Corntney Modelewski, MA, LLPC, an active member of SMEDA and a Kalamazoo therapist that specializes in Cognitive Behavioral Therapy and DBT. She has written this months blog article on Exposure and Response Prevention (ERP). http://www.southwestmichiganeatingdisorders.org/directory/
Exposure and Response Prevention (ERP) is a therapy for Obsessive Compulsive Disorder (OCD) that requires being in the presence of something that causes fear – exposure – and not avoiding the feared situation – response prevention. It can also be used during eating disorder treatment, with growing research to support its use in Anorexia Nervosa and Bulimia Nervosa. For example, in 2011 the International Journal of Eating Disorders published an article about data support ERP use to aid in weight restoration, fear of eating, learning to tolerate fear, and relapse prevention in those with Anorexia Nervosa when used as part of a treatment plan.
With a licensed mental health therapist, a list called a hierarchy is made up of feared situations to be used as exposure tasks. Distress ratings on a scale of 0 – 100, called Subjective Units of Distress (SUD), are included on the hierarchy as well. The hierarchy gives the frame for treatment.
As an example...
Feared Situation SUD (0-100)
Skip one day of exercise 55
Eat at a Chinese buffet restaurant 95
Have friends over for dinner and eat in front of them 100
Walk through a grocery store without buying anything 35
Fill pantry with canned food 70
Eat apples with therapist 60
It's common for individuals to have more than one mental health concern, especially anxiety or OCD. It helps to treat eating disorders and anxiety at the same time when doing ERP. Kind of like killing two birds with one stone.
As an example...
Anorexia and OCD with Contamination Fear Hierarchy
Feared Situation SUD (0-100)
Eat sucker that has touched a grocery cart seat 70
Hold a raw steak for five minutes before cooking 75
Eat a bag of M&Ms off of therapist's office floor 30
Eat an egg salad sandwich in the bathroom at home 45
Play with neighbor's dogs, eat meal without washing hands afterwards 80
Treatment structure will look like this:
- One hour weekly appointments for 14 – 16 weeks.
- Agreeing to one-half to two hours per day working on exposure tasks outside of session.
- Getting hands-on help from the therapist to show how to complete the exposure tasks and prevent the person from trying to avoid fear.
- Time to talk about feelings with the therapist after exposure tasks.
- Exposure tasks outside of sessions may include help from friends, family, or members of the treatment team.
- Tracking distress on a sheet of paper, including lessons learned from the activity, and other homework as assigned by the therapist and other treatment team members.
- Repeating exposure tasks until SUDs go down.
To sum it up, ERP is a process that addresses fears unique to the individual's needs. One of ERP's main goals is to help people learn skills to use when therapy is complete and encourage people to use their own ERP as needed. In other words, ERP is to help people with eating disorders to become their own ERP therapist.
Recommended YouTube video:
Sources: (Many of these sources can be found in PubMed.)
Foa, Edna B., Elna Yadin, and Tracey K. Lichner. Exposure and Response (ritual) Prevention for Obsessive-compulsive Disorder: Therapist Guide. Oxford: Oxford UP, 2012. Print.
(Exposure and Response/Ritual Prevention for Obsessive-Compulsive Disorder: Therapist Guide, Edna Foa, Elna Yadin, and Tracey K Lichner, 2012)
Simpson, H. B., et al. (2013). Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders. Cognitive Behaviour Therapy, 42(1), 64-76. doi:10.1080/16506073.2012.751124
(Treatment of Obsessive-Compulsive Disorder Complicated by Comorbid Eating Disorders, Cognitive Behaviour Therapy, 2013, Simpson, et al)
Steinglass, J. E., Sysko, R., Glasofer, D., Albano, A. M., Simpson, H. B. and Walsh, B. T. (2011), Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. Int. J. Eat. Disord., 44: 134–141. doi:10.1002/eat.20784
(Rationale for the Application of Exposure and Response Prevention to the Treatment of Anorexia Nervosa, International Journal of Eating Disorders, 2011, Steinglass et al)
Toro, J., Cervera, M., Feliu, M., Garriga, N., Jou, M., Martinez, E., & Toro, E. (2003). Cue exposure in the treatment of resistant bulimia nervosa. International Journal of Eating Disorders, 34(2), 227-234. doi:10.1002/eat.10186
(Cue Exposure in the Treatment of Resistant Bulimia Nervosa, International Journal of Eating Disorders, 2003, Toro, et al)