Exposure and Response Prevention (ERP) Therapy is a top treatment for Obsessive-Compulsive Disorder (OCD). It helps people face their fears and feel anxiety, discomfort, and uncertainty without using compulsive behaviors. This process is key to helping individuals learn to handle distress and reduce OCD symptoms over time, giving them hope and control. 

Exposure and Response Prevention 

ERP has two main parts: exposure and response prevention. Exposure means facing the thoughts, images, objects, or situations that cause anxiety or discomfort. This can be done by directly facing the feared situation (real-life exposure), imagining the feared situation (imaginal exposure), or experiencing feared physical sensations (interoceptive exposure). Response prevention means not doing compulsive behaviors or mental rituals in response to the exposure. The goal is to stop the cycle of compulsion and reduce dependence on these behaviors for relief. Successful ERP involves not doing any compulsion while feeling anxiety and discomfort. 

Working with an ERP-trained therapist is very important. The therapist helps the client identify specific obsessions and fears, understand what triggers their anxiety, and recognize unique compulsions and rituals. This support reassures both the person with OCD and their families by identifying both obvious and hidden compulsions and providing a plan for recovery. Compulsions can include behaviors like checking, arranging, cleaning, tapping, or repeating, or mental compulsions like mental reassurance, thought suppression, rumination, mental checking, and mentally repeating words or phrases. Identifying compulsions is crucial as they are not always obvious, with mental compulsions being very hard to recognize and address. 

One challenge in doing ERP successfully is identifying and stopping compulsions and making sure that one compulsion is not replaced with another. For example, a client might stop a behavioral compulsion but start a mental compulsion instead. The main idea of ERP is learning to handle discomfort without trying to escape it through compulsions. This involves being aware of one’s responses to triggers and learning to live with anxiety and uncertainty without using compulsions. 

Exposures and OCD 

Exposures are crucial to recovering from OCD because the disorder makes people think they cannot handle the distress they feel when facing their fears. Also, OCD makes people believe that certain bad things will happen if they do not do specific compulsions. The purpose of exposure is to help individuals repeatedly see that their feared consequence does not happen even when they do not give in to their compulsion. This is the only way to break the OCD cycle because safety behaviors are the only part of the cycle that people can control. They cannot control their unpleasant thoughts, feelings, or sensations, but they can choose to react in a way that does not reinforce them. The more a person with OCD does exposure and response prevention, the more their brain learns that the initial trigger was not dangerous to begin with, reducing obsessions over time. 

Clients often ask what they should do during an exposure if not their compulsion. The answer is to stay present. For the exposure to work, the person must not do anything to reduce discomfort. Instead, they are encouraged to stay in the moment, feel uncomfortable, and notice their unpleasant thoughts, feelings, and sensations with curiosity and without judgment. This approach lets the individual see that anxiety decreases over time without the need to do anything about it. Trying to escape the discomfort only provides temporary relief and keeps the cycle going. 

Break free from the cycle of OCD

It is important to note that the goal of ERP is not to get rid of unpleasant thoughts, feelings, or sensations but to learn how to tolerate them without using compulsions. By facing their fears and not doing compulsions, individuals can see that their anxiety decreases over time and that they can handle the distress without using compulsive behaviors. This empowers them to break free from the cycle of OCD and regain control over their lives. ERP is a structured and systematic approach to treating OCD designed to build confidence in mental health professionals and help individuals regain control over their lives by reducing the power of obsessions and compulsions. Through the guidance of an ERP-trained therapist, clients can learn to face their fears, tolerate discomfort, and achieve lasting relief from OCD symptoms, showing how effective this approach is. Exposure and Response Prevention Therapy is a powerful tool in treating OCD, leading to lasting relief and a renewed sense of hope and empowerment. 

  

References 

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 

Abramowitz, J. S., McKay, D., & Storch, E. A. (Eds.). (2017). Obsessive-compulsive disorder: Contemporary issues in treatment. Wiley-Blackwell. 

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press. 

Franklin, M. E., & Foa, E. B. (2011). Treatment of obsessive-compulsive disorder. Annual Review of Clinical Psychology, 7(1), 229-243. https://doi.org/10.1146/annurev-clinpsy-032210-104533 

March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. Guilford Press. 

Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37(Suppl 1), S29-S52. https://doi.org/10.1016/S0005-7967(99)00049-2 

Posttraumatic stress (PTSD) can severely interfere with functioning, resulting in intrusive memories, depression, disrupted sleep, anxiety, and avoidance of situations that bring back memories of the trauma. But the symptoms of some trauma survivors, particularly those who have experienced prolonged abuse or captivity, don’t neatly match traditional symptoms of PTSD. In the 1980s, some therapists and researchers began to advocate for recognition of a new variety of PTSD called complex posttraumatic stress disorder or C-PTSD. Although C-PTSD is not listed in the Diagnostic and Statistical Manual of Mental Disorders, therapists are increasingly recognizing the issue, which requires different treatment and produces different symptoms.

What Is Complex PTSD?

PTSD is a reaction to a threatening event, and the event is usually a single event that occurred for a brief duration. Traumatic events that might cause PTSD include watching a loved one die, witnessing a violent act, rape, assault, and military combat. C-PTSD, by contrast, is more likely to occur when a person experiences multiple or ongoing traumas or when a single trauma lasts for a long time and leads to feelings of captivity. Survivors of concentration camps, people who were regularly abused as children, domestic violence survivors, military personnel who are exposed to ongoing violence, people who have experienced repeated sexual assaults, and kidnapping victims may experience C-PTSD.

While PTSD typically causes disturbances—such as flashbacks, avoidance of locations or situations that remind a person of the event, or chronic fear and depression—to the traumatic event, C-PTSD is more likely to cause identity and personality disturbances in addition to the symptoms of traditional PTSD. This is because people exposed to prolonged trauma may begin to view the trauma as a core part of their identity or as something they caused, and sometimes they might question their own memories—believing, for example, that perhaps the trauma didn’t really happen.

Symptoms of Complex PTSD

C-PTSD has many of the same symptoms as PTSD, including intrusive memories or flashbacks, depression, anxiety, avoidance, and changes in personality. However, people with C-PTSD also experience symptoms that people with PTSD don’t normally have. These include: [fat_widget_trauma_ptsd_right]

Treatment for Complex PTSD

Because C-PTSD is a relatively newly recognized condition, there’s still some debate about how it should be treated. Exposure therapy, which is highly effective with PTSD, is still being studied for its effectiveness in treating C-PTSD. As C-PTSD may mean dozens of traumatic memories or years of trauma, some clinicians have argued exposure therapy is impractical. C-PTSD researchers have generally recommended a stage-based treatment approach that includes the following phases:

  1. Establishing safety and helping the client find ways to feel safe in his or her environment or eliminate dangers in the environment.
  2. Teaching basic self-regulation skills.
  3. Encouraging information processing that builds introspection.
  4. Helping the client to integrate his or her traumatic experiences.
  5. Encouraging healthy relationships and engagement.
  6. Strategies designed to reduce distress and increase positive affect.

References:

  1. Complex PTSD. (n.d.). National Center for PTSD. Retrieved from http://www.ptsd.va.gov/professional/pages/complex-ptsd.asp
  2. ISTSS complex PTSD treatment guidelines. (n.d.). International Society for Traumatic Stress Studies. Retrieved from http://www.istss.org/AM/Template.cfm?Section=ISTSS_Complex_PTSD_Treatment_Guidelines
  3. Walker, P. (n.d.). Emotional flashback management in the treatment of complex PTSD.Psychotherapy.net. Retrieved from http://www.psychotherapy.net/article/complex-ptsd

Emotional eye“…Not all psychological impacts can be encompassed by a list of symptoms or disorders.” —From Principles of Trauma Therapy

Make no mistake about it, Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment is a psychiatric textbook. However, it is a rare breed of psychiatric textbook. It has a soul. To borrow from the dialectic wisdom of Marsha Linehan, the question in mental health treatment is often “What is being left out?” This book fills the void in terms of a comprehensive examination of the causes of trauma. It is not solely focused on the lists of symptoms. There are some areas where the book has “left out” important information, but emphasis on cultivating compassion for trauma survivors makes up for it.

John N. Briere and Catherine Scott describe how challenging behaviors exhibited by people who have gone through traumatic events are normal and within the context of psychological resilience: “Although therapists may interpret these behaviors as ‘resistance,’ such avoidance often represents appropriate protective responses to therapist process errors.” (p. 170). The adaptive functioning—or attempts to “metabolize” the trauma—is often interpreted as sabotaging or therapy interfering, but in reality, it suggests the clinician is in error (e.g., moving too fast in therapy). Unfortunately for the person in therapy, these attempts to lessen the pain can inadvertently prolong their trauma (this is what’s called the “pain paradox”). The unskillful attempts used to extinguish the pain often produces an increase in pain for the individual.

