The answer is, it might. But it is not the Exposure and Response Prevention (ERP) itself, rather is a result of unfavorable conditions or inappropriate applications.
Briefly, ERP methodically exposes individuals to anxiety-provoking stimuli while preventing safety behaviors. ERP helps to retrain the brain and reduce distress with repetitive practice.
I would say that most people have a least some reservations about trying the treatment called exposure and response prevention (ERP). There is evidence that as many as one in five will refuse to do it.[1] I have seen other articles suggesting even higher refusal rates. If you search on the topic, you can find professionals and clients who object to it.
I get it. I have treated hundreds of people and I have never met anyone who was excited about it. However, exposure and Response Prevention (ERP) is widely regarded as the most effective treatment for OCD, emetophobia and other anxiety-related conditions. If it is done correctly with favorable conditions, it can change your life.
So what are the conditions that would suggest ERP is not advisable?
Using it on the wrong problem
ERP should only be used for anxiety disorders. Anxiety disorders involve exaggerated cognitive distortions and the exposure process provides a correction to the error(s). It disconfirms the threat because the threat is inaccurate in some way. Additionally, It helps change dysfunctional expectations of the threat. Other types of problems with different dysfunctional beliefs that do not involve “overestimating threats” that are “reinforced by avoidance and safety behaviors” will not respond successfully and may even get worse like anger, addiction, depression, mood disorders, etc. It is contraindicated for anything but anxiety disorders.[2]
Not enough time
For emetophobia, assuming moderate to high anxiety, the bare minimum of sessions using ERP is approximately 15 or more. This is probably a minimum for OCD and other anxiety disorders as well. If the number of sessions is limited by insurance (private or national), finances or stopping treatment too soon, ERP is less likely to be effective and maybe counterproductive. ERP requires repetition, variability (e.g., time, stimuli used, situations, etc.) and motivation. If the exposure is too intense, patients will not continue. If there is no time to add in variability, even if the specific exposures are effective, the impact will not generalize. For example, if you are afraid of elevators, you have to be exposed to multiple elevators for treatment to be successful. Although some simple phobias can be treated within a few hours, that is virtually never the case with emetophobia, OCD, Panic disorder, etc.
Recently I was made aware of how, in a particular national healthcare system, ERP has gotten a very negative reputation in that country. This is especially true for those with emetophobia. In this particular system, CBT sessions are limited to 6 – 8 sessions. With any anxiety disorder, except for some specific phobias, this is completely untenable. I would imagine it would go something like this. One or two sessions to get the necessary background, explain the process, and provide enough psychoeducation for someone to be willing to even agree and somewhat understand ERP. That leaves 4 – 6 sessions. Then the provider has to make a decision. If one starts with less challenging exposures you won’t have time to make progress. If the provider decides the most headway will be gained by higher challenge exposures then it gets very intense, very quickly. In my experience, virtually no one will go home and practice that. Because the outcome desired is enough evidence to disconfirm the threat, this approach could have the opposite effect. Instead of disconfirming the danger, it might in fact, seem to prove the danger. If there is not enough time to even touch a normal hierarchy and the exposure cannot be repeated enough, it could backfire.
Unrealistic Expectations
You may not realize your expectations until you are surprised by them not being met. ERP may take longer and be harder than expected (way more than 6 sessions). Some individuals may expect ERP to “cure” their anxiety disorder quickly or eliminate the symptoms entirely. When this doesn’t happen, they may feel discouraged and stop treatment. It is more accurate to think of treatment as mastering a new set of skills rather than being “cured.” Like any other skill to be mastered, it takes time, persistence and practice/repetition. Be open to not knowing exactly what to expect, which is, of course, very hard when you are anxious. Ask questions. You need to understand the process as much as possible.
