As I wrote in a previous post, exposure and response prevention (ERP) is considered the most effective psychological treatment for anxiety disorders. However, there are certain conditions and incorrect applications that can render it less effective or inadvisable. Following are several of those conditions.
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.
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