Do you ever wonder what the difference is between desensitization and ERP? What we are trying to teach a client with a phobia or OCD about this confusing topic?
Recently we received a question from a therapist new to CBT with ERP that is worth pursuing a little further.
Here is the question: “I’m wondering if you can help me understand the difference between a goal of desensitization to phobias or OCD and a goal of using exposure and response prevention (ERP) to learn a new lesson about phobias or OCD. They feel very similar to me. Is the difference really in the depths you are going? Does desensitization focus on the trigger? “
We thought this was a great question and here are both of our answers:
Elizabeth DuPont Spencer:
With ERP, we ask our clients to do the trigger activity, and stay with it. Usually, anxiety falls, but that isn’t the point. The point is for them not to do the response (compulsion for OCD, or avoidance for anxiety). By doing exposures, clients teach their brains that they can tolerate anxiety, whenever it appears and whatever the trigger may be. This is a new way of thinking about something that generally takes up a lot of time and attention prior to therapy. Anxious worry, obsession and avoidance can dominate the time and attention of someone suffering from anxiety. As clients do exposures they learn to pay less attention to the anxiety topic and they are also working to increase attention to things that are important in life that they choose to spend time with.
People with anxiety can have spontaneous panic or new phobias because our brains just trigger easily. It’s not a huge problem once we learn that we can tolerate the anxious feeling. By not adding to our distress with a lot of distorted thoughts like “oh no, I can’t take this” or, “darn it all, here it is again,” the anxious feelings move on, stop being so upsetting, and generally take up less space in our brains. We can also generalize this learning across many different triggering situations without having to work on each one separately.
When we used to work towards desensitization, we were looking for anxiety to go away after many ERP sessions of the triggering event. Since for any anxious person there may be multiple triggering topics, desensitization to each can take a long time. Additionally, we now know that desensitization isn’t always possible. Sometimes our clients become desensitized, and sometimes they don’t. We frustrate our clients if we hold out desensitization as the ultimate goal, and it’s not necessary to live a rich, full life, which is the goal of CBT with ERP.
You are correct, that desensitization focuses on the trigger. ERP focuses on the fear. So, for example, you may have an obsession trigger about heights but your fear is not that you will fall, the fear is that you could push someone else over. This leads to a compulsion not to be near heights with someone else or to engage in safety behaviors. Someone with this type of obsession may also have fears of harming others in different trigger situations like walking by the water and pushing someone in. To avoid that fear trigger, they might obey the compulsion not to be in those situations. Just as important as changing the focus from the trigger to the fear, ERP helps you strengthen anxiety tolerance so you can apply this skill to any triggering situation. For that person with the trigger about heights, then, you do not want to desensitize to heights, you want to learn to tolerate your thoughts about harming someone when you are up high or near the water and tolerate the accompanying anxiety without engaging in avoidance or safety behaviors.