Anxious Parenting Practicalities Part 1/10: Exposure Response Prevention Exercises and Kids
Spoiler alert: if you already know what ERP is and just want to get to the part about using ERP when you have kids, skip down to the heading about ERP and kids...if not, read on!
Exposure Response Prevention therapy (ERP) is a common therapeutic method for people with OCD. You can read about it in-depth here, but for the purposes of this post, I'm just going to briefly summarize what ERP is, and how it works:
Essentially, ERP is a system of exercises that helps you purposely expose yourself to the triggers of your obsessions (hence the 'exposure' part of ERP) while intentionally resisting the urge to avoid the trigger or perform compulsions (hence the 'response prevention' part of ERP). The goal of ERP is to remain exposed to a trigger until both the trigger itself and the obsessions/compulsions it causes fade in duration and intensity (in psychological terms, this is referred to as a drop in anxiety, or 'habituation'). ERP is generally conducted with a therapist at first, but over time, patients can learn to conduct exposures safely on their own. That's the route I took, and it's what I recommend to anyone looking to try ERP.
Now, before you go harbouring images of ERP as some sort of Fear Factor reboot (read this if you don't get that reference), let me also explain a key component of ERP: the exposure hierarchy. Basically, an exposure hierarchy is a list you make using a personal trigger and a SUD scale. SUD stands for Subjective Units of Discomfort, and it's nothing more than a rating system for the level of fear and discomfort a trigger causes. For example, if contamination is a trigger for you, you might have some scenarios - say, touching a public elevator button - that rank at 40 out of 100 on your SUD scale. Comparatively, you might have other triggers - say, touching a faucet lever on a public bathroom sink - that rank at a 95 on your SUD scale. The higher the SUD rating, the higher your level of fear and anxiety. For most people, anything that ranks at 25 and under is nothing more than day-to-day stress and discomfort. 30 - 50 are things that warrant your attention, but are not cause for panic. Anything from 80 onward represents a significant challenge that could potentially derail your ability to function, and anything over 95 is likely panic-inducing. Here's an example of a SUD scale I used to confront my obsessions around heights:
Standing at the edge of a cliff – 100
Walking on a narrow hiking trail with a steep drop-off to one side – 95
Standing at the edge of a ten-metre diving platform – 90
Zip-lining – 85
Leaning on the rail of an outdoor balcony at a high-rise build- ing – 80
Walking on the roof of a house – 75
Standing on the top rung of a stepladder – 60
Climbing at a rock-climbing gym – 50
Crossing wooden bridges on hiking trails – 40
Walking on high climbers at parks – 30
Climbing the first one or two branches of a tree – 20
Standing at the top of a big staircase – 10
The reason you create an exposure hierarchy is simple: you can't start ERP with your worst trigger. It's like trying to scale a mountain face with no training, or trying to teach your twin two year-olds to move eggs from one carton to the other without help; it simply won't work (apologies to my wife for the wasted carton of eggs...it seemed like a good idea at the time). Like any training method, you have to start either at or just beyond your comfort zone. For me, the starting place for my heights-related hierarchy was climbers at a park. The process is pretty simple, really: you expose yourself to a trigger, wait for the fear and discomfort to come up, and then either sit with the fear until it subsides, resist the urge to perform a compulsion until the urge subsides, or both. With enough practice, you can work your way up your hierarchy and, in doing so, develop a stronger threshold for the amount of fear and discomfort you can withstand. Less fear and discomfort means less impact on your life for that particular trigger. Simple, yet powerful, isn't it?
Now, if you're anything like I was when I first started ERP, you might be thinking 'great, that's all well and good, but how do I use that with intrusive thoughts about my kids? I'm not going to expose them to increasingly contaminated toys just to prove they won't get sick, am I?'
The answer is no, of course you're not going to do that. Some exposures can't be practiced in real life (read more about some rules for conducting exposures here). In those cases, you need to rely on imaginal exposures.
Conducting ERP With Kids: Imaginal Exposures
Imaginal exposures are exactly what they sound like: instead of conducting an exposure in real life, you imagine the exposure in as vivid detail as possible, usually by writing the trigger scenario out. All the same rules still apply: you still need to create and follow a hierarchy, it's still important to get advice from a therapist at first, and you still have to work at your own pace. The goal is still the same, too: less fear and discomfort, and less control over your life for your triggers.
Personally, I'm a big fan of imaginal exposures for parents. Here's why: first, it's a totally private exercise. There's no need to go anywhere, set anything up, or spend any money. All you need is a notebook, a pen and some quiet time. Second, you're in complete control over the exposure. If you don't like what you're writing, you can stop and discard the paper, or you can pause and come back after seeking help or advice. Third - and this is really important - you can keep your written exposure and re-read it at a later date. This is part of a process called cognitive defusion (read more about it here), which essentially means getting space from your thoughts so that you can think about your thoughts rather than simply thinking and reacting to them.
So, if we put this in the context of parenting, you can now explore those obsessions you have about your kids getting contaminated by strange bacteria without ever putting them at risk (your kids, not the bacteria). You can also keep your written exposures as samples of your work to share with a therapist, and as a way to reflect on your progress over a longer period of time.
One disclaimer before we finish, though: imaginal exposures about your kids and family will never be easy. I still remember the first time I tried an imaginal exposure about obsessive thoughts I was having about one my kids falling from a height and not being able to save them. I wrote out the exposure and literally broke down at my desk. That particular exposure was too intense, and I needed to go back down my exposure hierarchy to something more manageable, such as one of my boys falling off a low step. Even now, having completed that particular exposure hierarchy, it still makes me cringe to even type words about my boys getting hurt (literally, I just cringed). But, I can now talk and type about it without an imminent and overwhelming fear of the events actually coming true, so that's something to feel good about.
If you're wanting to know more about what ERP looked like for me, or if you want to see more examples of ERP exercises and exposure hierarchies I created, I encourage you to check out my book (retailers are listed on the main page of this website). I created the book and this website to get the conversation about parenting and mental health out into the open, and I hope that both this blog and the book will achieve that goal, ideally with the best results saved for you, the reader.