[fat_widget_trauma_ptsd_right]The pervasive message in Principles of Trauma Therapy is that a person’s symptoms due to a trauma can resolve via therapeutic engagement within a safe, therapeutic environment. The treatment approach is eclectic, and it weaves together strategies from various models (e.g., cognitive behavioral therapy, psychodynamic approaches, and mindfulness). People in therapy are given the opportunity to develop a coherent narrative of their past experiences, while learning stress reduction skills and psychoeducation through validation, respect, and supportive encouragement.

At the heart, Principles of Trauma Therapy comes from the theoretical perspective of exposure therapy and much of the content centers around this orientation for treatment. The clinician invites the person in therapy to develop alternative perceptions to their negative beliefs about themselves (oral and written) and the environment where the trauma manifested, while reducing “conditioned emotional responses” (CER).

To simplify, the recollection of the traumatic memory (i.e., exposure) occurs by activating the emotional states and schemas. The “disparity” that occurs is based on the idea that the therapy space is safe, so the person in therapy is counter-conditioned to realize they will not be harmed by experiencing the intense emotions that surround the memories. The integration of memories and emotions through exposure—along with the inability to avoid (i.e., CER) in the moment—creates resolution. The emotions are no longer as powerful. The positive results occur if the clinician is able to finesse the client’s capacity to “regulate and tolerate the associated painful affect” (p. 267). Briere and Scott advocate a titrated exposure to avoid both undershooting the level of exposure and not overwhelming the person in therapy. This person should be emotionally activated to allow processing to take place, but not to the point that their coping resources are overwhelmed, which leads to avoidant behaviors (i.e., to seek safety from the distress).

Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane?

There are a couple of areas that should have been addressed more thoroughly in the text. Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane? This form of therapy elicits pain for the person in therapy, often expressed in the form of panic attacks, dissociation, and intense anxiety through a re-experiencing of the trauma. Is it morally right for clinicians to prescribe this approach? Does the end justify the means? Or, are there other treatment approaches that can be used to relieve the immense amount of suffering experienced by trauma victims?

Principles of Trauma Therapy provides only a brief conceptualization of eye movement desensitization and reprocessing therapy (EMDR). In 2004, the APA acknowledged EMDR as a recommended effective treatment of trauma. According to Shapiro (2001), EMDR is the most empirically studied treatment for posttraumatic stress (PTSD). The philosophy of EMDR treatment does not differ drastically from exposure therapy: deconditioning disturbing input, redefining the event, finding meaning in it, and eliminating self-blame, while integrating new skills (Shapiro, 2001). The stark difference between EMDR and exposure therapy is the method of delivery, as well as the path a person in therapy takes toward healing. Exposure therapy is analytical with a narrative-driven process that involves a significant amount of “homework” assignments for the person in therapy. It also runs a risk of vicarious traumatization (for both the therapist and person in treatment) due to repeatedly describing the often horrific events.

The internal process of EMDR utilizes an approach of holding a negative cognition (e.g., “I am unlovable”) paired with what is often an image of the traumatic event (a pre-established target). The person is instructed to focus on the image, negative thoughts, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation (e.g., eye movements, auditory stimuli, or tactile sensors). They are witnessing in their mind’s eye what surfaces. The clinician does not hear all of the details of the trauma, nor does he or she provide analysis of the experience. Dialogue is at a minimum. It is provided through repeated, brief check-ins between sets of bilateral stimulation; “What comes up now?” or “What did you notice that time?”

Principles of Trauma Therapy has an agenda in terms of promoting exposure therapy, but it also offers a holistic array of coping strategies—for both the therapist and the person in therapy—to increase one’s awareness of bodily reactions and ways to create a vocabulary for the feelings that arise. This mindful mentality is more than a subtle emphasis. Empirically validated mindfulness interventions are presented (e.g., acceptance & commitment therapy, dialectical behavior therapy, mindfulness-based stress reduction, and mindfulness-based cognitive therapy) as to disillusion the reader from the spiritual, Buddhist connotation. Clinicians are encouraged to maintain an open awareness to their own mental states (e.g., reduction of reactivity) without judgement, in order to mirror this process for people (e.g., attending to the breath, a here-and-now focus). There are also scripts for new clinicians and comprehensive assessment material that is applicable to anyone in therapy.

