While exposure therapy for OCD can be very effective, it is not uncommon for people to quit treatment because they are unwilling to experience the intense distress that can accompany an exposure exercise. In addition, and perhaps more importantly, many people do not fully understand the rationale behind exposure-based treatments, and thus have trouble sticking with it when things get tough. Education that helps people understand exposure therapy can help improve its chance of success rate. This article discusses how exposure therapy can be used to treat OCD, including how it works and how effective it can be.
Why Exposure Works for OCD
In exposure-based therapy, a trained therapist or counselor works with the person with OCD to expose them to the object of their fear, either by imagining it or through real-world exposure, and then changing the response to that stimulus. This treatment is formally known as exposure and response prevention (ERP), and it is a type of cognitive behavioral therapy (CBT). In ERP, the focus is on facing fears while preventing compulsive behavior that is usually used to alleviate feelings of anxiety. A healthcare provider can help refer you to a therapist who is trained in this method.
Habituation in Exposure Therapy
Exposure-based treatments take advantage of a natural process called habituation. Habituation occurs when a person stops responding or paying attention to a stimulus, such as a thought, object, place, person or action, with repeated exposure. Everyday life is full of examples of habituation. For instance, when people first move to a new neighborhood, they may be aggravated by the noise of a busy highway that runs near their house. However, with each passing day, the noise from the highway fades into the background until it is no longer even noticed. In this example, the person has become habituated to the sound of the highway.
Avoidance Reinforces Fear
At the same time, exposure-based therapies reduce avoidance, which reinforces fearful thoughts. This is important because avoiding things we are afraid of sends a very powerful message to our brains that there really is good reason for our fear and that we do not have the skills to cope with it. Let’s look at a practical example to see how exposure works to promote habituation.
An Example of Avoidance
Imagine that you have a fear of dogs. Now picture yourself on a sidewalk as someone approaches you with their dog. As the dog approaches your anxiety will start to rise. If you run away, your anxiety will subside immediately—but you will be teaching yourself that you cannot handle dogs, that the distress dogs cause you is intolerable, and that avoidance is the only way to stay safe. Avoidance would keep you stuck being afraid of dogs forever, as you would never get a chance to unlearn this fear and challenge these beliefs.
An Example of Habituation
On the other hand, if you did not run away but instead let the dog come up to you, your anxiety would likely get higher than you are used to for longer than you are used to. However, with time, and provided the likely possibility that the dog did not bite you, your anxiety would decrease through the natural process of habituation. If you met this dog on the sidewalk every day for a month without incident, your brain would continue to unlearn its fear of dogs and your level of anxiety would decrease. At the same time, what distress you did experience would disappear more and more quickly. Eventually, you would feel no distress at all when encountering the dog. You might even enjoy spending time with him. In short, you would be habituated to the dog.
Habituation and Exposure in OCD Treatment
Exposure exercises in behavior therapy for OCD operate on the same principles as those in the above example. Essentially, patients are exposed to feared objects, such as a contaminated door handle or difficult thoughts, like a loved one dying in a car crash, over and over again until their anxiety has decreased. People who have OCD are prevented from engaging in rituals or compulsions during the exposure. Rituals are a form of avoidance that prevent you from unlearning your fear and realizing that you can, in fact, cope with the anxiety caused by obsessions.
Effectiveness of Exposure Therapy
Obsessive compulsive disorder is usually treated with medication, psychotherapy, or both. Each person’s specific treatment plan will vary based on their needs, but evidence suggests that exposure-based treatments can be helpful for many. According to a 2019 research review, ERP is one of the most effective types of treatment for obsessive compulsive disorder. Some randomized controlled trials indicate that it is equally or even more effective than selective serotonin reuptake inhibitors (SSRIs, a medication that may be prescribed for anxiety or depression). The National Institute of Mental Health notes that exposure and response prevention can be effective in reducing compulsive behaviors in OCD, even among those who do not wish to take medication. However, around half of people do not show improvement, and between a quarter and a third drop out of treatment early. This may be due, in part, to the nature and severity of OCD symptoms. Those with less severe symptoms appear to benefit from exposure treatments more than those with more severe symptoms.
Alternatives to Exposure Therapy
People who cannot tolerate exposure therapy or for whom it is not effective may need different treatment for OCD. This might include medication, cognitive-behavioral therapy, acceptance and commitment therapy, or a combination of these.
A Word From Verywell
Exposure requires you to tolerate your anxiety being higher than you are used to for longer than you are used to. However, once this short-term discomfort passes, in the long term your fear will subside and you will no longer need to engage in the rituals or avoidance that dominate your life. Exposure-based therapies offer an effective way to reduce symptoms of OCD, but they require patience and you have to be willing to give them a chance to work.