Lack of Motivation or Engagement
I have seen well over 150 patients with emetophobia. What I write next, I mean literally, NO ONE wants to do exposures. What people want it to be less afraid and not be dominated by this phobia. The irony of being anxious on purpose in order to become less anxious is not lost on patients. This takes some serious determination. ERP requires active participation and effort, which can be daunting for individuals who are severely anxious or uncertain about the process. If someone is not motivated or does not fully engage in the treatment, progress may stall. A crucial element for anyone considering ERP is this: You are anxious anyway. ERP, done well, will be a matter of scheduling the anxiety in a fairly predictable manner and at levels the patient is will to tolerate as well as practicing different responses. All anxiety disorders are marked by difficulty with uncertainty. That means the treatment will feel risky. A willingness to accept the world as it is, with it risks, is part of how this is successfully treated.
Co-Occurring Conditions
There are other mental health issues that may need to be treated first like major depression. Major depression will certainly impact motivation and depending on severity must be substantially resolved before starting ERP. Neurodivergence can complicate ERP. While ERP can still be effective, it may require much more time, repletion, and variability. ADHD can complicate ERP in various ways. It won’t necessarily impact the effectiveness or ERP but issues such as consistent practice can be problematic. More than one type of anxiety disorder can add complexity. I have, on occasion, treated other phobias by going back and forth from one set of exposures to another, it is definitely preferable to work on one at a time. If there are signficant co-occurring problems, it may be imperative to address the other conditions first so they don’t interfere with ERP.
Inadequate Therapeutic Support
Not all therapists are equally trained or experienced in delivering ERP. Poorly structured sessions, inadequate support during exposures, or lack of personalization in treatment can limit its effectiveness. Of the most frequent examples of previous unsuccessful ERP attempts I have heard from clients, especially with emetophobia, the provider introduced exposures that were too intense, too soon. Many therapists struggle with the idea of making clients anxious on purpose. I certainly worried about that as I began to implement ERP as part of my practice. If ERP is too tentative it will be slow going indeed.
Severe Anxiety or Trauma History
For individuals with a history of trauma or extremely high levels of anxiety, ERP may feel intolerable or re-traumatizing. This can make it difficult for them to fully engage in exposures. A medical referral may be necessary in order to reduce the level of anxiety to the point it can be practiced and tolerated. ERP will likely still be part of their treatment but may need to be approached using much less challenging triggers.
Cognitive Rigidity or Insight Challenges
Some individuals with anxiety disorders may struggle with poor insight or cognitive rigidity, making it difficult for them to understand or accept the rationale behind ERP. This is especially true for individuals with severe anxiety or those who believe their compulsions are substantially justified. Thinking compulsions are justified may be factors for OCD and emetophobia. It is not uncommon for people with emetophobia to believe their safety behaviors have been the main reason they have not gotten sick.
Lack of Family or Social Support
A lack of support from family or a hostile home environment can hinder ERP progress. For example, if family members accommodate compulsions or criticize the individual’s struggles, it may interfere with or reinforce the disorder.
Therapeutic Plateau or Resistance
Some individuals may see initial progress with ERP but hit a plateau where further improvement becomes difficult. Resistance to certain exposures or avoidance of specific triggers is usually the reason. These are strongly applied safety behaviors. It is quite common (mostly adults) to stop treatment after some helpful improvement because things are not as bad. This is usually not a good plan because the anxiety is more likely to return.
Conclusion
While ERP is a powerful tool for managing OCD, it is not a one-size-fits-all solution. When ERP doesn’t work, it often points to the need for adjustments in the treatment plan or additional support for the individual. With proper assessment, expert guidance, and a willingness to adapt, most barriers to ERP success can be overcome.
[1] Ong, C. W., Clyde, J. W., Bluett, E. J., Levin, M. E., & Twohig, M. P. (2016). Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say?. Journal of anxiety disorders, 40, 8–17. https://doi.org/10.1016/j.janxdis.2016.03.006
[2] Abramowitz J. S. (2013). The practice of exposure therapy: relevance of cognitive-behavioral theory and extinction theory. Behavior therapy, 44(4), 548–558. https://doi.org/10.1016/j.beth.2013.03.003
David Russ