Intentional Practice – Part I

You’re wondering if you are doing ERP correctly and if it will make you better. Great question. There’s a lot to discuss, so we’ll break this up over the next several weeks. 

ERP stands for exposure and response prevention. It is a cognitive behavioral treatment technique. Anxiety is created, maintained, and intensified by experiential avoidance. We’re trying to do the opposite of experiential avoidance to recover from anxiety and OCD. Your past behavior helps us identify what will trigger your anxiety and in what way you will want to avoid. As an example, if you have previously felt anxious and stopped driving when you had a thought about hitting someone with your car, the next time you drive, you will likely have that thought, feel anxiety, and have the urge to stop driving. You aren’t having that thought and feeling anxious because it is more likely happen. You are having that thought and feeling because you acted as though it was threat in the past. For this example, exposure is driving and response prevention is not stopping. Easy, right? Just do the opposite of what your anxiety wants. 

I hope this concept is actually easy for you to understand and I hope that you recognize how hard it is to practice. Here are some reasons that ERP is hard: 

1. Anxiety is everywhere. By the time you seek out a psychologist, you likely had so much anxiety so often that it’s hard to tell what triggers it, what you are thinking and feeling, and what types of avoidances maintain it. That’s my job. It’s helpful if you self-monitor, but I’m the one that listens for and identifies the patterns between your thoughts and your avoidances. Consider this…  it isn’t your fault if you can’t seem to figure out what you’re doing wrong and why you experience so much anxiety. Physicians listen to your lungs when you have a cold. Psychologists listen to your thinking when you have anxiety to identify what maintains it. You don’t expect yourself to identify bronchitis and the same goes for anxiety. It’s not for fault that its happening and it is not your responsibility to identify what’s wrong on your own. It is your responsibility to take ownership over your recovery in the context of guidance and support. 

2. Avoidance is experiential. Uncertainty responds to experience, not thinking. You have to teach your body that uncertainties that previously didn’t feel safe are safe enough to live within and that it isn’t helpful to brace against uncertainties with no answer. You can’t just tell yourself that driving is safe enough, flying is safe enough, you’ll be fine at that presentation, and no one will reject you at that social event. 

To overcome those fears and all others, you have to put your body in your feared situation, let yourself feel scared, stay in the experience, and refrain from anything afterwards that undermines your learning. 

Exposure is putting your body in a feared situation, letting yourself feel scared, and staying in the experience while you feel scared. Response prevention is refraining from physical or mental compulsions, reassurance seeking, or avoidance of any form after the exposure. 

3. Anxiety shifts. Your anxiety and OCD are as smart as you are. Sometimes avoidances and compulsions are very easy to identify but very hard to consistently challenge. Sometimes avoidances are primarily cognitive and emotional and they are hard to identify and trigger. Sometimes as soon as you go towards and surrender to one type of content, you have a new intrusion with the same pattern that seems unique and overwhelming. 

Anxiety disorders are the worst. Seriously. What a nightmare. Recovery is a really slippery process that can’t easily be checked off a to-do list. That said, you need to do something. Hold onto your anxiety and OCD even while it slips through your fingers. Let’s work to identify your anxiety triggers and responses and be intentional about your practice. 

4. Recovery requires an attitude shift. The concept of ERP can appear to give too much credit to content. If you identify what you fear and then make a hierarchy of steps to go towards it, this implies that the content of your fear is actually the issue, rather than the process by which you are responding to uncertainty. 

For instance, let’s say your fear is that you are a bad person and if people knew the real you, you would be rejected. You probably try to get certainty about your true motives and what people think of you via need-to-tell compulsions and mental review. Some exposures you might do in order of easy to hard include: 
1) Refrain from clarifying a comment when you have the thought that you were misunderstood. (Act passively inauthentic at a time where it would be socially inappropriate to clarify.)  
2) Refrain from sharing a detail that seems important. (Act passively inauthentic at a time that would be socially acceptable to clarify.) 
3) Tell a loved one that you are feeling the opposite of what you actually feel. (Act actively inauthentic.) For example, you might tell your Mom that you enjoyed a date, even though you felt anxious too.

In this example, you are doing exposure and response prevention to feared content regarding authenticity. You aren’t trying to prove to yourself that there is nothing to fear. You are trying to generalize the attitude of acceptance towards uncertainty about your motives and uncertainty about how others perceive you. 

ERP is a helpful technique, because it gives you a framework in which to practice your new attitude.

Rather than thinking, my ERP hierarchy is going to cure my anxiety forever!

I want you to be thinking, I happen to currently fear this content. I am going to use exposure and response prevention with my current feared content so that I have the opportunity to practice approaching uncertainty with an open and willing attitude.

To what types of uncertainties are you willing to practice surrender?