What Is ERP for OCD and Why It Works for Kids
One of the questions I get asked a lot in therapy, and honestly one of the first things I talk about with families experiencing OCD, is “What is ERP for OCD?”
In this post, I’m going to explain ERP (Exposure and Response Prevention) therapy exactly how I describe it to clients in my office. I’m also going to use two analogies to help make sense of what is going on in the brain during OCD treatment.
The Tarantula Analogy, How Exposure Works
Let’s say I start dating someone who has a pet tarantula. I’m absolutely terrified of spiders, but for some reason, I have to get to a place where I can live with this tarantula.
One way I could try to do this is by locking myself in a room with the tarantula for a few hours. If you came back in three or four hours, do you think I would be more or less calm? The answer is definitely less calm.
That approach is called flooding, and it doesn’t work. It’s not something we would ever do, not in real life and not in ERP treatment, because we know it overwhelms the brain and doesn’t create lasting change.
What we do instead is create a hierarchy or an exposure ladder. So, using the tarantula example, I might first go and look at pictures of cute spiders, then pictures of real spiders. After that, I might watch YouTube videos of cute, animated, funny spiders, then move on to watching YouTube videos of real spiders. Next, I might go into the room and look at the tarantula in its cage. From there, I might use that social media filter where the tarantula crawls across your face, and eventually, I would work up to being able to touch or hold the tarantula.
By doing this, I slowly acclimate or get myself used to thinking about spiders in a way where I’m able to manage my fear. That’s the exposure part of ERP.
The Puppy Analogy, How Compulsions Get Reinforced
Another way I explain what’s happening in OCD is through a puppy analogy.
Let’s say I get a new puppy. Every time I come in through the garage door, the puppy runs and jumps on me. In all of my infinite wisdom, I decide that if I keep treats in my car or right outside of the garage door, I can throw the treat across the room as soon as I come in the door and the puppy will run and get it.
Will that work? Yes! For most dogs, they will go chase they treat and not jump on me. But the problem is then we have conditioned the dog that in order to not jump on us, it needs a treat.
If we then decide that we want the dog to not jump but to sit and wait for the treat- we can do it! However, at first, the dog is going to actually try to jump on us more because it’s going to do everything in its power to get that treat (called an extinction burst). But if we persist, we are able to eventually teach the dog to sit and stay and wait for the treat and not jump on us in order to get it.
This is called positive reinforcement, which we know is the strongest kind of operant conditioning (think Pavlov’s dogs). The teaching the dog to sit and wait and not jump- that’s like the response prevention part of OCD.
How This Relates to OCD and ERP
This is very similar to what happens in OCD. OCD sets off an alarm and says, “What if something bad happens? What if I did something wrong? What if_______?”
OCD makes someone have a thought and it makes them feel icky and of course, they don’t like that feeling, so they do something to make it go away. That might be checking, washing, asking for reassurance, or doing a ritual. In other words, throwing the dog a treat.
And it works. It does make OCD go away…for a few seconds….minutes…or maybe hours. But soon enough, OCD is back, wanting another treat.
The goal of ERP therapy is to teach OCD to sit and stay and realize it doesn’t need a treat at all. By doing the ritual or compulsion, or providing reassurance to the person, we are validating the brain that those scary what ifs are actually real/possible. But we know those compulsions or reassurance don’t actually prevent the scary thing from happening, and so, we can expose ourself to the scary thought and not do the compulsion and by doing so teach our brain that our scary thought is really just a false alarm and we can ignore it!
Putting It All Together
Hopefully, these two analogies help you understand that the exposure part of ERP means creating a hierarchy and slowly working through it to get used to the hard thing. The response prevention part means not giving OCD the treat it wants.
More simply put, OCD gives me a thought, usually with some kind of “what if” attached, which makes me feel icky. Because I feel icky, I do something to make that icky feeling go away. That works for a little while, but then the cycle starts again. ERP interrupts this cycle by not doing the something to make the icky feeling go away, but in a gradual, purposeful, and controlled manner.
Making ERP Work for Kids
ERP works, but it isn’t always fun. When we are doing ERP with kids, we try to find ways to make it fun, make it a game, or build in external motivators. Fighting back against worry thoughts is hard, and some of the thoughts kids have are really scary.
Furthermore, in almost every OCD case, parents are providing some form of reassurance.
Now, while reassurance isn’t helpful in the context of OCD, I always tell parents that every form of reassurance I’ve seen started as good parenting. For example, if you have a child who is afraid of the dark and you check under the bed, peek in the closet, or label a bottle of air freshener as “Monster Away Spray,” that’s adaptive and works when they’re three. But when they’re thirteen, it’s no longer helpful, and it actually reinforces the fear.
Reassurance starts off good, but over time it ends up reinforcing the very thing we’re trying to reduce. That’s why one of the things we assess during intake is whether both the parents and the child are ready to fight back against OCD and make changes.
Sometimes families don’t have the bandwidth to fully commit to ERP because it requires time and consistency outside of session and that’s ok. We know that when kids and families do ERP practice daily, they get better. ERP really does bring relief to both children and families.
Final Thoughts
ERP therapy for kids is one of the most effective, evidence-based treatments for OCD. It helps children learn that they can handle icky feelings and that OCD doesn’t have to run the show.
If you’re looking for OCD child therapy in Indianapolis or want to learn more about exposure therapy for children, our team at Indy Child Therapist specializes in helping kids and families face fears with confidence.