Exposure Response Prevention (ERP) Therapy is the most effective treatment for Obsessive-Compulsive Disorder (OCD), and it can also be an incredibly effective treatment for anxiety disorders. ERP is a behavioral intervention, and it's something that Jenna Overbaugh is hugely passionate about. I came across Jenna’s Instagram a while back and I was blown away by the insight and knowledge that she shares, and you can truly feel her passion for helping people who are struggling with OCD and anxiety.
Jenna is a mom and a therapist at NOCD. NOCD is an organization that provides telehealth services for people struggling with OCD and related conditions. Jenna loves helping people face their fear and build self-confidence. She values educating her clients, and also giving them the tools they need to manage their recovery independently. Jenna has also personally struggled with anxiety and OCD, and she shares some of her personal experience in this episode, along with lots of helpful tips and tools for OCD and anxiety recovery!
JENNA’S PERSONAL EXPERIENCE WITH ANXIETY & OCD
Jenna shares that she remembers struggling with feelings of anxiety as a young girl, mostly in social situations. And when she was in college, the anxiety she experienced was more academically driven. Jenna is very open and shares that she’s still an anxious person today, but that you probably wouldn’t know it seeing or speaking to her. She often doubts herself and has a lot going on in her mind.
Jenna shares that when she had her son, things became more severe and impairing. She began struggling with postpartum OCD and struggled specifically with harm intrusive thoughts, sexual intrusive thoughts, and some contamination fears. And it got to the point where she was so afraid that she had hurt her son unknowingly, that she would get up sometimes multiple times in the middle of the night to check on him. Jenna went through her own treatment and went through ERP as a sufferer. She shares that it's made her such a more compassionate therapist, and that it's made her more equipped to help herself personally and others.
WHAT IS ERP?
ERP is the gold standard treatment for OCD, anxiety, and related conditions (conditions such as hoarding). ERP works really well for other anxiety disorders like social anxiety, phobias, and generalized anxiety disorder. ERP is seen as a two part solution for a two part problem. With OCD you have obsessions and compulsions. The obsessions are the recurring and intrusive experiences, and the compulsions are the safety or compensatory behaviors that someone feels a drive or an urgency to do in order to feel better. And the compulsions negatively reinforce the obsession for next time. They temporarily make you feel better, but end up making you feel worse in the long run.
ERP involves exposure and response prevention (or ritual prevention). With ERP, you work with a therapist to do exposures, which are things that you do intentionally to face your fears. Jenna gives the example of when she was struggling with postpartum OCD and she’d wake up in the middle of the night and have the thought of… What if I hit my son and I don’t remember? She shares that exposure and response prevention look like staying in her bed and resisting checking on her son. And part of her exposure also involved looking at images of children with bruises. The response prevention piece is so important because it’s not just about facing your fears, it’s also about facing your fears and not following it up with a ritual that may make you temporarily feel better. It’s about teaching yourself that you can tolerate the emotions and move forward without doing the rituals.
WHERE DO YOU START WITH ERP?
Jenna shares that ERP truly starts with psychoeducation. It’s becoming aware of and learning what’s going on. It’s learning why you feel the need to do what you need to do, and why it makes you feel better in the moment, and why it’s making you feel worse, and why you need to do this thing instead. The therapist conducting ERP often wears a teacher hat because they are teaching the individual how to eventually learn to be their own therapist, and learn how to create their own exposures and generate their own list of triggers.
The next step is self-monitoring. This step encourages the individual, while in the moment, to write down their triggers either in a journal or on their phone. Jenna shares that triggers for her looked like driving with her baby, getting ready for bed (because this is the time she’d often have intrusive thoughts about her baby), or scratches or marks on her baby. And triggers will look different for everyone, even if you’re struggling with similar things. Another important note is that exposures are specific to the individual, your triggers, and goals, so exposures will look different for everyone.
The next piece of self-monitoring is to write down what your compulsions or rituals are. What are the things you feel the need or urgency to do? Is it checking? Is it going back and replaying things? Is it asking my partner for reassurance? Is it asking somebody to do the thing for me that I don’t want to do? Is it avoiding? Once you’ve identified your triggers and rituals, you can find a place to start with doing exposures. Jenna gives the example of an exposure for her being driving with her son. And she shares that when starting, the exposure didn’t have to look like driving 30 minutes on the highway with him, or driving in busy places. Instead, it could look like driving around the block, or pulling out of the driveway, or putting him into the carseat and then taking him out of the carseat and going back into the house.
As Jenna says, “There’s always a way to water down these exposures and to do it in a way that’s not blowing you out of the water, and having you do something that’s totally out of your comfort zone and a 10 out of 10.”
IS ERP USED FOR PANIC DISORDER OR AGORAPHOBIA?
Jenna shares that ERP is in fact helpful for panic disorder and agoraphobia. She explains that when treating people for OCD, it’s rarely just OCD that someone is struggling with. And typically whether you’re struggling with OCD or panic, you have a fear of fear. She shares that if she thinks somebody might benefit from ERP therapy, she takes them through the anxiety sensitivity index, which is a questionnaire that asks you questions like… Do you get nervous when you start to sweat? Do you get nervous when you start to feel your heartbeat racing? How do you feel when you’re nervous in a public place? This questionnaire helps the client and their clinician to identify to what extent the individual has anxiety sensitivity (or a fear of fear).