Principles of Trauma Therapy has a final, comprehensive directory of trauma-centered psychopharmacological interventions with content relative to psychobiology. This is extremely informative, but one has to question some of the research that was referenced. One concluding statement regarding the efficacy of selective serotonin re-uptake inhibitors (SSRIs) as antidepressant medication gave me pause. It was noted that SSRIs “have been found to be equally effective in reducing symptoms and improving quality of life across most clinical trials” for many diagnoses. The example reference was to a 2000 study comparing monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and some selective serotonin re-uptake inhibitors (SNRIs) for depression. [1] The citation did not match the broad sweeping claim as the study itself notes “clinically insignificant” differences in efficacy as well as tolerability between SSRIs. [1] Read this section with a grain of salt and consider newer research when determining the efficacy of medication for victims of trauma.

Despite the focus on the individual in this book, the reader is walked through the “victim variables”, “characteristics of the stressor”, and “social response and supports” that affect the outcome for the trauma victim, which forces a cultural vista. Briere and Scott implicitly connect to the fact that our society’s disenfranchised groups of individuals (e.g., people of color and in poverty) are much more susceptible to posttraumatic symptoms.

Trauma is no longer just a micro level problem, but an issue of social justice and equality. The book maps out the generational influences and cyclical effects of trauma. There is an “additive effect” of multiple traumatic events throughout one’s life. For example, a survivor of childhood abuse who has residual effects into adulthood will react with “especially severe, regressed, dissociated, or self-destructive responses to the adult trauma” (p. 22). Earlier treatment interventions are essential to desensitize these reactions to stress.

Briere and Scott provide a stylish blend of the metaphysical and tangible aspects of trauma. They do this with learned experience, academic research, and hope as a means to expose the wide-ranging consequences of trauma. If you are a clinician searching for an in-depth examination of the components, conceptualization, causal mechanisms and treatment of trauma, then Principles of Trauma Therapy is here to the rescue.

References:

  1. Mace, S. and Tayler, D. (2000). Selective serotonin reuptake inhibitors: a review of efficacy and tolerability in depression. Expert Opinion on Pharmacotherapy: 1(5). 917-933.
  2. Briere, John & Scott, Catherine. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment (2nd Edition). SAGE Publications, Inc; Second Edition – DSM-5 Update edition (March 26, 2014).

Corrective learning is a process that occurs when existing conceptions and beliefs are replaced by more adaptive ones. For individuals with anxiety, panic, and phobias, exposure therapy is a common form of treatment that aims to produce corrective learning.

During exposure therapy, individuals are exposed to things they fear or that threaten them. Because these situations or things are usually avoided as a result of anxiety, the theory behind exposure therapy posits that being confronted with the feared item or event in a controlled environment will allow the individual to realize that his or her fears surrounding that item or event will not be realized. It is also believed that the level of fear or anxiety that is experienced during the exposure directly predicts the level of reduction in anxiety at treatment outcome. In other words, the more fearful or anxious someone is during a session, the more he or she will be able to overcome that fear in the long run.

This theory has been tested at length. However, Alicia E. Meuret of the Department of Psychology at Southern Methodist University in Texas wanted to examine this further. In a recent study, Meuret assessed the physiological and emotional responses of 34 participants with agoraphobia and panic as they underwent either a cognitive behavioral or breathing-based exposure therapy. She found that the participants all experienced increases in panic and anxiety during the sessions, as evidenced by physiological markers and emotional responses, but that these increases did not lead to better outcomes. In fact, the more panicked and fearful the individuals were, the worse their treatment outcomes. Additionally, in contrast to existing research, Meuret found that symptom reduction during treatment did not predict treatment outcome. In other words, even if the individuals experienced spikes in treatment severity during exposure and then were able to reduce their anxiety as the session continued, this drop did not lead to better overall outcome.

It has been suggested that allowing a client to experience symptom reduction during exposure provides a sense of self-control and mastery for the client and accomplishment for the therapist. And although this may indeed be true, the reduction of symptoms after exposure does not seem necessary for treatment success. In fact, the treatment outcomes were similar for those who left sessions with symptoms that were elevated as well as with symptoms that were diminished. Meuret believes that these results contradict the theory that fear reactivity is an indicator of treatment outcome, although her study was limited by sample size and the fact most of the participants were well-educated white females. “More research is needed to examine the underlying mechanism of corrective learning during exposure across therapy types,” she said.

Reference:

  1. Meuret, Alicia E., Anke Seidel, Benjamin Rosenfield, Stefan G. Hofmann, and David Rosenfield. Does fear reactivity during exposure predict panic symptom reduction? Journal of Consulting and Clinical Psychology 80.5 (2012): 773-85. Print.

