitment Therapy conceptualizations, you might recognize this mindset as experiential avoidance, which is at the root of the development and maintenance of all emotional problems.
Resistance is a completely understandable response, though it is not useful. I see mental resistance as the universal human default gut response to all things unpleasant. An intentional turn toward being willing to experience the inevitable discomfort life throws at us is not a skill we learn and then we’re good for the rest of our lives. It is a choice we must keep making over and over again. Sometimes doing so is easy, other times it is the hardest thing we’ll ever have to do.
What does resistance look like?
So what does mental resistance look like within the context of exposure? If you are approaching exposures as if you are a contestant on Fear Factor, clenching your teeth as you white knuckle through it, thinking “Let’s just get this over with…,” then that’s a good sign you are not in a good state of mind to grow and learn. After the exposure, resistance might take the form of spending excessive time ruminating as you try to figure out or reassure yourself about something that happened during the exposure.
As you can see by these examples, the learning purpose of the exposure is being lost. By saying “This is terrible, I can’t stand this. This has to go away now!” during an exposure you are inadvertently reinforcing the fear-related belief that you indeed can’t tolerate feeling this way. Your mind is closed down and not open to growth. This will further activate the amygdala (brain’s alarm system) and keep your brain and body on high alert about something that is counter to your therapy goals. For more on mindset during exposures, see Dr. Reid Wilson’s excellent blog about the topic.
If you’ve been feeling stuck, hopefully you can take some time and reflect on if any of the aforementioned barriers are getting in your way. Getting stuck and unstuck is part of the typical process of change. No barrier is without solutions. If you’ve tried exposure therapy before and had limited success, or would like to give it try for the first time, we’d love to help you navigate treatment for a recovery that lasts. Please reach out to our care coordinator at email@example.com to schedule a free, 15 minute consultation call.