We all experience anxiety, and of course we’d all prefer to feel good, clear, with it, and comfortable, but the reality is that we do experience these things sometimes and we can’t prevent these sensations all the time. But what we can do is prevent our suffering with it, and we can prevent the exacerbation that we often contribute to the initial problem. Jenna shares that she often introduces interoceptives after psychoeducation and after some successful exposures, and these are essentially body exposures.
Interoceptives are intentionally evoking the uncomfortable physiological sensations like dizziness. For example, Jenna may have somebody spin in a chair and then sit with the uncomfortable feeling and then rate how uncomfortable it is and how much they don’t like the sensation. And the goal isn’t to spin in the chair and not feel dizzy. The goal is to spin in the chair and not freak out and have your whole world come to an end in that moment because you feel dizzy. Or if you fear feeling short of breath, she may have you run in place for thirty seconds or breathe through a straw.
And the first few times you do this exercise, you may rate the sensations you experience as a six or seven, and then you do it a couple of more times and it’s a five, and then you do it a couple of more times and it’s a four or a three. And the intent isn’t to get down to a zero, but the intent is to get to the point where you feel like… Okay, this isn’t so terrible, I can move on with my life. And there’s also the inhibitory learning process which looks like… Okay, that was uncomfortable and it didn’t last forever. That was uncomfortable and I didn’t die. That was uncomfortable and I still got through it. And you can also pair interoceptives with other exposures.
WHAT ELSE CAN OCD LOOK LIKE?
Jenna shares that the real monster of OCD is doubt. It’s not about contamination, or your baby, or your sexual orientation, or your relationship… So much emphasis gets put on the content being the problem, when the real problem is the intolerance of uncertainty and doubt. OCD often bounces from theme to theme, kind of like whack a mole. One month it’s their relationship relationship they’re worried about, and then all of a sudden it’s their sexual orientation, and then it’s contamination because of COVID. And it makes sense that it bounces because it was never the superficial content areas to begin with, it was always about doubt and the need for certainty and intolerance for discomfort.
OCD latches onto whatever you find value in, or whatever you’re not able to accept certainty about. Jenna shares, “I accept the uncertainty. I know that every time I get into the car it’s not a one hundred percent guarantee. I accept that. I hope nothing happens, of course. And I also accept that just because something is possible doesn’t mean it’s probable. I roll those dice because it’s of my value to go and get my child from daycare, to have autonomy, to get my own groceries, to go to work, and do whatever I need to do. The risk is not greater than the reward.” But Jenna is very honest and she shares that with her son, there were many times that she thought that the stakes were just too high, and that she wasn’t going to tolerate the uncertainty. But it’s important to remember that wherever you are not tolerating uncertainty, that’s what OCD will latch onto. She again emphasizes that the big monster with OCD is doubt.
Jenna shares that although ERP is the gold standard treatment for OCD, nothing is perfect and there is always an exception to the rule. She shares that there are people who are treatment non-responsive, and also people who are treatment resistant. Treatment non-responsive are people who do everything and everything is right, and the clinician believes to the best of their ability that they’ve tried everything they can, and the client is trying everything that they can and they’re just not responding to treatment. And in this scenario, the clinician may recommend a higher level of care, or TMS, or some other invasive type of treatment, or a medication change.
Treatment resistant are people who could probably make progress but they just aren’t there yet. They aren’t motivated, or they’re actively resistant in treatment. But Jenna shares that with the grand majority of individuals, ERP can work especially if you find the right therapist fit.
Jenna shares some beautiful client success stories. I recommend tuning into the full episode to listen!
IF YOU’RE WANTING MORE INFO ON ERP, OR TO GIVE IT A SHOT…
If you have OCD or an anxiety disorder, it’s so important that you find somebody who is knowledgeable, trained, and has experience in exposure and response prevention. ERP is under the CBT umbrella, but just because a therapist does CBT doesn’t mean that they know how to do ERP. And just because somebody says that they work with people who have OCD, it doesn’t mean that they are qualified to teach ERP. It’s so important to find somebody that knows, understands, and is knowledgeable about ERP.
And if you’re unsure if somebody is qualified, ask the therapist questions! Questions like… How long have you been working with this community? What is your level of experience working with people who have OCD? What can I expect from you as you from my therapist doing ERP? Because If you don’t get ERP, not only can it be unhelpful and keep you stagnant, it might actually be detrimental.
NOCD - All therapists are trained and specialize in OCD treatments.
iOCDf.org - International OCD Foundation with lots of helpful resources.
Psychologytoday.com - You can find a therapist who specializes in OCD treatment.
And advocate for yourself to get the best treatment for you!
HOW TO CONNECT WITH JENNA:
Podcast, therapy services, resources, all the things: jennaoverbaugh.com
On Instagram: @jenna.overbaugh