Woman with curly hair sitting on therapist's couch with head leaned on hand. Sitting next to her, a female therapist in a grey coat is listening and taking notes on a clipboard.Learning about the stages of healing can be distressing, motivating, upsetting, or uplifting. No matter how you feel, your reaction is not wrong. Acknowledging your emotional response to the stages of healing can allow you to harness your emotions’ energy and reach out to a trained therapist.

When looking for a therapist, it is vital to keep in mind that, regardless of what type of psychotherapy you pursue, your therapist should empower you and welcome you as a collaborator in your therapy, not attempt to impose control over you. Studies have found that individuals who are active participants in their therapy are more satisfied with the therapy. In addition, it is crucial that you feel safe in your therapeutic relationship.

There is no magical treatment that will heal you overnight, nor is there one form of psychotherapy that is right for everyone, but you should be able to find a therapist, as well as a therapeutic approach, that works for you. Healing is like a marathon. It requires preparation, repeated practice, courage, determination, and the support of others—including that of a professional coach or therapist.

While there are numerous therapy approaches, the purpose of all trauma-focused therapy is to integrate the traumatic event into your life, not subtract it. This article discusses the most common forms of trauma therapy. Each approach is described in its most pure form, but keep in mind that many therapists combine different types of therapies.

Pharmacotherapy

Pharmacotherapy is the use of medications to manage disruptive trauma reactions. Medications have been shown to be helpful with the following classes of reactions/symptoms:

Taking medication does not make one’s trauma reactions and pain evaporate. Medications can only help make the symptoms less intense and more manageable.

If you decide to use medications, consult a psychiatrist and continue working with that psychiatrist for as long as you take the medications. Inform the psychiatrist of how the medications are impacting you. Some medications have side effects that may or may not be tolerable to you, and some people do not respond favorably to medications. Medications are most effective when individuals pursue therapy concurrently.

Behavior Therapy

The most common form of behavior therapy is exposure. In exposure therapy, one gradually faces one’s fears–for example, the memories of a traumatic event–without the feared consequence occurring. Often, this exposure results in the individual learning that the fear or negative emotion is unwarranted, which in turn allows the fear to decrease.

Exposure therapy has been found to reduce anxiety and depression, improve social adjustment, and organize the trauma memory. There are various forms of exposure therapy:

Exposure therapy is a highly effective treatment for posttraumatic stress (PTSD).

Another form of behavior therapy is Stress Inoculation Training (SIT), also known as relaxation training. Stress Inoculation Training teaches individuals to manage stress and anxiety.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is grounded in the idea that an individual must correct and change incorrect thoughts and increase knowledge and skills. Common elements of cognitive behavioral therapy trauma therapy include:

Eye Movement Desensitization and Reprocessing (EMDR)

Therapists who perform EMDR first receive specialized training from an association such as the EMDR Institute or the EMDR International Association. An EMDR session follows a preset sequence of 8 steps, or phases. Treatment involves the person in therapy mentally focusing on the traumatic experience or negative thought while visually tracking a moving light or the therapist’s moving finger. Auditory tones may also be used in some cases. Debate regarding whether eye movements are truly necessary exists within the field of psychology, but the treatment has been shown to be highly effective for the alleviation and elimination of symptoms of trauma and other distress.

Hypnotherapy

There is no one guiding principal for hypnotherapy. In general, a hypnotherapist guides the individual in therapy into a hypnotic state, then engages the person in conversation or speaks to the person about certain key issue. Most hypnotherapists believe that the emotions and thoughts that an individual comes into contact with while under hypnosis are crucial to healing.

Psychodynamic Therapy

The goal of psychodynamic trauma therapy is to identify which phase of the traumatic response the individual is stuck in. Once this is discerned, the therapist can determine which aspects of the traumatic event interfere with the processing and integration of the trauma. Common elements of psychodynamic therapy include:

Group Therapy

There are a variety of different groups for trauma survivors. Some groups are led by therapists, others by peers. Some are educational, some focus on giving support, and other groups are therapeutic in nature. Groups are most effective when they occur in addition to individual therapy. It is important for a trauma survivor to choose a group that is in line with where one is in the healing journey:

Any therapist, regardless of which type of therapy she or he works from, desires to help you grow and heal through your traumatic experience.

Together, you and your therapist will strive to acknowledge and identify:

As always, reach out for help and know that you do not need to go it alone.

Reference:

  1. What is the actual EMDR Therapy session like? (n.d.). Retrieved from http://www.emdrresearchfoundation.org/for-the-public/what-is-the-actual-emdr-therapy-session-like
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